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THE HISTORY, THEORY AND PRACTICE OF RESTRICTED BLOOD FLOW

RESISTANCE TRAINING (RBFRT/KAATSU)

Conference Paper · October 2015

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ISTORIJAT, TEORIJA I PRAKSA TRENINGA SA OPTEREĆENJEM UZ
RESTRIKCIJU KRVOTOKA (RBFRT/KAATSU)
SAŽETAK
Trening sa opterećenjem uz restrikciju krvotoka (RBFRT/KAATSU) je relativno novi metod treninga koji
dovodi do pozitivnih efekata u prirastu snage i hipertrofije mišićnog tkiva kao i do sada poznati trening
visokog intenziteta ≤70 % 1RM ali za dosta kraći trenažni period i bez rizika od povređivanja. KAATSU
trening se izvodi uz niskointenzivno trenažno opterećenje između 20 i 50% 1RM dok se relativno lagan i
fleksibilan pojas postavlja na proksimalni deo donjeg ili gornjeg ekstremiteta koji obezbeđuje optimalan
površinski pritisak. KAATSU trening ne uzrokuje ishemiju skeletnih mišića, već prouzrokuje stanje
povlačenja krvi u kapilare mišića ekstremitata nad kojim se aplikuje pritisak. Klinička ispitivanja koja su
sprovedena u prethodnih 15 godina dokazala su da KAATSU trening ne dovodi samo do povećanja
mišićne mase i snage kod zdravih osoba, rekreativaca i sportista već ima pozitivan uticaj i na druge
specifične populacije poput astronauta te pacijenata sa kardiovaskularnim i ortopedskim oboljenjima.
Ključne reči: KAATSU, RBFRT, restrikcija krvotoka, okluzija, treninga sa opterećenjem, snaga, mišićna
masa, hipertrofija, efekti.

THE HISTORY, THEORY AND PRACTICE OF RESTRICTED BLOOD

FLOW RESISTANCE TRAINING (RBFRT/KAATSU)
Armin Paravlić1, Stefan Đorđević1
1Faculty of Sport and Physical Education, University of Niš, Niš, Serbia

SUMMARY
Restricted blood flow resistance training (RBFRT/KAATSU) is a relatively new method of training that
leads to positive effects in the strength gain and hypertrophy of muscle tissue such as high intensity
resistance training of ≤70 % of 1RM but for much shorter period and without risks of injuries. KAATSU
Training consists of performing low-intensity resistance training while a relatively light and flexible cuff
is placed on the proximal part of one’s lower or upper limbs, which provides appropriate superficial
pressure. KAATSU Training does not induce ischemia within skeletal muscle, but rather promotes a state
of blood pooling in the capillaries within the limb musculature. Applied basics and clinical research
conducted over the past 15 years has demonstrated that KAATSU Training not only improves muscle
mass and strength in healthy volunteers and athletes but also benefits patients with cardiovascular and
orthopedic conditions, even astronauts.
Keywords: KAATSU, RBFRT, restricted blood flow, occlusion, resistance training, strength, muscle mass,
hypertrophy, effects.

INITIAL CONSIDERATIONS
Resistance training has long been acknowledged as an effective stimulant resulting in hypertrophy and an
increase in skeletal muscle strength (American College of Sports Medicine position stand, 2009).
According to ACSM recommendations, high-intensity training (≥70% 1RM) with a low number of
repetitions before reaching muscle fatigue (8≤12 repetitions maximum) can lead to changes in the
functional and morphological characteristics of muscular tissue in favor of hypertrophy and an increase
in muscle strength (ACSM, 2009).
Higher training intensity is frequently linked with orthopedic complications (Miyachi, Kawano, Sugawara,
Takahashi, Hayashi et al., 2004; Roth, Martel, Ivey, Lemmer, Metter et al., 2000), such as pain in the joints
and lower back. During a training process which includes a method of high-intensity training (HIT),
athletes run a higher risk of injury (Fry, Kraemer, Van Borselen, Lynch, Triplett et al., 1994). Medium-
intensity resistance training is recommended as a measure against ageing, increasing muscle strength and
endurance (Nakajima, 2007).
Increases in muscle mass and strength are effects that are not easily achievable in clinical tests, since they
require a prolonged period, no shorter than 2 months in duration, of high-intensity training (Roth et al.,
2000). However, HIT is not recommended for the elderly as it increases the risk of injury to the skeletal
system, soft tissue, as well as the circulatory system. Moreover, an increase in arterial stiffness, one of the
indicators for atherosclerosis, has also been found in healthy young persons following HIT (Miyachi,
Donato, Yamamoto, Takahashi, Gates et al., 2003; Miyachi et al., 2004; Kawano, Tanaka & Miyachi, 2006).
These findings indicate that high-intensity training (≥70% 1RM ) should only be administered with great
care, both for athletes and for physically active people in general, and especially when it comes to
developing children, the elderly (ACSM, 2009), convalescents, as well as individuals with cardiovascular
diseases. Conventional training conducted with an intensity lower than 70% 1RM is considered less
efficient for increasing strength and achieving muscle hypertrophy (McDonagh & Davies, 1984, Kraemer,
Adams, Cafarelli, Dudley, Dooly et al., 2002). For the reasons noted above, new methods of training need
to be explored, ones that would have the same effect regarding strength and hypertrophy gains, yet with
minimal side-effects for the human skeletal, muscular and cardiovascular systems.
Studies conducted over the last decade have demonstrated that low-intensity resistance training (LI-RT)
can lead to hypertrophy and increase in the strength of skeletal muscles using only 20-30 % 1RM
(Takarada, Tsuruta & Ishii, 2004; Karabulut, Abe, Sato & Bemben, 2010; Yasuda, Fujita, Ogasawara, Sato &
Abe, 2010).

THE CONCEPTION OF THE IDEA OF KAATSU – RBFRT TRAINING

This training method was conceived in Japan by Professor Yoshiaki Sato who began conducting
experiments in the early 1960s, first on himself and later on his patients (Sato, 2005).
"I started this training during my first year of high school after seeing a bodybuilder on TV for the first
time in my life. In the fall of 1966, I had the inspiration for the KAATSU training while paying respect to
the Holy Buddha at a memorial site. During the ceremony my legs went numb as a consequence of the
position I was sitting in (kneeling on the floor with my back straight). I started massaging my calves and
noticed a swelling and discomfort in this area, very similar to what I would feel after resistance training
targeting the calf muscles. My assumption was that this feeling of swelling was caused by decreased blood
flow to the muscle" (Sato, 2004a; in: Sato, 2005).
It took many experiment repetitions in order to determine the optimal position for applying pressure
with the aim of decreasing blood flow to the active muscle. Applying too much pressure would result in
my skin going blue and, had I continued with this line of training, thrombosis would have ensued. It is
very difficult to optimally decrease blood flow to achieve positive effects. It should be emphasized that
this technique ought not to be applied without a thorough knowledge of the appropriate application of
the KAATSU apparatus (Sato, 2005).

THE THEORETICAL FOUNDATIONS OF THE KAATSU OR LI-BFR TRAINING

METHOD
A review of literature to date yielded several terms used to refer to LI-RT, depending on the
demographics of the context where the studies were conducted. The method is termed KAATSU in Japan
(Sato, 2005), which translates as “additional pressure”, whereas in the Europe and US it is termed BFOT,
i.e. Blood Flow Occlusion Training, or RBFRT,i.e. Restricted Blood Flow Resistance Training (Loenneke,
G.J. Wilson & J.M. Wilson, 2010; Fahs, Loenneke, Rossow, Thiebaud & Bemben, 2012).
The Kaatsu method is a new resistance training method which stimulates muscle fibers and can
contribute to hypertrophy and the increase in strength of skeletal muscles, even at low resistance
intensity (Sato, 2004a).
The Kaatsu training method is a type of resistance training where, in the course of muscle activity,
occlusion is used to decrease venous and arterial blood flow through the active extremities. A special belt
or elastic band is placed on the proximal end of the extremity, the "root" of the arm or leg, and this is
accompanied by a dynamic-type muscle contraction (Sato, 2004a; Loenneke et al., 2010; Fahs et al.,
2012).
The novelty of this training method compared to other principles known to date is that this is a short-
duration, low-intensity training which results in an increase in strength and muscle hypertrophy. A
number of studies have so far found that one of the prerequisites for gaining muscle mass and strength is
in fact functional stress, that is, mechanical stress caused by high-intensity resistance training (Fluck &
Hoppeler, 2003; Goldberg, Etlinger, Goldspink & Jablecki, 1975; in: Jones & Rutherford, 1987; Baldwin,
Valdez, Herrick, MacIntosh, & Roy, 1982; in: Adams & Haddad, 1996), in addition to other factors such as
protein synthesis, diet, physical activity and growth factor (Sandri, 2008). By using this method,
functional stress of the recruited muscle is achieved more quickly.
The advantage of the KAATSU training method in relation to methods known to date is that similar, or
even better, results in terms of hypertrophy and muscle strength can be achieved more quickly using a
low-intensity training method of 20%-50% 1RM.

THE PRINCIPLE OF APPLYING OCCLUSION AND TRAINING METHOD

INSTRUCTIONS
A special KAATSU device or elastic band is placed around the proximal section of the extremity whose
muscle we wish to stimulate. The pressure can be relatively low, as in the study by Yasuda et al. (2010),
which demonstrated that the positive effects of this method can be achieved with an occlusion of just 30
mmHg. More frequently, however, an average pressure of 100 mmHg is used, since this is sufficient
stimulant for restricting venous blood flow, resulting in blood retreating to blood vessels distal to the
occlusion site, which in turn leads to arterial blood flow restriction (Moore, Burgomaster, Schofield,
Gibala, Sale et al. 2004). One study noted positive effects after applying pressure as high as 250 mmHg
(Nakajima, Kurano, Sakagami, Iida, Fukumura, et al. 2010). It is important to emphasize that these studies
did not use constant pressure every day for the duration of the treatment. The pressure applied was
varied, with its values in the lower numbers at the beginning of the treatment and rising gradually as the
treatment progressed, from one practice session to another, to the maximal values noted above. The
significance of such a method lies in adapting the muscle tissue to new conditions, namely the applied
blood flow occlusion.
Given the nature of the KAATSU method, studies use only two regions to apply the bands – the upper and
lower extremities (Takarada & Ishii 2002; Yasuda, et al., 2010), with a weekly frequency of sessions
ranging from 3 (Ishii, Madarame, Odagiri, Naganuma & Shinoda, 2005; Karabulut et al., 2010) to 6 times
per week (Yasuda, Abe, Sato, Midorikawa, Kearns et al. 2005; Yasuda et al., 2010), and a daily frequency of
up to twice daily (Abe, Beekley, Hinata, Koizumi & Sato, 2005; Yasuda et al., 2005). Stress intensity
compared to 1RM varied from 20 % (Abe et al., 2005; Yasuda et al., 2005) to 50% (Takarada & Ishii
2002), the number of sets from 3 to 5, the number of repetitions from 15 to 30, mainly until reaching
muscle fatigue.
Typical low-intensity training is conducted at an intensity of 20-50 % 1RM with a duration of concentric
and eccentric contractions of 2 seconds (Takada, Okita, Suga, Omokawa, Kadoguchi, et al., 2012). 1 RM is
calculated based on the maximal amount of weight a person can lift under normal conditions, sans blood
flow restriction. Between three and five sets are done, with each exercise finishing in voluntary fatigue as
a consequence of contraction. This is done to ensure a high concentration of metabolites in the engaged
muscle. Rest periods between sets vary from 30 seconds (Yasuda et al., 2005; Takarada & Ishii 2002; Abe
et al., 2005) to one minute (Karabulut et al., 2010; Nakajima et al., 2010; Barcelos, Nunes, de Souza, de
Oliveira, Furlanetto et al., 2015). The occlusion is applied for as long as the exercise is performed,
regardless of the pauses between sets. The duration of exercise is between 5 and 10 minutes, depending
on all the aforementioned training variables.
KAATSU TRAINING EQUIPMENT
Sato dedicated a considerable amount of time to perfecting the technique and acquiring new knowledge
about the KAATSU training method, including about a dozen of his students in the process of following his
work. Ten years and several thousand participating students later, the KAATSU training method was
generalized for public usage in 1983. During this period, Sato came to a firm decision about working on
improving the equipment (Figure 1) for achieving occlusion, to which purpose he had previously used the
remnants of a common bicycle inner tube.
In December 2003, a new KAATSU training device was developed (KAATSU MASTER(tm)), providing
much greater precision and pressure control for ensuring safety (Figure 2) (Sato, 2005).

Figure 1. Kaatsu cuff with pressure

sensor Figure 2. Kaatsu training Master

KAATSU TRAINING PROJECTS IN JAPAN

Today, joint projects include collaboration with Tokyo University Technology Licensing Organization, Ltd.
(CASTI); basic research on biochemical and molecular mechanisms associated with KAATSU Training
(headed by Dr. Naokata Ishii of The University of Tokyo); applied research on the effect of acute KAATSU
Training on muscular hypertrophy which could be used for the prevention of disability among the elderly
(headed by Dr. Takashi Abe of The Tokyo Metropolitan University); animal research on the use of
KAATSU Training on racehorses for injury prevention and rehabilitation (headed by Dr. Kenneth H.
McKeever, Rutgers University, Equine Science Center); and medical research on the use of KAATSU
Training for functional rehabilitation from cerebrovascular disorder (Dr. Yoshiharu Yokogawa, Shinshu
University, School of Medicine). These projects are ongoing with many promising preliminary results
being reported (Abe, Sato, Inoue, Midorikawa, Yasuda, et al. 2004a; Abe, Kearns, Manso, Sato, Sleeper, et
al. 2004b; Kawada, Waga, Sato, Abe & Ishii, 2004; Yasuda, et al. 2005; prema: Sato, 2005).

APPLICABLE POPULATIONS
Referring to the previous experimental studies, this method has broad application value among the
human population. It has been proven effective in athletes (Takarada, Sato & Ishii, 2002), in patients in
the postoperative rehabilitation period, especially for patients with ACL knee injury (Takarada, Takazawa
& Ishii, 2000), patients with cardiovascular disease, elderly persons (Karabulut, et al., 2010); and even
astronauts (Iida, Kurano, Takano, Kubota, Morita, et al. 2007), without difference in relation to gender.

Because occlusion training allows individuals to train at much lower intensities with the benefits of
higher intensity training, it may be highly useful for other postoperative populations than ACL injuries as
it had been studied (Takarada, et al., 2000), and for improving muscular function in the bedridden older
population. Patients who are injured, specifically ACL injuries, have been shown to benefit from an
occlusive stimulus. With knee surgery, suppressing the disuse atrophy of thigh muscles has been
regarded as important because the rehabilitation usually takes a prolonged period to regain the original
muscular strength. Takarada, et al. (2000) showed that when an occlusion was present even without an
exercise stimulus, it was effective in diminishing the disuse atrophy of knee extensor 3 days after surgical
operation.
KAATSU may also be useful in the cardiac rehabilitation setting because occlusion has been shown to
significantly stimulate the exercise-induced GH, IGF, and vascular endothelial growth factor (VEGF)
responses with the reduction of cardiac preload during exercise (Takano, Morita, Iida, Asada, Kato, et al.
2005). GH and IGF-1 have been established as regulators of cardiac growth, structure, and function, and
GH has been applied for treatment of congestive heart failure (Khan, Sane, Wannenburg & Sonntag, 2002).
There is a wide spectrum of KAATSU training studies in wich have been found to have positive effects on
elderly, when it comes to increasing the strength, hypertrophy of muscle tissue (Nakajima, et al. 2010;
Karabulut, et al., 2010, Abe, et al., 2005), and post occlusive blood flow for both sex (Patterson &
Ferguson, 2011).
Astronauts are also a unique population that could benefit from occlusion training. During spaceflight,
several health concerns arise due to the changes in cardiovascular function that occur due to
weightlessness. When gravitationa hydrostatic gradients are abolished, there is a shift of intravascular
fluid from the capacitance vessels of the legs and lower body centrally toward the head. Elevations of
capillary blood pressure and increased capillary perfusion pressure in tissues of the head have been
shown to cause facial intracranial edema and headache. On return to Earth, orthostatic intolerance is the
most serious symptom of cardiovascular deconditioning; in addition, significantly reduced exercise
capacities and increased resting heart rate are also observed regardless of the duration (Blomqvist,
Buckey, Gaffney, Lane, Levine, et al. 1994; Buckey, Lane, Levine, Watenpaugh, Wright, et al, 1996; prema:
Iida, et al. 2007). Almost every astronaut after the space flight experiences orthostatic hypotension and
reduced upright exercise capacity, which is likely attributed to the microgravity-induced hypovolemia,
decreased baroreflex responsiveness, decreased skeletal muscle tone, and increased venous compliance.
When occlusion has been applied on both thighs in supine subjects, it induced the hemodynamic,
hormonal, and autonomic alterations that were very similar to standing. Ilda et al. conclude that occlusion
training may be a promising and safe method to counter symptoms of orthostatic intolerance and muscle
atrophy in astronauts (Iida, et al. 2007).

IN LIEU OF A CONCLUSION
RBFRT/KAATSU is a new method of training which has not yet been studied in depth in this part of the
world. This method has great training potential in terms of developing strength and muscle hypertrophy
in different populations. I believe that further empirical studies on different populations are needed in
order to fully explore the claims about the positive effects of this method on the development of desired
functional abilities.

The characteristics of KAATSU training are as follows:

 Short-term and low-intensity loads;

KAATSU training with high-intensity loads has little effect, but it may be rather dangerous.
Needless to say, restricting blood flow for a long time should be avoided.
 Hemostasis with a tourniquet should be avoided;
 KAATSU training should, in principle, be conducted by KAATSU trainers and instructors;
This is believed to be one of the reasons why serious complications have been seldom occurred
until now.
 It is said that over 200,000 people are currently conducting KAATSU training to improve the
muscle strength of able-bodied people, sportsmen and older people, and for health maintenance
purposes (Nakajima, Morita & Sato, 2011).
 Main side effects include petechial hemorrhage beneath the skin which is caused by applied
pressure and disappears after a few days of application, chills, numbness, and dizziness
(Nakajima, et al., 2011).
 There are also now hopes that it can be applied to the rehabilitation of patients with a variety of
diseases (Sato et al., 2007;) which is proven to be reality (Iida, et al. 2007; Takano, et al. 2005;
Takarada, et al., 2000; Karabulut, et al., 2010).
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