Skip to main content Skip to main navigation menu Skip to site footer

Effect of low-intensity resistance training with blood flow restriction on isometric quadriceps peak torque in knee osteoarthritis

  • Alvita Sari ,
  • Meisy Andriana ,
  • I Putu Alit Pawana ,
  • Damayanti Tinduh ,
  • Dwikora Novembri Utomo ,
  • Soenarnatalina Melaniani ,


Link of Video Abstract:


Background: Knee osteoarthritis (OA) is one of the most common chronic progressive diseases impacting people worldwide. Quadriceps muscle weakness contributes to knee-OA-related functional decline. Traditional interventions aimed at increasing muscle strength in knee-OA commonly involve high-intensity resistance training but may result in joint pain due to high compressive forces. An isometric test may be better performed with a lower level of fatigue and obtain greater tolerance for knee-OA subjects due to their articular manifestations. Current recommendations for knee-OA include low-intensity resistance training (LI-RT) performed with blood flow restriction (BFR), a potential intervention for a patient who does not tolerate high loads due to lower mechanical stress. The aim of this study is to determine the effects of blood flow restriction with a low-intensity resistance training program for six weeks on quadriceps muscle strength using an isokinetic dynamometer in patients with knee OA.

Methods: Twenty-eight patients aged 50-70 years old with knee-OA in Physical Medicine and Rehabilitation Outpatient Clinic Soetomo Hospital Surabaya were randomized into the control group (CG) and intervention group (IG). Both groups underwent a 6-week supervised training program consisting of LI-RT (30% 1-RM) two sessions/week. The intervention group received an additional application of blood flow restriction on 1/3 of the upper thigh with 50 mmHg occlusion pressure. Both groups were assessed for muscle strength by isometric quadriceps peak torque using an isokinetic dynamometer before and after the protocol.

Results: Significant increases were found for isometric peak torque of quadriceps between pre and post-evaluations for LI-RT + BFR group / IG (p-value 0.000) and LI-RT group / CG (p-value 0.002). There was a significant difference in isometric peak torque improvement between the two groups (p-value 0.043). The efficiency of training time in the blood flow restriction group had a larger effect size value.

Conclusion: Low-intensity resistance training with BFR was more effective in enhancing the isometric peak torque of quadriceps compared with the low-intensity resistance training only, so it could be added as an alternative intervention for knee-OA patients.


  1. Jardim RAC, de Sousa TS, Dos Santos WNN, Matos AP, Iosimuta NCR. Blood flow restriction with different load levels in patients with knee osteoarthritis: protocol of a randomized controlled trial. Trials. 2022;23(1):41.
  2. Rosita PE, Kurniawati PM, Utomo DN. Profile of Age, Gender, and Body Mass Index in Patient with Knee Osteoarthritis in Surabaya. Surabaya Phys Med Rehabil J. 2021;3(1):23.
  3. Ferlito JV, Pecce SAP, Oselame L, De Marchi T. The blood flow restriction training effect in knee osteoarthritis people: a systematic review and meta-analysis. Clin Rehabil. 2020;34(11):1378-1390.
  4. Cui A, Li H, Wang D, Zhong J, Chen Y, Lu H. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies. EClinicalMedicine. 2020;29-30:100587.
  5. Tim Riskesdas 2018. Laporan Riskesdas 2018 Nasional.pdf. Lemb Penerbit Balitbangkes. Published online 2018. Riskesdas 2018 Nasional.pdf
  6. Nadia AF, Abdallah MM, Mohammed MM, et al. Effect of Low Load Resistance Blood Flow Restriction Training on Knee Osteoarthritis. Med J Cairo Univ. 2018;86(12):4297-4306.
  7. Mahmoud WS, Elnaggar RK, Ahmed AS, Mahmoud WS. Influence of Isometric Exercise Training on Quadriceps Muscle Architecture and Strength in Obese Subjects with Knee Osteoarthritis. 2017;6(3):1-9.
  8. Egwu OR, Ayanniyi OO, Adegoke BDO, Olagbegi OM, Ogwumike OO, Odole AC. Effect of self-management education versus quadriceps strengthening exercises on pain and function in patients with knee osteoarthritis. Hum Mov. 2018;19(3):64-74.
  9. Susanti A, Wardhani RIL, Pawana IPA. The Relationship Between Quadriceps Muscle Atrophy and Proprioception Function in Knee Osteoarthritis Patients. Surabaya Phys Med Rehabil J. 2019;1(2):59.
  10. Petersen SR, Bell G, Bagnall KM, Quinney HA. The Effects of Concentric Resistance Training on Eccentric Peak Torque and Muscle Cross-sectional Area. J Orthop Sports Phys Ther. 1991;13(3):132-137. doi:10.2519/jospt.1991.13.3.132.
  11. Simpson D, Ehrensberger M, Nulty C, et al. Peak torque, rate of torque development and average torque of isometric ankle and elbow contractions show excellent test-retest reliability. Hong Kong Physiother J. 2019;39(1):67-76.
  12. Ventura A, Muendle B, Friesenbichler B, Casartelli NC, Kramers I, Maffiuletti NA. Deficits in rate of torque development are accompanied by activation failure in patients with knee osteoarthritis. J Electromyogr Kinesiol. 2019;44:94-100.
  13. Pitsillides A, Stasinopoulos D, Mamais I. Blood flow restriction training in patients with knee osteoarthritis: Systematic review of randomized controlled trials. J Bodyw Mov Ther. 2021;27:477-486.
  14. dos Santos LP, do Espírito Santo RC, Ramis TR, Portes JKS, da Silva Chakr RM, Xavier RM. The effects of resistance training with blood flow restriction on muscle strength, muscle hypertrophy and functionality in patients with osteoarthritis and rheumatoid arthritis: A systematic review with meta-analysis. PLoS One. 2021;16(November):1-20.
  15. Cerqueira MS, De Brito Vieira WH. Effects of blood flow restriction exercise with very low load and low volume in patients with knee osteoarthritis: Protocol for a randomized trial. Trials. 2019;20(1):1-9.
  16. Amorin S, Alexandra P, Hans D, et al. The effects of blood flow restriction exercise on vascular function in the elderly: A systematic review. Integr Clin Med. 2019;3(1):1-6.
  17. Sami W, Alrukban MO, Waqas T, Asad MR, Afzal K. Sample Size Determination In Health Research. J Ayub Med Coll Abbottabad. 2018;30(2):308-311.
  18. Mahmoud WS, Osailan A, Ahmed AS, Elnaggar RK, Radwan NL. Optimal parameters of blood flow restriction and resistance training on quadriceps strength and cross-sectional area and pain in knee osteoarthritis. Isokinet Exerc Sci. 2021;29(4):393-402.
  19. Cook SB, LaRoche DP, Villa MR, Barile H, Manini TM. Blood flow restricted resistance training in older adults at risk of mobility limitations. Exp Gerontol. 2017;99:138-145.
  20. Loenneke JP, Fahs CA, Rossow LM, et al. Effects of cuff width on arterial occlusion: Implications for blood flow restricted exercise. Eur J Appl Physiol. 2012;112(8):2903-2912.
  21. Ohta H, Kurosawa H, Ikeda H, Iwase Y, Satou N, Nakamura S. Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthop Scand. 2003;74(1):62-68.
  22. Noyes FR, Barber-Westin SD, Sipes L. Blood Flow Restriction Training Can Improve Peak Torque Strength in Chronic Atrophic Postoperative Quadriceps and Hamstrings Muscles. Arthroscopy. 2021;37(9):2860-2869.
  23. Tennent DJ, Hylden CM, Johnson AE, Burns TC, Wilken JM, Owens JG. Blood flow restriction training after knee arthroscopy: A randomized controlled pilot study. Clin J Sport Med. 2017;27(3):245-252.
  24. Bryk FF, dos Reis AC, Fingerhut D, et al. Exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial. Knee Surgery, Sport Traumatol Arthrosc. 2016;24(5):1580-1586.
  25. Giles L, Webster KE, Mcclelland J, Cook JL. Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: A double-blind randomised trial. Br J Sports Med. 2017;51(23):1688-1694.
  26. De Zwart AH, Dekker J, Lems WF, Roorda LD, Van Der Esch M, Van Der Leeden M. Factors associated with upper leg muscle strength in knee osteoarthritis: A scoping review. J Rehabil Med. 2018;50(2):140-150.
  27. Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Exercise with Blood Flow Restriction: An Updated Evidence-Based Approach for Enhanced Muscular Development. Sport Med. 2015;45(3):313-325.
  28. Pearson SJ, Hussain SR. A Review on the Mechanisms of Blood-Flow Restriction Resistance Training-Induced Muscle Hypertrophy. Sport Med. 2015;45(2):187-200.
  29. Manini TM, Clark BC. Blood flow restricted exercise and skeletal muscle health. Exerc Sport Sci Rev. 2009;37(2):78-85.
  30. Yasuda T, Ogasawara R, Abe T. Combined effects of low-intensity blood flow restriction training and high-intensity resistance training on muscle strength and size. Published online 2011:2525-2533.
  31. Lum D, Barbosa TM. Brief Review: Effects of Isometric Strength Training on Strength and Dynamic Performance. Int J Sports Med. 2019;40(6):363-375.
  32. Buckner SL, Jessee MB, Mattocks KT, et al. Determining Strength: A Case for Multiple Methods of Measurement. Sports Med. 2017;47(2):193-195.
  33. Sumide T, Sakuraba K, Sawaki K, Ohmura H, Tamura Y. Effect of resistance exercise training combined with relatively low vascular occlusion. J Sci Med Sport. 2009;12(1):107-112.
  34. Kubota A, Sakuraba K, Koh S, Ogura Y, Tamura Y. Blood flow restriction by low compressive force prevents disuse muscular weakness. J Sci Med Sport. 2011;14(2):95-99.
  35. Brandner CR, May AK, Clarkson MJ, Warmington SA. Reported side-effects and safety considerations for the use of blood flow restriction during exercise in practice and research. Tech Orthop. 2018;33(2):114-121.
  36. Fahs CA, Rossow LM, Loenneke JP, et al. Effect of different types of lower body resistance training on arterial compliance and calf blood flow. Clin Physiol Funct Imaging. 2012;32(1):45-51.
  37. Cardoso RK, Araujo AM, de Freitas MP, Rombaldi AJ. Effect of training with partial blood flow restriction in older adults: A systematic review. Rev Bras Cineantropometria e Desempenho Hum. 2018;20(2):219-228.
  38. Kemnitz J, Wirth W, Eckstein F, Culvenor AG. The role of thigh muscle and adipose tissue in knee osteoarthritis progression in women: data from the Osteoarthritis Initiative. Osteoarthr Cartil. 2018;26(9):1190-1195.
  39. Cerqueira MS, Costa EC, Santos Oliveira R, Pereira R, Brito Vieira WH. Blood Flow Restriction Training: To Adjust or Not Adjust the Cuff Pressure Over an Intervention Period? Front Physiol. 2021;12(June):1-11.
  40. Ferraz RB, Gualano B, Rodrigues R, et al. Benefits of Resistance Training with Blood Flow Restriction in Knee Osteoarthritis. Med Sci Sports Exerc. 2018;50(5):897-905.

How to Cite

Sari, A., Andriana, M., Pawana, I. P. A., Tinduh, D., Utomo, D. N., & Melaniani, S. (2024). Effect of low-intensity resistance training with blood flow restriction on isometric quadriceps peak torque in knee osteoarthritis. Bali Medical Journal, 13(2), 785–791.




Search Panel

Alvita Sari
Google Scholar
BMJ Journal

Meisy Andriana
Google Scholar
BMJ Journal

I Putu Alit Pawana
Google Scholar
BMJ Journal

Damayanti Tinduh
Google Scholar
BMJ Journal

Dwikora Novembri Utomo
Google Scholar
BMJ Journal

Soenarnatalina Melaniani
Google Scholar
BMJ Journal