Efficacy and safety of blood flow restriction exercise training in adults aged 60 years and older: an umbrella review of systematic reviews

Abstract

Blood flow restriction (BFR) exercise may permit older adults to train at lower mechanical loads. Interpretation of the review literature is complicated by heterogeneous age boundaries, BFR and exercise prescriptions, effect metrics, safety definitions and primary-study overlap. We evaluated efficacy and safety-related evidence for BFR exercise in adults aged 60 years and older. PubMed, Web of Science, SPORTDiscus, Cochrane Library, Embase and Scopus were searched from inception to 1 April 2026 for systematic reviews, meta-analyses and network meta-analyses. Two reviewers independently screened records, extracted data and appraised review quality using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2). We appraised primary-study age applicability, blood flow restriction prescription against 14 methodological domains, exercise reporting against the Consensus on Exercise Reporting Template (CERT), proximity to volitional failure and adverse-event ascertainment. Primary-study overlap was quantified using the corrected covered area (CCA). Source-review estimates were extracted without re-pooling, and certainty was summarized using a Grading of Recommendations Assessment, Development and Evaluation (GRADE)-informed approach. Nine reviews were included. Overlap was very high (CCA 15.28%; 80 review-primary-study occurrences; 36 unique studies). Primary-study mean ages ranged from 60.5 to 76.4 years, and three reviews included or explicitly acknowledged participants younger than 60 years. No review reported body position during arterial or limb occlusion pressure assessment or during exercise, and eight blood flow restriction assessment/apparatus domains were absent from all reviews. In the principal strength/hypertrophy review, 4 of 14 trials prescribed sets to failure and none quantified proximity to failure. Low-load blood flow restriction showed a small-to-moderate strength advantage over traditional low-load training (7 studies; 25 comparisons; n = 201; SMD 0.44, 95% CI 0.28 to 0.60; I²=0%; moderate certainty), whereas high-load training showed a small advantage over low-load blood flow restriction (8 studies; 23 comparisons; n = 189; SMD − 0.23, 95% CI -0.41 to -0.05; I²=0%; moderate certainty). Hypertrophy estimates were low-certainty and based on 6 studies (9 comparisons; n = 114) versus high-load training and 2 studies (5 comparisons; n = 31) versus low-load training. Clinical adverse events were predominantly passively reported. Thrombotic/coagulation biomarker estimates were based on 4 studies (6 trials; n = 93) versus low-load training and 2 studies (4 trials; n = 39) versus passive control and cannot establish clinical safety. Mobility evidence was very low-certainty, and direct falls-incidence evidence was absent. Low-load blood flow restriction may improve standardized strength compared with low-load training but remains slightly inferior to high-load training; whether either difference is clinically meaningful is unknown. Hypertrophy comparisons do not establish equivalence because evidence was low-certainty and effort/failure was incompletely reported. Clinical safety, falls prevention and patient-centred benefits are not established. PROSPERO CRD420261371438.