The effects of high-pressure versus low-pressure blood flow restriction resistance exercise in individuals with lower limb musculoskeletal injuries and persistent pain: a randomised controlled trial

Luke Gray; Russell J. Coppack; Robert Barker-Davies; Robyn P. Cassidy; Alexander N. Bennett; Nick Caplan; Gavin Atkinson; Lauren Bradshaw; Luke Hughes; Peter Ladlow

doi:10.1016/j.ptsp.2026.101920

The effects of high-pressure versus low-pressure blood flow restriction resistance exercise in individuals with lower limb musculoskeletal injuries and persistent pain: a randomised controlled trial

Luke Gray, Russell J. Coppack, Robert Barker-Davies, Robyn P. Cassidy, Alexander N. Bennett, Nick Caplan, Gavin Atkinson, Lauren Bradshaw, Luke Hughes, Peter Ladlow

Department for Health

Research output: Contribution to journal › Article › peer-review

Abstract

Objectives: Compare the efficacy and acceptability of low load blood flow restriction (BFR) using two different limb occlusion pressures (LOP) on pain and function in individuals with lower-limb musculoskeletal injury (MSKI) and associated persistent pain.

Design: Randomised controlled trial within a military residential rehabilitation setting.

Participants: Twenty-eight individuals (N = 21 male; N = 7 female) with lower-limb MSKI were randomly allocated into: 1) BFR-RE with 80% LOP (BFR80), or 2) BFR-RE with 40% LOP (BFR40). Both groups completed 7x BFR-RE sessions during 5-days of residential rehabilitation at 20% 1-repetition maximum.

Main outcome measures: The primary outcome measure was the Brief Pain Inventory (BPI). Secondary outcomes include injury-specific outcomes, pain pressure threshold (PPT) and lower-limb muscle strength assessment. All reported outcomes reflect changes in scores.

Results: BPI ‘worst’ displayed a time × group interaction (p = .013), driven by higher pain in BFR80 from pre-to post-intervention (standardised mean difference [SMD] = 1.532, p = .006). There was a significant time × group interaction for BPI ‘severity’ (p = .022), driven by significant between-group differences at T3 (BFR80-BFR40: SMD = 1.305, p = .015). PPTs improved within-session and over time.

Conclusion: Both pressures demonstrated cumulative exercise-induced hypoalgesia via rising PPTs. BFR80 reported increased ‘worst’ pain score. Lower LOP may better preserve training volume and exercise tolerability.

Original language	English
Article number	101920
Journal	Physical Therapy in Sport
Volume	79
Early online date	17 Apr 2026
DOIs	https://doi.org/10.1016/j.ptsp.2026.101920
Publication status	Published - 31 May 2026

Data Availability Statement

Requests for data sharing from appropriate researchers and entities will be considered on a case-by-case basis. Interested parties should contact PL.

Funding

The study was jointly financed by Defence Medical Services Research Steering Group (UK) and Northumbria University (UK) as part of a PhD programme. External funding from Delfi Medical Innervations Inc (USA) has also been provided but had no influence over study design, analysis or write up.

Keywords

Blood flow restriction
Military
Musculoskeletal injury
Persistent pain

ASJC Scopus subject areas

Orthopedics and Sports Medicine
Physical Therapy, Sports Therapy and Rehabilitation

Access to Document

10.1016/j.ptsp.2026.101920Licence: CC BY

Cite this

Gray, L., Coppack, R. J., Barker-Davies, R., Cassidy, R. P., Bennett, A. N., Caplan, N., Atkinson, G., Bradshaw, L., Hughes, L., & Ladlow, P. (2026). The effects of high-pressure versus low-pressure blood flow restriction resistance exercise in individuals with lower limb musculoskeletal injuries and persistent pain: a randomised controlled trial. Physical Therapy in Sport, 79, Article 101920. https://doi.org/10.1016/j.ptsp.2026.101920

The effects of high-pressure versus low-pressure blood flow restriction resistance exercise in individuals with lower limb musculoskeletal injuries and persistent pain: a randomised controlled trial. / Gray, Luke; Coppack, Russell J.; Barker-Davies, Robert et al.
In: Physical Therapy in Sport, Vol. 79, 101920, 31.05.2026.

Research output: Contribution to journal › Article › peer-review

Gray, L, Coppack, RJ, Barker-Davies, R, Cassidy, RP, Bennett, AN, Caplan, N, Atkinson, G, Bradshaw, L, Hughes, L & Ladlow, P 2026, 'The effects of high-pressure versus low-pressure blood flow restriction resistance exercise in individuals with lower limb musculoskeletal injuries and persistent pain: a randomised controlled trial', Physical Therapy in Sport, vol. 79, 101920. https://doi.org/10.1016/j.ptsp.2026.101920

Gray L, Coppack RJ, Barker-Davies R, Cassidy RP, Bennett AN, Caplan N et al. The effects of high-pressure versus low-pressure blood flow restriction resistance exercise in individuals with lower limb musculoskeletal injuries and persistent pain: a randomised controlled trial. Physical Therapy in Sport. 2026 May 31;79:101920. Epub 2026 Apr 17. doi: 10.1016/j.ptsp.2026.101920

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title = "The effects of high-pressure versus low-pressure blood flow restriction resistance exercise in individuals with lower limb musculoskeletal injuries and persistent pain: a randomised controlled trial",

abstract = "Objectives: Compare the efficacy and acceptability of low load blood flow restriction (BFR) using two different limb occlusion pressures (LOP) on pain and function in individuals with lower-limb musculoskeletal injury (MSKI) and associated persistent pain. Design: Randomised controlled trial within a military residential rehabilitation setting. Participants: Twenty-eight individuals (N = 21 male; N = 7 female) with lower-limb MSKI were randomly allocated into: 1) BFR-RE with 80\% LOP (BFR80), or 2) BFR-RE with 40\% LOP (BFR40). Both groups completed 7x BFR-RE sessions during 5-days of residential rehabilitation at 20\% 1-repetition maximum. Main outcome measures: The primary outcome measure was the Brief Pain Inventory (BPI). Secondary outcomes include injury-specific outcomes, pain pressure threshold (PPT) and lower-limb muscle strength assessment. All reported outcomes reflect changes in scores. Results: BPI {\textquoteleft}worst{\textquoteright} displayed a time × group interaction (p = .013), driven by higher pain in BFR80 from pre-to post-intervention (standardised mean difference [SMD] = 1.532, p = .006). There was a significant time × group interaction for BPI {\textquoteleft}severity{\textquoteright} (p = .022), driven by significant between-group differences at T3 (BFR80-BFR40: SMD = 1.305, p = .015). PPTs improved within-session and over time. Conclusion: Both pressures demonstrated cumulative exercise-induced hypoalgesia via rising PPTs. BFR80 reported increased {\textquoteleft}worst{\textquoteright} pain score. Lower LOP may better preserve training volume and exercise tolerability.",

keywords = "Blood flow restriction, Military, Musculoskeletal injury, Persistent pain",

author = "Luke Gray and Coppack, \{Russell J.\} and Robert Barker-Davies and Cassidy, \{Robyn P.\} and Bennett, \{Alexander N.\} and Nick Caplan and Gavin Atkinson and Lauren Bradshaw and Luke Hughes and Peter Ladlow",

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T2 - a randomised controlled trial

AU - Gray, Luke

AU - Coppack, Russell J.

AU - Barker-Davies, Robert

AU - Cassidy, Robyn P.

AU - Bennett, Alexander N.

AU - Caplan, Nick

AU - Atkinson, Gavin

AU - Bradshaw, Lauren

AU - Hughes, Luke

AU - Ladlow, Peter

PY - 2026/5/31

Y1 - 2026/5/31

N2 - Objectives: Compare the efficacy and acceptability of low load blood flow restriction (BFR) using two different limb occlusion pressures (LOP) on pain and function in individuals with lower-limb musculoskeletal injury (MSKI) and associated persistent pain. Design: Randomised controlled trial within a military residential rehabilitation setting. Participants: Twenty-eight individuals (N = 21 male; N = 7 female) with lower-limb MSKI were randomly allocated into: 1) BFR-RE with 80% LOP (BFR80), or 2) BFR-RE with 40% LOP (BFR40). Both groups completed 7x BFR-RE sessions during 5-days of residential rehabilitation at 20% 1-repetition maximum. Main outcome measures: The primary outcome measure was the Brief Pain Inventory (BPI). Secondary outcomes include injury-specific outcomes, pain pressure threshold (PPT) and lower-limb muscle strength assessment. All reported outcomes reflect changes in scores. Results: BPI ‘worst’ displayed a time × group interaction (p = .013), driven by higher pain in BFR80 from pre-to post-intervention (standardised mean difference [SMD] = 1.532, p = .006). There was a significant time × group interaction for BPI ‘severity’ (p = .022), driven by significant between-group differences at T3 (BFR80-BFR40: SMD = 1.305, p = .015). PPTs improved within-session and over time. Conclusion: Both pressures demonstrated cumulative exercise-induced hypoalgesia via rising PPTs. BFR80 reported increased ‘worst’ pain score. Lower LOP may better preserve training volume and exercise tolerability.

AB - Objectives: Compare the efficacy and acceptability of low load blood flow restriction (BFR) using two different limb occlusion pressures (LOP) on pain and function in individuals with lower-limb musculoskeletal injury (MSKI) and associated persistent pain. Design: Randomised controlled trial within a military residential rehabilitation setting. Participants: Twenty-eight individuals (N = 21 male; N = 7 female) with lower-limb MSKI were randomly allocated into: 1) BFR-RE with 80% LOP (BFR80), or 2) BFR-RE with 40% LOP (BFR40). Both groups completed 7x BFR-RE sessions during 5-days of residential rehabilitation at 20% 1-repetition maximum. Main outcome measures: The primary outcome measure was the Brief Pain Inventory (BPI). Secondary outcomes include injury-specific outcomes, pain pressure threshold (PPT) and lower-limb muscle strength assessment. All reported outcomes reflect changes in scores. Results: BPI ‘worst’ displayed a time × group interaction (p = .013), driven by higher pain in BFR80 from pre-to post-intervention (standardised mean difference [SMD] = 1.532, p = .006). There was a significant time × group interaction for BPI ‘severity’ (p = .022), driven by significant between-group differences at T3 (BFR80-BFR40: SMD = 1.305, p = .015). PPTs improved within-session and over time. Conclusion: Both pressures demonstrated cumulative exercise-induced hypoalgesia via rising PPTs. BFR80 reported increased ‘worst’ pain score. Lower LOP may better preserve training volume and exercise tolerability.

KW - Blood flow restriction

KW - Military

KW - Musculoskeletal injury

KW - Persistent pain

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DO - 10.1016/j.ptsp.2026.101920

M3 - Article

SN - 1466-853X

VL - 79

JO - Physical Therapy in Sport

JF - Physical Therapy in Sport

M1 - 101920

ER -

The effects of high-pressure versus low-pressure blood flow restriction resistance exercise in individuals with lower limb musculoskeletal injuries and persistent pain: a randomised controlled trial

Abstract

Data Availability Statement

Funding

Keywords

ASJC Scopus subject areas

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