Abstract
Background: Spinal cord injury (SCI) results in substantial impairment of upper extremity muscle strength and endurance, critically affecting functional independence, activities of daily living, and overall quality of life. Conventional high-intensity resistance training protocols, while effective for muscle hypertrophy, present significant challenges for individuals with SCI due to compromised neuromuscular control, heightened fatigue susceptibility, and increased risk of musculoskeletal complications. Blood flow restriction training (BFRT), which combines low-intensity resistance exercise with partial vascular occlusion, has emerged as a promising alternative rehabilitation strategy that may enhance upper extremity muscle strength and endurance while minimizing mechanical stress and training-related complications.
Objective: To systematically review and synthesize the current evidence regarding the efficacy, safety, and optimal application parameters of blood flow restriction training for improving upper extremity muscle strength and muscular endurance in individuals with spinal cord injury.
Methods: A comprehensive systematic search was conducted across multiple electronic databases including PubMed, Scopus, Web of Science, CINAHL, and Google Scholar to identify interventional studies published between January 2010 and October 2025. Studies were included if they involved adult participants with spinal cord injury, implemented blood flow restriction training targeting upper extremity muscles, and reported quantitative outcomes for muscle strength and/or muscular endurance. Screening, data extraction, and quality appraisal were performed according to PRISMA 2020 guidelines. Intervention parameters, outcome measures, and safety profiles were systematically extracted and analyzed.
Results: Twelve studies involving 160 participants with chronic cervical and thoracic spinal cord injury met the inclusion criteria. These studies comprised randomized controlled trials, pilot investigations, and quasi-experimental designs. Blood flow restriction training interventions varied in duration from 4 to 8 weeks (mean: 6.5 weeks), utilized individualized limb occlusion pressures ranging from 40% to 60% of arterial occlusion pressure, employed low-intensity resistance exercises at 20-40% of one-repetition maximum, and were administered at frequencies of 2-3 sessions per week. Significant improvements in upper extremity muscle strength were consistently observed, with mean grip strength increases ranging from 5 to 7 kilograms across studies. Muscular endurance outcomes, assessed through sustained contraction protocols and time-to-fatigue measurements, demonstrated substantial enhancements following blood flow restriction training interventions. Safety profiles were uniformly favorable, with no serious adverse events, thromboembolic complications, or cardiovascular incidents reported. Minor transient discomfort during cuff application represented the most commonly reported side effect.
Conclusion: Blood flow restriction training appears to be a feasible, safe, and effective rehabilitation approach for enhancing upper extremity muscle strength and muscular endurance in individuals with spinal cord injury. The technique offers distinct advantages over conventional high-load resistance training by achieving comparable muscular adaptations while employing substantially lower mechanical loads. Further large-scale randomized controlled trials utilizing standardized protocols and incorporating extended follow-up periods are warranted to establish optimal dosing parameters and confirm long-term efficacy and safety in diverse spinal cord injury populations.