Effect of blood flow restriction training on the magnitude and temporal characteristics of post-activation performance enhancement: a systematic review and meta-analysis

Abstract

Objective: To systematically compare the acute effects of blood flow restriction combined with preconditioning (to induce post-activation performance enhancement) versus preconditioning alone or sitting, low-intensity preconditioning combined with blood flow restriction versus high-intensity preconditioning, and sitting combined with blood flow restriction versus sitting on sports performance using a multilevel meta-analysis. Methods: Following the PRISMA guidelines, Web of Science, PubMed, SPORTDiscus, and CNKI databases were systematically searched (from inception to May 24, 2025). Inclusion criteria: (1) healthy individuals who were at least physically active; (2) studies with at least one of the following four comparisons: preconditioning + blood flow restriction vs. preconditioning alone; preconditioning + blood flow restriction vs. sitting; low-intensity preconditioning + blood flow restriction vs. high-intensity preconditioning; sitting + blood flow restriction vs. sitting; (3) sports performance (e.g., jump, sprint, bench press throw) as the primary outcome; (4) randomized or non-randomized crossover/parallel designs; (5) published in peer-reviewed Chinese or English journals. Risk of bias was assessed using ROB-2, and evidence quality was evaluated with GRADE. Data were fitted using cluster robust variance estimation and a three-level mixed-effects model, with small-sample corrections. Subgroup analyses and meta-regression explored moderators and sources of heterogeneity. Results: Twelve studies (196 participants, 12 women, 184 men) were included. Main findings: (1) Preconditioning + blood flow restriction was more effective than preconditioning alone in enhancing sports performance (ES=0.21, 95%CI=0.01-0.40, GRADE=low), with the best effect at recovery times of 4-12 min and 50% arterial occlusion pressure (ES=1.49); (2) Preconditioning + blood flow restriction did not significantly differ from sitting (ES=0.52, 95%CI=-0.12-1.15, GRADE=very low), but preconditioning + 140 mmHg blood flow restriction was superior to preconditioning alone (ES=1.21, 95%CI=0.14-2.28); (3) Low-intensity preconditioning + blood flow restriction did not differ from high-intensity preconditioning (ES=-0.10, 95%CI=-0.84-0.64, GRADE=low); (4) Sitting + blood flow restriction did not significantly differ from sitting (ES=0.24, 95%CI=-0.03-0.52, GRADE=very low). Notably, the effects of the latter two comparisons significantly decreased with recovery time (β=-0.04, P < 0.01 and β=-0.04, P=0.02). Conclusion: Preconditioning combined with blood flow restriction is more effective than preconditioning alone in inducing post-activation performance enhancement, preliminarily suggesting the use of 50% arterial occlusion pressure and 4-12 min recovery time. However, preconditioning combined with blood flow restriction does not appear to be more effective than sitting, possibly due to insufficient number of included studies. Additionally, low-intensity preconditioning + blood flow restriction can achieve similar post-activation performance enhancement as high-intensity preconditioning, while the potential benefit of sitting + blood flow restriction on sports performance may diminish over time. Overall, it is preliminarily recommended to use low-intensity preconditioning (e.g., 30% one-repetition maximum squat or bodyweight training) combined with 50% arterial occlusion pressure or 140 mmHg blood flow restriction, with 4-12 min recovery before subsequent performance testing.

1. Introduction

Post-activation performance enhancement (PAPE) refers to the acute improvement in sports performance following a maximal or near-maximal voluntary contraction. Typically induced by low-volume, high-intensity preconditioning, PAPE manifests approximately 2.5-11 minutes after the conditioning activity, with performance enhancements ranging from 2% to 10%. PAPE is widely utilized in warm-up routines and complex training to acutely and chronically enhance athletic performance. The phenomenon is governed by the dynamic balance between fatigue and potentiation; specifically, when the rate of fatigue recovery exceeds the decay of potentiation, a PAPE window is observed. Therefore, optimizing preconditioning protocols hinges on maximizing the potentiation effects while minimizing fatigue.

Blood flow restriction (BFR) training, which involves applying a pressurized cuff to the proximal limb to reduce arterial inflow and venous return, has gained popularity as a method to augment training adaptations. BFR combined with low-load resistance exercise can induce muscle hypertrophy and strength gains comparable to high-load training. However, its acute effects on PAPE are less clear. Some studies suggest that BFR may enhance PAPE by increasing muscle activation and metabolic stress, while others report no additional benefit. The temporal characteristics of PAPE, such as the optimal recovery time and the magnitude of enhancement, may also be influenced by BFR.

Given the conflicting evidence, this systematic review and meta-analysis aimed to compare the acute effects of BFR combined with preconditioning versus preconditioning alone, preconditioning + BFR versus sitting, low-intensity preconditioning + BFR versus high-intensity preconditioning, and sitting + BFR versus sitting on sports performance. By synthesizing available data, we sought to provide evidence-based recommendations for the use of BFR in PAPE protocols.