Lower-limb blood flow restriction training for improving multiple dimensions of muscle strength and physical performance in older adults: a systematic review and meta-analysis

Age-related declines in muscle strength and function accelerate frailty and heighten the risk of sarcopenia in older adults. Lower-limb blood flow restriction (BFR) training offers potential low-stress alternatives capable of inducing similar muscular adaptations. To systematically evaluate the effects of lower-limb BFR training on muscle strength and physical performance in older adults with and without musculoskeletal conditions, and to examine its potential role in sarcopenia prevention and early management. Electronic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, the Physiotherapy Evidence Database (PEDro), Scopus, and Web of Science, were searched up to 20 July 2026. Eligible randomized controlled trials (RCTs) included adults aged 50 years or older who participated in lower‑limb BFR training—such as low‑load resistance training with BFR (LL‑BFR) or walking with BFR (W‑BFR)—and compared these interventions with low‑load resistance training (LL‑RT), high‑load resistance training (HL‑RT), conventional walking, or no‑training control conditions. The main outcomes were muscle strength (e.g., knee extension, leg press, handgrip) and physical performance (Timed Up and Go [TUG], 30 s Chair Stand Test [30CST], Six‑Minute Walk Test, balance). Methodological quality was evaluated using the PEDro scale, and the certainty of the evidence was judged according to the GRADE framework. Twenty-five RCTs involving 819 participants were included. Compared to no intervention, meta-analysis of the data estimated that LL-BFR improved multiple domains of physical performance, including knee extension strength (SMD = 1.23; 95% CI: 0.49–1.98), leg press strength (SMD = 1.24; 95% CI: 0.16–2.31), 30CST (MD = 3.55; 95% CI: 2.32–4.78), and Timed Up and Go Test (MD = − 2.15; 95% CI: − 3.05– − 1.24). W-BFR was more effective than conventional walking, yielding greater improvements in knee extension strength (SMD = 0.8, 95% CI: 0.23 to 1.38), 30CST (SMD = 2.75, 95% CI: 2.06 to 3.45), TUG (MD = -0.46, 95% CI: -0.59 to -0.32). When comparing LL-BFR with LL-RT, the former had superior effects on strength measures. Compared with HL-RT, LL-BFR showed no significant differences in muscle strength or physical performance. Both LL-BFR and W-BFR may improve lower-limb muscle strength and physical performance in older adults, particularly when compared with no intervention or conventional walking. Lower-limb BFR training may therefore have a potential role in sarcopenia prevention and early management in aging populations, especially for individuals who are unable to tolerate high mechanical loads.