Effects of Combined Blood Flow Restriction and Neuromuscular Electrical Stimulation Versus Blood Flow Restriction Alone: A Systematic Review and Meta-Analysis
6 affiliations
- 1RAK College of Medical Sciences, Ras Al Khaimah Medical and Health Sciences University (RAKMHSU), Ras Al Khaimah 11172, United Arab Emirates
- 2Department of Community Medicine, RAK College of Medical Sciences, RAK Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
- 3Department of Surgery, RAK College of Medical Sciences, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
- 4Department of Paediatrics, RAK College of Medical Sciences, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
- 5Department of Obstetrics and Gynaecology, RAK College of Medical Sciences, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
- 6RAK College of Nursing, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah 11172, United Arab Emirates
Abstract
Background/Objectives: Blood flow restriction (BFR) training is increasingly combined with neuromuscular electrical stimulation (NMES) in musculoskeletal rehabilitation to augment strength and hypertrophy, but whether NMES adds benefit beyond BFR alone remains uncertain. This systematic review and meta-analysis compared combined BFR + NMES with BFR alone for muscle strength, muscle morphology (mass, thickness, cross-sectional area), neuromuscular activation, and functional performance. Methods: Randomized trials comparing simultaneous BFR + NMES with BFR alone were eligible. MEDLINE via PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception through 15 September 2026. Two reviewers independently screened studies and extracted data; risk of bias was assessed with Cochrane RoB 2 and certainty with GRADE. Random-effects meta-analysis was restricted to independent parallel-group comparisons; crossover and limb-randomized results were pooled only when paired effect estimates and variances were available, otherwise synthesized narratively. The protocol was registered in PROSPERO (CRD420251076162). Results: Five randomized trials involving 174 participants were included. The studies represented healthy-participant training, experimental limb disuse, acute physiological responses, and low-load training in football players with knee osteoarthritis. Quantitative synthesis of torque-based strength found no clear difference between BFR + NMES and BFR alone (MD −41.78 Nm, 95% CI −396.68 to 313.12; p = 0.375; 2 trials, 52 participants), with substantial statistical heterogeneity. Cross-sectional area and rectus femoris EMG RMS were each reported by only two trials and were synthesized narratively. Certainty of evidence was very low across all outcomes. Conclusions: Current evidence does not establish a consistent additional benefit of adding NMES to BFR. The pooled torque-based estimate is exploratory because of the small evidence base, substantial statistical heterogeneity, imprecision, and differences in clinical context and outcome measurement. A possible effect on preserving muscle mass during short-term experimental disuse remains preliminary. None of the included trials directly investigated BFR + NMES following anterior cruciate ligament reconstruction (ACLR), and its effectiveness in this population remains undetermined.
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BibTeX
@article{aldawoodi2026effects,
title = {{Effects of Combined Blood Flow Restriction and Neuromuscular Electrical Stimulation Versus Blood Flow Restriction Alone: A Systematic Review and Meta-Analysis}},
author = {Shams Al-dawoodi and Ebrahim Safaii and Mohamedanas Mohamedfaruk Patni and Biji Thomas George and Subhranshu Sekhar Kar and Rajani Dube and Ramya Kundayi Ravi and Rikhil Rajiv},
journal = {Journal of Clinical Medicine},
year = {2026},
month = nov,
doi = {10.3390/jcm15218725},
url = {https://www.mdpi.com/2077-0383/15/21/8725},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Effects of Combined Blood Flow Restriction and Neuromuscular Electrical Stimulation Versus Blood Flow Restriction Alone: A Systematic Review and Meta-Analysis
AU - Shams Al-dawoodi
AU - Ebrahim Safaii
AU - Mohamedanas Mohamedfaruk Patni
AU - Biji Thomas George
AU - Subhranshu Sekhar Kar
AU - Rajani Dube
AU - Ramya Kundayi Ravi
AU - Rikhil Rajiv
PY - 2026
DA - 2026/11/08
JO - Journal of Clinical Medicine
DO - 10.3390/jcm15218725
UR - https://www.mdpi.com/2077-0383/15/21/8725
AB - Background/Objectives: Blood flow restriction (BFR) training is increasingly combined with neuromuscular electrical stimulation (NMES) in musculoskeletal rehabilitation to augment strength and hypertrophy, but whether NMES adds benefit beyond BFR alone remains uncertain. This systematic review and meta-analysis compared combined BFR + NMES with BFR alone for muscle strength, muscle morphology (mass, thickness, cross-sectional area), neuromuscular activation, and functional performance. Methods: Randomized trials comparing simultaneous BFR + NMES with BFR alone were eligible. MEDLINE via PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception through 15 September 2026. Two reviewers independently screened studies and extracted data; risk of bias was assessed with Cochrane RoB 2 and certainty with GRADE. Random-effects meta-analysis was restricted to independent parallel-group comparisons; crossover and limb-randomized results were pooled only when paired effect estimates and variances were available, otherwise synthesized narratively. The protocol was registered in PROSPERO (CRD420251076162). Results: Five randomized trials involving 174 participants were included. The studies represented healthy-participant training, experimental limb disuse, acute physiological responses, and low-load training in football players with knee osteoarthritis. Quantitative synthesis of torque-based strength found no clear difference between BFR + NMES and BFR alone (MD −41.78 Nm, 95% CI −396.68 to 313.12; p = 0.375; 2 trials, 52 participants), with substantial statistical heterogeneity. Cross-sectional area and rectus femoris EMG RMS were each reported by only two trials and were synthesized narratively. Certainty of evidence was very low across all outcomes. Conclusions: Current evidence does not establish a consistent additional benefit of adding NMES to BFR. The pooled torque-based estimate is exploratory because of the small evidence base, substantial statistical heterogeneity, imprecision, and differences in clinical context and outcome measurement. A possible effect on preserving muscle mass during short-term experimental disuse remains preliminary. None of the included trials directly investigated BFR + NMES following anterior cruciate ligament reconstruction (ACLR), and its effectiveness in this population remains undetermined.
SN - 2077-0383
ER -