Key Considerations When Conducting KAATSU Training: Review Article
Key Considerations When Conducting KAATSU Training: Review Article
Key Considerations When Conducting KAATSU Training: Review Article
KAATSU training is a novel training method conducted under special conditions of restricted muscle
blood flow of the limbs with a specially-designed KAATSU belt. In 2006, we conducted a
questionnaire survey across the whole of Japan to investigate the status of KAATSU training. After
Correspondence to: that, we have performed KAATSU training mainly for patients with cardiovascular diseases at a total
T. Nakajima, MD: Department of approximately 700 people per year, and no serious side effects of note have been found. However,
of Ischemic Circulatory it has also been applied for various purposes such as to increase the muscle strength and prevent the
Physiology, KAATSU Training,
University of Tokyo, 7-3-1
muscular atrophy of all kinds of patients including older people. And, in near future, it may be used to
Hongo, Bunkyo-ku, Tokyo, train more seriously affected patients with cachexia or sarcopenia. Therefore, in this review, we
Japan 113-8655 introduce the main matters reported over the five years since the questionnaire survey was conducted.
masamasa@pb4.so-net.ne.jp
In addition, we outline key considerations concerning the implementation of KAATSU training
centered mainly on our previous experience and reports reached to us.
See end of article for
authors’ affiliations Key words: KAATSU training, side effects, petechial hemorrhage, contraindication, restricted muscle
blood flow
However, it has been applied for various purposes caused by interference with platelet function and as a
such as to increase the muscle strength and prevent clotting factor defect, so careful examination by a
the muscular atrophy of all kinds of patients dermatologist is recommended.
including older people, and it is speculated that it will
be used to train more seriously affected patients with Point 4: Explain prior to KAATSU training that
cachexia or sarcopenia in near future. petechial hemorrhage beneath the skin may occur
We will therefore introduce the main matters after KAATSU training, particularly of the upper
reported over the five years since the questionnaire limbs.
survey was conducted. This normally disappears after a few days and does
not really obstruct continuation of KAATSU training,
1) Brain hemorrhage: there was one reported case of but it is vital to explain that there are very rare cases
brain hemorrhage during KAATSU training. It is of it becoming serious. This can be particularly
known that sudden deaths very rarely occur while problematic if not explained to young women.
playing sports. Sudden deaths have even been Specifically, cases of people visiting for beauty are a
reported in golf, running, and gateball. While there problem. Even patients taking anti-coagulant therapy
have been no reported sudden deaths during are not really a problem, but if their condition is
KAATSU training to date, sufficient caution is serious then training should be stopped. Patients that
required. As underlying diseases of sports-related are administered vibration machines concurrently
sudden deaths, it is said that hypertrophic with medicine have not been a problem so far, but
cardiomyopathy, cardiomegaly (cause unknown), there has been one case of worsening petechial
coronary artery malformation, coronary artery hemorrhage beneath the skin after KAATSU training.
sclerosis, aortic rupture, and brain hemorrhage are
common among people aged 35 years and below, 3) Rhabdomyolysis: One case with a serum CPK level >
while 80% of people aged over 35 years are affected 10,000 IU/L has been reported both in Japan and
by coronary artery sclerosis and brain hemorrhage. abroad. When feeling unwell in a hot and humid
Accordingly, the discovery of cardiocirculatory environment, repeated hard training may lead to
diseases is vital when giving medical checkups to rhabdomyolysis. In addition to the hardness of the
sportsmen and, needless to say, blood pressure training, patients are more susceptible when
management is particularly important. Consideration dehydrated. KAATSU training uses low-intensity
must also be given to breathing methods during loads so rhabdomyolysis is considered less likely to
muscle training (exhale when applying effort). occur than when using high-intensity loads.
KAATSU training uses low-intensity loads which Nevertheless, it is necessary to be cautious such as
raise blood pressure less than high-intensity loads cancel training when the patient is sick and provide
(rise to 250-300mmHg or more with high-intensity frequent fluid replacement during training. In
loads). In addition, hormones (catecholamine) which addition, heat stroke can occur more easily as it
cause increased heartbeat and blood pressure during becomes hotter, so ensure that patients are
exercise increase slightly during KAATSU training, replenished with sufficient fluids and electrolytes.
compared to exercises when muscle blood flow is not
restricted (Takano et al., 2005; Iida et al., 2007). 4) Cases of numbness lasting for days: While there have
Therefore, caution is required when dealing with been no reports of paralysis, be sure to adhere to the
patients with high blood pressure, heart disease, and KAATSU training time and not take too long, and
other diseases. attach the KAATSU belt to the correct area.
2) Petechial hemorrhage beneath the skin: This refers to 5) Venous thrombosis : One case has been reported.
red or purple bodily spots caused by microbleeding However, appropriate application of pressure in
(collapsed capillary vessels). Petechial hemorrhage KAATSU training does not lead to a worsening
beneath the skin is normally harmless and disappears coagulation system. Rather, it induces a fibrinolytic
within a few days. But, there were a few cases of state, which helps to restrict thrombus formation
petechial hemorrhage beneath the skin not (Nakajima et al., 2007; Madarame et al., 2010). In
disappearing and continuing for a while, however, addition, because KAATSU training is 15 to 20
they disappeared in the course. Although it may be minutes long, it is believed to contribute to the safety
unconnected, there were some cases of purpura, such of this treatment by not restricting blood flow for a
as purpura pigmentosa chronica, when conducting long time. But, out of 10,000 people, 1 to 3 ordinary
KAATSU. This continued for a few months and then people, 3 to 11 women in a normal pregnancy, 30 to
disappeared. They sometimes emerge as symptoms of 40 women after normal childbirth, and 100 women
thrombocytopenia (caused by side effects from that give birth by Caesarean section have venous
treatment for certain types of infectious diseases), thrombosis. Therefore, while KAATSU training is
T. Nakajima, T. Morita, Y. Sato 3
not thrombogenic unless reckless things are done, 〇 The blood vessels of people who take no
some of the subjects receiving KAATSU training exercise will not be accustomed to this training, so
have venous thrombosis from the beginning. take care when applying high pressure
Echocardiography is recommended for suspected 〇 Adhere to the KAATSU training time.
cases before starting KAATSU training.
II) Key considerations when conducting KAATSU
6) Venous injury and induration: This has continued for training
one to two months in women in their thirties and We will now provide information on basic
forties, and is sometimes accompanied by pain. After treatment information required for general exercise
cancelling the KAATSU training and taking a wait- therapy as it will serve as a useful reference for safety
and-see approach, it disappeared after one to two purposes when conducting KAATSU training. Basic
months. When KAATSU pressure becomes strong or treatment information required for general exercise
the appropriate pressure is not applied especially to therapy is shown in Table 1. Basic treatment
the upper limbs, this may eventually lead to venous information includes: 1) subjective symptoms; 2)
damage. previous medical history; 3) existence of lifestyle-
Pay attention to the following. related diseases; 4) family medical history; 5) lifestyle
〇 Repeat pressurization and depressurization, get habits. It also includes resting electrocardiograms if
blood vessels accustomed to this training, and apply possible and careful examination based on exercise
the appropriate pressure tolerance tests will also be required as appropriate.
Subjective symptoms
Chest pain / chest discomfort / palpitation / shortness of breath Yes
Dizziness / fainting / intermittent claudication Yes
Spondylosis symptoms / joint symptoms Orthopedic examination and guidance
History of disorder
Cardiovascular disease Yes
Orthopedic disorder Orthopedic examination and guidance
Existence of lifestyle-related diseases
High blood pressure Assessed severity
Diabetes Assessed severity
Hyperlipidemia Assessed severity
Obesity Assessed severity
Family medical history*
Myocardial infarction and sudden deaths in first degree relatives Yes
Lifestyle habits
Exercise / diet / smoking / alcohol Lifestyle guidance
Resting electrocardiogram
Myocardial infarction Yes
ST-T segment abnormality Yes
Ventricular arrhythmia Yes
Other important observations Yes
* A family medical history of relatively young sufferers such as father or first degree male relative aged under 55 or mother or first degree
female relative aged under 65 who have undergone myocardial infarction and coronary revascularization or died suddenly.
Table 1 and 2 are cited from the following papers, and changed: (1) Edited by Japanese Circulation Society et al. Guidelines for diagnosing
and treating cardiovascular disease. 2000-2001 Joint Research Group Report. Guidelines for exercise therapy for cardiovascular disease
(JCS 2002) (Group head: Saito) (2) Manual for prescribing exercise therapy. Journal of the Japan Medical Association, 116 (3), 1996.
4 Key considerations in KAATSU training
Table 2. Indications and contraindications for exercise therapy for lifestyle-related diseases
High blood pressure 140-159/90-94 mmHg 160-179/95-99 mmHg 180/100 mmHg or more
Men aged over 40 or women aged over CTR of 55% or more visible on a chest
50 that are in treatment and don't have a roentgenogram
contraindication value should undergo Life-threatening arrhythmia or ischemic
an exercise tolerance test if possible. change shown by an electrocardiogram
(excluding times when safety was
confirmed by an exercise tolerance test)
Uric protein of 100 mg/dl or hypertensive
change in the fundus oculi (more than IIb)
Diabetes Fasting blood glucose - Fasting blood glucose - 140 - 249 mg/dl Fasting blood glucose –
110 - 139 mg/dl Men aged over 40 or women aged over 250 mg/dl or more
50 that are in treatment and don't have a Urinary ketone body (+)
contraindication value should undergo Diabetic retinopathy (+)
an exercise tolerance test if possible.
Obesity BMI:24.0 - 29.9 BMI:24.0 - 29.9 and lower limb joint BMI:30 or more
damage
Orthopedic examination and exercise
restriction
2
TC: Total cholesterol; TG: Triglycerides; BMI: Body Mass Index (body weight (kg) / height (m) )
Recently, KAATSU training is often used to train Neurally-mediated syncope; refer to the
●
metabolic syndrome and obese patients. Table 2 paper (Sato et al., 2007) for details
shows indications and contraindications of normal ● Search for complications (heart diseases, etc.)
exercise therapy for lifestyle-related diseases. At a 2) During training, pay attention to the following:
blood pressure of 180/100 mmHg or more, exercise Sufficient stretching and fluid replacement
therapy is generally contraindication, so it would be Patients falling
better to give treatment at 160-179/95-99 mmHg. For 3) Get an expert opinion for high-risk matters and
cases of poorly-controlled diabetic retinopathy and don’t provide training for unknown cases.
extreme obesity with a BMI of 30 or greater, careful
examination for the coexistence of ischemic heart III) Clinical conditions and diseases to watch out
disease is recommended. It is believed that such for when conducting KAATSU training
indications will serve as a useful reference when Vascular endothelial damage, stagnation of blood,
conducting KAATSU training. and hypercoagulability are origins of pulmonary
Key considerations when administering KAATSU infarction and deep-vein thrombosis. KAATSU
training to older people and a variety of patients are training is not a tourniquet, which completely stops
listed as follows. the flow of blood in arteries and veins, and according
1) Pay attention to restricted blood flow to our past examinations of able-bodied people, it
● Adhere to the basics of KAATSU to prevent does not lead to an impairment of the coagulation
hemostasis with a tourniquet system. Rather, it induces a fibrinolytic state, which
● Take care not to allow overload has an antithrombotic effect (Nakajima et al., 2007;
T. Nakajima, T. Morita, Y. Sato 5
Madarame et al., 2010). In addition, there have been liaising with doctors for such cases. In addition, it is
no reports of pulmonary infarction. However, due to necessary to stop loading if overload is suspected,
the stagnation of blood occurring during KAATSU depending on the patient’s symptoms. In any case, it
training, pulmonary infarction and deep-vein can only be carried out under close supervision, and
thrombosis risk scores used by surgeons to conduct even more careful examination is required in the
safer KAATSU training will be introduced. future.
Point 5: Using risk factors in determining KAATSU Point 6: In principle, KAATSU training should not
training indication be provided or expert advice should be obtained
5 points History of deep-vein thrombosis (DVT); when dealing with hemodynamically unstable
hereditary thrombotic tendency; patients, especially patients suffering from
antiphospholipid antibody syndrome cardiovascular diseases etc.
4 points Pregnant women
3 points 1) Varicose veins of legs; 2) prolonged CONCLUSION
immobility (incapable of 8 hours As we move increasingly towards an aged society, it
thromboprophylaxis rehabilitation); is estimated that rehabilitation for patients with low
3) atrial fibrillation or heart failure exercise capacity and various complications such as
2 points 1) People aged over 60 years old; 2) BMI cardiovascular diseases will increase more and more.
> 30; 3) hyperlipidemia; 4) malignancy; KAATSU training is expected to attract increasing
5) using lower limb tourniquet; 6) using attention. Accordingly, we hope that you fully
oral contraceptives or adrenocortical understand and pay heed to the characteristics of
steroids; 7) quadriplegia; 8) high KAATSU training, and conduct sensible and effective
hemoglobin level training.
1 point 1) People aged 40 to 58 years old;
2) women; 3) 25 < BMI < 30 Point 7: To conduct safe as well as effective KAATSU
training
The higher the number of points the greater the 1. Confirm there are no contraindications that are
risk, and the higher the combined number of points identical to ordinary exercise therapy
for several risks the greater the risk. KAATSU training 2. KAATSU training should either not be provided
for people corresponding to 5 points (history of deep- or expert advice should be obtained when
vein thrombosis; hereditary thrombotic tendency; dealing with hemodynamically unstable patients
and antiphospholipid antibody syndrome) should be 3. KAATSU training is a contraindication or
avoided. Caution is required when dealing with caution should be exercised when dealing with
pregnant women, who have impairment of the thrombotic disease patients
coagulation system in the latter stages of pregnancy. 4. Explain about petechial hemorrhage beneath the
We do not conduct training for these pregnant skin and numbness etc. when starting training
women in principle. While there have been no 5. Training tailored to individuals’ physical capacity
reports of KAATSU affecting varicose veins of legs, a and condition
review of this is needed in the future. Older people Apply appropriate as well as safe and effective
and bedridden patients are considered to be suitable pressure
for KAATSU training, but it is necessary to exercise Never be too eager to gain results
care when providing KAATSU training for people Avoid hemostasis with a tourniquet.
that originally had thrombosis. In addition, some 6. Build a relationship of trust with patients
patients get thrombosis in the early postoperative 7. There is a possibility that presyncope and fainting
period and extreme caution needs to be exercised for will occur, but pay attention to prodromal
such patients. symptoms and take preventive measures such as
Since KAATSU training predominately involves the fluid intake.
restriction of blood flow, reduced stroke volume and 8. Older people, bedridden patients and postoperative
cardiac output may be discovered depending on the patients often have venous thrombosis prior to
extent of applied pressure (Takano et al., 2005; Iida et the training so exercise caution.
al., 2007). Even though KAATSU training reduces the 9. Ensure blood pressure is (< 160 /> 95 mm Hg)
preload and places little stress on the heart, it can 10. Implement safety measures such as AED
encourage a lower cardiac output for patients with a 11. Avoid conducting KAATSU training over a long
significantly reduced heart pumping ability, so time. Upper limbs: 10-15 minutes; Lower limbs:
extreme caution is required. It is therefore necessary 15-20 minutes
to carefully consider reducing KAATSU pressure or 12. In principle, never conduct training when the
only applying it to upper limbs or one-side, as well as patient is sick. Never continue performing
6 Key considerations in KAATSU training