If the COVID-19 pandemic is teaching us anything, it’s the importance of being healthy and having a robust immune response. Aside from old age, people with underlying health conditions such as diabetes and heart disease are at increased risk of complications from the disease, and obesity has been found to be the biggest determinant — after old age — for whether a patient will require hospitalization.1,2
The good news, of course, is that you have a lot of control over your own health. Obesity, insulin resistance, Type 2 diabetes and heart disease are all reversible, and if you want to prepare for the next pandemic (which is already being promised), you’d be wise to start improving your health rather than simply masking or “managing” your symptoms with drugs.
Aside from eating a healthy whole food (ideally organic) diet and implementing time-restricted eating, exercise is a foundational health strategy that will strengthen your immune function.3,4
According to research5,6,7 published in the March 19, 2020, issue of Redox Biology, exercising regularly may also help prevent acute respiratory distress syndrome (ARDS), a lethal complication and major cause of death among patients with COVID-19.
Similarly, a review8 published in the journal Nutrients, February 28, 2020, details how physical activity and diet shape your immune system during aging and, of course, we now know that the elderly are at a disproportionally high risk of severe COVID-19 illness and death.
Importantly, the review details how exercise helps improve immunosenescence and slows down the aging processes of both the innate and adaptive arms of your immune system.
Blood Flow Restriction Training May Be an Ideal Choice
Blood flow restriction (BFR) training, which I perceive to be the greatest innovation in exercise training in the last century, was developed in Japan by Dr. Yoshiaki Sato in 1966. There, it’s known as KAATSU.
Aside from dramatically improving muscle tone, BFR is also a wonderful tool for post-surgical rehabilitation, allowing you to regain physical function in a fraction of the time that you would normally anticipate.
KAATSU, known more generically as Blood Flow Modification, was introduced outside of Japan by Steven Munatones, after a 13-year mentorship by Sato. In this interview, Munatones provides some of the history behind this radical innovation, and how he facilitated its overseas migration and its headquarters in Southern California.
What Is BFR?
BFR involves exercising your muscles — using no or very light weights — while partially slowing arterial inflow and modifying venous outflow in either both proximal arms or legs.9 In KAATSU, venous flow reduction is achieved by using thin elastic pneumatic bands on the extremity being exercised.
By modifying the venous blood flow, you create a relatively hypoxic (low oxygen) environment in the exercising muscle, which in turn triggers a number of physiological benefits.
BFR increases vascular endothelial growth factor (VEGF), which acts as “fertilizer” for growing more blood vessels and improving their lining (endothelium). It also increases the production of hormones such as growth hormone and IGF-1, commonly referred to as “the fitness hormones.”10
Sato got the inspiration for BFR in 1966 when, during a Buddhist ceremony that required him to sit on his heels, he noticed a distinct tightening of his calves, as if he’d been doing weighted heel raises. He wondered what the physiological process for that might be, and for the next seven years, he experimented on himself.
“He experimented with every kind of tire tube, strand and rope that he had. He put bands on his legs, around his waist, on his chest, his arms, forearms, even his forehead,” Munatones says, to figure out the best way to modify his blood flow and replicate traditional weight training.
Eventually, Sato developed the KAATSU protocols that are still in use today. Between 1996 and 2015, Sato, along with exercise physiologist Naokata Ishii, Ph.D., and Dr. Toshiaki Nakajima, a renowned cardiologist at the University of Tokyo Hospital, performed a variety of groundbreaking research, proving the benefits of KAATSU and discovering its underlying mechanisms.
How KAATSU Was Brought to the US
For the first 27 years, all of Sato’s information was restricted to Japan — primarily the University of Tokyo Hospital — and the Japanese language. In 2001, Munatones, who speaks fluent Japanese, was asked to coach the U.S. national swim team at the world championships held in Japan.
“That’s when I first found out about Sato,” he says. “I visited his office in Tokyo. I saw a huge line of people waiting to see him at his office. The people would come out quite happy.
I’d ask them in Japanese, ‘How do you feel?’ They’d say, ‘I feel great.’ I’d ask them how they felt before. They said, ‘There was a strain in my back,’ or ‘I had broken my finger,’ or a variety of injuries and ailments.
When I met Dr. Sato, he said to me very softly — he is a very humble man with a very soft voice — ‘I was waiting for you.’ I said, ‘Oh really? I didn’t even know about you until three days ago.’ He said, ‘Well, I’ve been anxious to share this with the rest of the world, because I think everybody in the world should be doing KAATSU.'”
After 13 Years of Mentorship, Munatones Got the Green Light
Sato does not speak English and doesn’t travel outside Japan, which is why he’d not been able to introduce it to a global audience before. Munatones decided immediately he wanted to learn the system and Sato agreed to teach him. That mentorship ended up taking 13 years.
“It was a very Japanese mentorship,” Munatones says. “I learned the Japanese way of thought, their social protocols and the expectations of the respect between different levels of society …
[You have to] accept — whether you’re trying to be a sushi chef, a Japanese sword master, a kimono maker, it doesn’t matter — that you don’t know what that length of mentorship or apprenticeship will be. If you’re good, it might only be eight years. If you’re not good, it might be 18 years. In my particular case, it was 13 years …
I learned everything. I learned how to wrap the bands, what to look at a person physiologically. We went through his research labs. We used Doppler machines and ultrasound machines.
We tested, prodded and poked people with blood samples before and after KAATSU. He really wanted me to learn what was the mechanism of KAATSU. That’s what I did for 13 years. I was going to Japan at least four times a year.
When I first met Sato, there was no information written. It was all in his head … I had to write a how-to book. I had to capture the information in his head and what he had showed me and explained to me, and make English words for that, because there were no English words for what he was teaching me.
The only word I kept was the original Japanese word KAATSU. It’s formed by two Japanese characters: KA, which means additional, and ATSU, which means pressure. That’s the additional pressure that the band and the equipment is placing on the limbs.
Everything else, all the explanations of KAATSU, we translated over the 13-year period. He wanted to make sure that if I was going to share this with the rest of the world, that I had as much information and experience as possible, and in English, to share with the rest of the world.”
The Development of KAATSU Equipment
Originally, and up to about 2006, Sato had used very long elastic bands. He’d wrap and unwrap a patient’s limbs in 20-second cycles, doing eight cycles per limb, which was a laborious process. Munatones, who had a background in engineering, suggested they invent an easy to use device to replicate this cycled blood flow restriction.
“I had lived in Japan for seven years previously, working in Hitachi R&D Labs. I had the skillsets to develop a machine, to create a product that attempted to replicate what Sato and his Japanese colleagues were doing with their own hands,” Munatones says.
The original KAATSU Master device became commercially available in 2006, was quite large and had a $16,000 price tag. Since then, the technology has improved, gotten much smaller, and far less expensive.
The latest device, KAATSU Cycle 2.0, is now only $800, which you can purchase from KAATSU Global. This is the best exercise investment I have ever made and now that the price is finally under $1,000, it’s become accessible to far more people.
BFR Benefits Your Vascular System
The first clear benefits of KAATSU were increased muscle mass, regardless of the age of the individual. However, as the science developed, it became clear that the mechanism behind this effect was actually increased elasticity of the vascular system. This is what triggers a cascade of biochemical changes that result in muscle growth. Munatones explains:
“Sato and the researchers theorized that [KAATSU] was replicating heavy exercise. Therefore, human growth hormone (HGH) was being secreted. That was leading to increased muscle tone or increased muscle mass.
But as we started to study more and more with magnetic resonance imaging (MRI) machines, Doppler devices and ultrasound, we realized that it was actually the strength or the elasticity of the three vascular walls — the inner, middle and the outer walls of the capillaries and veins — that were becoming more elastic. When that happened, there was a subsequent or secondary hormonal response.”
By creating a hypoxic environment, you catalyze hypoxia-inducible factor 1-alpha (HIF1A), which in turn catalyzes VEGF. VEGF is the strongest angiogenic signal your body produces. It’s a very powerful “fertilizer” for capillary growth and endothelial cells specifically. (That’s why it’s called vascular endothelial growth factor.) The end result is increased vascular elasticity.
BFR Has an Excellent Safety Record
Importantly, KAATSU is very safe, even for those with cardiovascular issues. At the University of Tokyo Hospital, Sato worked frequently with cardiovascular rehabilitation patients, people who’d had heart attacks, strokes or heart bypass surgery, and, when dealing with patients with cardiac issues, safety is a paramount concern.
Using pneumatic bands that were gentle and provided controlled pressure, even bedridden patients could be safely treated, and even under those conditions the patients increased their muscle tone.
Even paraplegics are benefiting from it, even though they’re unable to use weights of any kind. Simply strapping on the inflatable cuffs and using the KAATSU device’s cycling program (with intermittent inflation and deflation of the pneumatic bands at regular intervals), they can realize these benefits.
The cycling program pumps air in, maintains pressure for a prescribed time, releases the pressure, then adds pressure again, in cycles. With the help of a trainer or caregiver, a paraplegic patient can also perform passive exercise with the bands on.
In this case, they’d use the cycling mode — which inflates the cuffs for 20 seconds, releases the pressure for five seconds, inflates for 20 seconds, release for five, and so on — while the caregiver lifts their arm or moves their leg.
While the inflatable cuffs look quite simplistic, a lot of specific engineering has gone into their design and construction. Superficially, it resembles a blood pressure cuff. It does not work like one, however. Munatones explains:
“The band itself has an air bladder inside. That air bladder is inflated only to one side. Imagine a balloon. When you blow up a balloon, it expands uniformly. When we blow up the KAATSU band, it does not expand uniformly. It expands in one direction, the direction toward your skin.
People say, ‘Oh. That looks like a blood pressure cuff. That looks like a tourniquet.’ Outwardly, it does. Except, the tourniquet keeps the blood out. It occludes momentarily, so the physician or the nurse can check your blood pressure.
The KAATSU bands are specifically designed to keep the blood in on a practical basis. It reduces the venous flow back from the limb to the torso. It doesn’t completely obstruct it. You can view it as a type of ‘blood flow modification,’ because when you contract your muscles the blood is forced out of your muscle for a brief period.
When your muscle is not contracting, the blood remains in your muscle. That’s why the cycle [mode] — pressure on, pressure off, pressure on, pressure off — enables that blood flow to continue; the arterial flow in and the venous flow out. That is very important.
When a person does KAATSU, the palm of their hands and/or their feet become very pink, even a rosy, beefy red. In some athletes and very fit people, it actually turns it deep purple, because what’s happening is that all that blood is going in and is being modified coming out. There is what we call ‘blood pooling in the limb. That is the catalyst for a bunch of metabolite hormonal responses in the body.”
What Makes KAATSU Different From Other BFR Devices?
It’s important to understand the difference between the KAATSU devices and other inflatable surgical tourniquets used in blood flow obstruction (BFO) therapy.
The two are not the same, the primary and most crucial difference being that KAATSU never completely occludes or obstructs blood flow, whereas BFO does. Complete obstruction of blood flow comes with risks that you simply don’t get when using a KAATSU device. Munatones comments on the differences:
“The original intention of Sato was literally for every person on planet Earth, anywhere, anytime, to be able to do KAATSU. That’s a difficult bar to hit. We had to make sure that it was safe to use for every person on this planet.
Now, I’m not saying that every person on the planet will want to use this or should use it, but that was our engineering goal: To make a product that you could use at any age, in the comfort of your own home, without a medical practitioner actually applying it …
So, we set out to engineer a product that was easy to use and effective at the same time. Therefore, when other products come on the market and you have to go to your physical therapist and you have to use your own medical insurance to get reimbursed or pay for this, we believe that is [a block] for global adoption.
That’s why our original patients who were using this were among the most vulnerable patients possible, those with heart attacks, strokes or clots, who had undergone cardiac surgery. If it was safe for them, we knew it would be safe for most people on this planet …
I have no problem putting [the KAATSU device] on my parents … They’re 82 and 83. They use KAATSU daily. Sometimes twice a day. They have their own unit.
Their muscular form is great. They’re very active. My mother uses it in the pool for her arthritis. My father used it for his varicose veins and while riding a bike. They also use it in a variety of exercises. They’ve really been my guinea pigs here in California …
They’ve used KAATSU through hip replacements, knee replacements, et cetera. They do not go to a physical therapist after their surgeries. They just come home. They know how to use the KAATSU equipment themselves — and they don’t even know how to use a computer. They live very close to me. But it’s quite easy to implement.”
KAATSU Training Modes
We’ve already mentioned one of the two training modes — the cycling mode — available on the KAATSU device. In cycling mode, the cuffs are inflated for 20 seconds and deflated for five seconds, for eight repetitions. (Some units allow for variations in that cycle). In training mode, the cuffs remain inflated throughout your exercise.
“The KAATSU cycle started in 1973. I always enjoyed this story. Sato went on a skiing trip and broke his ankle. He instinctively theorized that KAATSU would be helpful for his bones to heal,” Munatones says.
“Now, he’d come from a long line of physicians. His father said, ‘Come into the hospital. We’ll take care of you.’ He, being sort of the rebellious out-of-the-box thinker, said, ‘No. I’m just going to treat myself with KAATSU.’
He wrapped his leg with the bands as he normally did. And because there was so much blood pooling in the area where his ankle was broken, it was very discomforting. He unwrapped it after about 30 seconds.
He says, ‘Well, there’s a lot of blood going to the injured part. That’s a good thing. I’m going to wrap it again.’ That was the catalyst for this KAATSU cycle. They’ve been doing that for decades now.
KAATSU training is when you don’t want to be tethered to a machine. You want to go out for a walk. Or you’re a boxer and you’re boxing in the gym. Or you’re a swimmer in a pool. Or you are a cyclist.
In this case, we inflate the bands to what we call your optimal pressure, whatever the appropriate pressure is for you, and you can untether yourself from the machine and go ahead and do whatever exercise or motion that you want. We recommend limiting that to 20 minutes.”
In short, the cycling mode allows you to exercise even when you cannot perform a regular workout. For example, if you’re bedridden, or are just starting a training program, have limited mobility due to excess weight, if you’ve broken a bone or have recently had surgery — these are all instances where the cycling mode can be extremely beneficial.
“They’re not going to go to a gym. They might not even want to lift dumbbells. In this case, we can do the KAATSU cycle and just ask them to move their limbs very slowly as they contract their muscles,” Munatones says. “That has the same effect as untethering the bands and doing what we call KAATSU training [while] lifting dumbbells.”
The training mode, meanwhile, is great for athletes and anyone who wants to maximize the benefits from their regular exercise, such as their walking or swimming routine. You can detach the air tubes from the bands once they’re inflated, which allows you unrestricted mobility to do whatever exercise you want, while wearing the bands.
The Older You Are, the More You Need BFR
While great for competitive athletes, BFR can radically transform the health of our aging population, as it effectively improves vascular and cognitive function, and lowers your risk for both osteoporosis (brittle bones) and sarcopenia (age-related muscle loss).
Without question, the older you are, the more you need BFR training. Even if it doesn’t improve your life span (which it probably would), it will undoubtedly improve your health span — the number of years you remain in good health before you die.
Nicotinamide adenine dinucleotide (NAD) is a very important coenzyme in your body that has become increasingly appreciated for its influence on health and mitochondrial function in the last decade. BFR has been shown to increase NAD levels by 30%, and that can have a profound influence on your health span.
NAD supplements and precursors can cost between $1 and $2 per day, and that alone can help justify the cost of the equipment; you don’t have to pay for expensive supplements because your body makes it.
As you age and start losing muscle, you also lose protein stores, and this can significantly increase your risk of dying if you get ill or injured. You need the protein reserve that muscle mass provides, and BFR, in my experience, is one of the most effective ways to improve your muscle mass and strength.
I think it’s important to understand that KAATSU is not some fly-by-night marketing gimmick. It’s nothing short of a fitness revolution. While still relatively unknown, once people — especially health professionals — get a taste of what it can do, there’s no doubt it’ll become a mainstay.
Helpful Training Resources
To learn more, check out my BFR Training PDF. There you will also find the details and specific videos and instructions on how to perform BFR and the various equipment options that are available.
You can also find a free training program on KAATSU.com. This can be particularly useful right now, as many gyms are still closed. Live online ZOOM training sessions are given every Monday through Friday at 6 p.m. Eastern/3 p.m. Pacific time.
Access it by going to KAATSU.com and clicking on the banner on the top of the page. Each session is also recorded, so if you cannot attend live, you can find the replay on KAATSUBLOG.com. Laurel Kuzins, who leads the workout, is a certified KAATSU, yoga, Pilates and high-intensity trainer.