CASE REPORT

KAATSU-walk training increases serum bone-specific

alkaline phosphatase in young men
M.D. Beekley, Y. Sato, T. Abe

Int. J. KAATSU Training Res. 2005; 1: 77-81

Previous research has shown that high intensity resistance training causes increases in bone density
and increases in serum measures of bone turnover like bone-specific alkaline phosphatase (BAP).
Medium intensity or low intensity training (like walking) does not result in these changes. However,
low intensity training with blood flow restriction (KAATSU) has shown promise in bone and muscle
Correspondence to: rehabilitation settings. We hypothesized that there would be increases in serum BAP following low
Dr. T Abe, Department of intensity KAATSU walk training. Healthy men walked on a treadmill twice per day (at least 4 hours
Exercise and Sport Science, between sessions) for 3 weeks with (KAATSU; n=9) or without (Control; n=9) blood flow occlusion
Tokyo Metropolitan University,
1-1 Minami-ohsawa, Hachioji, pressure belts on their thighs. After three weeks of training, the KAATSU group experienced
Tokyo 192-0397, Japan significant increases in MRI-measured muscle CSA (P<0.01), 1-RM muscle strength (P<0.01), and
abebe@comp.metro-u.ac.jp serum BAP levels (P<0.05). Percent change in BAP was 10.8% for the KAATSU-walk and 0.3% for
the Control-walk. There was no significant change in serum IGF-1 for either group. We conclude
See end of article for
authors’ affiliations
that 3 weeks KAATSU walk training increases BAP, a serum marker of bone turnover.
Key words: bone metabolic marker, KAATSU-walk training, muscle hypertrophy

INTRODUCTION exercise.
Osteoblasts are a type of cell responsible for Low-intensity (20% of 1-RM) resistance training
deposition of the protein matrix of bone. The protein combined with restriction of muscular venous blood
matrix of bone is where calcium salts (particularly flow (KAATSU) via a special cuff can increase skeletal
phosphates) are deposited. Osteoblasts are rich in muscle volume and strength in men and women
alkaline phosphatase [Watts, 1999]. Bone-specific [Abe et al., 2005; Takarada et al., 2000a]. Also, in a
alkaline phosphatase (BAP) is a tetrameric study of patients who underwent reconstruction of
glycoprotein found on the membrane of the the anterior cruciate ligament, KAATSU cuff use
osteoblast cell. Although the function of BAP is not alone decreased the CSA of the thigh muscle
fully understood, BAP levels are considered to reflect extensors and flexors by only ~9% each, while CSA
osteoblastic activity and can therefore be used as a of the control groups’ (no KAATSU) thigh muscle
marker of bone formation [Gundberg, 2000]. extensors and flexors decreased by 21 and 11%,
Because high impact and/or high-intensity physical respectively [Takarada et al., 2000b]. Interestingly,
activity such as jumping or resistive exercise has several clinical studies reported that femoral head
beneficial effects on bone mass and strength [Bemben avascular necrosis or bone atrophy was improved
et al., 2004; Creighton et al., 2001; Taaffe et al., following KAATSU resistance training [Inoue et al.,
1997], BAP activity may be stimulated by high 2002; Odagiri 2004]. Therefore, we hypothesized
intensity physical activity. Previous published studies that an increase in resting serum BAP level could
reported that serum BAP level increased after a single occur following KAATSU resistance training. Thus
bout of high intensity physical exercise [Rudberg et the purpose of this case study was to investigate the
al., 2000; Wallace et al., 2000]. Also, following 4 chronic effect of 3 weeks of twice-daily walk training
months of high intensity (75% of 1-RM) resistance combined with KAATSU on resting serum BAP level
training, resting serum BAP is increased [Tajima et al., in young men.
2000]. However, there is no significant change in
serum BAP after a single bout of moderate intensity METHODS
(50-75% of 10 repetition maximum) resistance Subjects
exercise [Whipple et al., 2004]. Finally, low intensity Eighteen healthy young men [mean (SD) age, 21.3
exercise like walking also results in no significant (2.8) yrs; height, 174 (5) cm; body mass, 64.8 (5.3)
change in bone mineral density [Welsh et al., 1997]. kg] volunteered to participate in the study . All
The differing results between those studies may be subjects led active lives, with 8 of 18 participating in
explained, in part, by the intensity of resistance regular aerobic exercise. However, none of the
78 BAP and Kaatsu training

subjects had participated in a regular resistance valid only when the subject used proper form and
exercise program for at least one year prior to the completed the entire lift in a controlled manner
start of the study. The subjects were randomly without assistance. On average, five trials were
divided into two training groups: a walk-training with required to complete a 1-RM test. Approximately 2-3
restricted venous blood flow from the leg muscles min of rest was allotted between each attempt to
(KAATSU-walk, n=9) group and a walk-training ensure recovery.
without restricted leg muscle blood flow (Control-
walk, n=9) group. All subjects were informed of the MRI-measured muscle CSA and volume
procedures, risks, and benefits, and signed an Magnetic resonance imaging (MRI) images were
informed consent document before participation. captured using a General Electric Signa 1.5 Tesla
The Tokyo Metropolitan University Ethics Committee scanner (Milwaukee, Wisconsin, USA). A T1-
for Human Experiments approved the study. weighted, spin-echo, axial plane sequence was
performed with a 1500-millisecond repetition time
Training protocol and blood sampling and a 17-millisecond echo time. Subjects rested
The subjects in both KAATSU-walk and Control- quietly in the magnet bore in a supine position with
walk groups participated in three weeks of supervised their legs extended. Contiguous transverse images
walk-training. Training was conducted twice per day with 1.0-cm slice thickness (0 cm interslice gap) were
(morning and afternoon sessions, with at least 4 obtained at mid-point of the thigh for each subject.
hours between sessions), six days per week for 3 The MRI scan was segmented into four components
weeks. Following a warm up, the subjects performed (skeletal muscle, subcutaneous adipose tissue, bone,
walking (50 m/min for five 2 min bouts, with 1 min and residual tissue) by a highly trained analyst, and
of rest between bouts) on a motor-driven treadmill. then traced. For each slice, the skeletal muscle tissue
Subjects in the KAATSU-walk group wore a pressure CSA was digitized and calculated using NIH image
belt (Kaatsu-Master, Tokyo, Japan) on each leg software. The estimated CV of this measurement was
during training. On the first day of the training, the 2.1% [Abe et al. 2003]. The average value of the
belt pressure was 160 mmHg, and the pressure was right and left sides of the body was used. This
increased 10 mmHg each day until a final cuff measurement was completed prior to (baseline) and
pressure of 230 mmHg was reached. The restriction 3 days after the final training (post-testing).
pressure of 160-230 mmHg was selected for the
occlusive stimulus as this pressure has been suggested Hormonal analyses
to restrict venous blood flow and cause pooling of Resting venous blood was drawn from each subject
blood in capacitance vessels distal to the belt, and at baseline (pre-testing) and 3 days after the final
ultimately restricts arterial blood flow [Takarada et al. training (post-testing). All blood samples were
2000a]. The estimated coefficient of variation (CV) of obtained at the same time of day (9:00-10:00 AM)
this pressure measurement was 2.2%. The restriction following an overnight fast (12-13 hours). The
of muscular blood flow was maintained for the entire subjects were counseled to refrain from ingesting
exercise session, including the 1 min rest periods. alcohol and caffeine for 24 hours prior to blood
Subject leg blood flow was restricted for about 15 min collection and not to perform any strenuous exercise.
at each exercise session. The belt pressure was Serum BAP activity and IGF-1 were measured at
released immediately upon completion of the session. S.R.L. Inc. (Tokyo) by the use of commercially
The Control-walk group performed the same exercise available enzyme immunoassay (OSTEOLINKS-BAP,
at the same treadmill speed but without the pressure Sumitomo Seiyaku Biomedical Co., Osaka) and
belt. radioimmunoassay (Daiichi Radioisotope Laboratory,
Chiba).
One-RM strength measurements
One week prior to training, the subjects were Statistical Analyses
familiarized with strength testing equipment. Proper Results are expressed as means and standard
lifting technique was demonstrated for the leg press deviations (SD) for all variables. Statistical analyses
and leg curl exercises and all subjects performed were performed by a two-way analysis of variance
practice lifts prior to attempting maximal effort lifts. (ANOVA) with repeated measures [Group (Kaatsu-
Maximum dynamic strength (1-RM) was assessed walk and Control-walk) x Time (pre- and post-
prior to (baseline) and 3 days after the final training testing)]. Post-hoc testing was performed by a
(post-testing) for each exercise. After warming up, Fisher’s least significant differences test. Baseline
the load was set at 80% of the predicted 1-RM. differences between two groups and percentage
Following each successful lift the load was increased changes between baseline and post-testing were
by ~5% until the subject failed to lift the load through evaluated with a one-way ANOVA. The relationship
the entire range of motion. A test was considered between serum BAP activity and circulating IGF-1
M.D. Beekley, Y. Sato, T. Abe 79

Table 1. Percent changes in strength, muscle CSA and blood parameters following 3
weeks of walk training combined with (KAATSU) and without (Control) restriction of leg
muscle blood flow.

Leg press Thigh muscle Bone-specific IGF-1

1-RM CSA ALP

Control 1.3 ± 3.8 -0.6 ± 2.9 0.3 ± 8.9 -0.2 ± 14.7

KAATSU 7.5 ± 6.2 * 5.8 ± 3.8 † 10.8 ± 0.6 * 3.5 ± 15.0
CSA, cross-sectional area; ALP, alkaline phosphatase; IGF-1, insulin-like growth factor-1
*P<0.05, †P<0.01 Control vs. KAATSU

concentrations was assessed using Pearson’s product- (baseline 107 ± 20 kg, post-testing 108 ± 18 kg) and -
moment correlation coefficient. Statistical 0.6% (baseline 127.9 ± 19.2 cm2, post-testing 127.1 ±
significance was set at P < 0.05. 19.5 cm2), respectively in the Control-walk (Table 1).
A significant group x time interaction was observed
RESULTS for BAP (P = 0.049). Post hoc analyses indicated that
There were no statistically significant differences in KAATSU-walk experienced greater increases in BAP
1-RM strength, mid-thigh muscle CSA and blood compared with Control-walk after the training
parameters between KAATSU-walk and Control- (P<0.05, Figure 1). Percent change in BAP was
walk groups at baseline. Significant group x time 10.8% for the KAATSU-walk and 0.3% for the
interactions were observed for mid-thigh muscle CSA Control-walk (Table 1). There was no change
(P = 0.001) and leg press 1-RM strength (P = 0.029). (P>0.05) in IGF-1 between pre- and post-testing in
Post-hoc analyses indicated that KAATSU-walk both groups (KAATSU-walk: baseline 292 ± 89
experienced significant increases (P<0.01) in muscle ng/ml, post-testing 297 ± 72 ng/ml; Control-walk:
CSA and strength after training. Percent changes in baseline 288 ± 73 ng/ml, post-testing 289 ± 80
1-RM strength and muscle CSA were 7.5% (baseline ng/ml). Although there was no significant correlation
95 ± 16 kg, post-testing 102 ± 15 kg) and 5.8% between percent changes in BAP and IGF-1 (r = 0.44,
(baseline 123.0 ± 17.6 cm2, post-testing 129.7 ± 15.9 P = 0.078), a clear trend was noted.
cm2), respectively in the KAATSU-walk and 1.3%
DISCUSSION
Previous cross-sectional [Creighton et al., 2001;
Matsumoto et al., 1997] and longitudinal [Kerr et al.,
50
Pre-testing
1996; Walker et al., 2000] studies have reported that
Post-testing bone remodeling is influenced by physical activity.
High-intensity resistance training has been shown to
40 *
increase bone metabolic makers such as bone-specific
Bone-specific alkaline phosphatase (U/L)

alkaline phosphatase (BAP) and increase bone mass

[Tajima et al., 2000]. BAP has a role in the
30 mineralization of newly formed bone, although the
function is not fully understood [Watts, 1999].
Previous results suggest that the it is the high
20
mechanical stress to the bone as a result of high
intensity training that causes the changes in bone
density, size and metabolic makers. Low intensity
10 exercise training, on the other hand, has previously
not been shown to increase bone mass or remodeling
[Cavanaugh and Cann, 1988; Kerr et al., 1996;
0 Shinaki et al., 1996]. It is assumed that the low
Control KAATSU
intensity loads do not create enough strain to induce
Figure 1. Bone-specific alkaline phosphatase responses
following 3 weeks of walk training combined with (KAATSU) changes in bone mass or remodeling.
and without (Control) restriction of leg muscle blood flow. The major finding of the present study was that 3
*P<0.05 pre- vs. post-testing weeks of twice-daily KAATSU-walk training
80 BAP and Kaatsu training

increased serum BAP in young men. Our results are

similar to previous studies that detected an increase in References
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Takarada Y, Nakamura Y, Aruga S, Onda T, Miyazaki S, Ishii N M.D. Beekley, Department of Physical Education, United States Military
(2000c) Rapid increase in plasma growth hormone after low-intensity Academy, West Pint, NY, USA
resistance exercise with vascular occlusion. J Appl Physiol 88: 61-65. Y. Sato, Department of Ischemic Circulatory Physiology, Kaatsu
Watts NB (1999) Clinical utility of biochemical markers of bone Training, The University of Tokyo, Tokyo, Japan
remodeling. Clin Chem 45:1359-1368. T. Abe, Department of Exercise and Sport Science, Tokyo Metropolitan
Whipple TJ, Le BH, Demers LM, Chinchilli VM, Petit MA, Sharkey N, University, Tokyo, Japan
Williams NI (2004) Acute effects of moderate intensity resistance