ORIGINAL RESEARCH                                                                                                                         
 

                                                                                                                                                                
 

1  SAJSM VOL.  29 2017 

 

The use of negative pressure wave treatment in athlete recovery 
 

A Jansen van Rensburg1, MSc, D C Janse van Rensburg1, MD, 
H E van Buuren2, MSc (Exerc Physiol), C C Grant1, PhD, L 

Fletcher3, PhD 
 
1Section Sports Medicine, Faculty of Health Science, University of Pretoria, 

Pretoria, South Africa  
2Institute for Sports Research, University of Pretoria, Pretoria, South Africa  
3Department of Statistics, Faculty of Natural & Agricultural Sciences, 

University of Pretoria, Pretoria, South Africa 

 
Corresponding author: A Jansen van Rensburg 

                                        (audrey.jansenvanrensburg@up.ac.za) 

Lower body negative pressure (LBNP) 

treatment, also known as intermittent vacuum 

therapy, was developed for astronauts, to 

maintain the arterial blood supply of the lower 

body and compensate for weightlessness. Due 

to the low gravity in space, autonomic cardiovascular control 

deteriorates and orthostatic tolerance is re-established by 

means of LBNP therapy after exploration flights.[1]  

Designed to act as an external heart for the lower body, the 

LBNP device generates a rhythmic alternating pressure of 

intermittent waves of negative pressure (lower pressure), and 

normal pressure (atmospheric pressure). As described in 

available literature this mechanism causes strong capillary 

dilation and compression pulsations[2] through which blood 

circulation and perfusion in the lower limbs are increased.[3] 

Arteries dilate as oxygen (O2)-rich blood and nutrients are 

drawn into the tissue (hypobaric), resulting in a higher 

available concentration of O2 and supplements in the muscle,[4] 

followed by an atmospheric pressure phase, a relief of the 

reflux, when carbon dioxide (CO2) and metabolic waste 

products are pressed back into the upper body through the 

circulatory system and the lymphatic vessels.[5] This application 

of sub-atmospheric pressure to the lower portion of the body 

(below the iliac crest) consequently enhances the baroreflex that 

assists in maintaining blood pressure during orthostatic 

stress.[1,2]  

In clinical applications, the use of negative pressure has been 

indicated as an effective modality.[4,6] A study by Schneider et 

al.[7] indicated an improvement in heart rate and blood pressure 

responses observed with the application of LBNP after 15 days 

of bed rest.  

Following excessive training, athletes often experience 

symptoms of discomfort, muscular soreness and stiffness 

within 12–24h, which can contribute to the development of 

muscular fatigue resulting in deteriorating performance.[8,9] 

Delayed onset muscle soreness (DOMS) is an inflammatory 

reaction caused by the micro-damage of primary muscle. Sports 

massage is a popular treatment and a frequently applied 

intervention; however, evidence to support its efficacy as a 

technique to enhance recovery is still being explored.[10] 

Appropriate methods of recovery are, however, essential to 

restore an athlete’s physiological and psychological capacities. 

Prompt and sufficient recovery can also improve performance 

by enhancing training quality and tolerance to the training load, 

as well as improving the athlete’s adaptation to training. 

Without proper recovery following multiple training sessions 

or competitions, an athlete increases the risk for poorer 

performance and overuse injuries.[8,10] Mimicking sports 

massage by stimulating the circulatory system and lymphatic 

vessels, LBNP is claimed to play a vital role in the recovery of 

the athlete in order to maximise athletic performance in 

competitive sport. 

The endurance capacity in athletes differs, with highly 

trained athletes performing at a higher maximal oxygen 

uptake, presenting with minimum lactate accumulation. 

During exercise of increasing intensity, an increase in blood 

lactate concentration is an indication of a rise in glycogen 

metabolism within the muscle. However, the initial increase in 

blood lactate concentration implies the net result of lactate 

production in the muscle, and reflects that the appearance rate 

of lactate in the blood is higher than the disappearance rate (the 

result of a balance between the rate of production and 

removal).[11,12] This is referred to as the lactate threshold and is

Background: Athletes need to recover fully to maximise 

performance in competitive sport.  Athletes who replenish 

more quickly and more efficiently are able to train harder and 

more intensely. Elite athletes subjectively report positive 

results using lower body negative pressure (LBNP) treatment 

as an alternate method for rapid recovery, restoring and 

improving their impaired physical state. Objective data on the 

efficacy are lacking. 

Objectives: To investigate the effect of intermittent vacuum 

therapy on accelerating acute recovery following an athlete’s 

normal daily training schedule of strenuous exercise. 

Objective measurements of biological markers of muscular 

fatigue were used to assess recovery. 

Methods: Twenty-two male cricket players in a randomised 

cross-over study were divided into a treatment and control 

group respectively. Following a one-hour high-intensity gym 

session, the treatment group received three 30-minute LBNP 

exposure sessions over three consecutive days (0, 24 and 48 

hours). Blood lactate and creatine kinase biomarkers were 

collected to measure the recovery process. After 14 days 

groups were crossed over and the trial repeated.  

Results: Heart rate and blood pressure decreased noticeably 

during treatment, reverting to baseline levels after treatment. 

Lactate concentrations decreased in both groups after exercise 

termination; significantly more in the treatment (0.57±0.23 

mmol/l) than control group (0.78±0.22 mmol/l), p<0.001). 

Creatine kinase (CK) was similar in both groups. Athletes’ 

subjective assessments of recovery rated moderately high. 

Conclusion: LBNP therapy applied as treatment during 

routine schedule may have a systemic effect in lowering serum 

lactate levels, but not CK levels. Enhanced recovery of athletes 

is still unconfirmed. 

Keywords: lower body negative pressure, athlete restoration, 

athlete performance, athlete rehabilitation, athlete 

recuperation 
 

S Afr J Sports Med 2017;29:1-7. DOI: 10.17159/2078-516X/2017/v29i0a1544   

mailto:audrey.jansenvanrensburg@up.ac.za
http://dx.doi.org/10.17159/2078-516X/2017/v29i0a1544


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considered to be a good predictor of endurance exercise 

performance. The lactate threshold is often used to prescribe 

training intensities, based on the relationship between blood 

lactate levels and heart rate. In the same way, active recovery 

after strenuous exercise will clear the accumulated blood 

lactate levels faster than passive recovery. More so in an 

intensity-dependent manner, with maximum blood lactate 

clearance occurring with active recovery close to the lactate 

threshold.[12,13]  

The severity of muscle damage and injury is frequently 

monitored by blood serum CK enzyme activity levels.[14] 

Although debated by researchers, lactate concentration and 

blood serum CK activity levels are implemented as 

biomarkers in measuring the recovery process that is crucial 

for successful endurance capacity and sport 

performance.[12,13,14]  

Hormonal changes in the body are involved in regulating 

various physiological functions, and when activated are 

known to improve mental function and willpower, thus 

automatically increasing the subjective well-being of an 

individual.[15] The increased blood circulation in the entire 

body and brain achieved by the vacuum effect of the LBNP 

device may hypothetically also increase oxygen circulation 

and influence hormone levels and their release in the blood to 

enhance a feeling of perceived recovery experienced by the 

athletes, with the magnitude of improvement remaining of a 

perceptive nature. 

LBNP therapy is becoming popular through the promise of 

an innovative to optimise and accelerate sports recovery, 

increase physical performance and reduce breaks from 

training, with very little confirmed evidence. The objective of 

this study was to assess if intermittent negative pressure 

therapy applied to the lower body of athletes will affect 

known measures of muscular recovery and result in faster 

recovery time and recuperation.  

 

Methods 
Study design 

A randomised cross-over study design with repeated 

measures was performed to determine the effect negative 

pressure wave treatment has on the recovery of cricketers. An 

information letter with a full explanation regarding the nature 

of the study was given to all participants, and informed 

written consent forms were collected from each candidate 

prior to the study. The study protocol was approved by the 

Ethics Committee of the University of Pretoria, South Africa 

(Approval number 352/2013). 

 
Participants and selection criteria  

Twenty-two healthy male cricket players based at the TUKS 

Cricket Academy, at the High Performance Centre of the 

University of Pretoria, South Africa, were invited to 

participate. Players were randomly assigned to one of two 

groups and evaluated. After the second week the participants 

were crossed over and the study repeated over the following 

two weeks. Participant exclusion criteria included 

cardiovascular diseases, hypotony with proneness to collapse, 

diabetes, recent phlebotrombosis (<eight weeks), the risk of 

thromboembolism and smoking. Participants were instructed 

to refrain from drinking alcohol, and consuming caffeine 

products 24 hours prior to each study session. 

 
Study procedure  

All participants documented their personal information and 

history before the start of the study. The age, body mass, height 

and body mass index (BMI) of each athlete were recorded at the 

start of the study. Each player participated in the cross-over 

design during the four week study period: once in the 

treatment group (receiving LBNP treatment; ExT) and once in 

the control group (not receiving LBNP treatment; ExC). The 

two applications were separated by a washout period of 14 

days. Each trial assessment was completed over three 

consecutive days and followed the same routine physical, 

physiological and treatment conduct as illustrated in Figure 1. 

The cricket players continued to follow their regular weekly 

physical training programme consisting of seven hours 

conditioning and 10 hours cricket specific skills, with one 

competitive match on weekends, throughout the study period. 
 

Protocol 

On the first day of the trial (Figure 1) baseline physiological 

measurements (heart rate (HR); blood pressure (BP); blood 

oxygen saturation (SpO2)) and blood samples (Lactate (Lac); 

Creatine Kinase (CK)) were collected from the participating 

athletes pre-exercise. Participants then completed a one hour 

high-intensity gym session comprising of weighted exercises 

and plyometric upper and lower limb training. Directly after 

the exercise session, physiological measurements and blood 

sample collection were repeated. Players were randomly 

assigned to either receive one 30 minute LBNP treatment 

session (ExT) or remain seated in the treatment room with no 

exposure (ExC). A questionnaire (based on an ordinal rating 

scale of one to five) was completed by each player before and 

after every LBNP treatment session, to quantify their perceived 

recovery state (Table 1). Normal training proceeded in the 

afternoon and the players returned on Day Two and Day Three 

during which the same athletes once more received either a 

treatment session or remained unexposed. Physiological 

measurements and blood samples were collected daily before 

and during each treatment session, for both the treatment (ExT) 

and control (ExC) participants. Treatment sessions were 

labelled as: 0 hours after, 24 hours after and 48 hours after 

intense training. 

 
LBNP vacuum therapy 

The LBNP device for intermittent vacuum therapy comprises of 

a cylinder-shaped chamber into which the lower body of the 

athlete is placed. The athlete lies on his back, his legs and lower 

body up to the iliac crest bone, inside the chamber. The 

chamber, enfolding the lower body of the athlete, is sealed by 

means of a diaphragm (iris seal) around the waist. Alternating 

negative and normal pressure is generated in the chamber by a 

vacuum pump. The device generates rhythmic interchanging 

pressure waves of normal pressure (atmospheric pressure) and 

negative pressure (lower pressure) at alternating pulsations. A 

vacuum treatment with negative pressure setting of 68 mbar 

was regulated, with an atmospheric pressure:negative pressur



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alternating phase duration of 9:6 seconds. The LBNP device 

used during this study period was voluntarily supplied by 

Rapid Sports Medical Regeneration, South Africa. 

Physiological measurements 

Vital health assessments - heart rate (HR), blood pressure (BP) 

and blood oxygen saturation (SpO2) - were noted throughout 

the study, for both the ExT and the ExC athletes. SpO2 (oxy-

haemoglobin and deoxy-haemoglobin in the red blood cells) 

was monitored using a Finger Pulse Oximeter Probe (Anapulse 

ANP150). 

 
Blood lactate concentration  

A small blood sample (0.3µl) was collected by means of a lancet 

prick of the earlobe to determine the blood lactate 

concentration (mmol/l) of all athletes (both the ExT group and 

the ExC group). Analysis was performed using Lactate Pro™2 

test strips (Batch# B133B03L) and a portable blood lactate 

analyser (Arkray Pro2 LT-1730). Lactate was sampled at rest on 

Day One (Lac0), immediately after the one hour exercise 

session (Lac1) and directly after the first 30 min LBNP 

treatment session (Lac2). 

 
Serum creatine kinase enzyme activity levels (CK) 

CK levels (IU/litre enzyme activity) were assessed from 

approximately five ml of blood drawn from an antecubital vein 

by venipuncture. Blood samples were obtained at baseline and 

at 0 hours, 24 hours and 48 hours respectively after treatment 

and were analysed (Creatine Phosphokinase Assay; Beckman 

UniCel® DxC800 Synchron) to determine possible increases in 

CK blood serum levels.    
 
Perceived recovery questionnaire 

The questionnaire was based on an ordinal rating scale of one 

to five, to evaluate the perceived amount of recovery with 

LBNP therapy (of all athletes: ExC and ExT). The questions 

were designed to explore the subjective perceptions of their 

intensity of muscle soreness and their level of recovery, 

comparing pre-treatment and post-treatment on the LBNP 

device (Table 1). Athletes belonging to the ExT group were also 

questioned on their opinion of the effectiveness of LBNP 

therapy. 

 
Data analysis 

The data analysis consisted of descriptive statistics to 

Table 1. Perceived recovery questionnaire 

Question Ordinal rating scale 

1                                       5 

Pre-treatment:  

How does your body 

feel after exercise / 

before treatment? 

Extremely 

exhausted 

Excellent 

condition 

How do your muscles 

feel? 

Very heavy Excellent 

condition 

How does your body 

feel in terms of fatigue? 

 

I feel extremely 

fatigued 

I feel fully 

energised 

Post-treatment:  

How do your muscles 

feel? 

Very heavy Excellent 

condition 

How does your body 

feel in terms of fatigue? 

I feel extremely 

fatigued 

I feel fully 

energised 

How well rested and 

regenerated do you feel? 

 

Not recovered Very well 

recovered 

LBNP effectiveness:  

How do you feel after 

your treatment session 

on the LBNP device? 

My body still 

feels tired/ 

fatigued 

My body feels in 

great condition 

Do you have the 

impression that the 

LBNP device helped? 

Not impressed Extremely 

impressed 

 

 

 

 

Table 2. Baseline physical characteristics of participants (N=22) 

Variables 

 

Mean ± SD 

Age (years) 20±1 

Body weight (kg) 79.6±8.2 

Height (cm) 180.0±0.1 

BMI (kg/m2) 24.6±2.5 

 

 

. 

 

 

Fig.1. Procedure of physiological measurements and blood samples taken over three consecutive trial days. **Intervention starts. HR, heart 

rate; BP, blood pressure; SpO2, blood oxygen saturation; CK,  creatine kinase; Lac,  lactate; QU, questionnaire.  

 



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summarise the quantitative information. Repeated measures 

ANOVA was used to assess the changes in blood lactate 

concentration and CK activity levels over the 48 hour 

treatment period between the treatment and control groups. 

The proportional changes (after vs. before) of the treatment 

were evaluated and interpreted as follows: values smaller 

than one indicate a decrease, values larger than one an 

increase and a value of one would indicate no change took 

place.  

The results of the perceived recovery questionnaire were 

combined into pre-treatment recovery scores and post-

treatment recovery scores. Non-parametric Mann-Whitney U 

tests were performed to determine differences between the 

treatment and control groups for each of the three periods. 

The results were regarded as significant if p<0.05, one-tailed.  

 

Results 
The baseline physical characteristics of the participants at the 

start of the study are reported in Table 2. Figure 2 shows the 

systolic and diastolic BP for both the ExT and the ExC athletes. 

The negative pressure generated by the LBNP device on BP 

can clearly be seen in the systolic and diastolic fluctuations 

during the treatment sessions. Although there were slight 

changes in the HR and SpO2 measurements before and during 

each treatment session in the ExT and ExC groups, there were 

no significant differences in these physiological 

measurements; these differences are due to sample variation. 

Figure 3 illustrates the results of the blood lactate 

concentration (mmol/l) on Day One at baseline (Lac0), after a 

one hour (Lac1) intense exercise session, and after the first 30 

minute (Lac2) LBNP therapy session. The average blood 

lactate concentration (mmol/l) ratio (after vs. before) of the 

ExT group decreased after treatment, in comparison to the 

ExC group who did not receive treatment (0.57±0.23 vs. 

0.78±0.22, respectively, F(1;19)=9.420, p=0.006). No other 

significant differences were obtained.  

The CK measurements for both groups are shown in Figure 

4. Although there was an increase in CK enzyme activity 

following the first day’s training, the CK did not decrease 

significantly after three treatment sessions on the LBNP 

device (F(1;19)=0.172; p=0.683).  

Figure 5 shows the perceived recovery grading of both ExC 

and ExT athletes over a three day period during pre-treatment 

and post-treatment on the LBNP device (based on the questions 

in Table 1). The three pre-treatment questions were combined 

to get a pre-treatment recovery score, and the three post-

treatment questions were combined to get a post-treatment 

recovery score. There was a significant difference between the 

ExC and ExT groups (post-treatment score minus pre-treatment 

score) at all three time periods (0h p= 0.011; 24h p<0.001; 48h 

p=0.001). At post-treatment, after each of the 0 hour, 24 hour 

and 48 hour sessions, the ExT athletes reported a significant 

increase in their perceived degree of muscle feel, fatigue and 

recovery compared to the controls. The ExT group during each 

of the treatment periods indicated higher energy and recovery 

status than the ExC group.  

Discussion 
The decrease in the blood lactate concentration ratio of the 

treatment group compared to the control group (0.57±0.23 

vs. 0.78±0.22 mmol/l, respectively, p<0.001), following a 

single negative pressure treatment session, indicates that the 

use of the LBNP device succeeded in normalising lactate 

measurements more quickly, and may imply faster athlete 

rehabilitation and recovery. Per contra, the severity of 

muscle injury as indicated by the blood serum CK level of 

activity was not significantly reduced after three treatment 

sessions of negative pressure (F(1;19)=0.172; p=0.683). 

Negative vacuum pressure treatment did not affect the 

ongoing sports performance of the athletes, and no side 

effects were observed during the period the study was 

executed. All participants also form part of the same cricket 

academy and therefore their training schedules are fairly 

similar.  

Several physiological systems change when endurance 

training is induced (i.e. metabolic, cardiovascular, muscular, 

etc.), with the modification of lactate kinetic parameters a 

significant mediator to quantify the extent of exercise.[12] The 

mean blood lactate ratio between the control (ExC) and 

treatment (ExT) groups, directly after exercise vs. directly  

 

 

 

 

 

 

 

 

 

Fig.2. Systolic and diastolic blood pressure (N=22). M, Measurement.  



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5  SAJSM VOL.  29 2017 

 

 

 

 

 

  

Fig.3. Mean blood lactate concentration (mmol/l) on Day One at baseline (Lac0), after one hour of exercise (Lac1), and after 30 minutes 

therapy (Lac2) on the LBNP device (N=22). * Ratio significant at <0.01.  

. 

 

Fig.4. Mean creatine kinase enzyme activity on Day One at baseline (CK0), after one hour of exercise and the 1st therapy session (CK1), 

after the 2nd therapy session (CK2), and after the 3rd therapy session (CK3) (N=22). No significant decrease was found. 

 

Fig.5. Perceived recovery based on an ordinal scale indicating the post-treatment recovery score minus pre-treatment recovery score responses 

of both ExC and ExT athletes groups on the LBNP device, for the 0 hour, 24 hour and 48 hour sessions. Ordinal scale relates to questions A-

F in Table 1.* Significant at 5% level; ** Significant at 1% level.  

 



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after the 1st treatment session, demonstrated a significantly 

faster decrease in the treatment group, indicating the 

efficiency of the LBNP device to stimulate blood flow and 

as an aid in the removal of lactate.  

However, the daily academy training and competition 

programme the athletes followed, although fairly similar, 

may also have influenced the CK serum results. Again, the 

objective of evaluating negative pressure effect on recovery 

under acute athlete performance conditions is highlighted 

in this study.  

The stimulation of the circulatory system and the 

lymphatic vessels by the rhythmic alternating pressure of 

the LBNP device may conceivably mimic massage therapy. 

Sports massage is used by athletes with the belief that it 

will stimulate lymph flow and reduce muscle tightness in 

order to accelerate recovery and enhance performance. 

Improvement in muscle tone and a sense of feeling 

recovered and energised by the increased concentration of 

endorphins in the brain has also been advocated. Although 

many claimed benefits and numerous personal perceived 

experiences promote sports massage as the treatment of 

choice, research evidence on its appropriate use is scarce[10] 

with contradictory evidence that manual massage has any 

significant impact on the physiological and psychological 

factors associated with recovery following exercise.[9,10] 

Recovery may be reliably assessed both at pre- and post-

treatment with one-dimensional tools, such as individual 

evaluated numeric rating scales. Athletes who were treated 

with the LBNP device during their routine weekly training 

programme reported an increased subjective impression of 

treatment compared to that of the control athletes. A 

perceived improvement in muscle feeling and fatigue was 

seen, and they experienced increased training motivation 

and an enhanced feeling of recovery in general. The 

athletes described the treatments as ‘pleasant’ and rated 

their treatment sessions on the LBNP device as highly 

effective, reflecting the impression that the treatment 

sessions may help them to recover more quickly. At post-

treatment, after each of the 0 hour, 24 hour and 48 hour 

sessions, the ExT athletes reported a significant increase in 

their perceived degree of muscle feel, fatigue and recovery 

compared to the controls. The ExT group, during each of 

the treatment periods, indicated a higher energy and 

recovery status than the ExC group. The perceived 

perceptions of recovery that increased after each vacuum 

therapy session provides some support for the use of the 

LBNP device as a recovery strategy to improve the 

recovery state of the athlete. It has to be noted that the 

project specifically targeted short-term acute recovery and 

does not reflect on how the use of the LBNP device will be 

perceived over the long-term. The performance, 

motivation and subjective wellbeing of the athlete may 

well be further enhanced with the continuous use of the 

device. 

A limitation to this study is the short period the LBNP 

treatment was implemented, but the core emphasis was to 

determine acute athlete rehabilitation and recovery based 

on known measures of muscular recovery within a short 

period of time after high-intensity exercise. Beneficial to the 

device itself will be a further examination of its effectiveness 

and significance based on performance enhancement, 

recovery and rehabilitation of athletes, and the advanced 

development of various treatment programmes. 

 

Conclusion 
Based on this study, LBNP therapy implemented as an 

applied treatment within cricket players’ normal routine 

training and competition schedule, in an effort to assist in 

the recovery of players over a short period of time, seems to 

have a systemic effect in lowering serum lactate levels, but 

not CK levels. The enhanced long-term recovery of athletes 

using this device to replenish faster and recuperate more 

efficiently as advocated, are still unconfirmed. 

 

Acknowledgements: The authors are grateful to Gustav 

Obermeyer of Rapid Sports Medical Regeneration (RSMR), 

South Africa who voluntarily supplied the Vacumed (LBNP 

device) for the research performed at the University of Pretoria, 

South Africa.  

 

Conflicts of interest: There are no conflicts of interest related to 

this study.  

 

Source of funding: The authors declare that they have not 

received any funding for this study. 

 

Statement: The protocol was approved by the Ethics 

Committee of the University of Pretoria, South Africa 

(Approval number 352-2013). Experiments comply with the 

current laws of South Africa in which they were performed. 

 
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