Blood Flow Restriction

Therapy

By Jason Krupka SPT, CSCS, PES

What is Blood Flow Restriction Therapy?
Blood flow restriction (BFR) training involves applying proximal compression, usually an elastic wrap
or BP cuff to limit the blood flow to a muscle while performing low resistance (20-30% 1RM)
training. 1

Compression should limit venous but not arterial blood flow.

The wraps should be snug but not excessively discomforting. On a scale from 1-10, pressure should
be about a 7.2

BFR allows a low resistance and low joint load alternative to traditional higher stress training to build
muscle size and strength.

Certain muscle groups can have BFR easily applied such as the quadriceps, hamstrings, calves,
biceps and triceps, however muscle groups such as the RTC and/or gluteals are harder to
occlude. 1
BFR Pictures
How does Blood Flow Restriction Therapy Work?
Metabolic accumulation results in greater fatigue and recruitment of fast twitch fibers, muscle cell
swelling and blood pooling causing an increase in anabolic signaling 1,5

Metabolic stress is the buildup of metabolites, which are more prevalent in oxygen-limited states 2

Production of metabolites drive cellular signaling that enhances protein synthesis and satellite cell
activation which are prerequisites for muscle growth 2

BFR brings greater metabolic stress through elevated lactate levels, which leads to increased GH
and IGF-1.

All of these changes lead to increases in molecular signalling pathways (mTOR and myostatin
pathways) and muscle protein synthesis 6
History of Blood Flow Restriction
Interest in BFR training originated from the development of Kaatsu training by Yoshiaki Sato.

Sato originally experimented on himself by applying different bicycle tubes, ropes and bands on
different parts of his body

In 1994, Sato applied for his first patents as he began to make the first Kaatsu bands available
commercially 6
Who can use Blood Flow Restriction Therapy?
Anyone with difficulty regaining strength and endurance after injury or muscle trauma

Elderly populations

Healthy athletes

Patients who cannot participate in traditional strength-training exercises or those with chronic
weakness.

Post-operative patients

Contraindications
History of DVT, pregnancy, varicose veins, high blood pressure, and cardiac disease 6
Blood Flow Restriction Therapy in Rehab
ACSM states that low resistance does not provide adequate stimulus to increase strength or
hypertrophy.
However, when the same low resistance is combined with BFR, increases are comparable to
high resistance training10

Hypertrophy usually occurs when loads are >70% of 1RM, however hypertrophy has been shown
with BFR at 20% 1RM 6

BFR training increases hypertrophy better than training without BFR when using matched loads. 6

BFR with low resistance appears to be similar to training with (unmatched) high loads. 6

Non-resistance training (walking) with BFR appear to be able to produce some gains in muscular
size 6
Blood Flow Restriction Therapy Research 11

Twelve males aged 21 3 years with a minimum of 1 year of resistance training experience.

1x30, 3x15 repetitions at 30% of their leg press 1RM under control and BFR 11

Thirty seconds of rest occurred in between sets

7 out of 10 pressure was described as moderate pressure without pain.

Clarkson and Hubal indicated that 2472 hours postexercise muscle swelling and soreness are
noninvasive, indirect measures of muscle damage.
No changes in 24-hour muscle swelling or soreness were noted and there were no
differences between groups
Peak power returned to within 5% of baseline at 24 hours suggesting minimal muscle
damage occurred
Blood Flow Restriction Therapy Research 13

Six subjects performed bilateral leg extensions, with their proximal thigh compressed at 214 mmHg
throughout the session via a pressure tourniquet. 13
5 sets were completed until failure at 20% 1RM.

Plasma concentrations of GH, NE, La, and CPK were measured before and after exercise.

All showed increased levels after exercise with occlusion, compared to no changes in the control
group when done at the same intensity and quantity.
At 15 minutes post exercise, GH was 290x higher that of the resting level

The results suggest that light resistance combined with occlusion stimulates greater GH secretion
 21
Blood Flow Restriction Therapy Research
Twenty-three healthy individuals (59 71 years) volunteered to participate.
Subjects performed the leg press 2x per week for 12 weeks.
The HRT group performed 4 sets of 10 repetitions with 70% 1RM
The LRT-BFR group performed 4 sets: 1x30, 3x15 repetitions with 20% 1RM.
The average pressure was 71 9 mmHg. The cuff was maintained throughout the entire
session.

Both programs were significantly effective in increasing leg press 1RM (HRT: 54%, LRT-BFR:
17%) and quadriceps CSA (HRT: 7.9%, LRT-BFR: 6.6%)

2030% 1RM combined with BFR can be an effective alternative to HRT in improving muscle
strength and mass in elderly populations.
 15
Blood Flow Restriction Therapy Research
Twenty male participants aged 23.5 years with a minimum of 1 year of training experience.
Blood flow to the biceps was restricted during the first 4 weeks (BFR-HI) or the second 4 weeks (HI-
BFR) of an 8 week program.
To control for total volume, the non-BFR subjects performed three sets of curls at half the repetitions
and two times the load of the BFR group
If a BFR participant completed 30 reps at 30% 1RM, the non-BFR group performed 15
repetitions at 60% 1RM
There were no differences between groups at baseline. However, both the BFR-HI and HI-BFR CSA
increased signicantly from baseline to week 4 (6.9% and 8.6%, P<001) and from weeks 4 to
week 8 (4.1%, and 4.0%, P<001), respectively
These results suggest BFR at low intensities can stimulate hypertrophy comparable to high intensity
training.
 16
Blood Flow Restriction Therapy ACL Research
Sixteen patients after ACL reconstruction were divided into an experimental (aged 22.4 2.1 yr) and
control group (aged 23.0 2.5 yr)
The experimental group received five sets of occlusion for 5 minutes and no occlusion for 3 minutes,
twice a day.
Pressure was initially set at 180 mmHg and was gradually elevated at a 10 mmHg step
depending on the postoperative recovery of each subject.
Results
Knee extensor CSA decreased by 20.7% and 9.4% in the control and experimental groups,
respectively.
Knee flexor CSA decreased by 11.3%, and 9.2% in the control and experimental groups,
respectively.
Occlusive stimuli combined with standard rehab protocols can diminish disuse atrophy of thigh
muscles during post operative rehab.
 14
Blood Flow Restriction Therapy in the Elderly
Twenty-four healthy, postmenopausal women (58.2 6.6 yr) exercised twice a week for 16 weeks
using a single-arm dumbbell curl.
Low intensity (50% 1RM) exercise with occlusion at 110 mmHg (LIO)
Low intensity exercise without occlusion (LI)
High intensity (80% 1RM) exercise without occlusion (HI).
Subjects performed three sets with 1 minute rest breaks
In each set of LIO and HI, subjects lifted the weight until failure, whereas in LI they
matched the number of reps performed by the LIO group.
CSA and muscle strength of elbow flexor muscles after LIO were larger than those after LI and
similar to those after HI.
Despite low level resistance, occlusion causes activation of sufficient fast-twitch fibers required for
gaining muscular size and strength.
 19
Blood Flow Restriction Therapy in the Elderly
25 subjects over 60 years of age volunteered to perform training under one of three conditions:
Concurrent training group vs Blood-flow restriction group vs Control group
CT group performed the leg press for 410 repetitions at 70% 1RM
BFR group performed 130 and 315 repetitions at 20% 1RM
The average pressure used was 678.0 mmHg.
The CT and BFR showed similar increases in:
Quadricep CSA (7.3%, and 7.6%, respectively)
Leg Press 1RM (38.1% and 35.4%, respectively)
VO2peak (9.5% and 10.3% respectively).

These findings suggest that BFR may be an effective alternative to improve muscle strength and
hypertrophy in the elderly.
 20
Blood Flow Restriction Therapy in the Elderly
Fifteen elderly women with OP (aged 62.2) were randomized into: (a) low-intensity training with BFR
(LI+BFR); (b) high intensity training (HI); and (c) control.
Training lasted 12 weeks and two weekly sessions separated by 48 hours were performed

HI group performed four sets until failure with 80% of 1RM and 2-minutes rest between sets

LI+BFR group performed four sets until failure with 30% of 1RM and 30-seconds rest between sets
The mean pressure used was 104.20 7.88 mmHg.

Results showed significant increases in 1RM in both experimental groups, but with no significant
differences between groups.

Low-intensity strength training combined with BFR seems to be effective for increasing muscle
strength in elderly women with OP.
 22
Blood Flow Restriction Systematic Review
47 studies included healthy participants that had a mean age of 34 18 yrs (1870).

BFR training had greater increases in strength and size when pressure >150 mmHg compared to
pressures <150 mmHg

BFR evidence is showing that strength and hypertrophy can improve with 2050% 1 RM
Applicable to those who seek strength while reducing stress on tendons, ligaments and healing
structures

Muscular adaptations present quickly, however, training durations >6 weeks seem to offer greater
gains in strength.

Evidence suggests that pressures > 200 mmHg are no more effective at increasing metabolites than
moderate pressures (150 mmHg or 130% systolic BP) 10
Adverse Case Study 18

The patient was a 30-year-old Japanese man (BMI 28.1) with no remarkable medical history
On the first day of training, he performed squats (3 sets of 20 reps) with BFR under the instruction
of a qualified trainer.
The next morning, he developed severe muscle pain with high fever and pharyngeal pain.
Nakajima et al. reported that the incidence of rhabdomyolysis due to BFR training was 0.08%
Secondary factors that exacerbate exercise-induced muscle damage are dehydration, bacterial or
viral infections, heat stress, and/or supplement and drug use
In this case, infection (strep throat) was also suspected to be related to muscle damage.
Inappropriate BFR training, particularly in cases of deconditioning, bacterial or viral infections, or
medication has a risk of rare complications such as rhabdomyolysis
Limitations to Blood Flow Restriction Therapy 17

It is not practical to standardize cuff pressure especially with the multiple methods used for
occlusion (Kaatsu cuffs, elastic bands, rubber bands)

Unlike the Kaatsu apparatus, which has a pressure sensor, it is virtually impossible to determine the
degree of external pressure with other devices 7

The research to date that uses only bodyweight exercise during BFRT shows mixed results 7

Excessive occlusion could lead to overactivation of skeletal muscle reflexes leading to sympathetic
hyperreactivity and increased cardiovascular risk
Important for patients with cardiovascular disease (e.g., HTN, HF, and PAD)
Practical Application
First clear any patient contraindications via patient PMH
History of DVT, pregnancy, varicose veins, high blood pressure, heart failure and/or PAD
Using a BP cuff, inflated halfway between patient systolic and diastolic (approx 100 mm/hg)
Subjective patient pressure 7/10
Patient should feel no numbness or tingling
Exercises:
Lower extremity: QS, SAQ, LAQ, HR, TKE, Ankle PRE, Leg press, Bridges
Upper extremity: Bicep curls, Wrist extension/flexion, Supination/pronation
3 to 5 sets using 20-30% of patients 1RM to fatigue with 30-60 second rest between sets 1
Re-assess patient response to occlusion such as HR, BP and subjective pain levels
References
1. Blood Flow Restriction Training for Sport & Rehabilitation - Premax Blog. (n.d.). Retrieved July 31, 2016, from http://www.premax.co/blog/blood-
flow-restriction-training-for-sport-and-rehabilitation

2. Blood Flow Restriction Training. (n.d.). Retrieved July 31, 2016, from https://www.t-nation.com/training/blood-flow-restriction-training

3. Sumide T et al (2009) Effect of resistance exercise training combined with relatively low vascular occlusion. J Sci Med Sport 12(1):107-112

4. Lowery RP et al (2014) Practical blood flow restriction training increases muscle hypertrophy during periodized resistance programme. Clin
Physiol Funct Imaging Jul;34(4):317-21

5. Loenneke JP et al (2010) A mechanistic approach to blood flow occlusion. Int J Sports Med 31(1):1-4

6. Blood flow restriction training - the research. (n.d.). Retrieved July 31, 2016, from https://www.strengthandconditioningresearch.com/blood-flow-
restriction-training-bfr/

7. Squeezing some facts out of blood flow restriction training A guest blog by Paul Head. (2015). Retrieved July 31, 2016, from
https://thesportsphysio.wordpress.com/2015/03/11/squeezing-some-facts-out-of-blood-flow-restriction-training-a-guest-blog-by-paul-head/

8. Hylden C et al (2015) Blood flow restriction rehabilitation for extremity weakness: a case series. J Spec Oper Med. 2015 Spring;15(1):50-6.

9. Blood Flow Restriction Training in Rehabilitation Patients. (n.d.). Retrieved July 31, 2016, from https://clinicaltrials.gov/ct2/show/NCT02174770
References
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