Definitive Guide to Blood Flow Restriction Training (2023)

In this guide, I'm sharing everything you need to know about blood flow restriction training, also known as occlusion training or just BFR training.

Here's everything we currently know about the science of blood flow restriction training, including some of the scientific evidence on the safety and effectiveness of BFR training. Read or skip to the next section:

What is Circulation Restriction Training?

Circulatory restriction training is a technique that allows you to perform exercises with reduced blood flow to the arm or leg. This is usually done with a cuff or brace placed snug around the limb to reduce but not completely obstruct blood flow. The advantage of training to restrict blood flow is that a person can exercise at a lower intensity but still have the benefits of high intensity exercise.

• Keep reading: Best BFR bands, armbands and gear

Unless you've been living under a rock, we're assuming you've heard of, and maybe even practiced, blood flow restriction training. Its popularity has exploded in recent times, largely due to the media and stories of professional athletes relying on so many "fly at night" treatments.

The point, however, is that the BFR is neither new nor just a fad.

BFR research has been going on for over 20 years, and we're here to say it's solid. And as we continue to learn more, it continues to show promise.

When I first heard about circulation restriction training, I must admit I was a little skeptical. Over the years, I've seen many fads come and go in our professions.

For example, let's play a little game...

As soon as possible, think of something we do in the rehabilitation or fitness professions that DOES NOT have a strong scientific basis or clinical research to support its use.

Wait wait…

Pretty easy, right? There are too many of them to be sure.

Now let's think of some that are the exact opposite. What has solid scientific basis and clinical evidence?

Hopefully the first thing that comes to mind is exercise and strength training. There is strong scientific evidence and clinical research to support strength training.

Now, another modality that should come into this discussion is blood flow restriction training.

I'm not one to jump on the bandwagon, but as more and more evidence comes out, it's clear that BFR is something to consider.

How does BFR training work? Let's dig a little deeper.

How are muscles strengthened?

It's probably a good idea to start with the basics of how muscles get bigger and stronger.

Simply put, muscles adapt through neural, mechanical, and metabolic mechanisms.

Many of these mechanisms involve multi-step pathways that will likely put you to sleep if we go into too much detail in this post, but it's still important to understand.

Simply put, it's all about load and volume.

on onehormonal point of view, Testosterone increases with high-impact compound exercise, while growth hormone increases with high-volume compound exercise.

This is an important concept...

High volume and moderate intensity will increase growth hormone, but low volume and high intensity will not.

Insulin-like growth factors (IGFs), myogenic stem cells (MSCs), vascular endothelial growth factor (VEGF), and the mTORC1 signaling pathway are activated during normal high-impact exercise.

Note above that the key term is "high rate". We need high loads to get stronger.

In short, all of these different pathways and "ingredients" are vital to muscle growth.

How does circulatory restriction training work?

there are severalproposed mechanisms for the functioning of the BFR.

Ourcurrent understandingis that exercise with blood flow restriction works through the indirect effect of metabolite accumulation and the hypoxic environment of exercise with arterial flow restriction. This results in greater fatigue, muscle activation, and also anabolic pathways that result in muscle adaptations compared to exercise without BFR.

So, knowing that it takes a combination of loads and volume to get stronger, what do we do in cases where people aren't fit or can't handle high loads? For example, after an injury or surgery. Or maybe someone who trains at home without access to weights to reach high loads.

This is where BFR training can help.

Blood flow restriction training can be a great addition to training because the same muscle building ingredients take place in a low impact environment.

With immobilization or atrophy, muscle protein breakdown occurs. In BFR training with low loads, and in some studies without load, several signaling pathways are activated to increase muscle protein synthesis.

Talking about the hypoxic environment and the mechanisms involved is basically a “snowball effect”. Less oxygen in the area accelerates fatigue and recruitment of higher threshold motor units. In other words, "start working" on the muscle. The reduced pH of the hypoxic environment is a hypertrophic stimulus.

There is also an added benefit of the "muscle pump" of cellular inflammation. In fact, compression causes metabolites to build up, and we've already discussed the benefits of increasing metabolites. Essentially, when compression is reduced or relieved, the floodgates open and put all those "muscle building ingredients" into the muscle.

Blood flow restriction in physical therapy

Regardless of the injury you're dealing with, muscle atrophy and weakness is a common impediment.

Methods to correct these shortcomings are usually performed immediately. Neuromuscular electrical stimulation, biofeedback, isometrics and cross-education are just a few of the methods we use to start building strength early while engaging tissues.

Unfortunately, heavy loads are not appropriate in the early stages of healing as they can overwhelm and damage the healing tissues.

This becomes an issue when someone is trying to recover from injury while gaining strength.

Resistance training guidelinesEncourage high loads that exceed 60% of one repetition maximum (1RM) for 8 to 12 repetitions.

We need reasonable burdens to achieve the desired adjustments. To make matters worse, the 1RM test is not appropriate at the beginning of rehabilitation. There are estimation models for 1RM, but they are not ideal.

BFR offers an option to cushion post-injury atrophy as well as increase strength in a low-impact environment. Essentially with training loads of 20-30% 1RM with 15-30 repetitions per set. This is much more true for training with healing tissues that are not yet ready to receive a more intense load.

Does circulation restriction training work?

Extensive research has been published documenting the effectiveness of BFR training.

Exercise to restrict blood flow has been shown to helpto mitigate atrophy, improve hypertrophy, increase strength and improve aerobic capacity, all in a low-impact environment.

This all sounds great, but what about specific diagnostic evidence?

If blood flow restriction training has so many benefits, we would expect positive results in certain diagnoses, right? Well that would be correct!

BFR after ACL reconstruction

We know from years of research that the quadriceps lose strength after knee surgeries such as ACL reconstruction. Happily,The BFR is well suited to assist with loss of strength and hypertrophy following ACL reconstructionit is anumber of studiesdemonstrated benefit from the use of BFR.

While there may not be many studies of BFR for other specific diagnoses, intuitively every post-op knee needs quadruple strength and hypertrophy, so you should feel good that you're getting similar benefits.

BFR for knee pain

Arguably, one of the most important things in any city that people come to us for is pain relief. Clearly, higher loads can aggravate already irritated tissue (or the patient!), making low-load BFR training attractive.

ONEnumber of studiesdemonstrated the benefit of BFR in relieving painpatellofemoral pain,knee osteoarthritis, and they work laterACL reconstructionjknee osteoarthritis.

BFR after immobilization

We all know the detrimental effects immobilization has on a muscle. You've seen it in patients (and maybe yourself if you've had surgery!). You guessed -BFR can also help with immobilization🇧🇷 Even if your patient is bedridden or can't do much, the BFR can help! how amazing is this

BFR in the geriatric population

If athletes are not your target audience and you are treating elderly or geriatric patients, the good news is that BFR is helping this population too.

Several studies have found that BFR helped with this.pain reliefjfunctional notesin elderly patients.

You certainly need to take more precautions (see below) and know who you are treating in this population, but when you think about it, if you can reap the benefits of strength training with lower loads, it's a win-win!

The only issue we've seen with this population is discomfort, and in our experience, a little more persuasion is needed.

Is blood flow restriction training safe?

Before diving into security, it's important to note that anything in the wrong hands or used inappropriately or in the wrong population can be potentially unsafe.

after i said thatBFR training has proven to be safe.

BFR has been used in a variety of musculoskeletal conditions and to date has not resulted in any serious adverse events for those who have no contraindications to BFR training.

Common side effects of BFR training are usually short-lived and include things like numbness, bruising, discomfort, bleeding from petechiae, skin abrasions, and delayed onset muscle soreness (DOMS).

These are usually not a concern. However, caution should be exercised in patients with heart disease or clotting problems.

Happily,A recent review has shown that the risk of blood clots or DVT is extremely low..

At this point, we recommend that BFR training begin about 2 weeks after surgery to reduce the risk of adverse events.

What are the contraindications of BFR training?

Based on previous safety guidelines, contraindications for BFR are focused on individuals with vascular insufficiency or cardiac involvement.

There may be an increase in cardiac stress due to the increased stroke volume and heart rate of the body trying to pump arterial blood to the tissues.

People with hypertension, diabetes, history of stroke or DVT, heart disease, active infections, pregnancy, bleeding disorders or other vascular insufficiencies (such as varicose veins) are contraindicated.

That said, it is wise to speak with the GP to determine if a patient is suitable for BFR training. However, when you think about it, there are often contraindications to other treatment modalities and approaches.

Basically, use your head.

Clinical thinking and decision making are just as important with BFR as they are with any other treatment approach you use.

Do you need certification to perform blood flow restriction training?

As with anything new, there are always a number of misconceptions surrounding BFR training. One that was specifically reported is the need for a specific certification to start BFR training.

The short answer is no, you don't need certification to use blood flow restriction training. BFR is for both in the context of practicephysiotherapistsjathletic trainer🇧🇷 Local authorities may have different policies, so it's always best to check your state's laws of practice to ensure you can use the BFR.

As with any other intervention you use, it is important to learn about the mechanism, how the treatment is administered, and the absolute and relative contraindications.

What are the best cuffs to restrict blood flow?

There are many blood flow restricting bands, bracelets and devices on the market: some good, some bad.

There are several factors to consider when choosing the best BFR cases. I have an in-depth article that goes into more detail, so be sure to check out my complete guide for all my recommendations:

• The best bands, bracelets and equipment to restrict blood flow

How to start blood flow restriction training

Now that you understand a little about the science of blood flow restriction training, I'm sure you're interested in learning more about how to get started using BFR safely and effectively.

Fortunately, learning BFR doesn't have to be complicated or expensive! You can even start with affordable cuffs that restrict blood flow.

Dan Lorenz and I teamed up to create aBlood flow restriction online trainingTo teach you exactly how we use BFR training for rehabilitation and training.

We truly believe that BFR is a technique we should all be using, the science is there. That's why we want to help you learn everything you need to know to get started with BFR training quickly and easily.

We'll cover the history and science in detail, discuss safety and effectiveness, and then show you exactly how we select BFR cuffs, determine the proper amount of pressure, and incorporate them into our programs.

You can start BFR training safely and effectively right away

This article was co-written with me by Dan Lorenz, my co-author of our newOnline Training Course on Circulation Restriction🇧🇷 Dan Lorenz, DPT, PT, ATC, LAT, CSCS is currently the Director of Sports Medicine at Lawrence Memorial Hospital/OrthoKS in Lawrence, KS. Dan specializes in performance enhancement, strength training and using exercise to restrict blood flow. He has published widely in professional journals, authored or co-authored several home-study courses and book chapters, and has been a guest speaker at local, state, and national conferences on these subjects across the United States.