Complete Physio’s Blood Flow Restriction Training (BFRT) Service offers BFRT to enhance rehabilitation from injury, post-operative rehabilitation and for general health and well-being.
Headed by Rehabilitation Physiotherapist, Reece Noble, this service forms part of Complete Physio’s comprehensive offering of health care services.
This article covers the following areas
- Introduction to BFRT
- What BFRT can be used for
- Comparison of BFRT to High Load Resistance Training
- Why light loads may be chosen over heavy loads
- How long BFRT takes to work
- The physiological benefits of BFRT
- What a session of BFRT involves
- Safety of BFRT
- Is BFRT right for you?
What is Blood Flow Restriction Training?
Blood Flow Restriction Training (BFRT), which is also commonly referred to as occlusion training or KAATSU (Japanese for “additional pressure”) training, is a specific form of exercise therapy used by physiotherapists, doctors and other health professionals in both rehabilitation and for general health improvement.
BFRT was invented in Japan by Dr Yoshiaki Sato in the 1960’s who called it KAATSU training. Since then there has been almost 50 years of academic research and development of BFRT, with over 400 peer reviewed articles showing its positive effects.
BFRT involves applying a medically approved pneumonic cuff, similar to the one used to take your blood pressure, to moderately but safely restrict the blood flow in and out of a limb and performing light exercise with that limb. This leads to blood and metabolites pooling in the limb, triggering a cascade of beneficial physiological effects.
The main aim of BFRT is to induce hypertrophy (hypertrophy = muscular growth), and it has shown to be very effective at achieving this . Hypertrophy is important because a bigger muscle means a stronger muscle, and strength is vital for almost all parts of life, not just for injury rehabilitation or when recovering from injury.
Whilst hypertrophy is generally the main aim of BFRT, it has a wide variety of physiological benefits beyond this, these benefits will be discussed further below .
What conditions and other health benefits can BFRT be used for?
BFRT can be utilised by health and rehab professionals to directly treat and in the treatment of a range of conditions and to achieve better general health outcomes. Some of these are;
- Post-surgical rehabilitation [3-14]
- Anterior Knee Pain (PFJP, Patella Tendinopathy) [15-18]
- Sarcopenia (age related loss of muscle mass)[19-26]
- Sports injury Rehabilitation [27-29]
- Strengthening for the management of
- Arthritis [15, 30-33]
- Osteoporosis/Osteopenia [34-38]
- Negate the negative effects of bed rest/immobilisation [12, 19, 39]
- Bone Fracture and Stress Injury Rehabilitation [19, 34-36, 40-42]
- Increased VO2 Max in elderly and athletic populations [24, 43-46]
- Improve vascular health/Circulation (Particularly in the elderly/aging population)[23, 25, 26, 47-52]
- Reduced risk of blood clots [25, 53, 54]
- Cardiac Rehab [55-57]
- Load management in athletes [58-61]
- Recovery post sports [62-64]
- Pre-Exercise Analgesia (pain reduction) [17, 65, 66]
- Ischemic preconditioning (preparing for exercise) [67, 68]
- Muscular gain for general health [20-26, 39, 41, 44, 60, 61, 69-81]
- Body Building [20-26, 39, 41, 44, 60, 61, 69-81]
- Diabetes management*
- Falls Prevention**
- Prevention of scar tissue formation***
*Increased muscle mass leads to reduced insulin resistance [82, 83]
** BFRT has been show to improve 30 second sit-stand test which is positively associated with reduced falls risk [25, 30, 31, 84-86]
*** BFR leads to down regulation of Myostatin which is a key step in scar tissue formation [87, 88]
Blood Flow Restriction Training vs High Load Resistance Training – same outcomes without the weight
Traditionally, high load resistance training (HLRT) is used to improve muscular strength and hypertrophy. Ultimately, by lifting heavy things our muscles will get stronger.
Where BFRT has great advantage over HLRT, is that hypertrophy and other beneficial health effects are able to be achieved using very light loads and in a short amount of time .
Simply put, BFRT = quick strength gains with low loads
Why would we only want to use light loads? This is to protect healing, compromised or sensitive tissue from injury which can occur by using too heavy a load.
We refer to a person with tissues described above as being “load compromised”, meaning they can’t handle heavy loads. A few examples of this are after surgery (e.g. ACL reconstruction), when a tissue is healing (e.g. a broken leg) or if a joint is degenerated (e.g. an arthritic knee).
Why not just use light loads by themselves?
A fair question to ask is why not just use light loads to achieve hypertrophy? Unfortunately, use of light loads alone does not cause enough stress to stimulate muscular hypertrophy .
To understand this better, it is helpful to know the two ways our body makes our muscles grow. These are in response to mechanical stress and metabolic stress .
- Mechanical stress, caused by lifting heavy loads above 70%+ of 1RM (1 RM = the maximum weight you can lift once),
- This leads to micro damage of muscle tissue. Micro damage is completely normal and when followed by natural healing, i.e. “Breaking down and building up”, leads to a bigger muscle.
- Blood pooling insode the limb stimulates the mTOR pathway – which is a pathway that stimulates the brain to upregulate protein synthesis – i.e. start building muscle
- Metabolic Stress is caused by a build-up of metabolites, which are natural chemicals, that our cells release in response to high intensity exercise (i.e. lifting heavy). These chemicals then stimulate the body to grow muscle.
Use of light loads alone does not cause enough of either of these stresses to stimulate the body to grow muscle.
How does the addition of Blood Flow Restriction make light loads stimulate hypertrophy?
BFRT is able to achieve increases in strength, but without the need for heavy loads predominantly by stimulating hypertrophy through metabolic stress pathways, along with sell swelling caused by blood pooling activating the mTOR pathway .
By restricting blood flow and using light loads during BFRT (lifting light or, in the very early stages of rehab, this exercise may be as light as walking or riding a bike with BFR), we deprive the working muscles of oxygen which leads to a build-up of metabolites & cell swelling in the working limb.
The hypoxic (low oxygen) environment also causes the Type II muscle fibres (strength fibres) to contract instead of type I fibres (endurance fibres).
This mimics what would occur using traditional HLRT, without mechanical force on the working tissues, meaning it safe for the tissues when load compromised.
Basically – your body gets tricked into working hard using a light load, which makes BFRT a fantastic tool to build strength, particularly in a rehabilitation setting.
Why not use BFRT instead of high load resistance training all the time?
A question that is often asked is “why would we not use BFRT in preference to HLRT all the time?”, there are two main reasons for this.
Firstly, if we look beyond just muscular strength, other tissues in our body, namely tendon and bone, require mechanical loading to build up strength and stay healthy. Utilisation of HLRT induces beneficial changes in bone and tendon health that BFRT cannot [91, 92].
On top of the benefit to tendon and bone, most studies show that HLRT leads to strength gains of 1.3-1.6x greater than BFRT [31, 35, 38, 41, 61, 71, 73, 77, 79, 93, 94], so to reach maximum levels of strength, HLRT is advised.
This is a consideration when rehabbing or preparing athletes for high level performance, where max strength is an important attribute.
In most cases, but not always, the goal is to progress onto HLRT. BFRT plays a vital role in starting rehabilitation and more specifically, building strength, much earlier than what otherwise could have without BFRT.
This also makes the commencing HLRT easier to achieve and it can be started at a much higher level, reducing overall rehabilitation times and improving outcomes.
How long does BFR take to work?
Improvement in muscular hypertrophy and strength can generally be seen after 2 weeks using BFRT, this is in comparison to traditional HLRT that takes 8-12 weeks to see improvements.
The reason for this difference is that strength gains seen using BFRT are driven by changes in the muscle tissue itself (i.e. hypertrophy)  whereas strength gains seen with traditional HLRT are driven by the nervous system for the first 8 weeks then hypertrophy takes over after that .
This is often taken into consideration when rehabilitating an athlete that needs to get back to performing very quickly.
The many physiological benefits of BFRT (it’s more than just hypertrophy)
Whilst hypertrophy has traditionally been the main aim of BFRT, a number of other physiological benefits have been discovered to be induced by BFRT
These are angiogenesis (growth of new blood vessels) , analgesia (pain reduction) [65, 66], reduced autophagy (tissue break down) [55, 80] and improvements in VO2 max (cardiovascular health) 
What does a session of Blood Flow Restriction Training involve? – the practical side
A session of BFRT will be different depending on a number of factors including what injury you have, what your goals are, your general health and how much training you have done in the past. This will be tailored to you by your physiotherapist to ensure it is effective and safe.
There are 3 ways we use BFRT, BFR + Resistance Training (BFR-RT), BFR + Aerobic Exercise (BFR-AE) and Passive BFR a thorough description of each and their applications can be found here.
In clinic BFR-RT and BFR-AE are the most common applications and a session will follow these steps;
- Safety checks
- make sure it is safe to conduct the session
- Find Arterial Occlusion Pressure (AOP)
- AOP = amount of pressure the cuff is inflated to that stops arterial blood flow into the limb
- This is the same as your systolic blood pressure (the higher number on a blood pressure reading)
- May not occur every session – commonly rechecked every 1-4 weeks
- Determine what % of AOP training will occur at
- Up to 50% is used in the arm and 80% is used in the leg
- Early in training lower pressures are used and then advanced
- These pressures allow blood to flow into the limb, but not out, which leads to the all-important pooling.
- Commence the exercise
- Lift a load 30% or less of 1RM
- 75 reps in sets of 30/15/15/15 with 30 seconds rest between
- Load will be advanced over time
- Undertake aerobic exercise for a set amount of time
- Commonly begins at 5 minutes and is progressed from there
- Cuffs are deflated
- If a second round of BFR is to be conducted within the same session
- 5 minutes rest if exercising the same limb
- Commence immediately if exercising a different limb
- If a second round of BFR is to be conducted within the same session
Is BFRT Safe?
As with any therapeutic or fitness intervention, safety must be the first consideration before undertaking BFRT. Overall, BFRT has been shown to be very safe, just as safe as regular strength training in fact [96, 97].
But there are some people that cannot use BFRT, here’s a list of common conditions that may exclude someone from being able to use BFRT.
- Unstable Cardiac Disease
- Active or recent blood clots including Deep Vein Thrombosis (DVT)
- Severe varicose veins
- Active infection
The BIG question – does BFRT increase the risk or cause blood clots?
As BFRT causes blood to pool inside the limb, a common question is about the risk of thrombogenesis (blood clots) or DVT whist using BFRT.
Current evidence suggests that there is no increased risk of blood clots or DVT whilst using BFRT, in those that do not already show signs or risk factors of clotting or DVT .
Blood clots are caused by 3 factors, known as “Virchow’s Triad”. 1. Stasis (stagnant blood), usually through inactivity, such as bed rest or long-haul travel, 2. Hypercoagulation (excessively easy clotting of the blood) and 3. Endothelial (Blood Vessel) damage .
Whilst BFRT does lead to partial stasis in the limb, the lack of complete occlusion by only using a % of AOP and also the short time BFRT is used (usually 8 minutes) ensures stasis is not to a level to induce coagulation. Patients will be assessed for the two other factors. Further to this BFRT does not show an increase of markers of thrombogenesis in the blood .
In fact, there is emerging evidence that BFRT is protective against blood clots and DVT through the release of Tissue Plasminogen Activator (tPA) which is a protein involved in the break-down of blood clots  and also by improving vein health [47-50, 52].
All patients will be screened by a health care professional prior to any BFRT to assess if it is appropriate and safe for them to undertake.
How do I know if BFRT is right for me?
The best way to assess if BFRT is appropriate to be used in your rehabilitation or general health care is to contact a physiotherapist or health care provider qualified in Blood Flow Restriction Training.
Also, here are some further articles written by Compete Physio team members on BFRT
For more information or book in for a physio assessment to find out if BFRT is an option for you, please email Reece direct on firstname.lastname@example.org.
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