The 4 Pillars of Blood Flow Restriction
Ischemic Pre-Post Conditioning/Cell Swelling
Short passive intervals with partial or total Limb Occlusion Pressure (90-100% LOP).
1. to attenuate loss of muscle mass when partially bedridden after surgery with load bearing restrictions.
2.Post Exercise for faster restitution.
3. Ischmemic Pre-Conditioning (IPC) for improved performance.
Low Intensity Cardiovascular Exercise
Performed continuously or in intervals with your preferred cardio vascular exercise.
Implications: In extension of 1st application simple cycling or walking when weight bearing activities are approved. Used in combination with BFR to regain muscle mass and strength. You can actually improve your muscle mass, strength and aerobic function depending on the starting point even at early rehab stages by applying the 2. Pillar.
Low Intensity Resistance Training
Augment your low-load training by BFR with less joint stress. Implications: Primarily as a bridge towards conventional resistance training during rehab. But also applicable for the average gym rat who would like to increase or maintain strength with less load, which is especially relevant for those who wants to build or maintain muscle mass as a supplement to high-load resistance training programs.
Return To Sport & Performance Applications
Improve athletic performance e.g. sprint speed and aerobic conditioning through interval training at submaximal effort and intensity.
For Additional Information About Specific Protocols Check The Complete BFR Guide From the Top Menu
The pillars are a progressive and systematic approach to blood flow restriction to help You or Your client from early rehab such as bedrest to athletic performance. These pillars can be progressed sequentially. The fourth pillar – return to sport applications is a less explored field of research, but You should expect more research in the future – stay tuned!
Please also see the Complete Blood Flow Restriction BFR Guide for a comprehensive run-through on the practical implementation and safety
- Resistance Training at about 20-50% of 1 Repetition Maximum (1RM) i.e. light to moderate load 30x15x15x15 reps with 30-45 seconds inter-set rest.
- Light plyometric training e.g. skipping and BFR running (not recommended to do powerful jumps such as box-jumps or maximum sprints
- Ischemic post-conditioning for improved restitution after exercise
- As a supplementation to Electrical Muscle Stimulation (EMS) in severe cases of muscle loss or difficulty in recruiting muscle, e.g. after reconstruction of cruciate ligament
- Potential add-on to Virtual Reality Rehab modalities GonioVR
BFR can be effectively combined with training, in several different ways and even without training or exercise
The Following applications should be used accordingly to the objective of the training, i.e. implications. In popular BFR science we identify these applications as the 4 pillars of Blood Flow Restriction:
Short intervals with partial or full Limb Occlusion Pressure (90-100% LOP) with or even without muscle contraction. Follow this link for an abstract on how to slow down loss of muscle mass in even in the absence of muscle work.
Implications: For example, as partially bedridden after major orthopedic surgical operations with severe restrictions, e.g. reconstruction of cruciate ligament or traumatic shoulder luxation’s.
Relevant products for you or your client will be “Rehab – Lower Body” or “Rehab – Upper Body”. Please notice, the Bluetooth Device can be used to assess LOP.
Combined with cardiovascular exercise:
Performed continuously or in intervals with your preferred cardio vascular exercise.
Implications: In extension of 1st application when weight bearing is aloud, simple walking on a treadmill or bike in combination of BFR are useful. You can actually improve your muscle mass, strength and aerobic function depending on the starting point even at this stage. In daily speech, this means that one can improve rapidly, i.e. “fast-track rehabilitation”.
Relevant products for you or your client, primarily: “Performance – Lower Body”, but also “performance – Upper Body” e.g. in the case of exercises with relevant fatigue of the upper body muscles.
Combined with low- or moderate load resistance training:
Implications: For all who wants to increase or maintain their strength but especially for those who want to build or maintain muscle mass often as supplementation to lifting heavy loads.
Relevant products for you or your client: all Complete Models.
Ischemic Post-conditioning or restitution modality.
When & Why?
Occlusion training for bodybuilders only?
No, not at all! In fact, there are important research on miscellaneous muscle and skeletal pathologies which proves that occlusion training (BFR) has significant effect on both strength and Patient Reported Outcome Measures (PROM). As a rule of thumb occlusion training is indicated if you have an acute or overload injury where you cannot do conventional resistance training i.e. lift heavy. For example, following orthopedic surgeries with absolute weight- or load bearing restrictions, or chronic conditions such as arthritis, as a many will find joint pain or joint swelling worsens during and after conventional resistance training. In such cases BFR exercises should be “first-line therapy”. Considering the above rationale, one can wonder why only a few private or public providers offers BFR therapy? – But as with so much other new technology, thus evidence-based, the implementation is always delayed. But especially considered the amount of high quality research i.e. randomized controlled trials (RCT’s) and the meta-analysis, BFR is here to stay and only tp grow in popularity in the forthcoming.
Below is listed some of the relevant musculoskeletal pains and other pathologies with reference to the relevant literature and RCT’s, in which BFR can be an effective therapy strategy for.
Relevant BFR Research from Prehab to Rehab Performance & Maintenance
- Diverse knee and hip conditions (1,2,3)
- Arthritis i.e. osteoarthritis and rheumatoid arthritis (4,5,6,7)
- Prehab and Rehab after ACL injuries (7,8)
- Patella femoral pain (PFP) aka. anterior knee pain (9,10,11)
- Joint replacements i.e. artificial shoulder, hip or knee (12,13)
- Degenerative and acute meniscus injuries (14,15)
- Hip impingement (FAI) (16)
- Unspecific shoulder pain and shoulder strength (17,18,19)
- Osteoarthritis of the GH and AC joint (different shoulder pains) (20,21)
- Bone fractures (20,21,22)
- Tendon injuries and tendon surgery (16,23,24)
- Disc herniation and non-specific back pain (25,26)
- Cartilage Injuries (20,21)
- Various muscle injuries (1)
- Sarcopenia, osteopenia and osteoporosis (27)
- General muscle building as an alternative or supplement to other training methods (27,28)
- Sports specific performance and support training (29-36)
- Aerobic Performance (VO2max) – Cardiovascular training – low intensity exercise i.e. on bike or treadmill (37-41)
- Improved Cardiovascular Health (42,43)
- Patient Reported Outcomes Measures (PROM) – Especially relevant for the elderly or impaired (5)
- Tendon Health & Tendinopathy (44,45)
- Football aka. Soccer Performance (46)
- Attenuate Muscle loss during Immobilization (47)
- Contra Lateral Effect on strength and hypertrophy (48)
- Hand Strength relevant for hand and finger arthritis (49)
- Sprint Speed / Running Velocity (34,35,36)
- Hypoanalgesic response aka. acute pain reduction (52)
- Hip arthroscopy rehab (research study in progress) (40)
- Physical function indicative of Activities of Daily Living (ADL) (53)
- Muscle strength and body composition in people living with HIV/AIDS (54)
- Type 2 Diabetes (55,56)
- Multiple Sclerosis as Static Balance, Lower Extremity Strength, and Thigh Hypertrophy (57)
- BFR in combination with Electrostimulation (EMS) in sever cases of muscle loss or inhibition (58)
1 Hughes et al. (2017) Blood flow restriction training in clinical musculoskeletal rehabilitation a systematic review and meta-analysis
2 Slysz et al. (2016) The efficacy of blood flow restricted exercise A systematic review & meta-analysis
3 William et al. (2017 Blood Flow Restriction Training- Implementation into Clinical Practice
3b Rush University Medical Center (2020) in progress Blood Flow Restriction Following Hip Arthroscopy. Not finished A/O 2020)
4 Segal et al. (2015) Efficacy of Blood Flow Restricted Low-Load Resistance Training in Women with Risk Factors for Symptomatic Knee Osteoarthritis
5 Ferraz et al. (2018) Benefits of Resistance Training with Blood Flow Restriction in Knee Osteoarthritis
6 Roschel et al. (2016 Low-intensity Resistance Training With Blood Flow Restriction Increases Muscle Function And Mass In Rheumatoid Arthritis
7 Harper et al. (2019) Blood-Flow Restriction Resistance Exercise for Older Adults with Knee Osteoarthritis- A Pilot Randomized Clinical Trial
7 Bryk et al. (2016) Exercises with partial vascular occlusion in patients with knee osteoarthritis a randomized clinical trial
7 Takarada et al. (2000) Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles
8 Hughes et al. (2018) Blood Flow Restriction Training in Rehabilitation Following Anterior Cruciate Ligament Reconstructive Surgery A Review
9 Ohta et al. (2003) Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction
10 Giles et al. (2017 Quadriceps strengthening with and without blood flow restriction in the treatment of PFP
11 Koråkakis et al. (2018) Blood Flow Restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading
12 Franz et al. (2018) Blood flow restriction training as a prehabilitation concept in total knee arthroplasty: A narrative review about current preoperative interventions and the potential impact of BFR
13 Gaunder et al. (2017 Occlusion training- pilot study for postoperative lower extremity rehabilitation following primary total knee arthroplasty
14 Blood Flow Restriction Training in Patients With Weight Bearing Restrictions After Knee Surgery. Not finished A/O 2020)
15 The Effect of Blood Flow Restriction Training on Muscle Atrophy Following Knee Surgery. (Not finished A/O 2020)
16 Scott et al. (2015) Exercise with blood flow restriction: an updated evidence-based approach for enhanced muscular development
17 Dankel et al. (2016) The Effects of Blood Flow Restriction on Upper-Body Musculature Located Distal and Proximal to Applied Pressure
18 Lambert et al. (2019) Blood Flow Restriction for Strengthening of the Rotator Cuff and Injury Prevention
19 Bowman et al. (2020) Upper-extremity blood flow restriction- the proximal, distal, and contralateral effects- a randomized controlled trial
19 Yasuda et al. (2010) Effects of low-intensity bench press training with restricted arm muscle blood flow on chest muscle hypertrophy- A pilot study
20 Bittar et al. (2018) Effects of blood flow restriction exercises on bone metabolism: a systematic review
21 Loenneke et al. (2013) Rehabilitation of an osteochondral fracture using blood flow restricted exercise a case review
22 Cancio et al. (2018) Blood Flow Restriction Therapy after Non-Operative Management of Distal Radius Fracture- A Randomized controlled pilot study
23 Mohmara et al. (2014) 5 Effects Of Low-intensity Concentric Combined With Blood Flow Restriction On Achilles Tendon
24 Yow et al. (2018) Blood Flow Restriction Training After Achilles Tendon Rupture
25 Amano et al. (2016) Effectiveness of blood flow restricted exercise compared with standard exercise in patients with recurrent low back pain: study protocol for a randomized controlled trial (not finished)
26 Stavres et al. (2018) The Feasibility of Blood Flow Restriction Exercise in Patients With Incomplete Spinal Cord Injury
27 Clarkson et al. (2017) Blood flow restriction walking and physical function in older adults- A randomized control trial
28 Rolnick et Schoenfeld (2020) Blood Flow Restriction Training and the Physique Athlete- A Practical Research-Based Guide to Maximizing Muscle Size
29 Christiansen et al. (2020) Training with blood flow restriction increases femoral artery diameter and thigh oxygen delivery during knee-extensor exercise in recreationally trained men
30 Christiansen et al. (2019a) Blood flow-restricted training enhances thigh glucose uptake during exercise and muscle antioxidant function in humans
31 Christiansen et al. (2019b) Cycling with blood flow restriction improves performance and muscle K+ handling and blunts the effect of antioxidant infusion in humans
32 Christiansen et al. (2018) Increased FXYD1 and PGC‐1α mRNA after blood flow‐restricted running is related to fibre type‐specific AMPK signalling and oxidative stress in human muscle
33 Takarada et al. (2002 Effects of resistance exercise combined with vascular occlusion on muscle function in athletes
34 Taylor et al. (2016) – Acute and chronic effect of sprint interval training combined with postexercise blood-flow restriction in trained individuals
35 Behringer et al. (2016) Low-Intensity Sprint Training With Blood Flow Restriction Improves 100-m Dash
36 Abe et al. (2015) Eight days KAATSU-resistance training improved sprint but not jump performance in collegiate male track and field athletes
37 Bennett et al. (2019) effects of blood flow restriction training on aerobic capacity and performance: A systematic review
38 Paton at al. (2017) The effects of muscle blood flow restriction during running training on measures of aerobic capacity and run time to exhaustion
39 Held et al. (2020) Low intensity rowing with blood flow restriction over 5-weeks increases VO2max in elite rowers- A randomized controlled trial
40 Kim et al. (2016) Comparative Effects of Vigorous-Intensity and Low-Intensity Blood Flow Restricted Cycle Training and Detraining on Muscle Mass, Strength, and Aerobic Capacity
41 Daeyeol et al. (2016) Comparative Effects of Vigorous-Intensity and Low-Intensity Blood Flow Restricted Cycle Training and Detraining on Muscle Mass, Strength, and Aerobic Capacit
42 Tanaka et al. (2017) The impact of aerobic exercise training with vascular-ESC_Heart_Failure
43 Nascimento et al. (2019) Effects of blood flow restriction exercise on hemostasis: a systematic review of randomized and non-randomized trial
44 Skovlund et al. (2020) The effect of low-load resistance training with blood flow restriction on chronic patellar tendinopathy – a case series
45 Centner et al (2019) Low-Load blood flow restriction training induces similar morphological and mechanical Achilles tendon adaptations compared to high-load resistance training
46 Kubo et al. (2006) Effects of low-load resistance training with vascular occlusion on the mechanical properties of muscle and tendon
47 Amani et al. (2019) BFR During Futsal Training Increases Muscle Activation and Strength
48 Barbalho et al. (2018) Addition of blood flow restriction to passive mobilization reduces the rate of muscle wasting in elderly patients in the intensive care unit – a within-patient randomized trial
49 Bowman et al. (2019) Proximal, Distal, and Contralateral Effects of Blood Flow Restriction Training on the Lower Extremities: A Randomized Controlled Trial
50 Velic & Hornswill (2014) KAATSU Training and Handgrip Strength
51 Credeur et al. (2010) Effects of handgrip training with venous restriction on brachial artery vasodilation
52 Hughes & Patterson (2019) Low intensity blood flow restriction exercise: Rationale for a hypoalgesia effect
53 Clarkson et al. (2019) Chronic Blood Flow Restriction Exercise Improves Objective Physical Function- A Systematic Review
54 Alves et al. (2020) Resistance training with blood flow restriction: impact on the muscle strength and body composition in people living with HIV/AIDS
55 Honda et al. (2016) Stair climbing-descending exercise for a short time decreases blood glucose levels after a meal in people with type 2 diabetes
56 Yoshihara et al. (2016) Effect of 6-Month Walking and Stair-Climbing Exercise Program and Walking with Blood Flow Restriction on Body Composition and Hemoglobin A1c Levels in Elderly People
57 Darvishi et al. (2017) Effect of Aerobic Training with Blood Flow Restricting on Static Balance, Lower Extremity Strength, and Thigh Hypertrophy in Females with Multiple Sclerosis
58 Natsume et al. (2015) Effects of Electrostimulation with Blood Flow Restriction on Muscle Size and Strength
Slysz et Burr (2018) The Effects of Blood Flow Restricted Electrostimulation on Strength and Hypertrophy