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How Effective is Blood Flow Restriction in Rehabilitation?

Blood flow restriction (BFR) training is a training method that utilizes a pneumatic cuff (like what’s used when taking blood pressure) or elastic straps to reduce blood flow to muscles during low load strength training. While wearing the cuff with moderate pressure (40% arterial occlusion), patients exercise at 30-40% of their one rep maximum. During heavy load strength training patients typically exercise at 70% of their one rep maximum. While the literature suggests that blood flow restriction training is safe, some of the safety concerns include potential peripheral blood vessel damage, increased sympathetic nervous system response, and decreased nerve conduction velocities. There are definite benefits regarding muscle hypertrophy (how big the muscle appears) but long-term strength gains still need more investigation.

Systematic reviews on blood flow restriction show that low load strength training with blood flow restriction was more effective than low load strength training alone, but not as effective as heavy load training without blood flow restriction.

In summary, there may be specific populations that benefit from blood flow restriction (depending on the goals of the individuals) but it is not necessary in achieving optimal results with your rehabilitation.

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Marc Hunley, PT, DPT

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Research Summaries:

Blood Flow Restriction Training After Knee Arthroscopy: A Randomized Controlled Pilot Study. David J. Tennent, MD,* Christina M. Hylden, MD,* Anthony E. Johnson, MD,* Travis C. Burns, MD,* Jason M. Wilken, PhD,† and Johnny G. Owens, mPT† (Clin J Sport Med 2017;27:245–252)

Seventeen patients completed the study. Significant increases in thigh girth were observed in the blood flow restriction (BFR) group at 6-cm and 16-cm proximal to the patella (P = 0.0111 and 0.0001). All physical outcome measures significantly improved in the BFR group, and the timed stair ascent improvements were greater than conventional therapy (P = 0.0281). The VR-12 and KOOS subscales significantly improved in the BFR group, and greater improvement was seen in VR-12 mental component score (P = 0.0149). The BFR group displayed approximately 2-fold greater improvements in extension and flexion strength compared with conventional therapy (74.59% vs 33.5%, P = 0.034). No adverse events were observed during the study. Take home point: In the 17 patients who participated in this study, blood flow restriction training produced greater thigh girth, greater confidence in knee function, and better timed stair ascent scores.

Magnitude of Muscle Strength and Mass Adaptations Between High-Load Resistance Training Versus Low-Load Resistance Training Associated with Blood-Flow Restriction: A Systematic Review and Meta-Analysis. Manoel E. Lixandra , Carlos Ugrinowitsch, Ricardo Berton, Felipe C. Vechin, Miguel S. Conceic, Felipe Damas, Cleiton A. Libardi, Hamilton Roschel (Sports Med DOI 10.1007/s40279-017-0795-y)
Based on the present data, maximum muscle strength may be optimized by specific training methods (i.e., high-load resistance training) while both high-load and blood flow restriction with resistance training seem equally effective in increasing muscle mass. Take home point: High load resistance training improves muscle strength over low load resistance training with blood flow restriction but they were both equally effective in increasing muscle mass. Further investigation needs to be done to determine if blood flow restriction would benefit individuals with physical limitations.

Effects of Blood Flow Restriction Training on Muscular Strength and Hypertrophy in Older Individuals: A Systematic Review and Meta‑Analysis. Christoph Centner, Patrick Wiegel, Albert Gollhofer, Daniel König; Sports Medicine (2019) 49:95–108
A total of 2658 articles were screened, and 11 studies with a total population of N = 238 were included in the meta-analysis. Take home point: This systematic review and meta-analysis reveals that low-load blood flow restriction (BFR) and walking with BFR can stimulate muscle hypertrophy and strength gains in older populations. But, BFR research is still limited and further investigation needs to be done to support the use of it in the older individuals.

Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Hughes L , et al. Br J Sports Med 2017;0:1–11. doi:10.1136/bjsports-2016-09707
Twenty studies were eligible, including ACL reconstruction (n=3), knee osteoarthritis (n=3), older adults at risk of sarcopenia (n=13) and patients with sporadic inclusion body myositis (n=1). Analysis of pooled data indicated low-load blood flow restriction training had a moderate effect on increasing strength, but was less effective than heavy-load training. Take home point: Heavy load resistance training was more effective in increasing strength versus low load resistance training with blood flow restriction.

Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction. Journal of Sport and Health Science. 13(1)· April 2015
All 24 subjects in this study (they were divided into 2 groups) had a significant reduction of quadriceps anatomical cross section area (ACSA) from 2 days before surgery to 16 days after surgery. During the intervention period, the occlusion group lost 13.8% and the control group lost 13.1% of their quadriceps ACSA, respectively. Take home point: There was no significant difference between the occlusion and control groups with regards to atrophy of the quadriceps muscles following ACL reconstruction surgery.

The Role of Blood Flow Restriction Therapy Following Knee Surgery: Expert Opinion. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 8 (August), 2018: pp 2506-2510
Take home point: Research has demonstrated only short-term improvements (2-16 weeks) in muscle strength and hypertrophy with blood flow restriction application following knee surgery. Thus, the long term benefits have yet to be determined.

Blood flow restriction training and the exercise pressor reflex: a call for concern. Am J Physiol Heart Circ Physiol (September 4, 2015). doi:10.1152/ajpheart.00208.2015
Due to concerns that excessive restriction from blood flow restriction could lead to overactivation of muscle reflexes and/or central command with the consequential development of sympathetic hyper-reactivity and increased risk for cardiovascular-related adverse events, the safety of Kaatsu methods must be tracked. This is particularly true for individuals with established cardiovascular disease (e.g., HTN, HF, PAD), as even appropriate use of blood flow restriction techniques could lead to clinical deterioration due to intermittent sympathetic overactivity and blood pressure elevation. The latter is of considerable concern given the prevalence of undiagnosed and uncontrolled HTN and PAD within the U.S. population.


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