Blood Flow Restriction Therapy

Tyler Magaha, PT, DPT, CSCSFounder/Owner Warrior Sports Physical Therapy 3316 5th Avenue Suite 300, Altoona, PA 16602

There is a new rehabilitation tool that has become popular among healthcare professionals, particularly physical therapists. This tool is called blood flow restriction therapy, or BFR for short. Most, if not all physical therapists and orthopedic/sports medicine doctors have become familiar with this tool and its usage, however a lot of patients that come in to me still are not familiar with BFR and its uses/benefits. I am writing this article to clarify what BFR is and what its most common uses are in the orthopedic and sports medicine setting.

The proof is out there. BFR is an EXTREMELY effective physical therapy rehabilitation tool. Most research done on BFR focuses on subsequent muscle strength and hypertrophy gains that result from its usage, especially post-operatively. Traditional research performed on muscle  hypertrophy suggests that an individual must lift at least 65% of their 1 RM in order to elicit hypertrophy gains. Research on BFR shows that loads as low as 20-30% of 1 RM can create the same exact muscle hypertrophy stimulus! 

There are two different training goals that I commonly use BFR for:

  1. The postoperative patient/athlete. As a rehab professional, there is a need to respect tissue healing times, therefore it is inappropriate to externally load a patient at 65% of their 1 RM right after a surgery. BFR allows us to regain muscle strength and hypertrophy in and around the surgically altered tissues without risking tissue damage. One systematic review even writes: “Compared with low-load training, low-load BFR training is more effective, tolerable, and therefore a potential clinical rehabilitation tool.”
  2. An athlete needs extra volume work in their programming, however external stress is already high (ex. In-season competition) and more heavy volume loading may not be the most viable option for them. 

Other research looking at strength gains has shown that there is potential for significant strength gains with BFR training. It is important to note that this is still less than than strength gains seen with heavy loading (I will refer back to this later), however it is extremely promising to know that when heavy external loading is not allowed (i.e after surgery), we can still get stronger!

So, how does BFR create this muscle hypertrophy and strength stimulus? I like to explain the answer to this question in as simple of a way as possible: BFR is a way to mimic a strength training environment without the external mechanical load. BFR usage forces strength training to occur not because the individual is working at an intensity that would elicit a strength training response, but because the individual is not even given the biological resources to do anything other than strength train. By depriving muscle tissue of oxygen via blood flow to the area, there is no way the body can train aerobically, so you are forced to strength train whether you want to or not. 

So this begs the question: Tyler, when do you use BFR clinically? All this information is nice, but simplify this and tell me how you use BFR in your physical therapy clinic. First off, I just want to give a shout out to SmartTools BFR2. I use their unit because it is personally calculated based on my patients current blood pressure and it is extremely easy to use and mobile. I use BFR on almost all of my patients post-operatively. I am always very diligent in screening for red flags and contraindications that may make BFR an viable option with a patient, however a majority of patients are able to use this. I typically will use a 30, 15, 15, failure rep scheme for each exercise. This rep scheme is common practice, however research shows that proper occlusion pressure and total occlusion time matter more than rep scheme. 


I will also use BFR when patients present with significant muscle atrophy in order to regain hypertrophy in those tissues. I use BFR when patients, particularly athletes come to me with isolated muscle strength and hypertrophy asymmetries that I believe are directly contributing to their chief complaint, but are in-season or already overloaded via other physical activity. Lastly, I have found success using BFR with overuse tendinopathy injuries, such as: lateral epicondylitis (tennis elbow), medial epicondylitis (golfers elbow), patellar tendinopathy (runners knee), and achilles tendinopathy. 

Overall, blood flow restriction training is a powerful tool that can provide a high level of value to your patients within your physical therapy clinic. These pieces of equipment are not cheap, however are well worth the investment into your physical therapy patients and will be a supplement in providing them the highest level of care possible.  

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