Blood flow restriction training (BFR), Occlusion therapy, Kaatsu training.
Completely new phrases, or a staple of your exercise routine?
Irrespective of your familiarity you may be asking yourself these questions.
Why are they training with tourniquets on their legs?
Is that just for Bodybuilders?
Is that not Dangerous?
Would you be interested if I told you that BFR training means you can achieve the same strength and muscle size results from lifting light weights compared to lifting heavy.
The blog post today is aiming to clear up common misconceptions, including the above questions. I will touch upon the science but most importantly suggest how you can implement BFR into your lifestyle or rehab journey to accelerate your results.
Irrespective of your views on going to the gym or lifting weights, strength training is good for you. Period.
If you are Athletic, suffer with osteoarthritis or are 99 years old you stand to benefit from performing resistance training to increase your strength.
Being stronger can aid athletic performance, control joint stresses, and improve your posture. Not to mention it is fundamental to help the 99-year-old out of the chair or up from the toilet.
The American college of sports medicine recommends that adults perform regular heavy load resistance training using external loads of 60-90 % of 1 repetition maximum to improve maximal strength gains (Garber et al., 2011).
However, some of you may find the thought of pushing yourself that close to your maximal capacity intimidating.
Although I actively encourage progressive strength programmes for all, research has shown that within the elderly populations heavy strength training results in high rates of programme dropouts due to joint flair ups and muscle aggravations (Liu and Latham., 2010).
Lifting close to your maximum may also not be advisable for people who need to prioritise tissue healing, or whose pain is a primary limiting factor.
Blood Flow restriction training
Originating from Japan in the 1970s but more recently gaining traction in the medical community BFR was devised from self-experimentation.
After kneeling for hours on his haunches whilst praying, Dr Yoshiaki Sako found that he had achieved a muscular pump in his calf muscles comparable with performing multiple sets of calf raises.
What ensued was years of trial and error.
A Deep Vein Thrombosis.
But critically some interesting findings of muscular development.
The technology and safety of the process has developed significantly since then, but the principle remains the same.
Research has shown that when performed effectively BFR training can elicit amazing results and can be an invaluable tool for multiple groups of people.
It has been shown that similar strength and muscular size benefits can be found by lifting 20% of your one rep max weight with BFR compared to traditional strength regimes without BFR (80-95% 1RM) (Gronfeldt et al., 2020).
And it is not just strength improvements.
Light Cycling with BFR has shown to elicit a greater aerobic fitness response compared to light cycling without BFR (Silva et al., 2019)
When BFR training is performed, limb venous returned is purposefully reduced/ inhibited using a cuff. In the clinic we have invested in cuffs that auto regulate the pressure after measuring the blood flow in relation to the pressure of the band.
With the limb occluded the physiological effect of the exercise changes slightly.
Because the limb blood flow is altered, and blood oxygen is limited it causes a preferential recruitment of your stronger/ faster muscle fibre types.
This is alongside a cell swelling response.
When combined, the overall effect is one of increased growth hormone production and increased protein synthesis (Loenneke, J. P. et al., 2012)(Yasuda. T., 2008)(Fujita, S.,2008)
In simple terms it places the muscle in a greater stress state for less effort. Catalysing the effects you would usually see from lifting heavier loads. This equals greater strength, aerobic fitness, and muscle size.
See the table below for an example of how the session format should be designed.
Strength Session Protocol
Aerobic Session Protocol
Why do Physios use it?
A large amount of Physiotherapy is about returning a client’s strength or advancing their strength beyond where it was preinjury/ surgery.
However, there are times in which lifting heavy weights is challenging due to pain, inflammation, and tissue healing.
This is where BFR is invaluable.
I can get a client stronger, faster and with less risk of them flaring up their pain as we can get great strength results with less load.
In fact, when compared to low load training alone BFR is preferential for patients recovering from ACL surgery and Osteoarthritis (Hughes et al., 2017a).
This is even more advantageous as BFR has been shown to work with exercises that can be performed very early post operatively whilst still in bed (Kubota et al., 2011)(Gorgey et al., 2016).
This method is known as passive BFR and we will be releasing a video very soon to highlight how it Is best performed.
Additionally, BFR has been shown to decrease pain when exercising. Specifically, if you are suffering with Patellofemoral pain syndrome (Korakakis, Whiteley and Giakas, 2018). This may result in an increase range of exercises being available for you to perform. Or returning to normal exercises sooner than you expected.
So, If we go back to those initial questions people may ask about BFR.
Why are you training with tourniquets on your legs/ arms ?
BFR allows for greater strength, size and aerobic fitness adaptations by lifting relatively light weights compared with traditional strength routines
Is it just for Bodybuilders?
Although this can be a great tool for bodybuilders, BFR training can be a useful tool for many different populations. Ultimately this exercise method best serves people who are either at risk of high load training/ cannot access heavy loads or want to vary their programming.
In short. Athletes, rehabbers, astronauts, and the elderly.
Is it Dangerous?
The safety of BFR has been extensively reviewed and has shown to provide no greater risk than heavy load training (Loenneke, J. P. et al., 2011; Loenneke, J. P. et al., 2014). Although for appropriate selection I would advise that you get in contact with a health professional who has experience of working with the modality as there are some screening questions to go through beforehand.
Watch this space for prescriptions of how to apply this form of training into your routine and how we use it to rehab clients.
Abe, T., Fujita, S., Nakajima, T., Sakamaki, M., Ozaki, H., Ogasawara, R., Sugaya, M., Kudo, M., Kurano, M., Yasuda, T., Sato, Y., Ohshima, H., Mukai, C. and Ishii, N., 2010. Effects of low-intensity cycle training with restricted leg blood flow on thigh muscle volume and VO2max in young men. Journal of Sports Science and Medicine, 9(3), pp. 452-458.
Abe, T., Kearns, C.F. and Sato, Y., 2006. Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training. Journal of Applied Physiology, 100(5), pp. 1460-1466.
Appell, H.J., 1990. MUSCULAR-ATROPHY FOLLOWING IMMOBILIZATION - A REVIEW. Sports Medicine, 10(1), pp. 42-58.
Berneis, K., Ninnis, R., Haussinger, D. and Keller, U., 1999. Effects of hyper- and hypoosmolality on whole body protein and glucose kinetics in humans. American Journal of Physiology-Endocrinology and Metabolism, 276(1), pp. E188-E195.
Brandner, C.R., Warmington, S.A. and Kidgell, D.J., 2015. Corticomotor Excitability is Increased Following an Acute Bout of Blood Flow Restriction Resistance Exercise. Frontiers in Human Neuroscience, 9.
Centner, C., Lauber, B., Seynnes, O.R., Jerger, S., Sohnius, T., Gollhofer, A. and Konig, D., 2019. Low-load blood flow restriction training induces similar morphological and mechanical Achilles tendon adaptations compared with high-load resistance training. Journal of Applied Physiology, 127(6), pp. 1660-1667.
Clark, B.C. and Manini, T.M., 2017. Can KAATSU Exercise Cause Rhabdomyolysis? Clinical Journal of Sport Medicine, 27(1), pp. E1-E2.
Corvino, R.B., Rossiter, H.B., Loch, T., Martins, J.C. and Caputo, F., 2017. Physiological responses to interval endurance exercise at different levels of blood flow restriction. European Journal of Applied Physiology, 117(1), pp. 39-52.
Crossley, K.W., Porter, D.A., Ellsworth, J., Caldwell, T., Feland, J.B., Mitchell, U., Johnson, A.W., Egget, D. and Gifford, J.R., 2020. Effect of Cuff Pressure on Blood Flow during Blood Flow-restricted Rest and Exercise. Medicine and Science in Sports and Exercise, 52(3), pp. 746-753.
da Silva, J.C.G., Silva, K.F., Domingos-Gomes, J.R., Batista, G.R., Freitas, E.D.D., Torres, V.B.C. and Cirilo-Sousa, M.D., 2019. Aerobic exercise with blood flow restriction affects mood state in a similar fashion to high intensity interval exercise. Physiology & Behavior, 211, p. 6.
de Boer, M.D., Selby, A., Atherton, P., Smith, K., Seynnes, O.R., Maganaris, C.N., Maffulli, N., Movin, T., Narici, M.V. and Rennie, M.J., 2007. The temporal responses of protein synthesis, gene expression and cell signalling in human quadriceps muscle and patellar tendon to disuse. Journal of Physiology-London, 585(1), pp. 241-251.
Fatela, P., Reis, J.F., Mendonca, G.V., Avela, J. and Mil-Homens, P., 2016. Acute effects of exercise under different levels of blood-flow restriction on muscle activation and fatigue. European Journal of Applied Physiology, 116(5), pp. 985-995.
Ferraz, R.B., Gualano, B., Rodrigues, R., Kurimori, C.O., Fuller, R., Lima, F.R., De Sa-Pinto, A.L. and Roschel, H., 2018. Benefits of Resistance Training with Blood Flow Restriction in Knee Osteoarthritis. Medicine and Science in Sports and Exercise, 50(5), pp. 897-905.
Fujita, S., Abe, T., Drummond, M.J., Cadenas, J.G., Dreyer, H.C., Sato, Y., Volpi, E. and Rasmussen, B.B., 2008. Blood flow restriction during low-intensity resistance exercise increases S6K1 phosphorylation and muscle protein synthesis (vol 103, pg 903, 2007). Journal of Applied Physiology, 104(4), pp. 1256-1256.
Fujita, T., Brechue, W.F., Kurita, K., Sato, Y. and Abe, T., 2008. Increased muscle volume and strength following six days of low-intensity resistance training with restricted muscle blood flow. International Journal of KAATSU Training Research, 4(1), pp. 1-8.
Garber, C.E., Blissmer, B., Deschenes, M.R., Franklin, B.A., Lamonte, M.J., Lee, I.M., Nieman, D.C. and Swain, D.P., 2011. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc, 43(7), pp. 1334-1359.
Gorgey, A.S., Timmons, M.K., Dolbow, D.R., Bengel, J., Fugate-Laus, K.C., Michener, L.A. and Gater, D.R., 2016. Electrical stimulation and blood flow restriction increase wrist extensor cross-sectional area and flow meditated dilatation following spinal cord injury. European Journal of Applied Physiology, 116(6), pp. 1231-1244.
Gronfeldt, B.M., Nielsen, J.L., Mieritz, R.M., Lund, H. and Aagaard, P., Effect of blood-flow restricted vs heavy-load strength training on muscle strength: Systematic review and meta-analysis. Scandinavian Journal of Medicine & Science in Sports, p. 12.
Holm, L., Reitelseder, S., Pedersen, T.G., Doessing, S., Petersen, S.G., Flyvbjerg, A., Andersen, J.L., Aagaard, P. and Kjaer, M., 2008. Changes in muscle size and MHC composition in response to resistance exercise with heavy and light loading intensity. Journal of Applied Physiology, 105(5), pp. 1454-1461.
Hughes, L., Paton, B., Rosenblatt, B., Gissane, C. and Patterson, S.D., 2017a. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med, 51(13), pp. 1003-1011.
Hughes, L., Paton, B., Rosenblatt, B., Gissane, C. and Patterson, S.D., 2017b. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. British Journal of Sports Medicine, 51(13), pp. 1003-U1041.
Kamel, H.K., 2003. Sarcopenia and aging. Nutrition Reviews, 61(5), pp. 157-167.
Keller, U., Szinnai, G., Bilz, S. and Berneis, K., 2003. Effects of changes in hydration on protein, glucose and lipid metabolism in man: impact on health. European Journal of Clinical Nutrition, 57, pp. S69-S74.
Korakakis, V., Whiteley, R. and Giakas, G., 2018. Low load resistance training with blood flow restriction decreases anterior knee pain more than resistance training alone. A pilot randomised controlled trial. Physical Therapy in Sport, 34, pp. 121-128.
Krawiec, B.J., Frost, R.A., Vary, T.C., Jefferson, L.S. and Lang, C.H., 2005. Hindlimb casting decreases muscle mass in part by proteasome-dependent proteolysis but independent of protein synthesis. American Journal of Physiology-Endocrinology and Metabolism, 289(6), pp. E969-E980.
Kubota, A., Sakuraba, K., Koh, S., Ogura, Y. and Tamura, Y., 2011. Blood flow restriction by low compressive force prevents disuse muscular weakness. Journal of Science and Medicine in Sport, 14(2), pp. 95-99.
Kubota, A., Sakuraba, K., Sawaki, K., Sumide, T. and Tamura, Y., 2008. Prevention of disuse muscular weakness by restriction of blood flow. Medicine and Science in Sports and Exercise, 40(3), pp. 529-534.
Lauver, J.D., Cayot, T.E., Rotarius, T. and Scheuermann, B.W., 2017. The effect of eccentric exercise with blood flow restriction on neuromuscular activation, microvascular oxygenation, and the repeated bout effect. European Journal of Applied Physiology, 117(5), pp. 1005-1015.
Liu, C.J. and Latham, N., 2010. Adverse Events Reported in Progressive Resistance Strength Training Trials in Older Adults: 2 Sides of a Coin. Archives of Physical Medicine and Rehabilitation, 91(9), pp. 1471-1473.
Loenneke, J.P., Fahs, C.A., Rossow, L.M., Abe, T. and Bemben, M.G., 2012. The anabolic benefits of venous blood flow restriction training may be induced by muscle cell swelling. Medical Hypotheses, 78(1), pp. 151-154.
Loenneke, J.P., Thiebaud, R.S., Abe, T. and Bemben, M.G., 2014. Blood flow restriction pressure recommendations: The hormesis hypothesis. Medical Hypotheses, 82(5), pp. 623-626.
Loenneke, J.P., Wilson, J.M., Wilson, G.J., Pujol, T.J. and Bemben, M.G., 2011. Potential safety issues with blood flow restriction training. Scandinavian Journal of Medicine & Science in Sports, 21(4), pp. 510-518.
Loenneke, J.P., Young, K.C., Wilson, J.M. and Andersen, J.C., 2013. Rehabilitation of an osteochondral fracture using blood flow restricted exercise: A case review. Journal of Bodywork and Movement Therapies, 17(1), pp. 42-45.
Mitchell, C.J., Churchward-Venne, T.A., West, D.W.D., Burd, N.A., Breen, L., Baker, S.K. and Phillips, S.M., 2012. Resistance exercise load does not determine training-mediated hypertrophic gains in young men. Journal of Applied Physiology, 113(1), pp. 71-77.
Natsume, T., Ozaki, H., Saito, A.I., Abe, T. and Naito, H., 2015. Effects of Electrostimulation with Blood Flow Restriction on Muscle Size and Strength. Medicine and Science in Sports and Exercise, 47(12), pp. 2621-2627.
Nielsen, J.L., Frandsen, U., Prokhorova, T., Bech, R.D., Nygaard, T., Suetta, C. and Aagaard, P., 2017. Delayed Effect of Blood Flow-restricted Resistance Training on Rapid Force Capacity. Medicine and Science in Sports and Exercise, 49(6), pp. 1157-1167.
Pearson, S.J. and Hussain, S.R., 2015. A Review on the Mechanisms of Blood-Flow Restriction Resistance Training-Induced Muscle Hypertrophy. Sports Medicine, 45(2), pp. 187-200.
Reeves, G.V., Kraemer, R.R., Hollander, D.B., Clavier, J., Thomas, C., Francois, M. and Castracane, V.D., 2006. Comparison of hormone responses following light resistance exercise with partial vascular occlusion and moderately difficult resistance exercise without occlusion. Journal of Applied Physiology, 101(6), pp. 1616-1622.
Silva, J.C.G., Domingos-Gomes, J.R., Freitas, E.D.S., Neto, G.R., Aniceto, R.R., Bemben, M.G., Lima-Dos-Santos, A. and Cirilo-Sousa, M.S., 2019. Physiological and Perceptual Responses to Aerobic Exercise With and Without Blood Flow Restriction. Journal of strength and conditioning research.
Slysz, J., Stultz, J. and Burr, J.F., 2016. The efficacy of blood flow restricted exercise: A systematic review & meta-analysis. Journal of Science and Medicine in Sport, 19(8), pp. 669-675.
Tabata, S., Suzuki, Y., Azuma, K. and Matsumoto, H., 2016. RHABDOMYOLYSIS AFTER PERFORMING BLOOD FLOW RESTRICTION TRAINING: A CASE REPORT. Journal of Strength and Conditioning Research, 30(7), pp. 2064-2068.
Takarada, Y., Takazawa, H., Sato, Y., Takebayashi, S., Tanaka, Y. and Ishii, N., 2000. Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans. Journal of Applied Physiology, 88(6), pp. 2097-2106.
Wang, Y. and Pessin, J.E., 2013. Mechanisms for fiber-type specificity of skeletal muscle atrophy. Current Opinion in Clinical Nutrition and Metabolic Care, 16(3), pp. 243-250.
Yasuda, T., Brechue, W.F., Fujita, T., Sato, Y. and Abe, T., 2008. Muscle activation during low-intensity muscle contractions with varying levels of external limb compression. Journal of Sports Science and Medicine, 7(4), pp. 467-474.
Yasuda, T., Fukumura, K., Uchida, Y., Koshi, H., Iida, H., Masamune, K., Yamasoba, T., Sato, Y. and Nakajima, T., 2015. Effects of Low-Load, Elastic Band Resistance Training Combined With Blood Flow Restriction on Muscle Size and Arterial Stiffness in Older Adults. Journals of Gerontology Series a-Biological Sciences and Medical Sciences, 70(8), pp. 950-958.
Yasuda, T., Ogasawara, R., Sakamaki, M., Ozaki, H., Sato, Y. and Abe, T., 2011. Combined effects of low-intensity blood flow restriction training and high-intensity resistance training on muscle strength and size. European Journal of Applied Physiology, 111(10), pp. 2525-2533.