Professional Documents
Culture Documents
Blood Flow Restriction Training in Rehabilitation: A Useful Adjunct or Lucy's Latest Trick?
Blood Flow Restriction Training in Rehabilitation: A Useful Adjunct or Lucy's Latest Trick?
Blood Flow Restriction Training in Rehabilitation: A Useful Adjunct or Lucy's Latest Trick?
A Useful Adjunct or
Lucy’s Latest Trick?
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
I
n the American cartoonist Charles M. Schulz’s comic series Peanuts, sion and exercise during weight training.
Lucy first pulled the ball away from Charlie Brown in 1951. Then This period included a stint in hospital
she continued to torture him for the next 48 years, using variations after a pulmonary embolism induced
by self-described reckless tourniquet
on the theme. As a physical therapist of a certain age, every time
application.
I hear of some new approach promising more for less, I become Later, after opening his own fitness club,
Journal of Orthopaedic & Sports Physical Therapy®
Charlie Brown: “This has never worked in the past, so why should I the Japanese now former high school stu-
believe it will this time? But wouldn’t it be great if it were true?” Ever dent was injured while skiing. He reported
the optimist, my eternally misguided en- explained by increased collateral circula- that he had fractured both ankles and in-
thusiasm leaves me lying on my back, tion. Perhaps alternate mechanisms were jured “cartilage and the medial ligament”
embarrassed, and vowing, “They won’t in play (other than improved blood flow), of his knee. He refused the recommended
fool me next time.” somehow enhancing muscle function?11 surgery and hospitalization because of the
Then along comes an intervention This much was the result of scientific demands of his business. Instead, he opted
claiming that some low-intensity exer- investigation. Now we enter the realm for occlusion training combined with iso-
cise performed while wearing a blood of retrospective self-report from an indi- metrics of his casted limb for 2 months.
pressure cuff will result in strength vidual whose business depended on the He claimed he had hypertrophy, rather
gains, improved performance, shorter results—your “Spidey-sense” should al- than atrophy, of his casted leg and good
postexercise recovery, and maybe even ready be tingling. functional outcomes.48 Commercial ap-
pain reduction. “Good grief,” indeed. Or Coincidentally and independently, a plication of his approach over the ensuing
will it work this time? Japanese high school student noticed decade saw growing popularity, along with
that after a period of sustained sitting patent applications for equipment and
Blood Flow Restriction while attending a religious ceremony, techniques in a number of countries, and
Training: Early Origins he experienced a feeling of discomfort “certifications” for practitioners adding to
In the 1960s, scientists noticed improved and swelling similar to that experienced the business model.
walking tolerance in people with in- after performing “strenuous calf-raise By now, the alarm bells should be deaf-
termittent claudication after a physical exercises.”48 For the next 5 years, he self- ening to those looking for a science-based
training program.29 The changes were not experimented with variations of occlu- intervention, free of commercial influence.
1
Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar. The author certifies that he has no affiliations with or financial involvement in
any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Rod Whiteley, Rehabilitation
Department, Aspetar Orthopaedic and Sports Medicine Hospital, PO Box 29222, Doha, Qatar. E-mail: rodney.whiteley@aspetar.com t Copyright ©2019 Journal of Orthopaedic &
Sports Physical Therapy®
An otherwise healthy, relatively untrained occluded muscles are failing, is the most which are valid compared to Doppler ul-
adult can expect muscle hypertrophy likely mechanism.12 trasound.30 More expensive commercially
with loads as low as 15% to 30% of the Effects on muscle strength are lower available systems allow for automatic
1-repetition maximum when performing with low-load resistance training com- measurement and application of a pre-
exercises to volitional failure (exercise to bined with blood flow restriction than scribed limb occlusion pressure, and can
fatigue),5,13 although the effects of hyper- with heavy resistance training, despite be adjusted during the exercise.39,56
trophy are more consistently achieved similar objective muscle mass gains.17
with higher loads and lower repetitions, This might be due to enhanced fiber re- Blood Flow Restriction Training’s
especially when matching total work (eg, cruitment in heavy resistance training.19 Performance and Recovery Enhancement
70% of 1-repetition maximum).2,13,46 Early research in this area used arbitrary Cousin: Ischemic Preconditioning
The patient in pain may present a co- training occlusion pressures for all par- In a likely apocryphal story, native South
nundrum: you may not be able to pre- ticipants, typically not accounting for Americans applied tourniquets to their
scribe sufficiently high absolute load exercise position or individual variability. legs immediately before important long-
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
to ensure hypertrophy. If you conclude Limb occlusion pressure will vary de- distance runs for performance enhance-
the pain is caused by inadequate muscle pending on the girth of the limb,33 the ment.36 In experiments in the middle
strength, then the conundrum is difficult cuff used,40 and body position16 (eg, lying of the 20th century, there was a dose-
to resolve and might even be intractable. compared to sitting or standing).50,52 Limb response relationship between measures
You might also face a similar challenge occlusion pressure is different for different such as time to exhaustion and the du-
where strengthening is indicated but individuals, and even the same individu- ration and intensity of application of a
loading the joint is not (eg, post surgery al at different times of the day18,21,25 (eg, tourniquet to completely occlude limb
or resolving osteochondral defects). morning versus afternoon, before or after perfusion prior to exercise.41,44 A flurry
“I really want to start strengthening as recent exercise or coffee consumption). of investigation followed, which failed to
Journal of Orthopaedic & Sports Physical Therapy®
soon as possible. Do I really have to wait replicate these findings. This field lay fal-
until the pain settles down? What if pain Measuring and Adjusting low for years.36
prevents the patient from loading? What Occlusion Pressure In the mid 1980s, animal experiments
if the pain doesn’t settle down?” Failing to individualize limb occlusion documented reductions in cardiac infarc-
pressure might explain inferior strength tion following bouts of ischemic precondi-
Hypertrophy Is Possible With Low gains compared with standard heavy re- tioning.14,42 Meaningful, albeit conflicting
Loads and High Repetitions: Enter sistance training.16 However, while this is and objectively small, improvements in
Blood Flow Restriction Training biologically plausible, research in this area sporting performance after local (eg, leg
Low-load resistance training with the is sparse. Cuff width is an important deter- during leg exercise) and remote (eg, arm
addition of blood flow restriction can minant of limb occlusion pressure, and the during leg exercise) ischemic precon-
achieve equivalent hypertrophy to that of wider the cuff, the lower the required pres- ditioning20,36,47 prior to cycling,14 swim-
high-load resistance training.6,17,34 Plau- sure to occlude the limb.49 A wider cuff ming,23 and running3 may be possible.
sible mechanisms of action, each with also has the benefit of less local discom- Modest gains are acquired with cycles
some evidence in humans, include locally fort24,37 and lower chance of bruising.38,39 of 3 or 4 bouts of 5 minutes of occlusion
induced swelling in the muscle cells, im- Clinicians should individually tailor and 5 minutes of reperfusion performed
proved local neural function (increased occlusion pressure for safety and best a few hours prior to the event.9,31,47 There
fiber recruitment), improved central neu- outcomes.16,32 They should measure limb is less research examining any benefit of
ral function (increased cortical motor ex- occlusion pressure in the position in which ischemia as an intervention to improve
citability), and increased muscle protein the exercise will be performed and con- recovery post exercise, and the results are
synthesis.10,19,28 duct the exercise as a percentage of this mixed at best.4
Blood flow restriction training may also pressure. In the lower limb, 40% to 80% Routine postexercise application of
have additional hypertrophy benefits in of limb occlusion pressure is effective.32 3 or 4 bouts of 5-minute occlusion/re-
muscles not directly affected by the blood Higher occlusion pressure might be desir- perfusion (30-40 minutes in total)45 is
flow restriction. Measurable improve- able, although it is associated with more likely not feasible in a team setting. The
Researchers noticed that patients with training is very common.53 Likely, many blood flow restriction compared to
anterior knee pain that was present dur- tens of thousands of patients have par- a similar period of high-intensity
ing single-leg squatting (a reassessment ticipated in blood flow restriction train- strength training. Apply up to 80% of
sign often used in people with this con- ing, yet there are very few reports of limb occlusion pressure, and prescribe
dition) had substantially reduced pain serious adverse events when precau- about 75 repetitions in total. Aim for
immediately after a session of low-load tions have been followed.8,35,43,51,53 Local fatigue failure after the first 30 repeti-
resistance training with the addition of discomfort during the exercise (almost tions, followed by 3 more sets of 15 rep-
blood flow restriction. Further, this ben- ubiquitous) and bruising (unusual, but etitions at the same load (likely around
efit was retained for the duration of their not rare)43 are the main adverse effects, 15% to 30% of 1-repetition maximum).
session.26 There may be a pain-reducing although adverse events have been poor- Exercises can be performed on alter-
effect in excess of that seen through ly reported.17 nate days, and, after a while, even twice
matched placebo-controlled exercise.15,27 Far less common, but potentially daily. Expect hypertrophy changes after
However, this research is preliminary and very serious, are vascular problems. A at least 4 weeks, but probably closer to
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
must be replicated before one can con- medical history of vascular compro- 8 weeks (TABLE).
fidently conclude that it is a true effect. mise or risk of embolism is an absolute Progression to heavy-load resistance
contraindication to blood flow restric- training should continue to be your
It Can’t All Be Sunshine and tion training. Three reported cases of goal—blood flow restriction training is
Daisies? What’s the Risk? rhabdomyolysis7,22,51 suggest that com- only an interim step. There is less compel-
“Reckless” tourniquet application is as- promised renal function should be a ling evidence that you can be confident of
sociated with potentially disastrous side contraindication.57 Patients should al- performance, postexercise recovery, and
effects, embolism being chief among ways be monitored following exercise pain improvements, although this is an
them.48 No one should die as a result of for excessive muscle soreness.7 area to watch.
Journal of Orthopaedic & Sports Physical Therapy®
12. https://doi.org/10.3806/ijktr.1.6
2. American College of Sports Medicine. Position J Appl Physiol. 2010;108:141-146. https://doi. trial. Phys Ther Sport. 2018;34:121-128. https://
stand: progression models in resistance train- org/10.1007/s00421-009-1195-2 doi.org/10.1016/j.ptsp.2018.09.007
ing for healthy adults. Med Sci Sports Exerc. 15. G iles L, Webster KE, McClelland J, Cook JL. 28. Kubota A, Sakuraba K, Sawaki K, Sumide
2009;41:687-708. https://doi.org/10.1249/ Quadriceps strengthening with and without T, Tamura Y. Prevention of disuse muscular
MSS.0b013e3181915670 blood flow restriction in the treatment of patel- weakness by restriction of blood flow. Med Sci
3. Bailey TG, Jones H, Gregson W, Atkinson G, lofemoral pain: a double-blind randomised trial. Sports Exerc. 2008;40:529-534. https://doi.
Cable NT, Thijssen DH. Effect of ischemic Br J Sports Med. 2017;51:1688-1694. https://doi. org/10.1249/MSS.0b013e31815ddac6
preconditioning on lactate accumulation and org/10.1136/bjsports-2016-096329 29. Larsen OA, Lassen NA. Effect of daily muscular
running performance. Med Sci Sports Exerc. 16. H ughes L, Jeffries O, Waldron M, et al. Influence exercise in patients with intermittent claudica-
2012;44:2084-2089. https://doi.org/10.1249/ and reliability of lower-limb arterial occlusion tion. Lancet. 1966;288:1093-1096. https://doi.
MSS.0b013e318262cb17 pressure at different body positions. PeerJ. org/10.1016/S0140-6736(66)92191-X
4. Beaven CM, Cook CJ, Kilduff L, Drawer S, Gill 2018;6:e4697. https://doi.org/10.7717/peerj.4697 30. Laurentino GC, Loenneke JP, Mouser JG,
N. Intermittent lower-limb occlusion enhances 17. H ughes L, Paton B, Rosenblatt B, Gissane C, et al. Validity of the handheld Doppler to
recovery after strenuous exercise. Appl Physiol Patterson SD. Blood flow restriction training in determine lower-limb blood flow restriction
Nutr Metab. 2012;37:1132-1139. https://doi. clinical musculoskeletal rehabilitation: a sys- pressure for exercise protocols. J Strength
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
org/10.1139/h2012-101 tematic review and meta-analysis. Br J Sports Cond Res. In press. https://doi.org/10.1519/
5. Burd NA, West DW, Staples AW, et al. Low-load Med. 2017;51:1003-1011. https://doi.org/10.1136/ JSC.0000000000002665
high volume resistance exercise stimulates mus- bjsports-2016-097071 31. Lisbôa FD, Turnes T, Cruz RS, Raimundo JA,
cle protein synthesis more than high-load low 18. H unt JE, Stodart C, Ferguson RA. The influence Pereira GS, Caputo F. The time dependence of
volume resistance exercise in young men. PLoS of participant characteristics on the relationship the effect of ischemic preconditioning on suc-
One. 2010;5:e12033. https://doi.org/10.1371/ between cuff pressure and level of blood flow re- cessive sprint swimming performance. J Sci Med
journal.pone.0012033 striction. Eur J Appl Physiol. 2016;116:1421-1432. Sport. 2017;20:507-511. https://doi.org/10.1016/j.
6. Centner C, Wiegel P, Gollhofer A, König D. Effects https://doi.org/10.1007/s00421-016-3399-6 jsams.2016.09.008
of blood flow restriction training on muscular 19. H wang P, Willoughby DS. Mechanisms be- 32. Lixandrão ME, Ugrinowitsch C, Laurentino G,
strength and hypertrophy in older individuals: hind blood flow restricted training and its et al. Effects of exercise intensity and occlusion
a systematic review and meta-analysis. Sports effect towards muscle growth. J Strength pressure after 12 weeks of resistance training
Journal of Orthopaedic & Sports Physical Therapy®
Med. 2019;49:95-108. https://doi.org/10.1007/ Cond Res. In press. https://doi.org/10.1519/ with blood-flow restriction. Eur J Appl Physiol.
s40279-018-0994-1 JSC.0000000000002384 2015;115:2471-2480. https://doi.org/10.1007/
7. Clark BC, Manini TM. Can KAATSU exercise 20. Incognito AV, Burr JF, Millar PJ. The effects of s00421-015-3253-2
cause rhabdomyolysis? Clin J Sport Med. ischemic preconditioning on human exercise per- 33. Loenneke JP, Allen KM, Mouser JG, et al. Blood
2017;27:e1-e2. https://doi.org/10.1097/ formance. Sports Med. 2016;46:531-544. https:// flow restriction in the upper and lower limbs is
JSM.0000000000000309 doi.org/10.1007/s40279-015-0433-5 predicted by limb circumference and systolic
8. Clark BC, Manini TM, Hoffman RL, et al. Relative 21. Ingram JW, Dankel SJ, Buckner SL, et al. The in- blood pressure. Eur J Appl Physiol. 2015;115:397-
safety of 4 weeks of blood flow-restricted resis- fluence of time on determining blood flow restric- 405. https://doi.org/10.1007/s00421-014-3030-7
tance exercise in young, healthy adults. Scand tion pressure. J Sci Med Sport. 2017;20:777-780. 34. Loenneke JP, Wilson JM, Marín PJ, Zourdos MC,
J Med Sci Sports. 2011;21:653-662. https://doi. https://doi.org/10.1016/j.jsams.2016.11.013 Bemben MG. Low intensity blood flow restriction
org/10.1111/j.1600-0838.2010.01100.x 22. Iversen E, Røstad V. Low-load ischemic exercise- training: a meta-analysis. Eur J Appl Physiol.
9. Cocking S, Wilson MG, Nichols D, et al. Is there induced rhabdomyolysis. Clin J Sport Med. 2012;112:1849-1859. https://doi.org/10.1007/
an optimal ischemic-preconditioning dose to 2010;20:218-219. https://doi.org/10.1097/ s00421-011-2167-x
improve cycling performance? Int J Sports JSM.0b013e3181df8d10 35. Loenneke JP, Wilson JM, Wilson GJ, Pujol
Physiol Perform. 2018;13:274-282. https://doi. 23. J ean-St-Michel E, Manlhiot C, Li J, et al. Remote TJ, Bemben MG. Potential safety issues with
org/10.1123/ijspp.2017-0114 preconditioning improves maximal performance blood flow restriction training. Scand J Med
10. Cook SB, Scott BR, Hayes KL, Murphy BG. Neu- in highly trained athletes. Med Sci Sports Exerc. Sci Sports. 2011;21:510-518. https://doi.
romuscular adaptations to low-load blood flow 2011;43:1280-1286. https://doi.org/10.1249/ org/10.1111/j.1600-0838.2010.01290.x
restricted resistance training. J Sports Sci Med. MSS.0b013e318206845d 36. Marocolo M, da Mota GR, Simim MA, Appell
2018;17:66-73. 24. J essee MB, Dankel SJ, Buckner SL, Mouser Coriolano HJ. Myths and facts about the effects
11. Dahllöf AG, Björntorp P, Holm J, Scherstén JG, Mattocks KT, Loenneke JP. The cardio- of ischemic preconditioning on performance.
T. Metabolic activity of skeletal muscle in vascular and perceptual response to very Int J Sports Med. 2016;37:87-96. https://doi.
patients with peripheral arterial insufficiency. low load blood flow restricted exercise. Int J org/10.1055/s-0035-1564253
Eur J Clin Invest. 1974;4:9-15. https://doi. Sports Med. 2017;38:597-603. https://doi. 37. Mattocks KT, Jessee MB, Counts BR, et al. The ef-
org/10.1111/j.1365-2362.1974.tb00365.x org/10.1055/s-0043-109555 fects of upper body exercise across different lev-
12. Dankel SJ, Jessee MB, Abe T, Loenneke JP. The 25. K acin A, Rosenblatt B, Grapar Žargi T, Biswas A. els of blood flow restriction on arterial occlusion
effects of blood flow restriction on upper-body Safety considerations with blood flow restricted pressure and perceptual responses. Physiol Be-
musculature located distal and proximal to resistance training. Ann Kinesiol. 2015;6:3-26. hav. 2017;171:181-186. https://doi.org/10.1016/j.
applied pressure. Sports Med. 2016;46:23-33. 26. K orakakis V, Whiteley R, Epameinontidis K. Blood physbeh.2017.01.015
https://doi.org/10.1007/s40279-015-0407-7 flow restriction induces hypoalgesia in recre- 38. McEwen JA, Inkpen K, Younger A. Thigh tourni-
@ MORE INFORMATION
org/10.1249/MSS.0000000000000576 52. W
ilkins RW, Halperin MH, Litter J. The effect of
46. Ratamess N, Jr. ACSM’s Foundations of Strength the dependent position upon blood flow in the
Training and Conditioning. Philadelphia, PA: Wolt- limbs. Circulation. 1950;2:373-379. https://doi. WWW.JOSPT.ORG
Journal of Orthopaedic & Sports Physical Therapy®