Blood Flow

Restriction
Training
(BFRT)

Lara Nasser
History on BFRT
Dr. Yoshiaki Sato from Japan developed an
exercise method called “Kaatsu” in the
1960s.1 This method is based on blood flow
moderation exercise involving compression of
the vasculature proximal to the exercising
muscles.

He initially experimented on himself with

use of bicycle tubes, ropes, and bands at
different pressures on various body parts. After
years of trial and error and keeping track of the
https://www.kaatsu-global.com/?
different pressures used, he developed an Action=About.whyKAATSU

effective protocol to safely modify blood flow in

his limbs.1
What is BFRT?
➔ Blood flow restriction training
is achieved through the use of
external pressure over the
extremities. The applied
pressure maintains arterial
inflow while occluding venous
outflow distal to the occlusion
site.2
◆ The goal is to enable patients to
make greater strength gains while
lifting lighter loads. Reducing the
https://www.belmarrahealth.com/surprising-signs-poor-
overall stress placed on the limb. 2 blood-circulation/
 Physiological Mechanisms of BFRT
➔ Goal is to achieve muscle hypertrophy which is the increase in diameter of the
muscle as well as an increase of the protein content within the fibers. Muscle
strength is another goal achieved through an increase in the cross-sectional area of
the muscle.2,3
➔ The cuff helps to recreate a hypoxic environment.

When a muscle is placed under mechanical stress, the concentration of anabolic

hormone levels increase. The activation of myogenic stem cells and the elevated
anabolic hormones result in protein metabolism and thus muscle hypertrophy can
occur.2,3

Muscle Strength: Because the outflow of blood is limited using the cuff, capillary blood
that has low oxygen content collects and there is an increase in lactic acid. The result:
release of hormones, hypoxia and cell swelling will take place similar to performing high
intensity exercises.2,3
 Benefits4 Contraindicati
➔ Increase size of muscle
targeted
ons4
➔ Maintain muscle mass and
➔ Infection within an extremity
strength
➔ Impaired circulation
➔ Preserve muscle mass and
➔ Cancer
strength
➔ Open fracture
➔ Low impact on joints
➔ DVT
➔ Low intensity exercises
➔ Severe hypertension
needed
➔ Lymphedema
➔ Improve aerobic capacity
➔ Dialysis port
➔ Increasing muscle protein
synthesis
➔ Improve muscle collagen
production
Equipment
BFRT requires the use of a cuff as a
tourniquet. A doppler ultrasound can be
used to determine the blood flow to the
limb.

The pressure of the cuff depends on the

width of the cuff as well as the size of
the limb.3

https://www.bsrphysicaltherapy.com/2018/10/22/blood-flow-
restriction/
Procedure
For upper extremity: the tourniquet is placed on the upper arm and the cuff is
inflated to restrict 50% of the arterial blood flow and 100% of the venous flow.

For lower extremity: the tourniquet is placed on the upper thigh. The cuff is
inflated to restrict 80% of the arterial blood flow and 100% of the venous flow.

-> 20-30% of 1 repetition maximum (RM) general protocol.

https://www.dreamstime.com/therapist-
working-disabled-patient-using-special-
equipment-recovery-trauma-medical-
rehabilitation-physical-therapy-
image122688431
Research
Patterson SD, Hughes L, Warmington S, Burr et al. Blood flow restriction exercise
position stand: considerations of methodology, application, and safety. Front Physiol.
2019. 10.533. doi: 10.3389/fphys.2019.00533

➔ The use of blood flow restriction and exercise have been shown to effectively
increase skeletal muscle strength and/or hypertrophy in healthy young and older
populations. Blood flow restriction muscle hypertrophy and strength adaptation
are significantly greater than those achieved with low load resistance exercise
alone.
➔ Blood flow restriction training can be used with or without exercise incorporated.
➔ A common and frequently used set and repetition scheme exists that involves 75
total repetitions across 4 sets of exercises. 30 repetitions in the first set, 15
repetitions in each subsequent set. #
➔ Research has shown that use of blood flow restriction 2-3x/week for greater than
3 weeks or 1-2x/day for 1-3 weeks has demonstrated muscular hypertrophy. 20-
Research
Bond CW, Hackney K, Brown S, Noonan B. Blood Flow Restriction Resistance Exercise as a
Rehabilitation Modality Following Orthopaedic Surgery: A Review of Venous
Thromboembolism Risk. J Orthop Sports Phys Ther. 2019; 49(1):17-27. Doi:
10.2519/jospt.2019.8375

➔ In the early stages of rehabilitation following a total hip or total knee arthroplasty, the
post-surgical patient is often restricted by their desire to protect their surgically
repaired limb. These patients often cannot complete resistance exercise at the
preferred intensities.
◆ Total knee and total hip arthroplasties are projected to grow by 673% and 174%
respectively, by 2030.
➔ Blood flow restriction training can be an appropriate candidate to supplement low-
intensity physical rehabilitation exercises to achieve muscle mass and strength
restoration attributed to high-intensity resistance exercises.
➔ Eliciting muscle hypoxia and metabolic stress through the occlusion of underlying
vasculature can facilitate blood flow restriction adaptations.
➔ Can be used from knee OA, muscular weakness from disuse, sarcopenia, ACL
Safety

https://submar.com/7-winter-weather-construction-safety-tips-from-
Reported side effects while performing
BFRT exercises:

➔ Fainting and dizziness

➔ Numbness
➔ Pain & discomfort
➔ Delayed onset muscle soreness

** Safety concerns are mainly around

construct-connect/
the formation of venous
thromboembolism (DVT, PE) and
muscle damage.
Clinical Application
Blood flow restriction has been used in athletes and recreational training
to obtain muscle hypertrophy.

It can also be used in clinical populations that cannot perform high

intensity exercises because of the stage of their condition or pathology
involved.2
➔ Total hip arthroplasty
➔ Total knee arthroplasty
➔ ACL reconstruction
➔ Non reconstructive knee arthroplasty
➔ Sarcopenia
➔ Shoulder etiology https://pngimage.net/physical-
therapist-cartoon-png-3/
Who can provide BFR training?
➔ “Physical therapists (PT) have an existing firm foundation in anatomy,
physiology, therapeutic exercises, and the cardiorespiratory system, as well
as clinical reasoning, which are the components of the safe application of
blood flow restriction training.”6
◆ BFRT is within the PT professional scope of practice, per the APTA. 6

Health care professionals can enroll in BFRT seminars or weekend course as

continuing education credits.
References
1. Why Kaatsu. https://www.kaatsu-global.com/?Action=About.whyKAATSU Updated in
2020. Accessed on March 1, 2020.
2. Physiopedia Contributors. “Blood Flow Restriction Training” Physiopedia. Updated on
February 26, 2020. Accessed on March 6, 2020.
3. Patterson SD, Hughes L, Warmington S, Burr et al. Blood flow restriction exercise
position stand: considerations of methodology, application, and safety. Front Physiol.
10.533. doi: 10.3389/fphys.2019.00533

4. Bond CW, Hackney K, Brown S, Noonan B. Blood Flow Restriction Resistance Exercise as
a Rehabilitation Modality Following Orthopaedic Surgery: A Review of Venous
Thromboembolism Risk. J Orthop Sports Phys Ther. 2019; 49(1):17-27. Doi:
10.2519/jospt.2019.8375

5. American Physical Therapy Association. Blood-Flow Restriction Training (BFRT). APTA.

https://www.apta.org/PatientCare/BloodFlowRestrictionTraining/ Updated on May 25,
2019. Accessed on March 2, 2020.