Blood Flow Restriction Therapy

In recent years, the popularity of blood flow restriction (BFR) training has surged within the realm of physical therapy, as an adjunct to more traditional forms of conservative care. Developed in the late 1960s, BFR involves the controlled application of pressure to blood vessels during exercise, ideally utilizing specialized cuffs. 

This innovative approach has gained widespread recognition for its effectiveness in enhancing muscle strength, promoting tissue healing, and improving overall functional outcomes, making it a valuable treatment option for addressing a multitude of patient conditions.

What Is BFR?

Blood flow restriction or BFR rehabilitation is the brief and intermittent occlusion of venous (vein) blood flow using a tourniquet while exercising.

Using this technique, one can exercise with significantly lighter weights while still creating a growth and a strength response. This is unlike traditional exercises where, to get these positive responses to exercise, you would have to load your muscles with a considerable amount of stress, which would likely be inappropriate for patients recuperating from injured tissues and joints.

The Centeno-Schultz Clinic has been incorporating blood flow restriction over the last number of years with significant benefits. Its application can be sequenced either before or after injections depending on your physician’s discretion. We have included some FAQs below to help give you additional information on the BFR application as we utilize it in our clinic.

How Does It Work?

The application of BFR training while working out leads to a hormonal response that benefits the working muscles of the body. The BFR application utilizes this approach in fatiguing the muscle without damaging it. The brain responds to the muscle working by releasing growth hormone from the pituitary gland, which also will generate a positive benefit through the body.

BFR and the Brain

One area of interest is the potential for BFR to induce changes in neuroplasticity, the brain’s ability to reorganize itself by forming new neural connections. The increased release of certain growth factors, such as brain-derived neurotrophic factor (BDNF), may play a role in promoting neuroplasticity. This could have implications for cognitive function, learning, and rehabilitation after neurological injuries.

 How It Affects the Muscles

BFR leads to a variety of physiological responses in the muscles, contributing to its effects on muscle strength, hypertrophy, and endurance. BFR creates a hypoxic (low-oxygen) environment in the working muscles due to reduced blood flow. This leads to an accumulation of metabolic byproducts, such as lactate, hydrogen ions, and reactive oxygen species. 

The metabolic stress activates cellular signaling pathways associated with muscle growth and adaptation. It triggers an increase in growth hormone and insulin-like growth factor-1 (IGF-1), which are important for muscle protein synthesis and growth. It promotes the recruitment of fast-twitch muscle fibers even during low-intensity resistance exercise. These fibers typically require higher loads to be activated but are engaged more readily under BFR conditions. 

It has been shown to enhance muscle protein synthesis, the process responsible for muscle repair and growth, even with lower resistance loads. It also causes cell swelling within the muscle, leading to an increase in muscle protein synthesis and muscle hypertrophy. The swelling is thought to be due to fluid accumulation and cell volumization, contributing to the overall growth response. 

BFR training has been associated with increased muscle endurance, possibly due to enhanced fatigue resistance and changes in muscle fiber recruitment patterns. It may influence neuromuscular adaptations, enhancing motor unit recruitment and improving muscle coordination during exercise.

BFR allows individuals to achieve muscle fatigue and stimulate growth with lower resistance loads, reducing stress on joints and connective tissues. This makes it a valuable tool for individuals with joint issues or those recovering from injuries.

What BFR Does for Chronic Pain

BFR training has shown promising results in addressing chronic pain through various mechanisms. It allows individuals to achieve muscle strengthening and hypertrophy with lower resistance loads. 

This is particularly beneficial for individuals with chronic pain conditions affecting the joints, as it minimizes stress on these structures. It enables individuals to build muscle strength with low-intensity exercises, reducing the likelihood of exacerbating pain associated with higher loads. 

BFR may contribute to tissue healing by promoting localized growth factors and enhancing blood flow to the muscles. Improved blood flow can aid nutrient delivery and waste removal, supporting the recovery process.

It has been suggested that BFR also positively influences neuromuscular adaptations, potentially improving motor control and coordination. This can be beneficial for individuals with chronic pain conditions affecting muscle function. 

Exercise, including BFR, stimulates the release of endorphins, the body’s natural painkillers. This can contribute to pain modulation and improve the overall pain experience for individuals with chronic pain. 

By improving muscle strength and function, BFR may enhance overall physical performance and functionality, leading to an improved quality of life for individuals dealing with chronic pain. 

It has been explored in the context of various chronic pain conditions, including osteoarthritis, chronic low back pain, and musculoskeletal injuries. Its adaptability makes it a versatile tool for addressing pain in different parts of the body.

Who Benefits from BFR?

Applications for the use of blood flow restriction are diverse. Some patients go through an application of BFR prior to their blood draw to increase their platelet count, while others use blood flow training after their injections to maximize healing. 

Post-ACL Reconstruction

Blood flow restriction can be a valuable component of rehabilitation for patients post-ACL (anterior cruciate ligament) reconstruction. Here’s how BFR may benefit these patients:

• Muscle strengthening with reduced load: BFR allows individuals to engage in low-load resistance exercises, which is particularly beneficial during the early stages of post-ACL reconstruction when high-impact activities may be restricted. This enables the strengthening of the quadriceps and other muscle groups without placing excessive stress on the healing ACL graft.
• Minimized atrophy during immobilization: Immobilization following ACL surgery can lead to muscle atrophy. BFR helps mitigate this by facilitating muscle activation and hypertrophy even with lower resistance loads, preventing excessive muscle wasting during the recovery period.
• Improved range of motion and joint health: When combined with specific exercises, BFR may contribute to improved joint mobility and range of motion. This is crucial for post-ACL reconstruction patients who need to regain full functional capacity and prevent stiffness.
• Enhanced neuromuscular control: BFR has been associated with positive neuromuscular adaptations, potentially improving motor control and proprioception. This is important for ACL reconstruction patients aiming to restore stability and coordination around the knee joint.

Knee Pain

For individuals experiencing knee pain, whether due to osteoarthritis or other musculoskeletal issues, BFR can offer several benefits:

• Reduced joint stress: BFR allows for strength training with lower resistance, reducing stress on the knee joints. This can be crucial for individuals with knee pain, as traditional high-intensity resistance exercises might exacerbate discomfort.
• Improved quadriceps strength: BFR has shown effectiveness in improving quadriceps strength, which is essential for knee stability. Strengthening the quadriceps can help alleviate knee pain and enhance overall joint function.
• Enhanced muscle activation: BFR can enhance muscle activation even at lower loads, leading to improved muscle endurance and function. This is particularly relevant for individuals with knee pain who may struggle with traditional resistance training.
• Potential pain modulation: Exercise, including BFR, stimulates the release of endorphins, which can help modulate pain perception. This may contribute to a more positive experience for individuals dealing with knee pain.

Immobilization

During periods of immobilization, such as after surgery or injury, BFR can be beneficial in preventing muscle atrophy and maintaining overall muscle health:

• Muscle preservation: BFR allows individuals to engage in resistance exercises with lower loads, preventing significant muscle loss during periods of immobilization. This is crucial for maintaining strength and function in the immobilized limb.
• Acceleration of rehabilitation: BFR may expedite the rehabilitation process by promoting muscle activation and strength gains even in situations where traditional resistance training may be limited. This can contribute to a faster return to functional activities.
• Improved circulation and tissue healing: BFR’s effects on localized blood flow can facilitate nutrient delivery and waste removal, potentially aiding in tissue healing during the immobilization period.

BFR for Geriatric Patients

BFR holds promise as a rehabilitation tool for geriatric patients, offering specific advantages for this demographic:

• Safe resistance training: Geriatric patients often face limitations in tolerating high-resistance training. BFR allows for safe and effective strength training with lower loads, reducing the risk of injury and improving adherence to exercise programs.
• Maintaining muscle mass and function: BFR can help mitigate age-related muscle loss (sarcopenia) by promoting muscle protein synthesis and maintaining muscle mass. This is crucial for preventing frailty and maintaining independence in older adults.
• Improved joint health and mobility: BFR, combined with appropriate exercises, may contribute to joint health and improved mobility in geriatric patients. This is particularly important for enhancing overall functional capacity and reducing the risk of falls.
• Enhanced cardiovascular benefits: BFR has been associated with cardiovascular adaptations, potentially offering additional benefits for geriatric patients who may also benefit from improved cardiovascular health.

What Are the Different Types of BFR Therapy?

There are different types of BFR therapy in terms of how each muscle is used during the therapy. They are described below.

Resistance Training

How each muscle is used:

• Targeted muscle activation: In resistance training with BFR, the goal is to induce muscle fatigue and hypertrophy using lower resistance loads. The BFR cuffs are applied to the proximal portion of the limbs, typically the upper arms or thighs, to partially restrict blood flow.
• Promotion of fast-twitch fiber engagement: BFR encourages the recruitment of fast-twitch muscle fibers, even at lower loads, which may not be typically activated without blood flow restriction.
• Localized muscle activation: The controlled blood flow restriction amplifies the intensity of resistance exercises, ensuring that specific muscle groups are effectively engaged and challenged.

Example exercises:

• Upper body: Bicep curls, tricep extensions, and shoulder presses.
• Lower body: Leg presses, squats, and calf raises.

Aerobic Training

How each muscle is used:

• Aerobic exercise with restricted blood flow: BFR can be applied during aerobic exercises such as walking, cycling, or rowing. The cuffs are typically placed on the upper legs to partially restrict blood flow.
• Enhanced cardiovascular challenge: The restricted blood flow increases the cardiovascular demand of the exercise, leading to improved aerobic conditioning (VO2 max).
• Global muscle activation: Aerobic BFR engages a broader range of muscles compared to isolated resistance training. It promotes a more systemic physiological response.

Example exercises:

• Walking: BFR cuffs on the upper legs during brisk walking.
• Cycling: BFR applied while cycling at a moderate intensity.
• Rowing: BFR during rowing exercises.

Passive

How each muscle is affected:

• Resting state with blood flow restriction: Passive BFR involves applying cuffs to limbs while the individual is at rest. This may be used during periods of immobilization or in situations where active exercise is not feasible.
• Promotion of circulation: While not actively engaging in exercises, passive BFR still promotes localized blood flow and circulation to the muscles.
• Muscle pump effect: The intermittent restriction and release of blood flow create a “pump” effect, influencing nutrient delivery and waste removal like active BFR.

Examples:

• Resting state: Application of BFR cuffs while sitting or lying down without engaging in active movements.

BFR Outside the Clinic

BFR training has expanded beyond the clinical setting and is increasingly utilized in various fitness and athletic contexts. The use of bands and cuffs for BFR outside of physical therapy introduces a practical and accessible means for individuals to incorporate this technique into their training routines. 

Here’s a detailed discussion of the equipment used, specifically bands and cuffs, in non-clinical settings:

Bands and Cuffs

Bands: BFR bands are elastic straps or wraps that can be easily applied to the limbs to create controlled blood flow restriction. They are typically made of durable, elastic materials and come in various lengths and widths. Bands are wrapped around the upper portion of limbs, such as the arms or thighs, creating a circumferential pressure that partially restricts blood flow. 

Some bands have adjustable mechanisms, allowing users to regulate the tightness based on their comfort and the desired level of occlusion. Users need to ensure consistent and even pressure application to achieve effective BFR. Proper wrapping technique is essential for safety and efficacy.

Advantages:

• Portability: BFR bands are lightweight and portable, making them convenient for individuals who want to incorporate BFR into their home workouts, outdoor training sessions, or while traveling.
• Affordability: Compared to specialized BFR cuffs, bands are often more cost-effective, making them accessible to a broader range of fitness enthusiasts.

Cuffs: BFR cuffs are specialized inflatable bands or wraps designed for blood flow restriction. They are often made of durable materials and feature a mechanism to control the pressure exerted on the limb. Cuffs are typically placed on the upper arms or thighs, and the pressure is controlled by an inflation device. 

The cuffs can be adjusted to achieve personalized and precise levels of blood flow restriction. Users may need some guidance or practice to learn how to properly use and adjust BFR cuffs. Ensuring proper fit and pressure is essential for effective BFR.

Advantages: 

• Precision and control: BFR cuffs provide high levels of precision and control over the applied pressure, ensuring optimal safety and efficacy during BFR training. Here at the Centeno-Schultz Clinic, we only use Delfi BFR cuffs, a medical grade unit developed by the industry lead in the BFR field, the same system used worldwide by major sports leagues and collegiate teams.
• Reusability: Many BFR cuffs are reusable and can be used for multiple sessions, making them a durable and long-term investment.

What Are the Side Effects?

Possible side effects of blood flow restriction include:

• Numbness: Temporary numbness or tingling sensations in the limbs may occur during or after BFR. This is usually due to the restricted blood flow and pressure applied by the cuffs. It is generally harmless and dissipates once the cuffs are released.
• Bruising: Some individuals may experience mild bruising at the cuff application site. This can result from the pressure exerted on blood vessels during BFR. While bruising is typically minor, proper cuff application techniques can help minimize this side effect.
• Discomfort: Discomfort or a feeling of tightness is common during BFR, especially as the cuffs create localized blood flow restriction. This discomfort is part of the physiological response and usually subsides once the cuffs are removed. Adjusting cuff tightness within recommended guidelines can help manage discomfort.
• Hemorrhage: In rare cases, there may be a risk of internal bleeding (hemorrhage) if the cuffs are applied too tightly or if there are underlying vascular issues. It’s crucial to adhere to recommended pressure levels and guidelines, and individuals with pre-existing vascular conditions should consult healthcare professionals before engaging in BFR.
• Skin abrasions: Improperly applied cuffs or abrasive materials may cause skin abrasions. Ensuring a proper fit, using appropriate materials, and monitoring skin integrity can help prevent this side effect. Regularly inspecting the skin for any signs of irritation is essential.
• Delayed onset muscle soreness (DOMS): BFR may induce delayed onset muscle soreness, a normal response to exercise. This muscle soreness typically occurs 24-48 hours after BFR training and is part of the muscle adaptation process. It is generally mild and transient, similar to DOMS experienced with traditional resistance training.

What Are the Contraindications for BFR?

Instances where BFR may not be recommended for patients:

• Blood disorders: Individuals with blood disorders, such as deep vein thrombosis (DVT), peripheral artery disease (PAD), or other circulatory issues, should generally avoid BFR. Blood flow restriction may exacerbate existing vascular problems and pose an increased risk of complications, including thrombosis or compromised circulation.
• Muscle damage: BFR is not recommended for individuals with acute muscle injuries or severe muscle damage. Engaging in BFR exercises in such conditions may aggravate the injury, hinder the healing process, and potentially lead to further complications. Prior rehabilitation and clearance from healthcare professionals are essential before considering BFR for individuals with recent muscle damage.
• Hypertension or cardiovascular issues: Individuals with uncontrolled hypertension or severe cardiovascular conditions may be at an increased risk during BFR. The additional stress on the cardiovascular system may exacerbate blood pressure issues, leading to adverse events. Clearance from a healthcare professional is essential for individuals with cardiovascular concerns before engaging in BFR.
• Active infections or inflammatory conditions: BFR is generally not recommended for individuals with active infections or inflammatory conditions. Inflamed tissues may be more sensitive to the effects of blood flow restriction, potentially worsening symptoms or delaying the healing process. Clearance from healthcare professionals is necessary in such cases.
• Peripheral neuropathy: Individuals with peripheral neuropathy, a condition affecting nerve function in the extremities, may experience altered sensation and reduced ability to perceive discomfort during BFR. This lack of sensation can increase the risk of applying excessive pressure, potentially leading to injury. Close monitoring and guidance from healthcare professionals are crucial for individuals with neuropathy.
• Compromised skin integrity: BFR should be avoided if there are existing skin wounds, ulcers, or compromised skin integrity at the cuff application site. Applying cuffs over damaged skin can exacerbate skin issues, increase the risk of infection, and impede the healing process. Ensuring healthy skin conditions before BFR is essential.
• Pregnancy: BFR is generally not recommended during pregnancy due to the potential impact on blood pressure and circulation. The safety of BFR for pregnant individuals has not been thoroughly studied, and caution is advised to protect both maternal and fetal well-being.
• Lack of medical clearance: Before initiating BFR, individuals with any pre-existing health conditions or concerns should seek medical clearance from healthcare professionals. Conditions not mentioned specifically here may still warrant evaluation and guidance before engaging in blood flow restriction training.

How Safe Is BFR?

Here are some safety considerations for blood flow restriction therapy:

Certifications for Practitioners

Consider the following when it comes to certifications.

• Certified training: Our therapist here at CSC has received extensive training along with undergoing instruction from one of the industry leaders in BFR, Jonny Owens. Make sure to ask for credentialing of your provider to ensure they have the proper certification and training in blood flow restriction. Certifications ensure that practitioners are knowledgeable about the technique, its applications, and safety considerations.
• Understanding individual health profiles: Certified practitioners should conduct thorough assessments of patients’ health profiles, considering factors such as medical history, pre-existing conditions, and any contraindications. This information guides the safe and effective application of BFR tailored to each patient.
• Monitoring during sessions: Certified practitioners must closely monitor patients during BFR sessions. Continuous observation allows for real-time adjustments, ensuring that pressure levels and patient responses are within safe limits.
• Adherence to guidelines: Practitioners should adhere to established guidelines for BFR, including recommended pressure levels, cuff placement, and exercise protocols. This helps maintain consistency and safety across BFR sessions.

Use of Equipment

Certain considerations when it comes to the equipment being used include: 

• Properly fitted cuffs: It is crucial to use BFR cuffs that are properly fitted to the patient’s limb size. Ill-fitted cuffs may lead to uneven pressure distribution, increasing the risk of adverse effects. Practitioners should choose cuffs that match the patient’s limb circumference and anatomy.
• Adjustable cuff pressure: The BFR equipment should allow for precise control of cuff pressure. Adjustable mechanisms, often present in inflatable cuffs, enable practitioners to tailor the pressure to individualized and safe levels, preventing excessive occlusion.
• Regular equipment inspection: Practitioners should routinely inspect BFR equipment for wear and tear. Damaged cuffs or malfunctioning pressure control mechanisms can compromise safety. Regular maintenance ensures the equipment is in optimal condition for patient use.
• Education for patients: Practitioners must educate patients on the proper use of BFR equipment, including how to wear cuffs, adjust pressure, and communicate any discomfort. Patient understanding and cooperation are essential components of safe BFR therapy.
• Establishing patient comfort: Patients should be comfortable with the equipment used during BFR sessions. Practitioners should address any concerns or anxiety patients may have, fostering a positive and trusting environment for the therapy.
• Emergency preparedness: Practitioners should be prepared to handle emergencies related to BFR, including rapid deflation of cuffs if needed. Having emergency protocols in place and being trained in basic life support measures ensures a prompt and effective response.

What Are the Clinical Applications of BFR?

Numerous. Because BFR has a wide range of benefits, its application can look vastly different from patient to patient. While BFR can be utilized as a stand-alone treatment, we here at CSC use it more commonly in conjunction with other therapies such as our world-renowned orthobiologic injections. 

One promising method is to have our patients undergo a round of BFR just prior to their blood draw, thereby amplifying their platelet counts before going to our lab for processing. 

If the timeline or schedule does not allow for BFR to be performed before injections, then BFR after is also beneficial for our orthobiologic injections to enhance healing timelines along with improving the quality of the involved tissues.

Integrating Clinical Outcomes And Patient Goals With BFR

Blood flow restriction has emerged as a valuable adjunct in physical therapy, offering a novel and effective approach to enhancing tissue recovery and chronic pain management. 

As we conclude, it is essential to understand that BFR can be a helpful addition to traditional physical therapy, particularly for individuals undergoing injection-based therapies looking to utilize best practice standards in realizing their goals. 

As part of a holistic and carefully supervised rehabilitation strategy, BFR can contribute to improved muscle function, reduced pain, and enhanced overall well-being. However, individuals must work with qualified healthcare professionals or certified practitioners to ensure that BFR is applied safely and effectively based on their specific needs and conditions.

Come see what blood flow restriction therapy can do for you. Contact us today!

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Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training in both. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI). Dr. Schultz trained at George Washington School of…

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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