BFR Protocol

Written By Jeff Rolland

BFR Pressure Assessment

In order to standardize the application of Blood Flow Restriction training (BFR), you should always use a percentage of arterial occlusion pression (the amount of pressure required to cease blood flow to a limb). Since individualized cuff pressures are the safest method of application, allowing for proper progression of BFR. (1-3)

Arterial Occlusion Pressure (AOP) is influenced by: (2-4)

  • Blood pressure and body temperature

  • BFR cuff shape, width, and length

  • Body position

  • Limb circumference

  • Time of day

AOP can be determined by inflating the cuff being used during exercise up to the point where blood flow ceases (100% AOP) and using a percentage of that pressure (e.g., 50–80% of AOP) during exercise. (2,3)

AOP can be established quickly and reliably using Doppler Ultrasound or built in pressure sensors of several commercially available devices. (2,3)

AOP is body position dependent with AOP being highest in standing compared to seated, and lowest in supine. Thus, for accurate prescription during exercise, BFR should be measured in the intended exercise position. (4)

Safety of BFR (1,2,5-9)

Individuals respond similarly to BFR training and regular exercise. Therefore, anyone not appropriate for regular exercise should not commence BFR training.

The literature makes certain safety recommendations:

  • Use personalized arterial occlusive pressures (AOP)

  • Stay at or below 5-10min of total time under restriction per exercise

    -Allow 3-5 min of reperfusion between exercises

  • Wider cuffs restrict blood flow at lower overall pressures with improved comfort (cuffs range from 3-18cm in the literature)

  • Follow the low load BFR protocol and do not exercise clients to failure

    -Prevents the risk of exercise induced muscle damage 

There are inherent risks with BFR and thus all patients should be assessed for the risks and potential contraindications prior to BFR application.

Absolute Contraindications for BFR (require 3 or more risk factors present) (10)

  • Thrombophilia

  • Current hospital admission

  • >48 hours of immobility in the past month

  • In the past 3 months

    -Hospital admission

    -Surgery

    -Malignancy

    -Infection

Potential Contraindications to consider: (3,10-15)

  • Cardiovascular Disease

    -E.g. atherosclerotic vessels causing poor blood circulation, cardiopulmonary conditions, coronary artery disease, hemophilia, hypercoagulable states (blood clotting disorders), peripheral vascular disease, unstable hypertension, varicose veins or vascular endothelial dysfunction

  • Cancer or Tumor

  • Extremity Infection

  • Family medical history

    -E.g. Atrial fibrillation or heart failure, cancer, clotting disorders, connective tissue disorders, sickle cell anemia

  • Lifestyle factors

    -E.g. obesity, pregnancy, smoking or uncontrolled diabetes mellitus

  • Lymphadenectomy

  • Medications known to increase clotting risk

  • Musculoskeletal injury

    -E.g. open fracture, open soft tissue injury, postsurgical excess swelling, recent muscle trauma / crush injury, or skin graft

  • Post Surgery

    -The risk of VTE is increased nearly 100-fold in the first 6 weeks following surgery

  • Renal compromise or Chronic Kidney Disease

  • Rheumatoid arthritis

  • Venous thromboembolism (current or history)

*This is not an exhaustive list, and it is recommended that all patients be screened before BFR

 

BFR Clinical Pathway

  1. Attempt traditional heavy load strength training

  2. Educate on BFR safety concerns and benefits

  3. Clear potential contraindications

  4. Measure Arterial Occlusion Pressure (AOP) with machine or handheld doppler

  5. Implement low load BFR protocol 2-3x/week
    -Start at 50% AOP to mitigate DOMS
    -Ensure concurrent home program

  6. Advance patient to traditional strength training when able

  7. Use experience of metabolic stress to anchor patient’s future expectations of exercise intensity  

Low Load BFR Protocol (2,16-20)

Which BFR Cuffs to use?

1)H+ Cuffs
10% Discount code: JEFF10

Pros

  • Best priced BFR cuff on the market

  • 4 inch wide cuffs

  • Available in straight cuffs and curved cuffs
    (*Recommend curved cuffs)

  • Only need to purchase a set of cuffs and a hand pump
    (if you have access to a health care professional who can calculate your AOP)

Cons

  • Need a health care professional to use a handheld doppler to calculate your AOP

2) Smart Cuffs
10% Discount Code: JeffPhysio10r

Pros

  • Cuffs will automatically calculate AOP for the user

  • Only need to purchase a set of cuffs

  • 4-5” wide for the Large and XL cuffs

  • 2.75” wide for Small and Medium cuffs

Cons

  • Higher price point

  • 1. Minniti, M. C., Statkevich, A. P., Kelly, R. L., Rigsby, V. P., Exline, M. M., Rhon, D. I., & Clewley, D. (2020). The safety of blood flow restriction training as a therapeutic intervention for patients with musculoskeletal disorders: A systematic review. The American journal of sports medicine, 48(7), 1773–1785.

    2. Patterson, S. D. et al. (2019). Blood flow restriction exercise: Considerations of methodology, application, and safety. Frontiers in Physiology, 10(533), 1-5

    3. Rolnick, N. Kimbrell, K., Cerqueira, M.S., Weatherford, B., & Brandner, C. (2021). Perceived barriers to blood flow restriction training. Frontiers in Rehabilitation Science, 2, 1-14

    4. Hughes, L., et al. (2018). Influence and reliability of lower-limb arterial occlusion pressure at different body positions. PeerJ, 6, 1-12

    5. Hughes, L., Paton, B., Rosenblatt, B., Gissane, C., & Patterson S. D. (2017). Blood flow restriction training in clinical musculoskeletal rehabilitation: A systematic review and meta-analysis, Br J Sports Med, 51, 1003-1011

    6. Loenneke, J. P., Wilson, J. M., Wilson, G. J., Pujol, T. J., & Bemben, M. G. (2011). Potential safety issues with blood flow restriction training. Scand J Med Sci Sports, 21(4), 510-518

    7. Sabino de Queiros, V., et al. (2021). Effect of resistance training with blood flow restriction on muscle damage markers in adults: A systematic review. PLoS One, 16(6), 1-21

    8. Scott, B. R., Loenneke, J. P., Slattery, K. M., & Dascombe, B. J. (2015). Exercise with blood flow restriction: An updated evidence based approach for enhanced muscular development. Sports Med, 45(3), 313-325

    9. Thiebaud, R. S., Yasuda, T., Loenneke, J. P., & Abe, T. (2013). Effects of low-intensity concentric and eccentric exercise combined with blood flow restriction on indices of exercise-induced muscle damage. Interventional Medicine & Applied Science, 5(2), 53-59

    10. Bond, C. W., Hackney, K. J., Brown, S. L., & Noonan, B. C. (2019). Blood flow restriction resistance exercise as a rehabilitation modality following orthopaedic surgery: A review of venous thromboembolism risk. The Journal of orthopaedic and sports physical therapy, 49(1), 17–27.

    11. Brandner, C.R., May, A.K., Clarkson, M.J, & Warmington, S.A. (2018). Reported side-effects and safety considerations for the use of blood flow restriction during exercise in practice and research. Techniques in Orthopaedics, 33(2), 114-121

    12. da Cunha Nascimento, D., Schoenfeld, B. J., & Prestes, J. (2020). Potential implications of blood flow restriction exercise on vascular health: A brief review. Sports medicine,50(1), 73–81

    13. DePhillipo, N. N. (2018). Blood flow restriction therapy after knee surgery: Indications, safety considerations, and postoperative protocol. Arthroscopy Techniques, 7(10), e1037-e1043

    14. Kacin, A., Rosenblatt, B., Zargi, T.G., & Biswas A. (2015). Safety considerations with blood flow restricted resistance training. Annales Kinesiologiae, 6(1), 3–26

    15. Nascimento, D. D. C., Rolnick, N., Neto, I. V. S., Severin, R., & Beal, F. L. R. (2022). A Useful Blood Flow Restriction Training Risk Stratification for Exercise and Rehabilitation. Frontiers in physiology, 13, 808622.

    16. Anderson, A. B., Owens, J. G., Patterson, S. D., Dickens, J. F., & LeClere, L. E. (2019). Blood flow restriction therapy: From development to applications. Sports Med Arthrosc Rev, 27, 119-123

    17. Loenneke, J. P., Wilson, G. J., & Wilson, J. M. (2010). A mechanistic approach to blood flow occlusion. Int J Sport Med, 31, 1-4

    18. Loenneke, J. P., et al (2012). Blood flow restriction: An evidence based progressive model (review). Acta Physiologica Hungarica, 99(3), 235-250

    19. Patterson, S. D., Owens, J., & Hughes, L. (2020). The use of blood flow restriction in early stage rehabilitation following ACL injury: Implications for enhancing return to play. Aspetar Sports Med, 9, 58-61

    20. Scott, B. R., Loenneke, J. P., Slattery, K. M., & Dascombe, B. J. (2015). Exercise with blood flow restriction: An updated evidence based approach for enhanced muscular development. Sports Med, 45(3), 313-325

Jeff Rolland
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