Personalized Blood Flow Restriction Training Literature Review

Personalized blood flow restriction training is a training strategy (or an exercise modality) that involves exercising at low intensities (i.e. 20-35% 1-RM) while occluding venous blood flow out of a limb and restricting arterial blood flow into a limb by using a Doppler controlled computer tourniquet. This type of training is accomplished by wrapping off the proximal portion of a limb. In the upper extremity this is done at the level of the deltoid tuberosity, while in the lower extremity this is performed at the level of the greater trochanter of the femur. As future healthcare providers, we recommend using an FDA approved personalized tourniquet system to perform personalized blood flow restriction training (like that found at Owens Recovery Science) as opposed to other methods such as knee wraps and/or voodoo bands.

What Are the Theories As to Why Personalized Blood Flow Restriction Training Works?

The exact mechanism(s) as to whypersonalized blood flow restriction works is (are) NOT definitive; however, both mechanical tension AND metabolic stress are thought to be primary driving factors behind hypertrophic and strength adaptations following low-level intensity exercise with personalized blood flow restriction. While it appears that the relationship between metabolic stress and mechanical tension is synergistic in nature, it is thought that metabolic stress is more of a contributing factor. For further explanations, please see the specific sections labeled “Increased Production of Systemic Hormones” as well as “Increased Recruitment of Type II Muscle Fibers.” In addition to the following factors, it is also thought that during low level exercise with personalized blood flow restriction that Myostatin concentrations are decreased, which is a protein responsible for inhibiting muscle hypertrophy but also plays a role in scar tissue formation. In short, whether for prehab, rehab or performance, personalized blood flow restriction is a very effective strategy for adding muscle size and strength while minimizing load to tissues. The problem with saying minimizing breakdown here is when we tie it to performance. One thing we do not want to perpetuate is a belief that personalized blood flow training takes the place of lifting heavy.

Mechanical Tension

1. Mechanotransduction

Conversion of mechanical energy into chemical signals that regulate anabolic and catabolic pathways, thus creating a shift that bolsters protein synthesis so that it outweighs protein degradation. For a more detailed understanding of the effects of Mechanotransduction, please see Pearson & Hussain (2015). Reference – Zou et al (2011).

However, the following theorized mechanism is highly questionable, as personalized blood flow restriction is known to result in low mechanical tension. Reference – Pearson & Hussain (2015).

 

2. Muscle Damage

A systematic review by Loenneke et al (2014) found that overall the literature does NOT support muscle damage as a primary driving force for hypertrophy as seen by….

  • NO change in maximum voluntary contraction (MVC). Umbel et al (2009), Loenneke et al (2013a), Thiebaud et al (2013)
  • NO increase in blood markers (creatine kinase, lipid peroxide, interleukin-6). Reference – Takarada et al (2000a), Fujita et al (2007), Fry et al (2010)
  • NO change in C-reactive protein. Reference – Clark et al (11), Madarame et al (13)
  • Muscle soreness ratings similar to that of submaximal intensities and/or loads. Reference – Umbel et al (2013)

3. Increase Reaction Oxygen Species (ROS) Production

While increased production of ROS has been proposed as a potential mechanism for hypertrophic adaptations following low-level intensity exercise with personalized blood flow restriction, the literature at this point appears conflicting (see Takarada et al 2000 and Goldfarb et al 2008).

4. Nitric Oxide (NO)

Since NO production is heavily dependent on high mechanical tension, it would seem that low-level intensity exercise with personalized blood flow restriction would be insufficient to elicit appropriate concentrations of NO to induce hypertrophic adaptations; however, recent studies including Hunt et al (2012, 2013) have demonstrated increased conduit-artery maximal dilation, which is solely dependent on NO production. Thus, the following studies potentially hint at the synergistic nature that metabolic stress plays in conjunction to mechanical tension. NO has shown to stimulate satellite cell activation and proliferation (Anderson 2000) as well as facilitating mTOR activation, thus directly mediating protein synthesis (Ito et al [2013])

5. Heat Shock Proteins (HSPs)

During times of heat, hypoxia, acidosis and/or ischemia – reperfusion, HSPs are thought to be elevated to maintain homeostasis. While the evidence is conflicting as to whether or not HSPs contribute to anabolic processes, Pearson & Hussain (2015) hypothesized that maybe certain HSPs (i.e. HSP72 – Kawada & Ishii 2005) and not others (i.e. HSP70 – Fry et al 2010) are elevated during low-intensity exercise +  personalized blood flow restriction, thus leading to hypertrophic changes.

 

Metabolic Stress

 

1. Increased Production of Systemic Hormones

As opposed to growth hormone (GH) and/or insulin-like growth factor (IGF-1), the better hypothesized reason appears to be mechano-growth factor (MGH), which may activate a variety of anabolic cascades including mTOR (Sandri 2008), mitogen-activated protein kinase (MAPK) (Barton 2006) and/or calcium-dependent pathways (Tidball 2005) as well as directly resulting in satellite cell activation, proliferation, and differentiation (Yang & Goldspink 2002, Hill et al [2003)

2. Increased Recruitment of Type II Muscle Fibers

Hypoxic environments (i.e. reduced oxygen) AND metabolite accumulation (i.e. blood lactate, Pi, intramuscular pH [via H+ ions]) are hypothesized to result in increased type II muscle fiber recruitment to maintain force production and protect against muscular failure. Reference – Loenneke et al (2011), Yasuda et al (2010

3. Cell Swelling (or Intracellular Hydration)

 While previous research has purported that cell-swelling results in increased protein synthesis with a concomitant decrease in proteolysis, such rationalization is highly questionable as the evidence is quite scarce (Pearson & Hussain 2015). For a more detailed explanation as to why cell swelling may result in hypertrophic adaptations, please see the paper by Pearson & Hussain (2015).

4. Muscle Damage (see above)

5. Increased Production Reaction Oxygen Species (ROS) (see above)

  

 

Blood Flow Restriction Safety & Potential Uses

 

Safety Considerations

1. Contraindications

For those with a history of deep vein thrombosis (DVTs), hypertension (HTN), varicose veins and/or cardiovascular disease (CVD) as well as those who are pregnant,  personalized blood flow restriction should NOT be used. Reference – Loenneke et al (2011a) & Loenneke et al (2014b).

For further contraindications, please visit this post.

2. Potential Risks

  • Blood Clots/Thrombus Forming Factors
    • Personalized blood flow restriction did NOT increase markers of thrombin generation (i.e. prothrombin fragments 1 / 2 OR thrombin-antithrombin III complex [TAT]. Reference – Madarame et al (2010)
  • Venous Thrombus
    • When surveying 13,000 people using personalized blood flow restriction (younger than 20 to older than 80), the risk of a venous thrombus was approximately 0.055% (results were confirmed via blood markers including d-dimer, fibrin degradation product, prothrombin time as well a thrombin time. Reference – Nakajima et al (2006)
    • After 4 weeks of personalized blood flow restriction training (using 30% 1-RM), neither prothrombin time NOR d-dimer were acutely increased. Reference – Clark et al (2010)
  • Cerebral Anemia
    • When surveying 13,000 people using personalized blood flow restriction (younger than 20 to older than 80), the risk of cerebral anemia was approximately 0.277%. Reference – Nakajima et al (2006)
  • Pulmonary Embolus / Rhabdomyolysis
    • When surveying 13,000 people using personalized blood flow restriction (younger than 20 to older than 80), the risk for a pulmonary embolism as well as the risk for rhabdomyolysis was approximately 0.008%. Reference – Nakajima et al (2006)
  • Subcutaneous Hemorrhaging (i.e. bruising)
    • When surveying 13,000 people using personalized blood flow restriction (younger than 20 to older than 80), the risk for subcutaneous hemorrhaging (or bruising) was approximately 13.1%. Reference – Nakajima et al (2006)
  • Numbness
    • When surveying 13,000 people using personalized blood flow restriction (younger than 20 to older than 80), the risk for numbness was approximately 1.297%. Reference – Nakajima et al (2006)
  • Cold Feeling
    • When surveying 13,000 people using personalized blood flow restriction (younger than 20 to older than 80), the risk for feeling cold was approximately 0.127%. Reference – Nakajima et al (2006)
  • Muscle Damage
    • A systematic review by Loenneke et al (2014) found that overall the literature does NOT support that personalized blood flow restriction with low-intensity exercise can cause increased muscle damage….
      • NO prolonged decrease in muscle function
        • NO change in maximum voluntary contraction (MVC). Reference – Umbel et al (2009), Loenneke et al (2013a), Thiebaud et al (2013)
        • NO change in range of motion (ROM). Reference – Thiebaud et al (2013)
      • NO prolonged muscle swelling. Reference – Umbel et al (2009), Wilson et al (2013), Thiebaud et al (2013).
      • NO increase in blood markers of muscle damage
        • NO change in creatine kinase and/or lipid peroxide. Reference – Takarada et al (2000a)
        • NO change in c-reactive protein. Reference – Clark et al (11), Madarame et al (13)
      • Muscle soreness similar to that of when exercising at submaximal intensities. Reference – Umbel et al (2013)
  • Peripheral Blood Flow Changes
    • Similar to exercise without personalized blood flow restriction. Reference – Loenneke et al (2011)
  • Central Responses of the Cardiovascular System
    • Blood Pressure
      • While the data appears conflicting, Neto et al (2016) highlighted that these changes are within normal limits, thus suggesting that personalized blood flow restriction is a safe alternative to add to an exercise-training program (when cleared by a physician to do so).
             Low-Intensity Exercise with PBFR vs. Low-Intensity Exercise without PBFR
Higher with PBFRHigher w/o PBFRNo Sig DifferenceHigher w/HIT
Takano et al (2005)
Vieira et al (2013)
Poton & Polito (2014a)
Kacin & Strazar (2011)
Figueroa & Vicil (2011)
Fahs et al (2012)
Ozaki et al (2013)
Low-Intensity Exercise with PBFR vs. Moderate-Intensity Exercise without BPFR
Araujo et al (2014)
   Low-Intensity Exercise with & without PBFR vs. High-Intensity Exercise without PBFR
Poton & Polito (2014b)
Poton & Polito (2015)

*As highlighted by Dr. Zach Long, blood pressure readings during heavy resistance training have reached as high as 480/350 mmHg as well as 250/190 mmHg just with biceps curls. In comparison, blood pressure readings during low intensity exercise with personalized blood flow restriction have increased to considerably lower values of 180/100 mmHg.

  • Heart Rate
    • While the data appears conflicting, Neto et al (2016) highlighted that these changes are within normal limits, thus suggesting that personalized blood flow restriction is a safe alternative to add to an exercise-training program (when cleared by a physician to do so).
Low-Intensity Exercise with PBFR vs. Low-Intensity Exercise without PBFR
Higher with PBFRHigher w/o PBFRNo Sig DifferenceHigher w/HIT
Takano et al (2005)
Vieira et al (2013)
Loenneke et al (2010a)
Poton & Polito (2014a)
Kacin & Strazar (2011)
Figueroa & Vicil (2011)
Fahs et al (2012)
Loenneke et al (2012)
Araujo et al (2014)
Neto et al (2016)
       Low-Intensity Exercise with & without PBFR vs. High-Intensity Exercise without PBFR
Poton & Polito (2014b)
Poton & Polito (2015)
Fahs et al (2011)
Rossow et al (2011)
Brandner et al (2015)
Okuno et al (2014)
Hollander et al (2010)

*As highlighted by Dr. Zach Long, heart rate readings during heavy resistance training have reached as high as 170 bpm. In comparison, heart rate readings during low intensity exercise with personalized blood flow restriction have increased to considerably lower values of 110 bpm.

 

Potential Uses

1. Prehab

  • To Reduce the Risk of Overuse Lifting Injuries (such as strains and/or tendonitis)
    • While personalized blood flow restriction has shown to reduce tendon tension (which is beneficial for increasing exercise volume with less risk to soft tissue), it is still hypothesized that we need high intensity resistance training to improve the sufficiency of our tendons to transmit load, which is needed to increase our load tolerance capacity. The reason we say “hypothesized” is because there is research that shows that growth hormone (GH) levels may be elevated up to as much as 290% post-personalized blood flow restriction training. Because we know that GH plays a role with maintaining the ultra–structure of bone, contractile tissue as well as non-contractile tissue, personalized blood flow restriction may supply a route of potential tissue resilience similar to that of high intensity resistance training (Dr. Mario Novo (IG – @liftersclinic). 
      • Kubo, K., Komuro, T., Ishiguro, N., Tsunoda, N., Sato, Y., Ishii, N., Kanehisa, H., & Fukunaga, T. (2006). Effects of Low-Load Resistance Training with Vascular Occlusion on the Mechanical Properties of Muscle and Tendon. Journal of Applied Biomechanics 22, 112 – 119

2. Rehab

  • To Minimize Strength and Hypertrophic Losses Post-Surgically
    • Takarada Y, Takazawa H, Ishii N. Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles. Med Sci Sports Exerc, 2000:32 (12); 2035-2039
  • To Speed Up the Recovery Process by Loading A Muscle or Joint with Intensities that would Traditionally Require Very High Percentages of One’s 1-RM
    • How? Personalized blood flow restriction has been shown to directly influence collagen synthesis, vascular capillary growth, increase signaling of muscle specific stems cells, and alter metabolic function that would otherwise not be seen during the early or sub-acute phases of rehab
  • To Treat Acute Injuries (such as muscle strains)

3. Performance

  • To Increase Strength & Hypertrophy when Combined With High Intensity Resistance Training without Decreasing Performance
    • Yamanka, T., Farley, R., & Caputo, J. (2012). Occlusion Training Increases Muscular Strength In Division 1A Football Players. Journal of Strength and Conditioning Research 26 (9), 2523 – 2529
  • To Maintain Strength & Hypertrophy During Deloading
    • O’Halloran, J., Campbell, B., Wilson, J., & Kilpatrick, M. (2014). The Hypertrophic Effects of Practical Vascular Blood Flow Restriction Training.
  • To Improve Cardiorespiratory Fitness (i.e. VO2Max)
    • Abe, T., Fujita, S., Nakajima, T., Sakamaki, M., Ozaki, H., Ogasawara, R., Sugaya, M., Kudo, M., Kurano, M., Yasuda, T., Ohshima, H., Mukai, C., & Ishii, N. (2010). Effects of Low-Intensity Cycle Training with Restricted Leg Blood Flow on Thigh Muscle Volume and VO2Max In Young Men. J Sports Sci Med 9 (3), 452 – 458.
  • To Directly Increase Torque and Power Production

4. Prehab, Rehab and/or Performance

  1. To Introduce Intense Exercise without the Fear of Loading (which is especially beneficial for those persons who are unfamiliar with exercise)

5. General Health Considerations

  • To Improve Bone Health, Carotid Arterial Compliance, Vascular Endothelial Function and Peripheral Nerve Circulation (in older adults)
    • Hughes, L., Paton B., Rosenblatt, B., Gissane, C., & Patterson, S. (2017). Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis.

 

Frequently Asked Questions

 

Q: So Why Not Use Knee Wraps or Some OTher Device for Personalized Blood Flow Restriction?

Limb occlusion pressure (LOP) is defined as the minimal amount of pressure required to occlude blood flow. When performing personalized blood flow restriction, research has shown that LOP NEEDS to be highly individualized. In other words, personalized blood flow restriction should be performed by taking a certain percentage of one’s LOP, which is based off a variety of factors including limb size, systolic blood pressure, cuff width as well as cuff placement as highlighted by OwensRecoveryScience (IG – @owensrecoverscience). If using knee wraps and/or voodoo bands, this becomes virtually IMPOSSIBLE to account for all these factors, and potentially resulting in higher pressures than what are actually needed. Not only do these unnecessarily higher pressures increase the risk of adverse events (including those that are cardiovascular in nature) but discomfort is increased as well. Additionally, as highlighted by Hughes et al (2017), higher pressures do not translate to greater gains in muscular size, muscular strength, and/or endurance as 40% of one’s LOP has shown similar results to that of 90% of LOP without the increased discomfort. Additionally, concerning devices such as knee wraps and/or voodoo bands are NOT FDA-approved and thus may lead to liability claims if the individual using such methods experiences some sort of injury.

 

Q: Can I Use Personalized Blood Flow Restriction and Obtain Similar Hypertrophic Changes to that of Heavy Lifting?

You could! While personalized blood flow restriction has shown to stimulate greater hypertrophic changes when compared to low load resistance training without personalized blood flow restriction, it has also shown to result in similar hypertrophic changes to that of high intensity resistance training. (HIRT) However, as mentioned previously, HIRT is still needed to improve the sufficiency of tendons to transmit load, which is needed to increase one’s load tolerance capacity. So if possible, we recommend using both types of training.

 

Q: Can I Use Personalized Blood Flow Restriction and Obtain Similar Strength Changes to that of Heavy Lifting?

NO! While Personalized Blood Flow Restriction training has shown to stimulate much greater strength changes compared to low load resistance training without personalized blood flow restriction, high intensity resistance training appears to result in greater strength gains compared to personalized blood flow restriction. Interestingly enough, there are some studies using HIRT (i.e. 70% 1-RM) with personalized blood flow restriction which has shown to provide no additional muscle damage compared to HIRT BUT drastically enhances strength gains beyond that of HIRT alone.

 

Q: Can Personalized Blood Flow Restriction Be Used with Bodyweight Exercises or Does there Need to be an External Load?

Unfortunately, at this point in time, the two studies that have assessed bodyweight exercises vs. external weight directly have found contrary results. If interested, feel free to check out both Kang et al (2015) as well as Head et al (2015), both citations which are listed below. That being said, if we look at a majority of the literature, a lot of the time it has been performed with body weight exercises alone and have shown positive outcomes. Thus, it would appear that external weight is not necessary to stimulate hypertrophic and/or strength adaptations. However, beyond the initial stages of any exercise program, (if appropriate) one should consider adding external load to induce progressive overload.

  • Kang, D., Kim, H., Lee, K., & Kim, Y. (2015). The effects of bodyweight-based exercise with blood flow restriction on isokinetic knee muscular function and thigh circumference in college students. International Journal of Physical Therapy Science 27 (9), 2709 – 2712
  • Head, P., Austen, B., Browne, D., & Campkin, T. (2015). Effect of practical blood flow restriction training during bodyweight exercise on muscular strength, hypertrophy and function in adults: A randomized controlled trial. International Journal of Therapy and Rehabilitation 22 (6), 263 – 271

 

Q: Are there Positive Effects on Muscle Groups Proximal to the Cuff?

Lower Extremities – YES

In order to stimulate hypertrophic changes in non – restricted limb musculature in the lower extremity, it appears that resistance training is needed as a study by Sakamaki et al (2011) found that when walking was combined with personalized blood flow restriction that gluteus maximus and lower lumbar (L4-L5) musculature CSA did not change

  • Sakamaki, M., Bemben, M., & Abe, T. (2011). Legs and trunk muscle hypertrophy following walk training with restricted leg muscle blood flow. J Sports Sci Med 10, 338 – 340
  • Abe, T., Yasuda, T., Midorikawa, T., Sato, Y., Kearns, C., Inoue, K., Koizumi, K., & Ishii, N. (2005). Skeletal muscle size and circulating IGF-1 are increased after two weeks of twice daily “KAATSU” resistance training. International Journal of Kaatsu Training Research 1, 6 – 12

Upper ExtremitiesYES

  • Yasuda, T., Fujita, S., Ogasawara, R., Sato, Y., & Abe, T. (2015). Effects of low-intensity bench press training with restricted arm muscle blood flow on chest muscle hypertrophy: a pilot study. Clinical Physiology and Functional Imaging 30 (5), 338 – 343.

 

 

About the Author

Personalized blood flow restriction training madison franekMadison Franek is a third year doctoral of physical therapy student at Duke University. Prior to beginning graduate school, Madison earned his undergraduate degree in Exercise Science from the University of South Florida where he also became an NSCA certified strength and conditioning coach. While clinically Madison’s interests include injury risk reduction programs (particularly as it relates to the high school athlete), concussion management and blood flow restriction training, he is also passionate about increasing awareness as to the latest scientific research through his Instagram page @evidencebasedmvmt.

 

 

Bibliography

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