Blood Flow Restriction Training and The Physique Athlete
Blood Flow Restriction Training and The Physique Athlete
Research-Based Guide to
Maximizing Muscle Size
Nicholas Rolnick, DPT, MS1 and Brad J. Schoenfeld, PhD, CSCS, CSPS, FNSCA2
1
The Human Performance Mechanic, PHLEX NYC, New York, New York; and 2Health Sciences Department, CUNY
Lehman College, Bronx, New York
ABSTRACT studied in hundreds of published articles (70+% 1RM) lifting, making it an alter-
and is used by a wide variety of popula- native for physique athletes seeking to
Emerging evidence indicates that low
tions—from the injured (29,40) to the phy- maximize muscle growth without addi-
load blood flow restriction (BFR) training
sique athlete looking to maximize muscle tional joint stress (21,53). This article will
is an effective strategy to increase mus- growth during contest preparation (58). provide an evidence-based review of cur-
cular adaptations. Yet, it remains ques- rent research on the resistance-training
tionable as to whether combining BFR BFR training involves use of a compres-
sive cuff wrapped around the proximal benefits of BFR exercise with respect to
with traditional resistance training can hypertrophy and draw practical conclu-
portion of the limb so as to partially
potentiate hypertrophic adaptations. The sions as to how the strategy can be
reduce arterial flow and completely
purpose of this article is to provide an applied by physique athletes to optimize
restrict venous return (71). As a result,
evidence-based review of current increases in muscle mass.
blood pools in the extremity distal to
research on the topic including underly-
the cuff, altering the local muscular envi-
ing mechanisms of BFR training and BLOOD FLOW RESTRICTION
ronment. The reduction in blood flow
draw practical conclusions as to how TRAINING MECHANISMS OVERVIEW
from the applied pressure decreases oxy-
BFR can be applied by physique athletes (HYPERTROPHY FOCUSED)
gen delivery, challenging local energy
to optimize increases in muscle mass. The mechanisms underlying BFR RTare
metabolism and reducing the time
still contentious but appear to be some-
needed to reach volitional failure during
what modulated by similar processes as
aerobic training and resistance training
INTRODUCTION free-flow exercise. Skeletal muscle hyper-
(RT) compared with similar exercise
odern day blood flow restric- trophy occurs when net protein balance
M
without restriction (27,28,99). Because
tion (BFR) training was discov- is positive, providing a favorable environ-
of the unique metabolic environment in
ered in 1966 by Yoshiaki Sato, ment to induce muscle growth (16). Mus-
the limb from the compressive cuff, BFR
who called it KAATSU (“added pres- cle growth appears to be mediated by
training is commonly prescribed with
sure”) training (76). In the 54 years since loads as light as 20% one repetition max-
his discovery, BFR training has been imum (1RM) (71). Low-load RT with
KEY WORDS:
blood flow restriction exercise; bodybuild-
Address correspondence to Brad J. Schoen- BFR can provide similar increases in
ing; competition; muscle hypertrophy
feld, [email protected]. muscle mass compared with heavier
22 VOLUME 42 | NUMBER 5 | OCTOBER 2020 Copyright Ó National Strength and Conditioning Association
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mechanistic target of rapamycin complex contractions such as lactate, hydrogen facilitate greater type I fiber hypertrophy
1 (mTORC1), a molecular nodal point in ions (H+), ATP, and inorganic phos- by impairing calcium binding in type II
the anabolic molecular intracellular sig- phates are produced and are unable to fibers and thereby placing a greater bur-
naling pathway (36). Sufficient exit the limb through the venous system den on type I fibers to maintain force
stimulation of skeletal muscle via RT in- due to the restrictive cuff (56). These me- output as metabolically taxing exercise
duces post-exercise increases in tabolites interfere with the excitation– continues (35). This may help to explain
mTORC1 expression, eventually leading contraction mechanism causing earlier emerging research showing that low-
to visible increases in muscle size with recruitment of type 2 muscle fibers rela- load BFR elicits preferential hypertrophy
continued training (32,63). Both heavy- tive to the same exercise being performed of slow-twitch muscle fibers (8,9,43).
and light-load training, with and without in free-flow conditions (22,98). As fatigue Further research is warranted to better
BFR, performed to volitional failure have accumulates from the metabolic stress, elucidate mechanistic underpinnings of
shown to induce significant mTORC1 muscle contraction velocity slows and adaptations achieved with low-load
expression and, in longitudinal studies, muscle activation increases (85), ulti- BFR training.
are reported to produce similar increases mately stimulating anabolic processes.
in muscle size in various populations Metabolites also stimulate the group III– CELL SWELLING
(18,20,21,53). However, low-load exer- IV afferents in and around the muscle Cell swelling describes the acute
cise that is work-matched to BFR (i.e., fiber during contractions to promote increase in muscle thickness that results
30-15-15-15 repetitions) does not appre- increased blood flow to the exercising from accumulation of fluid in a limb
ciably increase mTORC1 levels nor alter muscle in an effort to reduce peripheral due to a lack of venous return (56). Fluid
mTORC1 downstream protein kinase fatigue accumulation (loss of the muscle is believed to shift from the plasma into
molecules such as S6 kinase beta-1 fiber’s ability to create force) (5). It is the muscle cell due to osmolality gradi-
(S6K1), and thus, these protocols are infe- ent differences (91). Fluid accumulation
theorized that group III–IV afferents
rior in producing appreciable gains in during and after exercise is believed to
can stimulate additional motor unit
muscle size (32,33), conceivably because be due to decreased oxygen availability,
recruitment through activation of the fu-
the intensity of effort is not sufficiently the accumulation of metabolites, and
simotor neuron-muscle spindle-motor
challenging to evoke a robust hypertro- subsequent increases in reactive hyper-
neuron pathway so as to ensure force
phic stimulus. Finally, administering emia (56,62,104). These factors have
remains steady during repeated muscular
mTORC1’s antagonist, rapamycin, blunts been linked to earlier type II muscle
contractions (34). The group III–IVaffer-
the muscle protein synthesis (MPS) fiber recruitment (42,73).
ents also have synapses onto the central
response to BFR exercise, highlighting
nervous system (CNS) and are postu- Increases in muscle thickness after exer-
the importance of this pathway during
lated to play a role in subjective increases cise have been correlated with long-
BFR exercise (36). Thus, it seems that
in perception of effort during exercise term muscle hypertrophy in free-flow
mTORC1 expression is crucial to the
(25,70). Higher levels of effort during and BFR exercise (28,44). BFR training
long-term hypertrophic response to
fatiguing contractions have been thought has been shown to significantly increase
BFR training regardless of the exact
to correspond with type II muscle fiber cell swelling over work-matched con-
mechanisms that differentiate low-load
recruitment (70). Importantly, when trols (103) while producing similar levels
BFR versus high-load traditional training.
free-flow low-load exercise is performed during exercise to failure (6,15,28,108)
with and without BFR to failure, both and high-load training (3,30,44). Thus,
RESISTANCE TRAINING:
MECHANISMS UNDERLYING report very high levels of effort and local- exercise with BFR can produce acute
HYPERTROPHY ized muscle pain, likely by the combined increases in cell swelling that hypothet-
Current theory proposes 2 primary effects of the accumulated metabolites ically can contribute to meaningful long-
mechanisms underlying the benefits stimulating group III–IV afferents and term changes in muscle size.
observed with low-load RT with BFR: the resultant changes in CNS activation Cell swelling is believed to act through
metabolite-induced accelerated fatigue (11,25,95,96). stimulation of an intrinsic volume sen-
and cellular swelling. Both mechanisms It is not clear whether metabolites them- sor in the muscle fiber that, when
have the capacity to create an anabolic selves contribute to an exercise-induced stretched, begins the process of MPS
environment in the muscle to augment hypertrophic response. Emerging evi- (56). When fluid is trapped in the limb
MPS responses to exercise and are dis- dence indicates that lactate mediates during and after exercise, the cytoskel-
cussed in the following subsections. anabolic processes both in vitro etal matrix becomes stressed, eventu-
(67,68,92,100) and in vivo (68,92). These ally leading to activation of anabolic
METABOLITE-INDUCED FATIGUE results may be attributed at least in part intracellular signaling pathways (56).
Metabolite-induced accelerated fatigue to a lactate-induced inhibition of histone It is questionable whether cell swelling
describes the phenomena that occur deacetylase activity (49), which serves as alone is anabolic in vivo because recent
when BFR is applied to an exercis- a negative regulator of muscle growth. research investigating a passive cell
ing limb. Byproducts of muscular Moreover, the buildup of H+ may swelling protocol performed with no
23
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BFR Training and the Physique Athlete
exercise failed to increase mTORC1 walking) and lack of perceived loss in over low-repetition training alone (i.e.,
expression (66). However, long-term thigh hypertrophy (58). A follow-up heavy training in the 6–10RM range)
passive cell swelling applications have MRI revealed significant healing of due to stimulation of the spectrum of
been shown to attenuate or completely his osteochondral fracture, and with muscle fiber types, although this
prevent disuse atrophy (47,86), lending conservative nonsurgical treatment, hypothesis remains somewhat
credence to the notion that cell swell- the individual was able to return to speculative.
ing may provide a low-level hypertro- high-load training. This report pro- BFR training may be an appealing
phic stimulus sufficient to maintain vides limited evidence that BFR can modality to integrate into the resis-
neutral net protein balance for a period. be successfully used in competitive tance exercise programs of physique
bodybuilders deep into contest prepa-
athletes due to the unique metabolic
BFR RESEARCH ON ATHLETES, ration despite the presence of lower
WELL-TRAINED INDIVIDUALS, AND stress it provides to the musculoskele-
extremity injuries that would impede
PHYSIQUE COMPETITORS tal system when training with lighter
heavy-load training.
To date, the research on using BFR loads and intensities not typical of
with physique athletes is sparse (1 case There does seem to be a superior ben- bodybuilding routines (69). The meta-
report). Therefore, this section will efit to maximizing hypertrophy in rec- bolic stress produced from BFR exer-
cover the relevant research pertaining reationally active individuals when cise may expose muscle fibers
to optimizing hypertrophy in combining low-load BFR (30% 1RM) (particularly type I fibers) to new
resistance-trained individuals and pro- with heavy loads (75% 1RM) in a lifting recruitment demands not obtained
fessional athletes using BFR training, program. Yasuda et al. (106) observed from traditional heavy-load training
drawing parallels (when appropriate) statistically significant increases of and thus provide a way to further aug-
to the physique athlete. +7.2% muscle cross-sectional area ment muscle hypertrophy in highly
(CSA) of the triceps brachii when com- trained athletes. Indeed, this has been
To the authors’ knowledge, the case bining low-load BFR and heavy lifting shown in national-level powerlifters
report by Loenneke et al. (58) on
compared with +4.4% when perform- undergoing two 1-week training blocks
a 22-year-old competitive male body-
ing low-load BFR alone in recreation- of BFR over 6.5 weeks using 30% 1RM
builder is the only published article
ally active men over a 6-week study during front squats compared with the
using BFR with physique athletes. This
period, highlighting the additive effects non-BFR group performing the same
case report provides some unique in-
of both types of training when per- exercise at 60–85% 1RM (8). Vastus
sights into the potential applications
formed concurrently. However, well- lateralis hypertrophy increased +7.7%
and benefits of BFR training in this
trained athletes may respond differ- in the BFR group versus 0% in the
population, especially during contest
ently due to their RT history. non-BFR group, with gains primarily
preparation. The article describes
a 22-year-old male bodybuilder who Previous research has shown that a 24- attributed to increases in CSA of type
developed knee pain 2 weeks before week routine consisting of heavy I muscle fibers. This study provides
his bodybuilding show. The individual elbow flexion exercise in competitive intriguing evidence that the addition
reported experiencing a pop in his right male and female bodybuilders did not of BFR can augment the hypertrophic
knee, and a subsequent MRI revealed substantially increase muscle CSA of response in highly trained athletes.
an osteochondral fracture; a surgical the elbow flexors (4). It is important Several other studies provide addi-
date was then scheduled after compe- to note that although the sample size tional support for the combined use
tition. The individual decided to use was small (n 5 10), half of the partic- of high-load training and low-load
low-load BFR RT for his legs twice ipants (3 males and 2 females) reported BFR training in athletes and well-
a week for the remainder of his contest using anabolic steroids concurrently trained individuals, although the re-
preparation instead of withdrawing throughout the program. Therefore, it sults on hypertrophy are not always
from the show. His lower-body train- seems that a single-mode approach consistent (Table 1). Most studies
ing routine exclusively comprised pain- (heavy lifting—6RM to 10RM) typical incorporating BFR into their training
free low-load BFR training performed of bodybuilding programs may not be used the strategy as a low-load supple-
predominantly in a 30-15-15-15 able to increase hypertrophy to a signif- ment to heavy-load training
scheme (30 reps on the first set, fol- icant extent after a period (5.5+ years (59,60,77,102), while others used BFR
lowed by 3 sets of 15 repetitions) twice training experience on average in the with heavy loads (70% of 1RM) (19) or
weekly, although he did occasionally bodybuilders in the aforementioned performed the same exercises but
incorporate failure training (58). The study), even with the use of anabolic substituted BFR at lighter intensities
individual ended up placing top 5 in agents. Multimode approaches using (8). The majority of the research using
his show and was able to exercise a combination of lower and higher rep- concurrent training show significant
pain-free; he ultimately postponed his etition schemes such as during low- improvements in muscle strength rela-
scheduled surgical date due to limited load BFR training (i.e., 30-15-15-15) tive to the non-BFR training groups
loss of functional ability (no pain could theoretically increase muscle size (19,60,102) with some showing
Table 1
Relevant studies on athletes and resistance-trained individuals using concurrent BFR and high load
References Participants Variables of interest Exercise protocol Frequency Duration Intensity
Yamanaka 32 Division IA Collegiate Strength: BP and SQ 1RM 30-20-20-20 repetitions of BP and SQ after regular HLT 33/wk 4 wk 20% 1RM
et al. Football Players (min 5- Hypertrophy: CM with or without BFR
(102) y RT experience); measures of upper
;19.2 y and lower chest and
arm girth, thigh girth
Luebbers 62 Division II Collegiate Strength: BP and SQ 1RM 4 Groups: 30-20-20-20 repetitions of BP and SQ after 23/wk per body region 7 wk 20% 1RM
et al. Football Players (avg. Hypertrophy: CM regular HLT with or without low-load BFR or low-load
(60) 7.1-y RT experience); measures of arm, leg, training; 1 group did not perform BP or SQ but
;20 y chest girth performed BFR
Scott et al. 21 Strength: 3RM BS 30-15-15-15 repetitions after regular HLT with or without 33/wk (except for week 5– 5 wk 20–30% 1RM
(77) Semiprofessional Male Hypertrophy: VL BFR 23/week)
Australian Football architecture
Players (avg. 1.63 BW
SQ); ;19.8 y
Cook et al. 20 Semiprofessional Male Strength: 1RM BP and BS 5 3 5 repetitions were performed with PU, BP and SQ 33/wk 3 wk 70% 1RM
(19) Rugby Players (min 2-y
RT experience); ;21 y
Bjornsen 19 National Level Strength: 1RM FS or MVIC Failure-15-12-Failure FS repetitions with or without BFR 53 FS/wk 3 2 wk 6.5 wk 24–31% 1RM
et al. (8) Powerlifters (16 men, 3 knee extension in addition to regular HLT; CON group performed 60–
women) (avg. ;5 y of Hypertrophy: Muscle fiber 85% 1RM FS
RT experience) analysis on VL, MT of
Strength and Conditioning Journal | www.nsca-scj.com
BFR 5 blood flow restriction; BP 5 bench press; BW 5 bodyweight; CM 5 circumferential; CSA 5 cross-sectional area; FS 5 front squat; HLT 5 high-load training; KW 5 knee wraps; LOP 5
limb occlusion pressure; MT 5 muscle thickness; MVIC 5 maximum voluntary isometric contraction; PN 5 pneumatic; PU 5 pull-ups; RM 5 repetition maximum; RF 5 rectus femoris muscle;
RT 5 resistance training; SQ 5 back squat; VI 5 vastus intermedius muscle; VL 5 vastus lateralis muscle; VM 5 vastus medialis muscle; YO 5 years old.
concurrent improvements in muscle Given emerging research showing that through increased tension on the band
hypertrophy (8,60,102), and yet, others hypoxia potentiates the RT-induced or strap provided by the user.
showing no effect of BFR training on myogenic response (13), it can be spec- Although both types of applications
strength or hypertrophy (77). Method- ulated that BFR may be an effective have shown to improve muscle mass
ological and/or participant character- strategy to promote increases in SC in the research (59,60,79,102), there ex-
istics may explain the variance in content. Indeed, a 3-week, high fre- ists some conflicting evidence on the
outcomes between studies. It seems quency BFR training program was potential safety of nonpneumatic appli-
that when groups are volume- shown to increase SC proliferation over cations (i.e., knee wraps). Commonly
equated, the results are mixed. Three work-matched low-load free-flow exer- recommended application of nonpneu-
studies show either no difference in cise (65). The findings led the authors to matic cuffs involve tightening knee
hypertrophy between groups (59,60) speculate that perhaps interspersing wraps to a perceived tightness of 6–7
or no changes at all (77), while one short blocks of low-load BFR training (on a scale where “where “10” is max-
study shows superior hypertrophy of into traditional RT programs might imal discomfort”) to achieve adequate
the BFR group over the volume- enhance hypertrophic long-term adap- occlusion pressure (59,77). However,
matched control (102). tations. However, the fact that the con- some studies suggest that individuals
Taking the aforementioned informa- trol performed work-matched sets have difficulty achieving a standardized
tion into consideration, the research raises that prospect that differences restrictive stimulus on a session-to-
tends to show that the addition of between conditions may have been session basis, overestimating or under-
low-load BFR training to a high- due to differences in proximity to failure. estimating applied pressures by as
intensity training program increases Other studies have reported no changes much as 25% (7). This may contribute
muscle hypertrophy in resistance- in SC/myonuclei concentrations after 6 to situations where individuals are
trained participants over periods of or 12 weeks of BFR training to failure exercising under full limb occlusion,
4–7 weeks compared with similar rou- (at 30% 1RM) compared with nonfai- increasing the risk of adverse events
tines performed without BFR, lure high-intensity training (70%+ even in healthy individuals. Further-
although more research is needed to 1RM) (26,80). It thus remains equivocal more, if the applied pressure is too
optimize RT exercise prescription to whether BFR is a viable strategy to low, the local metabolic environment
maximize hypertrophic potential in is not significantly altered thus render-
increase SC content in physique ath-
mixed training (i.e., heavy and light ing the addition of the cuffs ineffective
letes; further research is needed to draw
load) approaches. at accelerating fatigue accumulation at
evidence-based conclusions on
light loads (42,73).
Some evidence suggests that BFR may the topic.
enhance the satellite cell (SC) response Recently, some studies have investi-
Table 2 summarizes some of the impor-
to RT, thereby augmenting long-term gated alternative methods for stan-
tant considerations to make when
hypertrophic adaptations; an outcome dardizing cuff pressure with the use
applying BFR before training.
that would be of considerable benefit of practical BFR. Abe et al. (2) deter-
Researchers use a number of different mined that pulling elastic cuffs to 10–
to the physique athlete, particularly
BFR methodologies in the laboratory 20% of initial length achieved similar
those close to maximizing their genetic
setting that makes translating research reductions in brachial artery blood flow
capacity for muscle development. It
into practical recommendations chal- as that of a pressurized nylon cuff in-
has been proposed that each myonu-
lenging for the physique athlete. Prac- flated to 40 and 80% of resting arterial
clei controls the production of proteins
tical recommendations for the occlusion pressure, respectively. Simi-
for a finite volume of cytoplasm (the
physique athlete must take into con- larly, Thiebaud et al. (89) reported that
“myonuclear domain theory”), and
sideration BFR cuff safety, cost, and elastic knee wraps, either stretched by
beyond this theoretical “ceiling,” addi-
potential benefits with chronic use. 2 inches or to a length of ;85% of
tional nuclei must be derived from SCs
to realize further increases in muscle Research studies typically use cuffs thigh circumference, provided a valid
mass (72). The molecular underpin- that are pneumatic or nonpneumatic. alternative to pneumatically inflated
nings of how SCs are recruited to assist Pneumatic cuffs fill up with air by cuffs. It should be noted that these
in muscle building are beyond the external means (either manually studies used specially designed elastic
scope of this article, but in short— through a pump or automatically cuffs that allow for precise determina-
a damaging bout of exercise activates through a computer system or wireless tion of the magnitude of stretch; this is
a quiescent SC from the basal lamina of device) and apply the pressure to the a more difficult task with standard elas-
the muscle fiber to proliferate, differen- limb by increasing the amount of air tic wraps, rendering their practical util-
tiate, and ultimately fuse to the muscle within the bladder of the cuff. Non- ity somewhat limited.
fiber, donating nuclei and helping with pneumatic cuffs, such as elastic knee Ideally, pneumatic devices are recom-
repair and growth processes (90,110). wraps, apply pressure to the limb mended in the gym setting because
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BFR Training and the Physique Athlete
Table 2
Considerations for the practical application of BFR
Application variable Recommendation Research notes
Practical (knee wraps) using a perceived “7/10” Pneumatic using LOP Although KW have shown efficacy in a number of studies
tightness versus pneumatic (tourniquet) using (8,60,102), they do not allow the individual to obtain
limb occlusion pressure (LOP)a a standardized pressure from session to session (7). Bell
et al. (2019) showed that when individuals were asked to
pump the cuff pressure in the arms and legs to a “7/10”
tightness once each day over 3 d, it resulted in
overestimation/underestimation of LOP in the arms by
25% and legs by 20%. This suggests that setting pressures
relative to LOP may provide a more standardized
stimulus.
Cuff width—narrow or wide (5–17 cm) Depends—both are All different cuff widths have been shown to have efficacy
acceptable if using %LOP (71), but narrow cuffs require higher pressures to obtain
LOP, potentially increasing risk to underlying
neurovasculature (55). However, use of wider cuffs may
attenuate hypertrophy underneath the restriction site
(26), although setting to individualized LOP may mitigate
that chance (51). Narrow cuffs have also been shown to
be more comfortable compared with wider cuffs when
set to the same relative LOP (83).
Cuff position Proximal limb Safety concerns for a nerve injury arise with external
compression directly over vulnerable regions at the
elbow (ulnar nerve) or knee (common fibular nerve)
tractions the nerve and increases risk of demyelination
with muscular contractions. The neurovasculature is more
protected closer to the trunk due to increased soft tissue;
so application is best suited proximally.
Maximum no. of cuffs at one time 2 (2 upper body or 2 lower Although there is no research comparing the acute or
body) chronic safety of BFR applied to 4 limbs simultaneously,
bilateral BFR has been shown to increase heart rate to
compensate for loss of stroke volume during exercise,
increasing rate pressure productb threefold compared
with free-flow exercise (74). In individuals exercising with
more than 2 cuffs on simultaneously, it may unnecessarily
increase risk of adverse cardiovascular events and is
therefore not recommended.
Body position and LOP Determine LOP in the LOP has been shown to vary based on the position of testing
position (standing/sitting/ (38,78). Underestimating or overestimating LOP may
supine) of the exercise decrease effectiveness of nonfailure BFR exercise or safety
(71).
Determining LOP (frequency) Once every 4–8 wk LOP has not shown to change significantly in healthy
individuals over the course of 8 wk (61).
a
LOP 5 limb occlusion pressure, is determined either with an automatic BFR device or manually with an external Doppler and a pneumatic cuff.
LOP is preferably determined in the position of the exercise, where the individual is relaxed, and an external Doppler is positioned at the level of
the radial or posterior tibial artery. The cuff is gradually inflated until there is no audible sound heard from the Doppler. The cuff is gradually
deflated, and the first sound heard is the individual’s LOP. Recent research also supports the use of a pulse oximeter in the upper but not lower
extremities (111).
b
RPP 5 rate pressure product is calculated by the equation, “RPP 5 heart rate 3 systolic blood pressure” and is a measure of the workload on the
heart.
they are able to provide a more con- consumer. Newer technology has been cuffs in the gym setting. These cuffs
sistent restrictive stimulus for BFR recently released for consumer pur- can determine individualized suboc-
application, minimizing safety risk chase that removes some of the pre- clusive pressures without use of an
despite the higher cost to the vious barriers of using pneumatic external Doppler (the current gold
29
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BFR Training and the Physique Athlete
Table 3
Evidence-based practical recommendations for BFR resistance training
Programming variables to consider Recommendation Important notes
Frequency 2–33/wk for .3 wk, 1–23/d ,3 wk BFR training can be performed chronically 2–33/wk in combina-
tion with HLT or used to “shock” the musculoskeletal system for
a short period (,3 wk) for 1–23/d in the absence of HLT (like
during a deload week) (71). Of note, despite the low-load nature
of BFR, 1–23/d is very stressful and likely requires considerable
recovery (10 d) to observe benefits (9)
%LOPa Arms: 40–50% In nonfailure exercise, metabolic stress is shown to increase with
Legs: 60–80% higher pressures and in the legs, 40% LOP produces a similar
metabolic environment as free-flow exercise (42,73). However,
in the arms, 40% LOP produces similar outcomes as 90% LOP
(23).
No. of exercises per session Variable Most studies use either 1 exercise (i.e., leg extension); some use 2
exercises per muscle group performing a multijoint and single-
joint variation (i.e., leg press/leg extension) (21).
Repetition scheme 30-15-15-15 or failure training 3 Both routines show efficacy in numerous studies, but failure
multiple sets training tends to increase recovery time (97). Failure may be
needed to maximally fatigue target muscle groups, especially in
advanced trainees.
Maximum wear time 10–20 min Recommended to reduce risk of adverse events. Deflate after every
1–2 exercises and wait at least 1 min before reinflating (71).
Loads 20–50% 1RM Loads greater than 50% 1RM do not seem to augment the benefits
of BFR exercise (50). Loads less than 20% provide suboptimal
outcomes with respect to hypertrophy (14).
Tempo 1–2 s concentric/eccentric Lifting tempo should be between 1 and 2 s because most research
have used these numbers (71).
Interset rest 30–60 s Shorter rest periods augment metabolic stress to a greater degree
than longer rest periods (150 s) (54).
Continuous (CON) or intermittent Continuous CON application shows superior metabolic stress (84) and muscle
application (deflated during fatigue (107) despite similar levels of perceptual effort during
rest)b exercise (31). Of note, when BFR is removed (or not applied)
during the rest periods, tissue oxygen levels tend to recover,
reducing metabolic stress (73).
Before or after HLT? After, unless no HLT performed After HLT, as maximizing hypertrophy likely needs a combination
(deloads) of high mechanical and metabolic stress, which could be
sacrificed long term if BFR is performed before HLT due to acute
fatigue response with BFR exercise (69).
Multijoint or single-joint exercises? Botha Both types have shown to increase hypertrophy, but single-joint
exercises likely superior to drive growth to muscles distal to the
cuff due to higher local fatigue tolerance (41).
Exercise order in BFR—multijoint or Either, although single-joint may stress Both have shown to be effective, but likely excessive fatigue
single-joint? muscles distal to the cuff to accumulation during single-joint movements may impede
a greater degree completion of multijoint exercise performance.
a
LOP 5 limb occlusion pressure is the minimum pressure needed to completely restrict both arterial and venous flow to the limb. Exercise is
performed at a percentage of this value.
b
CON 5 continuous application describes when the BFR cuff is left inflated throughout the duration of the exercise versus deflated during the
rest periods.
BFR 5 blood flow restriction; HLT 5 high-load training (70+% 1RM); RM 5 repetition maximum.
the 15% conditions irrespective of the back squat or bench press involves proximal to the cuff be directly trained
BFR, with lesser absolute increases in additional hypertrophy of the proxi- with heavier loads without BFR to
hypertrophy compared with the 70% mal muscle groups (i.e., gluteals and maximize hypertrophy of these
1RM condition. Therefore, it seems pectorals) (1,10,105). However, the muscles.
that metabolite-induced fatigue and gains in hypertrophy are variable and Figure 1 highlights the gradual intro-
cell swelling act to augment the hyper- tend to be greater with individuals who duction of BFR RT into a heavy-load
trophic response to BFR RT in are more deconditioned (10,105). In RT program over 12 weeks. Although
response to external loads above 15% the physique athlete who can tolerate applied pressure is not specified,
1RM, but not lower. When integrating additional loading (70+% 1RM), BFR research has shown that a wide variety
BFR RT into exercise prescriptions, may not provide enough of a hypertro- of pressures can be used to improve
loads corresponding to at least 20% phic stimulus to the muscles proximal muscle hypertrophy at various loads
1RM should be used to ensure maxi- to the cuff to warrant its inclusion in (52). However, it seems that when
mal benefit in work-matched or failure a training program. This is attributed to using lighter loads closer to 20%
exercise protocols. decreased muscle activation secondary 1RM, higher relative pressures (50%
An observed benefit to BFR RT in to reduced training loads (especially LOP in the arms and 80% LOP in
untrained or injured populations when during nonfailure, multijoint exercise) the legs) may be needed to maximize
performing multijoint exercises such as (1). It is recommended that muscles muscle gains (52). In nonfailure
Table 4
Possible ways to progress BFR resistance training
Difficulty Range of motion Miscellaneous variables BFR variables
Easier Partial range of motion Avoid lengthening two-joint muscles (i.e., calf raises on the Nonfailure (30-15-15-15)
floor versus off step)
Single-joint exercises Lower pressure (40% arms,
60–70% legs)
Multijoint exercises
Bilateral (i.e., squats) Lower %1RM (20–35% 1RM)
1–2 exercises/session
Harder Full range of motion Intensification techniques (drop sets, compound sets, etc.) Failure (2–4 sets)
Single-joint exercises Full 2-joint muscle excursions (straight leg calf raise off step Higher pressure (50% arms/
Long-lever exercises (i.e., Straight leg into full dorsiflexion) 80% legs)
raise flexion)
Higher % 1RM (35–50% 1RM)
Multijoint exercises
Single-leg biased (i.e., lunge) 3–5 exercises/session
Single-leg dynamic (i.e., walking
lunge)
BFR 5 blood flow restriction; RM 5 repetition maximum.
31
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