Health Blog

High Intensity Benefits with Low Intensity Training — You CAN Cheat the System

MTI physical therapy is excited to be the first company in Seattle and the greater Eastside to offer blood flow restriction (BFR) training, with certified physical therapy providers. BFR involves performing resistance training, or cardiovascular training, with a computerized tourniquet system, that is similar to a blood pressure cuff, on the proximal upper and/or lower limbs.19, 28, 37, 80 The cuff is pressurized specific to each person to 50%-80% of the resting blood pressure. This approach impedes venous blood return during training while maintaining arterial flow, allowing for an accumulation of exercise metabolites and an exaggerated physiologic training response by the body consistent with higher load training, but performed at lower loads.19, 28, 37, 80 The BFR training approach was first developed as KAATSU, with over a 40 year history.61 KAATSU/BFR was adopted and by Johnny Owens, a physical therapist, at Brooke Army Medical Center to improve limb strength of wounded warriors without compromising vulnerable soft tissue and joint structures.

To maximize muscle strength and hypertrophy with resistance training, the American College of Sports Medicine (ACSM) and the National Strength and Conditioning Association (NSCA) recommend training at 70-80% of a one repetition maximum (1RM). BFR training allows a similar response to training but performed at 20% to 50% of 1RM. 11, 12, 23, 44, 51, 66, 78, 85, 86 Similarly, training aerobically is prescribed at 75% of VO2 max, where as BFR aerobic training is performed around 20% of VO2 max.6, 28, 53

Tissue Repair
Growth hormone is one of the influencers of collagen hypertrophy and healing 9, 16, bone density82, as well as muscle hypertrophy.79 An increase in growth hormone is associated with high resistance training.58 Despite training at low resistance, ischemia from BFR training creates a significant increase in growth hormone.22, 43, 56, 72 One of the implications for physical therapy is that injured or weakened tissues can train at low tolerable loads yet have a physiological response for healing as if high resistance training was performed. Bone health can be significantly influenced with BFR training, but with more than just a growth hormone response. After 2 days of BFR training at a cuff pressure 40% greater than the systolic blood pressure in the upper extremity, young-male subjects experienced a significant reduction in the [bone reabsorption marker serum N-terminal cross linking telopeptide of type 1 collagen] (this is hard to track) compared to those receiving only low-intensity exercise, as well as a 21% increase in serum bone-specific alkaline phosphatase, a marker of bone formation.73

Tissue Influences with BFR
Muscle Hypertrophy5, 15, 39, 41, 42, 48, 49, 54, 55, 59, 60, 68, 81, 83, 87
Does not accumulate metabolites38
Arterial Compliance13, 17, 18, 25, 26, 50, 52, 57, 84
Venous Compliance21
Tendon repair reponse2
Bony metabolism/density7, 82
Fibrinolytic Response (prevention of blood clots)20, 64, 67
Avoids muscle damage14, 24, 33, 36, 46, 69, 76, 77, 81

Preventing Post-Operative Muscle Atrophy
BFR training can significantly improve post-operative therapeutic outcomes. Muscle weakness and atrophy are associated with acute injury or post-operative conditions secondary to muscle inhibition from pain, edema, disuse and immobilization. Physical therapy can provide early, pain free exercise to reduce edema, maintain muscle activation and assist in staving off atrophy. With acute training, however, only low load training is tolerated, which can lead to some degree of muscle atrophy in early rehabilitation. BFR can solve this issue by allowing a high intensity response from the body with low load training. Training with BFR for 2 weeks following anterior cruciate ligament reconstruction surgery, atrophy was measured as only a 9.4% cross sectional area reduction compared to a 20.7% reduction in patients receiving placebo BFR.74 After 2 weeks of immobilization, subjects that received BFR demonstrated less knee and ankle muscle strength loss than non-active subjects and subjects performing isometric exercises.31 Another study demonstrated maintenance of muscle size and strength using BFR following a simulated 2-week non-weight bearing period on crutches.30

“Walk, Don’t Run”
Imagine improving your cardiovascular efficiency as if you were running while performing a comfortable walk. Or maybe you want the benefit of cycling the Swiss Alps while comfortably pedaling on a stationary bike. BFR has been used with aerobic training, typically performed while walking or cycling with pressure cuffs placed proximally in both lower extremities. For example, a 15-minute bout of BFR cycling at 40% VO2 max, 3 times per week, has shown a 6.4% improvement in VO2 max.1 BFR training is currently being used by many collegiate and professional sports teams.

Other Functional Training Outcome Studies with BFR
Cardiovascular fitness increases with walking4
Strength and cardiovascular influence with cycling27, 65
Hypertrophy with walking3, 51, 59
Strength and hypertrophy walking in elderly population4, 10, 50, 51
Sprint training8, 75

Is BFR Safe for Me?
BFR training is safest when performed with FDA approved machines that can specifically measure your blood pressure during training and constantly adjust the tourniquet force to maintain an established restriction in blood flow. Your physical therapist will have this equipment to safely test and dose your BFR training. Primary risks of using BFR include too much pressure leading to adverse stress on blood vessels, nerves and skin. Tourniquets are regularly used in the operating room to prevent bleeding during surgery and are inflated on average up to 100 mmHg above the systolic blood pressure. A review of 63,484 surgical procedures utilizing tourniquets found most surgeons safely applied them for 2 hours (on average) with a minimal complication rate of 0.04%.47 BFR training, by comparison, generally lasts only 10-15 minutes, with most sessions lasting less than 8 minutes to one specific muscle group. Additionally the pressure does not exceed resting blood pressure, as with surgery, but is on average set at 50% of the pressure in the upper limbs and 80% pressure in the lower limbs. In a systematic review of available research on issues related to the safety of BFR training, Loenneke et al. evaluated muscle damage, nerve conduction, cardiovascular stress, and oxidative stress. It was concluded that BFR is a safe training approach for individuals regardless of age and training status when used in a controlled environment by trained and experienced personnel.40 Our therapists have been certified in BFR training to assess whether it is indicated for you, and are able to specifically dose your program to be safe and effective.

Strength Training
How can low load make you stronger? Early therapeutic exercise in physical therapy does not focus on strength training, but lower level qualities of tissue repair, edema reduction, range of motion, coordination and muscle endurance. Later in the rehabilitation process, as tissue tolerance and coordination improve, strength training is added as a progression. BFR can be added to the early rehabilitation process using low-load training for high load results. Low-intensity training with blood flow restriction creates a low-oxygen environment causing activation of type II muscle fibers and anaerobic metabolism.29 With the lack of oxygen creating an anaerobic environment, a build-up of muscle waste products (metabolites) stimulate a number of changes required for muscle and bone strengthening.70 It is the combination of a hypoxic environment and increased metabolites that leads to an increase in growth factor hormone (GFH).71 An increase in growth hormone from a single session of BFR has been shown to increase 9 times baseline19, 56 up to 290 times (huh??).72 That is a lot of metabolistic (is this a word??) response for a relatively small bout of training.

Reviews of the literature continue to conclude the positive effects of BFR training.32, 34, 35, 45, 62, 63 BFR training has proven itself to be a valuable tool in the physical therapy profession. A greater response to tissue healing and muscle hypertrophy can be achieved safely in the early stages of rehabilitation. While it may not be for every patient, there are few contraindications and concerns. As a safe alternative to potentially damaging strength training, BFR provides much of the gain, while avoiding too much of the strain.

MTI Physical Therapy offers BFR training in all of our 7 clinics. Visit our website to find a location closest to you and then ask your physical therapist if BFR training can help you.


Jim RivardJim Rivard , PT, DMT, MOMT, OCS, FAAOMPT
Physical Therapist
MTI Physical Therapy – First Hill & Bellevue

Jim Rivard is the founder, co-owner and President of MTI Physical Therapy. Four years of post-graduate training specializing in orthopaedic manual therapy has made him an expert in a wide range of orthopaedic issues: sports rehabilitation, post-surgical rehabilitation, spinal injury, headache, TMJ disorders, work injury and motor vehicle collision. His passion for learning and development of clinical skill culminated in the establishment of MTI Physical Therapy as a teaching clinic for post-graduate training. His clinical achievements have been recognized with the attainment of Fellow in the AAMOPT in 1995 and a Board Certified Orthopaedic Clinical Specialist in 1997. He has been honored to currently serve as the President for the American Academy of Orthopedic Manual Physical Therapy, recognized internationally as the primary organization for manual therapy in the United States.


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