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Blood Flow Restriction 101

We're always looking for better ways to rehab and train our clients at Restore/Thrive. In the never-ending pursuit to find and apply best practices in our gym, we've come across one of the strangest, most uncomfortable, and uncommonly effective ways to maximize results. And not just to heal injuries. We're talking about hard-charging, heavy breathing, packing on slabs of muscle training results.

So what does this have to do with you? Everything. Because even though just about anything can work to get you stronger, nothing works forever. That means the linear strength training program you started in high school probably tapped out all the gains you hoped to make by the time you were 20. If you've amassed any serious time training in the gym, you know after that first six months to year-long wave of adaptation, it's exponentially harder to accumulate serious strength, muscle mass, and cardiovascular improvement. People can spend years spinning their wheels trying to catch that second wave of adaptation. And unless the stimulus is sufficient, the results will be less than stellar.

Blood Flow Restriction training (we'll refer to this from now on as BFR, for the sake of my slow typing speed) was first developed in Japan in 1966. Initially, bands were used and wrapped around the upper arms or upper thighs before users would perform very light weight or bodyweight exercises. In the early 2000s, researchers started experimenting with air cuffs as you would find on a blood pressure cuff.

Physiologically, researchers discovered that BFR training restricts venous blood flow (the blood going out of the muscle back to the lungs) while allowing arterial blood flow (blood coming into the muscle from the heart). It has also been observed that BFR training decreases the load on joints and ligaments while creating a monstrous anabolic environment for new muscle growth to the tune of a 200-300% increase in Growth Hormone (GH) and Insulin-Like Growth Factor-1 (IGF-1). Clinicians have observed that folks using BFR have less muscle and joint soreness after training, and respond faster to the training stimulus, building strength and muscle hypertrophy 2-3 times faster than previously expected norms.

Another shocking finding of the research was that BFR allows Type II muscle fibers (responsible for strength, speed, and size) to be recruited before Type I muscle fibers-completely opposite of what we assumed was the normal recruitment pattern of muscles for the better part of the last 40 years.

Anecdotally, while I was doing research for this article, I came across a PT in South Carolina who used BFR on a post-ACL-repair patient. In just two months' time after the patient's surgery, the size of his quadriceps on his operated leg was slightly bigger than the quadriceps on his non-operated side. For you non-PT folks, this is a fairly astounding report, as it is not abnormal for post-ACL tear patients to have significant atrophy of their operated leg quadriceps even 6 months after surgical repair.

What Does A BFR Session Look Like?

In the rehab setting, BFR is short and sweet. We recommend 2-3 sessions per week, wearing the cuffs for 6-10 minutes total. A patient may simply perform a straight leg raise, lying on their back, to fatigue, rest for up to 1 minute, then repeat to fatigue, until they have accumulated 6 to 10 minutes of exercise or have noted a pain level greater than 7/10.

On training days, BFR is a monster. Personally, I have melted my arms doing four sets of bench press with 95 pounds on the bar. The set and rep schemes vary slightly compared to the rehab application. Normally, a BFR training session will include 3 to 6 exercises, 3-4 sets of each exercise at most, 30-60 seconds rest between sets. The most common rep scheme is 30 - 15 - 15 - 15. BFR can be removed between exercises for 2-3 minutes or it can be used for extended training as well, ranging from 10 minutes at the low end to 30 minutes at the high end. These longer efforts usually involve walking on a treadmill or riding a stationary bike. I can't stress how hard and yet how gentle this is. You don't get sore. You can derive the benefits of lifting or training at 70% of your max intensity with only 20% of your normal load. That's a phenomenal way to manage the stress of heavy loading that comes with a traditional strength training program.

Is BFR The Wave Of The Future?

Slow down, Cowboy. There are some important precautions and absolute contraindications. We've included them below in a handy chart that makes you perform simple math, for your reading pleasure:

As you can see, BFR needs to be applied judiciously. Those of you prone to Google Search around for fitness advice will no doubt find a bevy of "Blood Flow Restriction Cuff Trainers". Unfortunately, there are a lot of folks out there looking to make a quick buck. And there are equally as many people not willing to spend the time, do the research, or invest the money to buy a safe and effective BFR system.

BFR simply modifies blood flow, it does not occlude or stop it completely. If you are using a rubber band or knee wrap to do your BFR training, you are not doing BFR training. You are performing occlusion training, which is counterproductive at best, and potentially fatal at worst. You absolutely have to measure the pressure you're putting in the cuff before you start rehabbing or training. Too much pressure can lead to potentially harmful side effects, including DVT (deep vein thrombosis-a potentially life-threatening condition) and rhabdomyolysis (which can lead to kidney damage, kidney failure, and possibly death).

A skilled professional should be checking your radial pulse between sets if you're doing upper extremity training, and checking your posterior tibial artery pulse if you're doing lower extremity training.

If you are struggling to regain strength after a surgery or injury or have hit a plateau in your training, BFR might be right for you. If you're interested in learning more about how BFR could fit into your rehab or training, click the "Inquire Now" button at the top of this page or email us at

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Dr. Tim Cummings is a strength coach, physical therapist, writer, speaker, and, along with his wife, Jess, the founder of Restore/Thrive. Tim splits his time between helping athletes, parents, and coaches fix acute and long-standing orthopedic injuries and programming post-rehab training programs for individuals looking to get back to their active lifestyles after an injury. He received his Bachelor of Arts in Exercise Science from the University of Missouri-Kansas City in 2004, and his Doctorate of Physical Therapy from Southwest Baptist University in 2010. He was certified as a Titleist Performance Institute Certified Trainer in 2011. He was certified as an IMPACT Concussion Management Provider in 2012 he was the first physical therapist in Kansas City to earn recognition as a MovNat certified trainer in 2014. He was the first physical therapist in Kansas City designated as The Ready State Certified Practitioner in 2015. He earned the Power Athlete Block One Coach certification in 2020. Tim’s background as an athlete includes a history of competitive baseball, basketball, cross-country running, and performance weightlifting. In his free time, he enjoys spending time with his wife Jess and their three children, Aiden, Evelyn, and Connor, their Cavachon puppy Coco, weightlifting, golfing, obstacle course racing, competitive eating, and wrestling with his kids.

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