BLUF: If you can’t get good fatigue in a targeted muscle group when resistance training for strength or hypertrophy secondary to pain, blood flow restriction (BFR) is the winning ticket. All you need to do if you want to try it is buy some cheap bands that you wrap high and tight around the limb you want to train, then exercise with the band(s) in place. This allows you to get much greater levels of fatigue with much lower resistance than is possible otherwise. Often, the resistance can be decreased enough that you can avoid irritating load sensitive tissues that would otherwise prevent you from getting a sick pump. Building up the muscles around such tissues, or even the process of training itself might even improve their tolerance to load over time and get you back to a level of function you consigned to being a memory of your youth!
Background
BFR has been around for a minute. The cliff notes version of the history is that a dude in Japan noticed that occluding blood flow helped him rehabilitate an injury he had super fast. He packaged his methods into something called Kaatsu training. For the kind of folks that are autistic when it comes to clinical research, consistency in the amount of occlusion applied was deemed necessary to figure out if this modality actually worked. A gentlemen named Johnny Owen working out of the Center for the Intrepid adjacent to Brooke Army Medical Center (BAMC) in San Antonio began using BFR techniques for limb salvage patients coming back from Iraq and Afghanistan. In order to maintain consistency, he used Delphi variable pressure tourniquets (the kind they use to keep you from bleeding out while undergoing orthopedic surgery to your limbs). These fancy devices have a Doppler radar build in that can assess the total occlusion pressure for a given limb.1 With that value, he used some trial and error using various set and rep schemes, and % occlusion pressure and settled on a particular set and rep scheme and optimal occlusion pressure for upper and lower extremities respectively. By all accounts he was able to get outstanding results for his patients allowing many service members to retain severely injured limbs that might otherwise have had to be amputated.
Johnny Owens Protocol
Johnny settled on one set of 30 reps followed by 3 sets of 15 reps with 30s rest between each set. 30-15-15-15. He also settled on 80% limb occlusion pressure for lower extremity (legs) and 50% limb occlusion pressure for upper extremity (arms). Johnny also prescribed a specific tempo of 5 seconds/rep (3 second eccentric, 2 second concentric)2. Now, someone more cynical than myself pointed out that this would put the entire protocol at just over 8min, which is the minimum amount of time that can warrant 1 unit of a time based code in our complex system of socialized medicine that tracks the productivity of medical providers with “relative value units.” This could be a coincidence, but it is perhaps something to consider if you’re skeptical that there is some kind of magic to this protocol. All I’d say is that I like the 30-15-15-15, but I think you can get good results with it even if you don’t adhere strictly to the Johnny Owen prescribed tempo that results in the protocol taking exactly 8min. There’s also been recent evidence published that the exact occlusion pressure doesn’t have to be 80% for lower and 50% for upper, which I mention here to transition into how I use BFR myself.
Grant’s Protocol
When it comes to exercise, the most important variable is compliance, and for this reason, I try to emphasize convenience. Using a $5,000 deplhi Owens Recovery Science variable pressure tourniquet is inconvenient. Even if you have one on hand, you’re supposed to get your max occlusion pressure every time you train, and this is a PITA as far as I’m concerned. Once you have it on, there are tubes that connect, and the battery doesn’t last a long time so sometimes there are power cables involved as well. Finally, going through 75 reps at a super-slow tempo (2 up 3 down is slower than you think until you do it to a clock) sucks. For these reasons, I use BFR bands that I’ve found through trial and error are cheap and comfortable. For upper body, I use some bands designed for BFR I bought online for $20. For lower body I like standard 3” knee wraps that I bought in the sports section of the Post Exchange. Like with everything else, I prefer compound movements over single joint exercises. It is simply more economical to train multiple joints and their corresponding muscles with the same exercise. I still like the 3-15-15-15 with 30s rest between sets, but I don’t track the tempo too closely, instead, I focus on fatigue. If my last rep of my last set is absolutely brutal, then I used the right tempo. Too easy, I slow it down next time or add weight. Too hard, I speed it up next time or lower weight.
How Tight?
Without the fancy Doppler radar, how do you know how tight to wrap the occlusion bands? I say for lower body, get them as tight as you can without it being painful. If you have a higher pain tolerance than me and you notice numbness and tingling, that is too tight, otherwise, you’re probably good. For upper body, I just shoot for about half the pressure you feel with an automatic blood pressure cuff that is maximally inflated. Again, if it isn’t painful and you don’t have numbness and tingling, its probably safe.
Example Exercise
My favorite exercise to do this with is doorknob squats. Using the doorknob you can adjust the resistance on the fly by changing how much you help yourself out of the hole while performing the squats. It also makes it easier to get through the greatest range of motion for you hip, knee, and ankle joints simultaneously while also making it easier to maintain a neutral lumbopelvic posture (a good habit if you want to progress to adding external load). For folks with anterior knee pain secondary to chondromalacia especially, this exercise is money. I would go so far as to say BFR doorknob squats are the single best thing someone with knee pain and chondromalacia could do to improve their level of pain free function. I’m currently trying to get my dad to forego a knee replacement with this very exercise. When I did my hospital rotation in PT school I just did BFR squats using this protocol for 8 weeks and cut out all of my other leg training. I progressed from doorknob to goblet squats doing it with 60lb kettle bell. My legs actually grew a little bit and I felt great.3
Why BFR?
There is actually a really good reason not to bother with BFR: If you don’t have any orthopedic injuries, I recommend you just lift weights like a normal person. If you don’t have injuries, you can just increase the load to get a good amount of fatigue and do 3 sets of 10 reps or whatever. BFR is way more of a hassle than just increasing the load and doing standard training. If, on the other hand, you find that you can’t train as hard as you used to because you’re all banged up, BFR is the single best way to achieve those levels of fatigue you know and love from your youth without the accompanying debilitating pain that comes with exceeding the load tolerance of your old ass non-contractile tissue. For anyone who gets injured and isn’t able to train as hard secondary to the temporary set back in load tolerance of some neuromusculoskeletal tissue, BFR can help you stay within that constrained post-injury performance envelope while still achieving enough fatigue to make some gainz.
How Does BFR Work?
That’s a great question! We don’t fully know. I think it has something to do with the way that contractile tissue regulates itself physiologically whereby activity produces metabolites that cause vasodilation. This is why you get a pump btw. These metabolites are probably very anabolic, if only because more blood and nutrition is able to get to these tissues under conditions of vasodilation. I also think it has something to do with a hacking of Henneman’s size principle. Typically you need more force to recruit the faster twitch muscle fibers, but how does the nervous system know how much force is being applied? Could the metabolic environment within the contractile tissue inform the nervous system of how many motor units need to be recruited? After all, under natural circumstances, faster twitch fibers are only needed to produce force at such a rate that could only be maintained by the phosphogen system and glycolysis. Perhaps a hypoxic environment sets conditions such that the muscle fibers equipped to perform in such an environment are recruited, even with lower levels of force. There is also the possibility that it has something to do with circulating metabolites, and that the local vasodilation caused by metabolites could facilitate the healing of other (non-contractile) tissues in the area. There is evidence that it works for proximal muscles as well (pectoralis major hypertrophy increased with occlusion at the upper arm). However it works, it is probably multi-factorial, and my stance is unequivocally that it does work. The only downside is, it is brutally hard. But some of us like that. For those of us that love to train hard, but are riddled with injuries, it is my very favorite modality.
Total occlusion pressure is the amount of pressure (generally measured in mm Hg) that it takes to totally occlude blood flow into a limb. This value is subjective from person to person, and even from limb to limb in the same person.
The concentric portion of a movement is when the prime movers are shortening. Eccentric is when prime movers are lengthening.
I’ll admit these N=1 experiments have had an outsized impact on my opinions on things, but I only share them after I find that the applied lessons are at least somewhat generalizable.
"BFR is the single best way to achieve those levels of fatigue you know and love from your youth without the accompanying debilitating pain that comes with exceeding the load tolerance of your old ass non-contractile tissue." I love this. Thank you.
I have been listening to this guy talk about it for a while, but have been reluctant to try. https://bfr.mercola.com/
Now with a knee injury, and your well explained recommendation, I think I will give it a try.