Blood Flow Restriction Therapy

Where We Are and Where We Are Going

Bryan G. Vopat, MD; Lisa M. Vopat, MD; Megan M. Bechtold, DPT; Kevin A. Hodge, MD


J Am Acad Orthop Surg. 2020;28(12):e493-e500. 

In This Article

Cuff Application

The goal of the restriction cuff is to provide sufficient external pressure to the proximal upper or lower extremity to occlude venous outflow while maintaining arterial inflow (Figure 2, A and B). Early use of BFRT cuff pressures were commonly greater than 200 mm Hg; however, recent investigations have found that similar results can be achieved with pressures as low as 50 mm Hg, with less risk of adverse effects.[6] Today, the restriction pressure applied is often based on a percentage of an individual's arterial occlusion pressure (AOP) or the pressure required to occlude all blood flow to the limb.[12] To calculate AOP, a blood pressure cuff is placed on the proximal extremity and Doppler ultrasonography is placed on the radial or dorsalis pedis artery. The cuff is inflated until no pulse is identified, and then it is slowly released. The pressure recording when the pulse returns is defined as the AOP.[13] The optimal pressure applied varies with each individual and is largely dependent on limb circumference and cuff width.[12] The optimal percentage of AOP is controversial; however, Counts et al[14] determined that similar effects on muscle development were obtained at 40% of AOP compared with 90% at 8 weeks.

Figure 2.

A, Cuff application to the upper extremity. (B), Cuff application to the lower extremity.

There are two options of restriction cuff: individualized BFRT and practical BFRT. Individualized BFRT is essentially an advanced surgical tourniquet that allows the user to dial into a specific percentage of AOP and maintains this pressure throughout the training session. This has proven beneficial, especially in the research setting where it provides standardized results. The other school of thought is practical Blood Flow Restriction (BFR), which uses a blood pressure cuff or elastic band to provide external pressure at a nonspecific value below AOP. This has shown to provide a safe, economically feasible, and effective method of performing BFRT in large groups.[1,15,16] It is based on the theory that an exact percentage of AOP is not essential, so similar strength gains can be produced at a lower cost. Although no studies were found directly comparing individualized BFRT with practical BFRT, several studies have shown positive effects on muscle development with practical BFRT.[15,17]