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

Applications and Outcomes

The research on how to best use BFRT in training routines is ongoing; however, current programs have shown promise in both athletic and rehabilitation settings. BFRT has been used in combination with walking, cycling, body weight training, and most commonly low-load resistance training. A recent review by Scott et al[12] recommends the following training protocol: one set of 30 repetitions, followed by three sets of 15 repetitions, each with 30-second breaks in between sets. Blood flow restriction is maintained throughout all sets to ensure adequate venous pooling. The entire routine is to be performed 2 to 3 times per week. This baseline template has been used in several investigations with positive results; however, it should be altered to best fit each individual. Table 1, Table 2 and Table 3 list exercise programs performed in previous investigations.

Elderly Patients

A loss of skeletal mass in the elderly persons is associated with a decline in physical function and activities of daily living.[18] It is also a strong risk factor for osteoarthritis which is the most common musculoskeletal condition affecting 250 million adults worldwide.[8] Several investigations have found that increased quadriceps strength consistently decreases symptomatic knee osteoarthritis, and the use of BFRT in the elderly persons can result in increased muscle cross-sectional area (CSA) and strength.[19,27,28] Loenneke et al[7] published a meta-analysis analyzing 11 studies comparing BFRT to low-intensity training and found relative improvements in muscle strength (effect size of 0.58 compared with 0.00 in control) and muscle hypertrophy (effect size of 0.39 compared with −0.01 in control).[7] Because these patients are often unable to tolerate high-load routines, BFRT may be used in these individuals to prevent muscle weakness and progressive osteroarthritis (OA).

The effect of BFRT on knee osteoarthritis in elderly women was investigated in a recent randomized control trial by Bryk et al.[19] Subjects with known knee osteoarthritis performed a 6-week program of quadriceps strengthening, with half randomized to the BFRT group (30% 1RM) and half to the control group (70% 1RM). Both achieved significant improvements compared with baseline in quadriceps strength (72% increase in BFRT versus 39% in control; however, no significant difference in the change score between the two groups) and knee pain (reduction in Numerical Pain Rating Scale of 3.7 in BFRT compared with control). However, the BFRT group had significantly lower knee discomfort during the training despite restriction pressures of 200 Hg. This is one of many investigations, Table 1, showing that BFRT may be a more tolerable option for developing improved strength, pain, and functional outcomes in patients with osteoarthritis.


BFRT is especially promising in the recovery of injured and postoperative patients. These patients have 10% to 30% strength deficits after completion of rehabilitation secondary to disuse, immobilization, or casting.[29] The goal of BFRT in the rehabilitation protocol is to promote earlier increases in strength while minimizing potential damage to connective tissues and joints. Takarada et al[2] determined that after anterior cruciate ligament (ACL) reconstruction, BFRT alone, without resistance training, has been shown to decrease muscle atrophy postoperatively (9.4% decrease in CSA in BFRT group versus 20.7% in control). Ohta et al[3] investigated the use of BFRT in postoperative anterior cruciate ligament reconstructions in a prospective randomized control trial. At the completion of a 16-week program, significant increases were noticed in thigh CSA (knee extensor CSA of 101% compared with 92% in control) and maintenance in strength (84% compared with 63% in control [injured/healthy leg ratio]) in the BFRT group. Thus, rehabilitation patients may use BFRT in a progressive manner increasing from BFRT alone to low-load BFRT in combination with traditional training routines in an effort to optimize and shorten the recovery process (Table 2).

Athletic Performance Training

BFRT has not been shown to recruit the degree of muscle units as high-load training methods. However, it has shown promise as an adjunct to traditional training routines in a number of investigations. High-load training routines can have potential negative effects on athletes through increased stress on connective tissues and muscular fatigue. The use of BFRT to supplement athletic performance training has the potential to counter the negative effects of high-load routines.[1]

Scott et al[1] recently published a review that investigated 12 studies concerning the use of BFRT in healthy athletes. The authors concluded that based on current evidence, BFRT can enhance muscular development in athletes and supplement high-load training routines. Yamanaka et al[16] examined the use of BFRT in augmenting the off season routine of 32 Division IA football players. Both groups completed their standard off season routine with the addition of four sets of bench press and squat (20% 1RM, 3× weekly), whereas the BFRT group supplemented these exercises with the use of elastic bands on the proximal extremity. The BFRT group had a statistically significant increase in bench press (7% versus 3.2%) and squat (8% versus 4.9%) compared with the control group. Interestingly, BFRT has also been shown to have potential benefit in aerobic and endurance training. In patients performing low-intensity cardiovascular exercise, investigations have found a small but significant increase in maximum aerobic capacity and ventilation. Park et al[25] found increases in maximum aerobic (11.6% increase) and anaerobic (2.5% increase) capacity after a 2-week trial of treadmill walk training (five sets of 3 minutes, twice daily) with BFRT in male collegiate basketball players with no change in volume-matched controls. Based on the current literature (Table 3), there may be potential benefit from using BFRT in addition to high-resistance training routines.[16,30]