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I
n the American cartoonist Charles M. Schulz’s comic series Peanuts, sion and exercise during weight training.
Lucy first pulled the ball away from Charlie Brown in 1951. Then This period included a stint in hospital
she continued to torture him for the next 48 years, using variations after a pulmonary embolism induced
by self-described reckless tourniquet
on the theme. As a physical therapist of a certain age, every time
application.
I hear of some new approach promising more for less, I become Later, after opening his own fitness club,
Charlie Brown: “This has never worked in the past, so why should I the Japanese now former high school stu-
believe it will this time? But wouldn’t it be great if it were true?” Ever dent was injured while skiing. He reported
J Orthop Sports Phys Ther 2019.49:294-298.
the optimist, my eternally misguided en- explained by increased collateral circula- that he had fractured both ankles and in-
thusiasm leaves me lying on my back, tion. Perhaps alternate mechanisms were jured “cartilage and the medial ligament”
embarrassed, and vowing, “They won’t in play (other than improved blood flow), of his knee. He refused the recommended
fool me next time.” somehow enhancing muscle function?11 surgery and hospitalization because of the
Then along comes an intervention This much was the result of scientific demands of his business. Instead, he opted
claiming that some low-intensity exer- investigation. Now we enter the realm for occlusion training combined with iso-
cise performed while wearing a blood of retrospective self-report from an indi- metrics of his casted limb for 2 months.
pressure cuff will result in strength vidual whose business depended on the He claimed he had hypertrophy, rather
gains, improved performance, shorter results—your “Spidey-sense” should al- than atrophy, of his casted leg and good
postexercise recovery, and maybe even ready be tingling. functional outcomes.48 Commercial ap-
pain reduction. “Good grief,” indeed. Or Coincidentally and independently, a plication of his approach over the ensuing
will it work this time? Japanese high school student noticed decade saw growing popularity, along with
that after a period of sustained sitting patent applications for equipment and
Blood Flow Restriction while attending a religious ceremony, techniques in a number of countries, and
Training: Early Origins he experienced a feeling of discomfort “certifications” for practitioners adding to
In the 1960s, scientists noticed improved and swelling similar to that experienced the business model.
walking tolerance in people with in- after performing “strenuous calf-raise By now, the alarm bells should be deaf-
termittent claudication after a physical exercises.”48 For the next 5 years, he self- ening to those looking for a science-based
training program.29 The changes were not experimented with variations of occlu- intervention, free of commercial influence.
1
Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar. The author certifies that he has no affiliations with or financial involvement in
any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Rod Whiteley, Rehabilitation
Department, Aspetar Orthopaedic and Sports Medicine Hospital, PO Box 29222, Doha, Qatar. E-mail: rodney.whiteley@aspetar.com t Copyright ©2019 Journal of Orthopaedic &
Sports Physical Therapy®
to ensure hypertrophy. If you conclude Limb occlusion pressure will vary de- distance runs for performance enhance-
the pain is caused by inadequate muscle pending on the girth of the limb,33 the ment.36 In experiments in the middle
strength, then the conundrum is difficult cuff used,40 and body position16 (eg, lying of the 20th century, there was a dose-
to resolve and might even be intractable. compared to sitting or standing).50,52 Limb response relationship between measures
You might also face a similar challenge occlusion pressure is different for different such as time to exhaustion and the du-
where strengthening is indicated but individuals, and even the same individu- ration and intensity of application of a
loading the joint is not (eg, post surgery al at different times of the day18,21,25 (eg, tourniquet to completely occlude limb
or resolving osteochondral defects). morning versus afternoon, before or after perfusion prior to exercise.41,44 A flurry
“I really want to start strengthening as recent exercise or coffee consumption). of investigation followed, which failed to
soon as possible. Do I really have to wait replicate these findings. This field lay fal-
until the pain settles down? What if pain Measuring and Adjusting low for years.36
J Orthop Sports Phys Ther 2019.49:294-298.
prevents the patient from loading? What Occlusion Pressure In the mid 1980s, animal experiments
if the pain doesn’t settle down?” Failing to individualize limb occlusion documented reductions in cardiac infarc-
pressure might explain inferior strength tion following bouts of ischemic precondi-
Hypertrophy Is Possible With Low gains compared with standard heavy re- tioning.14,42 Meaningful, albeit conflicting
Loads and High Repetitions: Enter sistance training.16 However, while this is and objectively small, improvements in
Blood Flow Restriction Training biologically plausible, research in this area sporting performance after local (eg, leg
Low-load resistance training with the is sparse. Cuff width is an important deter- during leg exercise) and remote (eg, arm
addition of blood flow restriction can minant of limb occlusion pressure, and the during leg exercise) ischemic precon-
achieve equivalent hypertrophy to that of wider the cuff, the lower the required pres- ditioning20,36,47 prior to cycling,14 swim-
high-load resistance training.6,17,34 Plau- sure to occlude the limb.49 A wider cuff ming,23 and running3 may be possible.
sible mechanisms of action, each with also has the benefit of less local discom- Modest gains are acquired with cycles
some evidence in humans, include locally fort24,37 and lower chance of bruising.38,39 of 3 or 4 bouts of 5 minutes of occlusion
induced swelling in the muscle cells, im- Clinicians should individually tailor and 5 minutes of reperfusion performed
proved local neural function (increased occlusion pressure for safety and best a few hours prior to the event.9,31,47 There
fiber recruitment), improved central neu- outcomes.16,32 They should measure limb is less research examining any benefit of
ral function (increased cortical motor ex- occlusion pressure in the position in which ischemia as an intervention to improve
citability), and increased muscle protein the exercise will be performed and con- recovery post exercise, and the results are
synthesis.10,19,28 duct the exercise as a percentage of this mixed at best.4
Blood flow restriction training may also pressure. In the lower limb, 40% to 80% Routine postexercise application of
have additional hypertrophy benefits in of limb occlusion pressure is effective.32 3 or 4 bouts of 5-minute occlusion/re-
muscles not directly affected by the blood Higher occlusion pressure might be desir- perfusion (30-40 minutes in total)45 is
flow restriction. Measurable improve- able, although it is associated with more likely not feasible in a team setting. The
must be replicated before one can con- medical history of vascular compro- 8 weeks (TABLE).
fidently conclude that it is a true effect. mise or risk of embolism is an absolute Progression to heavy-load resistance
contraindication to blood flow restric- training should continue to be your
It Can’t All Be Sunshine and tion training. Three reported cases of goal—blood flow restriction training is
Daisies? What’s the Risk? rhabdomyolysis7,22,51 suggest that com- only an interim step. There is less compel-
“Reckless” tourniquet application is as- promised renal function should be a ling evidence that you can be confident of
sociated with potentially disastrous side contraindication.57 Patients should al- performance, postexercise recovery, and
effects, embolism being chief among ways be monitored following exercise pain improvements, although this is an
them.48 No one should die as a result of for excessive muscle soreness.7 area to watch.
It took more than 30 years in prac-
tice, but we eventually got a clinical
J Orthop Sports Phys Ther 2019.49:294-298.
Suggested Clinical Reasoning for “cheat” that at least works for some se-
TABLE the Application of Low-Load Blood lect patients. Will there be another one
Flow Restriction Training* in my lifetime? I seriously doubt it, but
I’ll try to keep an open mind, if not an
Parameters •D
escription
empty head.
Indications • Hypertrophy required and heavy resistance training not clinically indicated
Contraindications • Vascular compromise, clotting disorders or other elevated risk of embolism, renal compromise,
Key Points
hypertension (systolic blood pressure of 140 mmHg or greater)
• In patients who cannot tolerate high
Warnings • Bruising is relatively common (in the upper limb especially). The exercise is very uncomfortable
loads, blood flow restriction train-
Applications • Measure limb occlusion pressure in the body position in which the exercise will be undertaken
• Set training pressure (40% to 80% of limb occlusion pressure for leg, 30% to 60% for upper
ing using low loads is associated with
limb). Note that higher pressures are associated with more discomfort but likely superior clini- similar hypertrophy effects to those of
cal outcomes conventional high-load training.
• First set: aim for voluntary failure at 30 repetitions at a rate of approximately 1 repetition every • Training pressures need to be at least
2 to 4 seconds
40% of limb occlusion pressure, and
• Second to fourth sets: same weight as first set, 15 repetitions, 30 seconds of recovery between
sets. Adjust weight up or down depending on performance in first set: harder if failure wasn’t
can be up to 80% (lower in the arm
achieved, easier if patient could not reach 30 repetitions than in the leg).
• Initially, alternate days; training can ultimately be performed twice daily • Wider cuffs require lower pressures to
• Expect to see meaningful results after at least 4 weeks of training occlude and are better tolerated.
• When clinically appropriate, shift to regular resistance training
• Safe application requires attention to
*The contraindications and warnings are those peculiar to blood flow restriction training, and are
contraindications and tailoring of the
in addition to usual care and precautions taken when prescribing resistance training. The exercise
parameters suggested are based on the most frequently reported regimens.17 pressure to the individual patient, the
exercise, and the cuff. t
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One. 2010;5:e12033. https://doi.org/10.1371/ between cuff pressure and level of blood flow re- cessive sprint swimming performance. J Sci Med
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