BFR: A Few Thoughts in Closing

 

One question that I have received before is what cuff should I use? My answer is that there are multiple options, from elastic squat bands (functional BFR), to the use of FDA regulated cuffs such as those from Owens Recovery Science. At Refine PT and Performance, we are currently using the Smart Tools Cuff.

 

Regardless of your choice, make sure to account for limb circumference and cuff width in your application of BFR, because both of these factors dramatically affect how much blood flow is restricted. The generalized range of pressure used in the research is typically around 160 mmHG and 200 mmHG. Venous flow should be occluded while arterial flow is safely restricted. Generally BFR is applied at 50% limb occlusion pressure in the upper extremity, and 80% in the lower extremity, although new approaches are emerging.  The main point is that it’s very important how much blood flow is restricted, not necessarily the device used (keep safety in mind here). It is very helpful to have a self-regulating cuff, because pressures will change with movement, but the pricing can be much steeper.

 

In the past few posts we’ve discussed all things blood flow restriction training. If you’re wanting more info, there are a ton of advocates and front runners that I’d follow to stay up to date. They are much smarter than I am, and I am regularly referring to research and the thoughts of leaders like these to build a deeper base with these topics.

 

Mario Novo
-Owens Recovery Science
-Mike Reinold and Champion Physical Therapy and Performance
-Zach Long
-JP Loenneke and colleagues 
-Many, Many more

 

Hopefully you’ve learned a few new things over the past few posts, but I encourage you to dig deeper on your own! The best rule of thumb is to continue learning as often and as much as possible, and keep an open mind. Many times over, new research overturns traditional rehab principles (such as the lack of effectiveness of ultrasound). It’s incredible how resilient we are as human beings, and how efficiently we were designed to function.

 

If you have pain, restrictions, or have recognized this style of training/rehabilitation as being something that could help you achieve your goals, we’d absolutely love to help. We pride ourselves on seeking to provide the the utmost in one-on-one patient care, and the use of blood flow restriction is no exception to that rule. We have seen significant improvement with its application in the clinic, and the goal will always be to help you achieve your goals when you walk through our doors. If you would like to discuss its potential application in your case, please give us a call!

 

Tyler Vaughn
PT, DPT, OCS, CSCS, CF-L1
Owner Pathology Apparel
Refine PTP
251-270-1551

 

BFR: The bridge

(From Low-load Resistance Training with BFR to High loads Without BFR)

 

Last post we discussed the benefits of the application of BFR training to low intensity endurance exercise, namely walking (and stationary cycling). The third rung in the ladder to full functional tolerance after injury or bed rest is the progression to resistance training. It is recommended that as resistance training is tolerated, BFR with endurance training is slowly phased out and replaced with resistance training.

 

It has been shown that training at 20-50% of your 1 repetition maximum (1RM) with blood flow restriction in various populations provided similar results to 50-80% of 1 RM without BFR (Takarada et al, Karabulet et al).

 

This difference in loading requirements can be extremely important because often, 70% and greater of 1RM will not be tolerated in post-injury or aging populations (although it is a goal to reach this point). This allows for the use of lighter loading to achieve a similar musculoskeletal response to heavier loading, without the joint stress or risk of injury.

 

There are various recommendations for dosing BFR with submaximal loads. A generally accepted sets/rep scheme that’s recommended is the following:

 

75 repetitions total
(30-15-15-15) 

 

I have found that initially, a volume of 75 repetitions might not be tolerated in those that have been de-conditioned, even at lighter loads.  In these cases, it can be helpful to work up to that range over time. Each client/patient is different and needs to be approached specifically. 3-4 sets to failure have also been used as well, but generally are more uncomfortable for the patient/client. Clinically, I prefer to shift towards heavier loading with BFR, with a progression to traditional loading as soon as it can be achieved safely, or without significant discomfort.

 

One example of a generalized progression would be something like the following:

 

-Application of BFR with submaximal loading 3x’s per week at 50 total reps per exercise
-Progression to 75 total reps per research-based protocol
-Increased resistance within the 75 rep scheme
-Addition of sets to failure OR addition of 1 day of increased loading without BFR to begin transition to traditional loading
-Primary utilization of heavier loading with less utilization of BFR (2:1).
-Full transition to classic progressive loading

 

This is just one example and I’m trying to steer clear of being too specific here because it really does depend on the individual, their exercise capacity, and an array of other factors.

 

One thing I would like to stress here is that higher load training is the long-term goal. It drives positive musculoskeletal adaptations and encourages improved overall function and wellness, not to mention confidence and resilience with daily tasks. Also, increased loading is paramount to address tendon stiffness and tolerance to further stress (aka real world requirements). I do not think that BFR training replaces traditional strength training methods, but I do believe it’s a tremendous tool for modifying and progressing exercise and tissue tolerance depending on the circumstances both aside from and in conjunction with heavier loading.

 

So far, there are a few proposed mechanisms for how low-resistance training with applied BFR achieves comparable results. Generally, it stimulates the process of protein synthesis through a cascade of events. The reduced oxygen environment with metabolic accumulation leads to further recruitment of type 2 muscle fibers as well as increased hydrogen accumulation, which makes the muscle more acidic and encourages the production of growth hormone. Also, there are increases in both mTOR and MAPK signaling (involved in protein synthesis), and inhibition of the production of myostatin (which is known to decrease protein synthesis). It also achieves the cell swelling that has been previously mentioned in recent posts with cuff application during bed rest and endurance training. Lastly, the protocol involves large amounts of time under tension, which has been shown to help with improving tendon load tolerance.

 

Ultimately, the progression that we’ve seen up to this point includes the initiation of BFR applied during bed rest and then in coordination with return to endurance exercise. As further loading is tolerated, BFR can be applied to low-load resistance training, with progression to further volume and then eventually further mechanical loading without BFR or some combination of both options.

 

BFR is certainly a useful tool, and has been one that I’ve used across various populations in post-operative cases, to combat generalized deconditioning, and even in cases of severe arthritic pain that had limited weight bearing tolerance. It has been an invaluable tool, and I look forward to further advances and applications.

 

Stay tuned for more in this series. If you’d like to find out more, or think you could potentially benefit from one-on-one physical therapy in the Daphne area, please feel free to contact us.

 

Tyler Vaughn
PT, DPT, OCS, CSCS, CF-L1
Owner Pathology Apparel
Refine PTP
251-270-1551

 

BFR: Low Intensity Exercise

 

In the last post, we focused on how to initiate the return to function progression with applied BFR following injury or other causes of bed rest. The 2nd rung on the ladder that leads to return to function would be application of BFR in combination with low-load, endurance training.

 

As soon as weight bearing can be tolerated, a shift towards endurance training with BFR becomes an option. Previously, it’s been shown that with the elderly (without BFR)., endurance training at 60-80% of heart rate reserve (higher intensity) can lead to increased muscle mass and strength (type 2 fibers). (Harber et al)

 

 It has also been shown that the use of BFR can achieve improvements in muscle function at much lower intensities than 60-80% of HRR (which is a positive when first progressing back to weight bearing). In one study, it was shown that increases in muscle mass and VO2 max could be achieved in this same population at 45% of heart rate reserve (Ozaki et al). Not only that, but carotid artery compliance improved in this study as well (cardiovascular health).

 

If full weight bearing can’t be consistently tolerated, low intensity stationary cycling with BFR at 40% of V02 max (relatively low exertion) can significantly impact muscle size as well (8 week study).

 

Basically, low intensity walking, cycling, or some combination of both supplemented with BFR for a minimum of 2 days per week after a period of bed rest can be sufficient to improve cardiovascular and musculoskeletal health.

 

Just like with the application of BFR during bed rest, application for BFR in the early phases of transitioning to light activity can prevent atrophy and encourage the improvement of vo2 max and lean body mass (strength) that will set the stage for further growth in the future.

 

Once further resistance can be tolerated, the next step in the progression to full functional tolerance of daily activity would be the addition of low-load resistance training, which we will talk about on the next post.

 

Stay tuned for more in this series. If you’d like to find out more, or think you could potentially benefit from one-on-one physical therapy in the Daphne area, please feel free to contact us.

 

Tyler Vaughn
PT, DPT, OCS, CSCS, CF-L1
Owner Pathology Apparel
Refine PTP
251-270-1551

 

BFR: Application with Bed Rest

 

In the last two posts, we’ve covered the basics of blood flow restriction, as well as discussed the importance of skeletal muscle in function and wellness. Next, we will piece together some applications of BFR.

 

1) Bed Rest

 

In many cases (following surgery, illness, or injury) bed rest is required to prevent further damage or problems, despite our understanding that it can cause significant loss of muscle mass in the young and aging populations (higher in the elderly).

 

In this case, when weight bearing cannot be tolerated or bedrest is imperative, Takarada et al demonstrated that BFR could be utilized even in the absence of exercise to decrease knee extensor and flexor atrophy, simply by applying a cuff for a standardized time interval (5 min on, 3 minutes off, for 5 repetitions, 2x daily). This was studied in a population with post-surgical ACL reconstructions (3 days – 14 days post-op).

 

This study actually reported decreases in skeletal muscle atrophy in the quadriceps from 20% to 9%! It seems that this is potentially due to cell swelling and/or tension and increased intermedullary pressure which mimics the weight bearing environment for the skeletal muscle and bones!

 

Along with prevention of muscle atrophy, there is also research to support BFR’s effects on the cardiovascular system as well (decreased eccentric and left ventricular atrophy). (Loenneke et al, 2012) While there is benefit to BFR application without exercise, ideally, as soon as the patient is able to tolerate exercises in the bed (supine) ideally they would would be added to further encourage improvement.

 

It has also been my experience that patients who have deconditioned more often have an even more pronounced response to BFR

 

This is just one use for blood flow restriction, and in future posts we will continue to explore other potential applications.
Stay tuned for more in this series. If you’d like to find out more, or think you could potentially benefit from one-on-one physical therapy in the Daphne area, please feel free to contact us.

 

Tyler Vaughn
PT, DPT, OCS, CSCS, CF-L1
Owner Pathology Apparel
Refine PTP
251-270-1551

BFR: Muscle Mass is King

 

In the last article, we discussed what blood flow restriction, or BFR, actually involves, as well as touched on its safety.

Next, let’s look at skeletal muscle as well as atrophy so we can better understand why/when BFR could be useful.

Most people already know the role of skeletal muscles in movement. But what about skeletal muscle as an endocrine organ?

 

Here’s three points to consider:

1) skeletal muscle is the largest disposal site of blood glucose (which is that blood sugar that everyone is worrying about due to type II diabetes rates skyrocketing).

2) skeletal muscle helps with lipid oxidation, AKA breaking down or decreasing body fat.

3) skeletal muscle naturally increases resting metabolic rate (RMR). This means that increasing skeletal muscle mass directly correlates to amount of calories burned at rest (how’s that for a diet plan).

In summary, increasing skeletal muscle mass is key in not only building strength and resilience, but also in maintaining systemic wellness, which we are all about here at Refine PT and Performance.

But let’s talk about the opposite side of the spectrum. Atrophy. Atrophy is a loss or breakdown of skeletal muscle mass. This can be caused by multiple variables; however, we are going to focus on inactivity.

 

Here’s the hallmark response to inactivity:

1) Decreased quality and quantity of muscle mass. Research has shown that as little as 7 DAYS of bed rest could cause negative responses and jumpstart the atrophy process in muscle.

2) Impaired immune and cardiovascular function. The effects of inactivity are systemic.

3)There is preliminary evidence that fully resting tendons can actually have similar effects to overtraining tendons.

4) Decrease in insulin sensitivity. This creates increased blood glucose levels, which prompts further release of insulin, causing decreased insulin receptor sensitivity and further resistance- insert downhill spiral- with the collision course set for type 2 diabetes.

With that being said, is everyone who has to spend 7 days in a hospital bed destined for diabetes and a lifetime of weakness?

Absolutely not.

But I will warn that prolonged periods of bed rest significantly increase that risk (specifically in the aging population). The great news is that our bodies were created to be resilient, and with proper application of movement and exercise, we will generally respond very well! The key thing to note here is how paramount physical activity and skeletal muscle health are!

After surgery or with inactivity due to pain, atrophy is often seen. One of the best ways to combat this is, in order to keep muscle size, is with the use of BFR. A bigger muscle doesn’t necessarily mean a stronger muscle, but a bigger muscle does allow for more potential to be a stronger muscle.

So, now that we’ve covered the basics, as well as the importance of physical activity in strength development and prevention of atrophy, our next post will cover applications of blood flow restriction.

Stay tuned for more in this series in the coming days! If you’d like to find out more, or think you could potentially benefit from one-on-one physical therapy in the Daphne area, please don’t hesitate to contact us.

 

 

Tyler Vaughn

PT, DPT, OCS, CSCS, CF-L1

Owner Pathology Apparel

Refine PTP

251-270-1551

Blood flow restriction (BFR) involves the restriction of arterial blood flow into the muscle, while occluding or stopping the venous blood flow out of the muscle, which then creates pooling of the venous blood. With this pooling effect, blood flow restriction also causes oxygen deprivation in the muscles, enhancing metabolic stress, and encouraging muscle adaptation (strengthening) without the requirement of significant loading of the joints.

To put it more simply, you will be able to achieve targeted results with much lower loads and mechanical stress.

For instance, with traditional resistance training, the gold standard for achieving noticeable increases in muscle size lies around 70% of your one repetition max (1 RM). However, for some populations, high load exercises may not be appropriate or safe (think post-surgical achilles repair, or elderly patient recovering from a 2 week stent of pneumonia).

 

But isn’t that dangerous?

 

This technique appears to offer no greater health risk than training with high loads, while greatly reducing the mechanical stress to the joints. (Loenneke et al, 2011).

 

In fact, pooling of venous blood actually stimulates natural tissue plasminogen activator (TPA) to be released, which is the same derivative used for clot busting in hospitals for ischemic strokes. In this way, when applied correctly, BFR is safe and does not increase risk of clotting.

 

What is the mechanism or how does BFR accomplish the noted improvements?

 

That part is still largely theoretical. There are a few predominant theories at this time:

 

Cell Swelling (becoming less prominent)
It could be due to cell swelling (which trips a volume receptor of sorts, that then increases production of mTOR, which has been shown to be high following resistance training as well).

 

Metabolite Theory
Oxygen deprivation (hypoxia) during BFR training leads to increased levels of lactate and free hydrogen in the muscle. The result is a decrease in pH, which encourages the production of growth hormone. Increased GH then stimulates increased levels of IGF-1 (insulin like growth factor), which supports muscle synthesis (increased production of HGH up to 290 fold- Takarada 2000).

Another theory proposes that improvement is elicited largely due to downstream affects of norepinephrine release (which prevents the decrease of protein synthesis usually seen with lack of activity).

 

Time Under Tension
There are yet other arguments for the fact that it’s still mainly about how much time the tendons/muscle units are under tension with BFR training as well.

 

The reality is that research is demonstrating positive responses to BFR that are not only beneficial, but safe. It likely involves multiple mechanisms working together.

 

Here are a few more notes to work through as we get prepare to discuss applications of BFR:

-BFR increases muscle protein synthesis in the elderly by up to 56% (Gundermann, 2012)

-Level of growth hormone was found to be elevated 10 minutes after activity, and remained elevated up to 40 minutes (Fujita, 2007)

-BFR has been found to increase collagen synthesis after as early as 2 weeks

-BFR decreases myostatin (which contributes to muscle protein breakdown) by up to 45%, which is comparable to high intensity training.

 

Summing it Up

In my clinical experience thus far with BFR, I’ve also noted decreased post-session or delayed onset muscle soreness despite a high RPE in the clinic (rate of perceived exertion) with all age groups, as well as significant reversal of functional decline in the aging adult population.

I don’t believe that any one specific training or rehab style fits into every case or with every client; however, this has been extremely beneficial in the clinic and with improving performance!

Stay tuned for more in this series in the coming days! If you’d like to find out more, or think you could potentially benefit from one-on-one physical therapy in the Daphne area, please feel free to contact us.

 

Tyler Vaughn
PT, DPT, OCS, CSCS, CF-L1
Owner Pathology Apparel
Refine PTP
251-270-1551

Did you know that falls are the leading cause of injury and injury death in individuals 65 years of age and older? Falls often lead to a decrease in functional ability, increased use of healthcare services, and an increase in patient anxiety. This anxiety and fear of falling again often causes these individuals to decrease their activity, resulting in impaired mobility and increased risk of morbidity and mortality due to being more sedentary (Berry and Miller, 2008).

This leads us to the question, what can we do as therapy professionals to reduce the risk of falls in the elderly population?

Older adults are the fastest growing segment of the US population. By 2060, the number of individuals 65 and older is expected to reach 98 million making up approximately 25% of the population; therefore, it is essential for us to understand and effectively dose exercise in this population in order to help them age well and decrease the risk of falls and fall-related injuries.

All too often, older adults are led to believe that they are fragile and weak, which causes them to avoid movement and more strenuous activities for fear of injuring themselves. Quite honestly, many healthcare professionals, including therapists, often believe and treat these individuals like they are incapable due to their age. This thought process is heavily flawed. Just because these individuals are older does not mean they are weaker. It is because of their age that movement and resistance training are even more critical. Each time an individual stands up from their recliner or gets up from the toilet, they are performing a squat. Every step they ascend to enter into their home is a step up. Every item they pick up off the floor is a deadlift. Every bag of groceries they carry into the home from the car is a type of carry.

So why are we not performing these exercises in the clinic?

When an older adult enters into a physical therapy clinic and the only exercises that they perform are things like straight leg raises, long arc quads, hip bridges, and banded hip abductions, we as therapy professionals are missing the boat. The exercises listed above are beneficial and have their place in the rehabilitation process; however, they should only be used as a stepping-stone to help older adults improve their ability to perform more functional tasks and to increase independence. Our interventions have to extend beyond the TheraBand and ankle weight and transition into more functional activities as the patient progresses.

Resistance training in older adults has been shown to improve blood pressure, mobility, muscle mass, strength, immune system function, blood glucose, and lipid profiles. All of which combat age-related chronic diseases that often are impacting the older adult population (Mcleod, et al. 2019).

A study performed in Australia assessed the effects of an 8-month long high-intensity resistance and impact (HiRIT) program in postmenopausal women older than 58 years of age that had low bone mass. Exercises performed throughout the study were deadlifts, back squats, overhead press, and jumping chin-ups with drop landings. The study found that the HiRIT program was superior to other lower-impact programs for enhancing bone mass at clinically relevant sites, as well as improving functional performance that impacts risk of falls (Watson, et al. 2019). Often this population avoids higher impact activities for fear that they will actually increase their risk of injury, but have we stopped to ask ourselves what the risk is if we don’t appropriately load this population?

There is greater risk of injury and functional decline from underdosing this population compared to the perceived possibility of injury from performing exercises such as squats and deadlifts that actually correlate more with tasks that are required of our older adult patients day in and day out.

If we aren’t preparing our older adults to handle the demands that are placed on them each day, we are doing them a disservice. In a healthcare system that is consistently producing fear of movement in the older adult population, I want to challenge us all to not give into this flawed system but to empower our older adults to stay active, pick up a kettlebell, dumbbell, or barbell, and take control of their health.

Makayla Palmer, PT, DPT
Refine PT and Performance

REFERENCES

Berry, S. D., & Miller, R. R. (2008). Falls: epidemiology, pathophysiology, and relationship to fracture. Current osteoporosis reports, 6(4), 149“154. https://doi.org/10.1007/s11914-008-0026-4

Mcleod, J. C., Stokes, T., & Phillips, S. M. (2019). Resistance Exercise Training as a Primary Countermeasure to Age-Related Chronic Disease. Frontiers in physiology, 10, 645. https://doi.org/10.3389/fphys.2019.00645
Watson, S., Weeks, B., Weis, L., Harding, A., Horan, S., & Beck, B. (2019). Highintensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: The liftmor randomized controlled trial. Journal of Bone and Mineral Research, 34(3), 572-572. doi:10.1002/jbmr.3659