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As chiropractors, we are masters of manual therapy, including joint manipulation and soft tissue techniques.
While manual therapy in the acute and subacute phases of injury is invaluable when the pain diminishes and the range of motion returns, we need to strengthen the injured tissue. Blood flow restriction training can unlock a powerful and new way to rehab patients in your practice.
Most times, the reason a patient is in our offices in the first place is the patients’ tissue, or joint(s) were unable to tolerate the demands applied to them (Figure 1).
These demands could be cumulative in nature or an acute episode.
When demand exceeds capacity, injury occurs.
The injured tissue can then only tolerate decreased demands.
Strength and hypertrophy can take between 12-16 weeks under normal training at high intensities (>65% 1-RM).
Usually, in the acute and subacute phases, the injured tissue can not tolerate heavy loads.
This inability to tolerate heavy loads is why many of us use resistance tubing, light dumbbells, and bodyweight exercises in the clinic to aid the rehabilitation process.
Unfortunately, muscle strength and hypertrophy do not appear to occur while using low-intensity resistance unless the low-intensity exercise is taken to failure.
Taking exercises to failure increases the injured tissue’s demand, creates exercise-induced muscle damage (EIMD), and retards healing.
The most successful means of improving muscle strength and achieving muscle hypertrophy is high load resistance training or lifting heavyweights.
High load training is defined as lifting at least 65% of one-repetition maximum (1-RM) at least two times per week per body area.
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Unfortunately, not everybody can lift heavyweights.
People who suffer from injuries, chronic pain, loss of muscle mass due to diseases such as cancer, HIV/AIDS, diabetes could benefit significantly if they could improve their muscle strength.
Still, more often than not, they are unable to practice high-load resistance training, or it is deemed clinically ill-suited for them.
Alas, there is hope for these individuals!
They can utilize a technique to achieve heavyweight lifting results while only using light loads (20-35% 1-RM) is called Blood Flow Restriction Training (BFRT).
Comparing BFRT to Low-Intensity Exercise and High-Intensity Exercise for muscle hypertrophy.
Notice how similar BFR and HIT are and how LI probably does not increase muscle size.
These findings are identical for strength, except BFR and HI are reversed, with high-intensity exercise being slightly better.
What is Blood Flow Restriction Training (BFRT)?
“BFRT is the brief and intermittent occlusion of blood flow to a limb at rest or while exercising. Using BFRT has been shown to increase strength and hypertrophy while similarly using low loads to high load training in about 1/3 of the time with no resultant muscle damage. Using light loads reduces the wear and tear on joints and tissue. BFRT can be used by nearly anyone who desires increased strength and hypertrophy.”
– Ed Le Cara
Blood Flow Restriction Training (BFRT) is a technique that allows you to improve your muscle size and strength using light loads, making BFRT a highly beneficial rehabilitation tool for all those who are unable to take part in high load resistance training.
BFRT essentially tricks the body and the brain into thinking high-intensity exercise is being performed even though only light loads are being used.
BFRT is performed using unique cuffs around either the arms or legs (but not both).
See Figure 4 and Figure 5.
The cuffs are inflated to a percentage of arterial occlusion pressure, and light exercises are performed.
A manual pump with external doppler ultrasound can be used to inflate the cuff and find the correct pressures, or new pumps with built-in dopplers are currently on the market (Figure 6).
Origins of Blood Flow Restriction Training
The application of BFRT dates back to 1966 when 18-year-old Yoshiaki Sato from Japan came to a sudden realization after having sat in a seiza position throughout a funeral; he noticed how tired his legs felt as if he had gone through an intense workout.
After suffering from an ankle injury that caused his leg to be in a cast for six weeks, he came up with BFRT as a rehabilitation tool.
He used belts to restrict blood flow, and to the awe of his doctors, when the cast was removed, his leg was not tender, relatively firm, and still strong as if he had not stopped engaging in exercise.
The disuse atrophy expected after a cast was almost non-existent!
Sato began investigating the technique further and soon started his training clinic in Japan.
The process soon became popular with bodybuilders and made its way across Europe, gaining significant popularity and KAATSU Training.
Due to the technique’s success, it has now been greatly studied, investigated, and researched.
There is now a wide variety of data available on the topic, along with various methods available that have improved upon the work of Dr. Sato.
BFR training has recently gained popularity with military personnel trying to regain muscle strength after injuries, Olympic athletes who want to achieve muscle strength without fatigue-inducing workouts, or any individual who cannot take part in heavy weight lifting and size.
The 3rd Generation of Smart Cuffs includes a built-in pump and doppler, which can be disconnected for use on the field, mat, court, or pool.
The Pro version also allows for continuous monitoring of cuff pressure while keeping the pump attached.
How does Blood Flow Restriction Training work?
Blood Flow Restriction mimics heavy weight lifting by partially restricting arterial inflow and entirely restricting venous outflow from the limb during rest or exercise.
In simple terms, the cuffs reduce the flow of blood moving back to the heart.
As a result, the body part you’re working on becomes saturated with blood and metabolites, causing an increase in muscle tension and metabolic stress.
Metabolic stress is the primary factor required for achieving muscle hypertrophy.
When you’re exercising with cuffs on, the cuffs compress the blood vessels within the muscle being trained, the stress of which results in reduced oxygen reaching the muscle.
This reduced oxygen environment creates a hypoxic environment around the muscle being exercised; the reduced oxygen levels thus induce the release of Hypoxia-Inducible Factor (HIF)-1, a protein complex that plays an integral role in the body’s response to low oxygen concentrations.
The release of this protein results in anaerobic lactate metabolism and the production of lactate, both of which contribute to improving muscle strength.
While exercising using BFRT, the body and brain think you are experiencing significant physical strain and signals the pituitary gland to release growth hormone and other capillary growth and protein synthesis mediators.
Contraindications to Blood Flow Restriction Training
While BFRT can be a positive and beneficial form of rehabilitation for many types of injuries and across all age groups, some precautions and contraindications should be considered before using this training type.
Individuals with inadequate circulatory systems, such as the presence of varicose veins, shiny or scaly skin, brittle or dry nails, and extreme hair loss pose a higher risk of side effects from the training and should seek their physician’s approval.
Others who struggle from obesity or loose limb tissue, arterial calcification, diabetes, sickle cell anemia, or hypertension also should take precautionary measures before proceeding with BFR rehabilitation.
Some contraindications for tourniquet use include the following:
- Venous thromboembolism
- Impaired circulation or peripheral vascular compromise
- Previous revascularization of the extremity
- Extremities with dialysis access
- Extremity infection
- Tumor distal to the tourniquet
- Medications and supplements are known to increase clotting risk.
- Open fracture
- Increased intracranial pressure
- Open soft tissue injuries.
- Post-traumatic lengthy hand reconstructions
- Severe crushing injuries
- Severe hypertension
- Elbow surgery (where there is concomitant excess swelling)
- Skin grafts in which all bleeding points must be readily distinguished
- Secondary or delayed procedures after immobilization
- Vascular grafting
- 4 weeks of negative COVID19 test
Research suggests that BFR rehabilitation training is safe for healthy individuals, varying comorbidities and training athletes.
However, taking the necessary precautions to determine potential eligibility is highly recommended. Taking a certification course will ensure safe and effective training for your patients.
How to Apply Blood Flow Restriction Training In Your Chiropractic Practice
The beauty of BFRT is strength and hypertrophy start occurring about week three as long as training is happening 2-3 times per week.
This volume fits perfectly into a rehabilitation setting.
Not much resistance is needed, so bands, body weight, and light dumbbells can be used.
Take the regular exercises you are currently using and apply BFR Cuffs to make your regular rehab exercises achieve strength and hypertrophy.
Step 1. Purchase FDA-listed BFR cuffs (I recommend Smart Cuffs from SmartTools.)
Step 2. Apply the cuffs to the limb(s) you want to affect.
Step 3. Inflate the cuffs using a special pump that measures arterial occlusion pressure.
Step 4. Have the patient use light loads and perform 30 reps, 15 reps, 15 reps, 15 reps, and release pressure. (A 30-second interset rest is recommended.)
Step 5. Move to another exercise.
Perform between 3-5 Exercises per session up to 2/day.
If you want your patients to utilize the techniques at home, they can purchase a BFR set, or you can rent sets to your patients, and they can perform their home exercise program with BFR under your supervision.
The Pro version is designed for clinicians and strength coaches.
The standard version is for consumers.
If you want to learn more, head over to smarttoolsplus.com