Blood Flow Restriction Training and the Physique Athlete: A Practical Research-Based Guide to Maximizing Muscle Size

Abstract

Emerging evidence indicates that low load blood flow restriction (BFR) training is an effective strategy to increase muscular adaptations. Yet, it remains questionable as to whether combining BFR with traditional resistance training can potentiate hypertrophic adaptations. The purpose of this article is to provide an evidence-based review of current research on the topic including underlying mechanisms of BFR training and draw practical conclusions as to how BFR can be applied by physique athletes to optimize increases in muscle mass.

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Blood Flow Restriction
Training and the Physique
Athlete: A Practical
Research-Based Guide to
Maximizing Muscle Size
Nicholas Rolnick, DPT, MS
1
and Brad J. Schoenfeld, PhD, CSCS, CSPS, FNSCA
2
1
The Human Performance Mechanic, PHLEX NYC, New York, New York; and
2
Health Sciences Department, CUNY
Lehman College, Bronx, New York
ABSTRACT
Emerging evidence indicates that low
load blood flow restriction (BFR)
training is an effective strategy to
increase muscular adaptations. Yet, it
remains questionable as to whether
combining BFR with traditional resis-
tance training can potentiate hyper-
trophic adaptations. The purpose of
this article is to provide an evidence-
based review of current research on
the topic including underlying mecha-
nisms of BFR training and draw prac-
tical conclusions as to how BFR can
be applied by physique athletes to
optimize increases in muscle mass.
INTRODUCTION
Modern day blood flow restric-
tion (BFR) training was dis-
covered in 1966 by Yoshiaki
Sato, who called it KAATSU (“added
pressure”) training (76). In the 54 years
since his discovery, BFR training has
been studied in hundreds of published
articles and is used by a wide variety of
populations—from the injured (29,40)
to the physique athlete looking to
maximize muscle growth during con-
test preparation (58).
BFR training involves use of a com-
pressive cuff wrapped around the
proximal portion of the limb so as to
partially reduce arterial flow and com-
pletely restrict venous return (71). As
a result, blood pools in the extremity
distal to the cuff, altering the local mus-
cular environment. The reduction in
blood flow from the applied pressure
decreases oxygen delivery, challenging
local energy metabolism and reducing
the time needed to reach volitional fail-
ure during aerobic training and resis-
tance training (RT) compared with
similar exercise without restriction
(27,28,99). Because of the unique met-
abolic environment in the limb from
the compressive cuff, BFR training is
commonly prescribed with loads as
light as 20% one repetition maximum
(1RM) (71). Low-load RT with BFR
can provide similar increases in muscle
mass compared with heavier (70+%
1RM) lifting, making it an alternative
for physique athletes seeking to maxi-
mize muscle growth without additional
joint stress (21,53). This article will pro-
vide an evidence-based review of cur-
rent research on the resistance-training
benefits of BFR exercise with respect
to hypertrophy and draw practical
conclusions as to how the strategy
can be applied by physique athletes
to optimize increases in muscle mass.
BLOOD FLOW RESTRICTION
TRAINING MECHANISMS
OVERVIEW (HYPERTROPHY
FOCUSED)
The mechanisms underlying BFR RT
are still contentious but appear to be
somewhat modulated by similar pro-
cesses as free-flow exercise. Skeletal
muscle hypertrophy occurs when net
protein balance is positive, providing
a favorable environment to induce
muscle growth (16). Muscle growth
appears to be mediated by mechanistic
target of rapamycin complex 1
(mTORC1), a molecular nodal point
in the anabolic molecular intracellular
signaling pathway (36). Sufficient
stimulation of skeletal muscle via RT
induces post-exercise increases in
mTORC1 expression, eventually lead-
ing to visible increases in muscle size
with continued training (32,63). Both
heavy- and light-load training, with
Address correspondence to Brad J. Schoen-
feld, brad@workout911.com.
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and without BFR, performed to voli-
tional failure have shown to induce sig-
nificant mTORC1 expression and, in
longitudinal studies, are reported to
produce similar increases in muscle
size in various populations
(18,20,21,53). However, low-load exer-
cise that is work-matched to BFR (i.e.,
30-15-15-15 repetitions) does not
appreciably increase mTORC1 levels
nor alter mTORC1 downstream pro-
tein kinase molecules such as S6 kinase
beta-1 (S6K1), and thus, these proto-
cols are inferior in producing apprecia-
ble gains in muscle size (32,33),
conceivably because the intensity of
effort is not sufficiently challenging to
evoke a robust hypertrophic stimulus.
Finally, administering mTORC1’s
antagonist, rapamycin, blunts the mus-
cle protein synthesis (MPS) response
to BFR exercise, highlighting the
importance of this pathway during
BFR exercise (36). Thus, it seems that
mTORC1 expression is crucial to the
long-term hypertrophic response to
BFR training regardless of the exact
mechanisms that differentiate low-
load BFR versus high-load traditional
training.
RESISTANCE TRAINING:
MECHANISMS UNDERLYING
HYPERTROPHY
Current theory proposes 2 primary
mechanisms underlying the benefits
observed with low-load RT with
BFR: metabolite-induced accelerated
fatigue and cellular swelling. Both
mechanisms have the capacity to cre-
ate an anabolic environment in the
muscle to augment MPS responses to
exercise and are discussed in the fol-
lowing subsections.
METABOLITE-INDUCED FATIGUE
Metabolite-induced accelerated fatigue
describes the phenomena that occur
when BFR is applied to an exercising
limb. Byproducts of muscular contrac-
tions such as lactate, hydrogen ions
(H+), ATP, and inorganic phosphates
are produced and are unable to exit the
limb through the venous system due to
the restrictive cuff (56). These metab-
olites interfere with the excitation–
contraction mechanism causing ear-
lier recruitment of type 2 muscle fibers
relative to the same exercise being
performed in free-flow conditions
(22,98). As fatigue accumulates from
the metabolic stress, muscle contrac-
tion velocity slows and muscle activa-
tion increases (85), ultimately
stimulating anabolic processes.
Metabolites also stimulate the group
III–IV afferents in and around the mus-
cle fiber during contractions to pro-
mote increased blood flow to the
exercising muscle in an effort to reduce
peripheral fatigue accumulation (loss of
the muscle fiber’s ability to create
force) (5). It is theorized that group
III–IV afferents can stimulate additional
motor unit recruitment through activa-
tion of the fusimotor neuron-muscle
spindle-motor neuron pathway so as
to ensure force remains steady during
repeated muscular contractions (34).
The group III–IV afferents also have
synapses onto the central nervous sys-
tem (CNS) and are postulated to play
a role in subjective increases in percep-
tion of effort during exercise (25,70).
Higher levels of effort during fatiguing
contractions have been thought to cor-
respond with type II muscle fiber
recruitment (70). Importantly, when
free-flow low-load exercise is per-
formed with and without BFR to fail-
ure, both report very high levels of
effort and localized muscle pain,
likely by the combined effects of the
accumulated metabolites stimulating
group III–IV afferents and the resul-
tant changes in CNS activation
(11,25,95,96).
It is not clear whether metabolites
themselves contribute to an exercise-
induced hypertrophic response.
Emerging evidence indicates that lac-
tate mediates anabolic processes both
in vitro (67,68,92,100) and in vivo
(68,92). These results may be attributed
at least in part to a lactate-induced
inhibition of histone deacetylase activ-
ity (49), which serves as a negative reg-
ulator of muscle growth. Moreover, the
buildup of H+ may facilitate greater
type I fiber hypertrophy by impairing
calcium binding in type II fibers and
thereby placing a greater burden on
type I fibers to maintain force output
as metabolically taxing exercise contin-
ues (35). This may help to explain
emerging research showing that low-
load BFR elicits preferential hypertro-
phy of slow-twitch muscle fibers
(8,9,43). Further research is warranted
to better elucidate mechanistic under-
pinnings of adaptations achieved with
low-load BFR training.
CELL SWELLING
Cell swelling describes the acute
increase in muscle thickness that re-
sults from accumulation of fluid in
a limb due to a lack of venous return
(56). Fluid is believed to shift from the
plasma into the muscle cell due to
osmolality gradient differences (91).
Fluid accumulation during and after
exercise is believed to be due to
decreased oxygen availability, the
accumulation of metabolites, and sub-
sequent increases in reactive hyper-
emia (56,62,104). These factors have
been linked to earlier type II muscle
fiber recruitment (42,73).
Increases in muscle thickness after
exercise have been correlated with
long-term muscle hypertrophy in
free-flow and BFR exercise (28,44).
BFR training has been shown to signif-
icantly increase cell swelling over
work-matched controls (103) while
producing similar levels during exercise
to failure (6,15,28,108) and high-load
training (3,30,44). Thus, exercise with
BFR can produce acute increases in
cell swelling that hypothetically can
contribute to meaningful long-term
changes in muscle size.
Cell swelling is believed to act through
stimulation of an intrinsic volume sen-
sor in the muscle fiber that, when
stretched, begins the process of MPS
(56). When fluid is trapped in the limb
during and after exercise, the cytoskel-
etal matrix becomes stressed, eventu-
ally leading to activation of anabolic
intracellular signaling pathways (56).
It is questionable whether cell swelling
alone is anabolic in vivo because recent
research investigating a passive cell
swelling protocol performed with no
BFR Training and the Physique Athlete
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exercise failed to increase mTORC1
expression (66). However, long-term
passive cell swelling applications have
been shown to attenuate or completely
prevent disuse atrophy (47,86), lending
credence to the notion that cell swell-
ing may provide a low-level hypertro-
phic stimulus sufficient to maintain
neutral net protein balance for a period.
BFR RESEARCH ON ATHLETES,
WELL-TRAINED INDIVIDUALS, AND
PHYSIQUE COMPETITORS
To date, the research on using BFR
with physique athletes is sparse (1 case
report). Therefore, this section will
cover the relevant research pertaining
to optimizing hypertrophy in
resistance-trained individuals and pro-
fessional athletes using BFR training,
drawing parallels (when appropriate)
to the physique athlete.
To the authors’ knowledge, the case
report by Loenneke et al. (58) on
a 22-year-old competitive male body-
builder is the only published article
using BFR with physique athletes. This
case report provides some unique in-
sights into the potential applications
and benefits of BFR training in this
population, especially during contest
preparation. The article describes
a 22-year-old male bodybuilder who
developed knee pain 2 weeks before
his bodybuilding show. The individual
reported experiencing a pop in his right
knee, and a subsequent MRI revealed
an osteochondral fracture; a surgical
date was then scheduled after compe-
tition. The individual decided to use
low-load BFR RT for his legs twice
a week for the remainder of his contest
preparation instead of withdrawing
from the show. His lower-body train-
ing routine exclusively comprised pain-
free low-load BFR training performed
predominantly in a 30-15-15-15
scheme (30 reps on the first set, fol-
lowed by 3 sets of 15 repetitions) twice
weekly, although he did occasionally
incorporate failure training (58). The
individual ended up placing top 5 in
his show and was able to exercise
pain-free; he ultimately postponed his
scheduled surgical date due to limited
loss of functional ability (no pain
walking) and lack of perceived loss in
thigh hypertrophy (58). A follow-up
MRI revealed significant healing of
his osteochondral fracture, and with
conservative nonsurgical treatment,
the individual was able to return to
high-load training. This report pro-
vides limited evidence that BFR can
be successfully used in competitive
bodybuilders deep into contest prepa-
ration despite the presence of lower
extremity injuries that would impede
heavy-load training.
There does seem to be a superior ben-
efit to maximizing hypertrophy in rec-
reationally active individuals when
combining low-load BFR (30% 1RM)
with heavy loads (75% 1RM) in a lifting
program. Yasuda et al. (106) observed
statistically significant increases of
+7.2% muscle cross-sectional area
(CSA) of the triceps brachii when com-
bining low-load BFR and heavy lifting
compared with +4.4% when perform-
ing low-load BFR alone in recreation-
ally active men over a 6-week study
period, highlighting the additive effects
of both types of training when per-
formed concurrently. However, well-
trained athletes may respond differ-
ently due to their RT history.
Previous research has shown that a 24-
week routine consisting of heavy
elbow flexion exercise in competitive
male and female bodybuilders did not
substantially increase muscle CSA of
the elbow flexors (4). It is important
to note that although the sample size
was small (n510), half of the partic-
ipants (3 males and 2 females) reported
using anabolic steroids concurrently
throughout the program. Therefore, it
seems that a single-mode approach
(heavy lifting—6RM to 10RM) typical
of bodybuilding programs may not be
able to increase hypertrophy to a signif-
icant extent after a period (5.5+ years
training experience on average in the
bodybuilders in the aforementioned
study), even with the use of anabolic
agents. Multimode approaches using
a combination of lower and higher rep-
etition schemes such as during low-
load BFR training (i.e., 30-15-15-15)
could theoretically increase muscle size
over low-repetition training alone (i.e.,
heavy training in the 6–10RM range)
due to stimulation of the spectrum of
muscle fiber types, although this
hypothesis remains somewhat
speculative.
BFR training may be an appealing
modality to integrate into the resis-
tance exercise programs of physique
athletes due to the unique metabolic
stress it provides to the musculoskele-
tal system when training with lighter
loads and intensities not typical of
bodybuilding routines (69). The meta-
bolic stress produced from BFR exer-
cise may expose muscle fibers
(particularly type I fibers) to new
recruitment demands not obtained
from traditional heavy-load training
and thus provide a way to further aug-
ment muscle hypertrophy in highly
trained athletes. Indeed, this has been
shown in national-level powerlifters
undergoing two 1-week training blocks
of BFR over 6.5 weeks using 30% 1RM
during front squats compared with the
non-BFR group performing the same
exercise at 60–85% 1RM (8). Vastus
lateralis hypertrophy increased +7.7%
in the BFR group versus 0% in the
non-BFR group, with gains primarily
attributed to increases in CSA of type
I muscle fibers. This study provides
intriguing evidence that the addition
of BFR can augment the hypertrophic
response in highly trained athletes.
Several other studies provide addi-
tional support for the combined use
of high-load training and low-load
BFR training in athletes and well-
trained individuals, although the re-
sults on hypertrophy are not always
consistent (Table 1). Most studies
incorporating BFR into their training
used the strategy as a low-load supple-
ment to heavy-load training
(59,60,77,102), while others used BFR
with heavy loads (70% of 1RM) (19) or
performed the same exercises but
substituted BFR at lighter intensities
(8). The majority of the research using
concurrent training show significant
improvements in muscle strength rela-
tive to the non-BFR training groups
(19,60,102) with some showing
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Table 1
Relevant studies on athletes and resistance-trained individuals using concurrent BFR and high load
References Participants Variables of interest Exercise protocol Frequency Duration Intensity
Yamanaka
et al.
(102)
32 Division IA Collegiate
Football Players (min 5-
y RT experience);
;19.2 y
Strength: BP and SQ 1RM
Hypertrophy: CM
measures of upper
and lower chest and
arm girth, thigh girth
30-20-20-20 repetitions of BP and SQ after regular HLT
with or without BFR
33/wk 4 wk 20% 1RM
Luebbers
et al.
(60)
62 Division II Collegiate
Football Players (avg.
7.1-y RT experience);
;20 y
Strength: BP and SQ 1RM
Hypertrophy: CM
measures of arm, leg,
chest girth
4 Groups: 30-20-20-20 repetitions of BP and SQ after
regular HLT with or without low-load BFR or low-load
training; 1 group did not perform BP or SQ but
performed BFR
23/wk per body region 7 wk 20% 1RM
Scott et al.
(77)
21
Semiprofessional Male
Australian Football
Players (avg. 1.63BW
SQ); ;19.8 y
Strength: 3RM BS
Hypertrophy: VL
architecture
30-15-15-15 repetitions after regular HLT with or without
BFR
33/wk (except for week 5–
23/week)
5 wk 20–30% 1RM
Cook et al.
(19)
20 Semiprofessional Male
Rugby Players (min 2-y
RT experience); ;21 y
Strength: 1RM BP and BS 5 35 repetitions were performed with PU, BP and SQ 33/wk 3 wk 70% 1RM
Bjornsen
et al. (8)
19 National Level
Powerlifters (16 men, 3
women) (avg. ;5yof
RT experience)
Strength: 1RM FS or MVIC
knee extension
Hypertrophy: Muscle fiber
analysis on VL, MT of
VL, VM, RF, VI
Failure-15-12-Failure FS repetitions with or without BFR
in addition to regular HLT; CON group performed 60–
85% 1RM FS
53FS/wk 32 wk 6.5 wk 24–31% 1RM
Lowery et
al. (59)
20 Resistance-Trained
Collegiate Males (min 1
y of RT experience);
;23 yo
Hypertrophy: BB MT
measurements
3330 repetitions with BFR
3315 repetitions with HLT
Groups performed same program for 8 wk but with and
without BFR (4 wk each) and then switched
23/wk 8 wk 30% 1RM BFR; 60%
1RM HLT
References Rest periods BFR application type BFR pressure applied BFR between rest periods? Outcomes? (only BFR reported)
Yamanaka
et al.
(102)
45 s KW N/A—2-inch overlap on KW Y Strength: +7.0% BP 1RM and
+8.0% BS 1RM
Hypertrophy: +3% in upper and
lower chest girth
Luebbers
et al.
(60)
45 s KW N/A—3-inch overlap on KW Y Strength: No differences in
increases in BP 1RM between
groups (+2.7–8.69 kg) but
differences in BS (+24.87 kg
versus 5.97–14.13 kg) 1RM
Hypertrophy: No differences
observed in increases in arm
or thigh measures between
groups; chest girth did not
increase in any group
BFR Training and the Physique Athlete
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Table 1
(continued)
Scott et al.
(77)
30 s KW N/A—“7/10 perceived tightness” Y Strength: No differences in
increases in SQ 3RM between
groups (+12.3–12.5%)
Hypertrophy: No changes in VL
architecture for any group
Cook et al.
(19)
90 s PN 180 mm Hg during PU, BP and SQ N Strength: +1.4% and +2.0% in BP
and BS 1RM in BFR group
compared with CON
Bjornsen
et al. (8)
30 s KW ;120 mm Hg Y Strength: No group differences
in MVIC KE (+9.4 Nm in BFR
versus 21.8 Nm in CON pre
to post) or 1RM FS (+4.1 kg in
BFR versus +5.9 kg in CON
pre to post)
Hypertrophy: Type 1 fibers CSA
increased more in BFR (974
versus 13 mm
2
)withno
differences in Type 2 fiber
CSA between groups. CSA of
VL increased in BFR versus
CON (+1.64 versus 0.12 cm
2
)
and similar trends observed
in RF and VM but not VI.
Lowery et
al. (59)
Not specified KW “6–7/10 perceived tightness” N/A No difference between HLT-BFR
and BFR-HLT groups in BB
hypertrophy (pooled means
3.66 60.06 cm to 4.11 6
0.07 cm)
BFR 5blood flow restriction; BP 5bench press; BW 5bodyweight; CM 5circumferential; CSA 5cross-sectional area; FS 5front squat; HLT 5high-load training; KW 5knee wraps; LOP 5
limb occlusion pressure; MT 5muscle thickness; MVIC 5maximum voluntary isometric contraction; PN 5pneumatic; PU 5pull-ups; RM 5repetition maximum; RF 5rectus femoris muscle;
RT 5resistance training; SQ 5back squat; VI 5vastus intermedius muscle; VL 5vastus lateralis muscle; VM 5vastus medialis muscle; YO 5years old.
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concurrent improvements in muscle
hypertrophy (8,60,102), and yet, others
showing no effect of BFR training on
strength or hypertrophy (77). Method-
ological and/or participant character-
istics may explain the variance in
outcomes between studies. It seems
that when groups are volume-
equated, the results are mixed. Three
studies show either no difference in
hypertrophy between groups (59,60)
or no changes at all (77), while one
study shows superior hypertrophy of
the BFR group over the volume-
matched control (102).
Taking the aforementioned informa-
tion into consideration, the research
tends to show that the addition of
low-load BFR training to a high-
intensity training program increases
muscle hypertrophy in resistance-
trained participants over periods of
4–7 weeks compared with similar rou-
tines performed without BFR,
although more research is needed to
optimize RT exercise prescription to
maximize hypertrophic potential in
mixed training (i.e., heavy and light
load) approaches.
Some evidence suggests that BFR may
enhance the satellite cell (SC) response
to RT, thereby augmenting long-term
hypertrophic adaptations; an outcome
that would be of considerable benefit
to the physique athlete, particularly
those close to maximizing their genetic
capacity for muscle development. It
has been proposed that each myonu-
clei controls the production of proteins
for a finite volume of cytoplasm (the
“myonuclear domain theory”), and
beyond this theoretical “ceiling,” addi-
tional nuclei must be derived from SCs
to realize further increases in muscle
mass (72). The molecular underpin-
nings of how SCs are recruited to assist
in muscle building are beyond the
scope of this article, but in short—
a damaging bout of exercise activates
a quiescent SC from the basal lamina of
the muscle fiber to proliferate, differen-
tiate, and ultimately fuse to the muscle
fiber, donating nuclei and helping with
repair and growth processes (90,110).
Given emerging research showing that
hypoxia potentiates the RT-induced
myogenic response (13), it can be spec-
ulated that BFR may be an effective
strategy to promote increases in SC
content. Indeed, a 3-week, high fre-
quency BFR training program was
shown to increase SC proliferation over
work-matched low-load free-flow exer-
cise (65). The findings led the authors to
speculate that perhaps interspersing
short blocks of low-load BFR training
into traditional RT programs might
enhance hypertrophic long-term adap-
tations. However, the fact that the con-
trol performed work-matched sets
raises that prospect that differences
between conditions may have been
due to differences in proximity to failure.
Other studies have reported no changes
in SC/myonuclei concentrations after 6
or 12 weeks of BFR training to failure
(at 30% 1RM) compared with nonfai-
lure high-intensity training (70%+
1RM) (26,80). It thus remains equivocal
whether BFR is a viable strategy to
increase SC content in physique ath-
letes; further research is needed to draw
evidence-based conclusions on
the topic.
Table 2 summarizes some of the impor-
tant considerations to make when
applying BFR before training.
Researchers use a number of different
BFR methodologies in the laboratory
setting that makes translating research
into practical recommendations chal-
lenging for the physique athlete. Prac-
tical recommendations for the
physique athlete must take into con-
sideration BFR cuff safety, cost, and
potential benefits with chronic use.
Research studies typically use cuffs
that are pneumatic or nonpneumatic.
Pneumatic cuffs fill up with air by
external means (either manually
through a pump or automatically
through a computer system or wireless
device) and apply the pressure to the
limb by increasing the amount of air
within the bladder of the cuff. Non-
pneumatic cuffs, such as elastic knee
wraps, apply pressure to the limb
through increased tension on the band
or strap provided by the user.
Although both types of applications
have shown to improve muscle mass
in the research (59,60,79,102), there ex-
ists some conflicting evidence on the
potential safety of nonpneumatic appli-
cations (i.e., knee wraps). Commonly
recommended application of nonpneu-
matic cuffs involve tightening knee
wraps to a perceived tightness of 6–7
(on a scale where “where “10” is max-
imal discomfort”) to achieve adequate
occlusion pressure (59,77). However,
some studies suggest that individuals
have difficulty achieving a standardized
restrictive stimulus on a session-to-
session basis, overestimating or under-
estimating applied pressures by as
much as 25% (7). This may contribute
to situations where individuals are
exercising under full limb occlusion,
increasing the risk of adverse events
even in healthy individuals. Further-
more, if the applied pressure is too
low, the local metabolic environment
is not significantly altered thus render-
ing the addition of the cuffs ineffective
at accelerating fatigue accumulation at
light loads (42,73).
Recently, some studies have investi-
gated alternative methods for stan-
dardizing cuff pressure with the use
of practical BFR. Abe et al. (2) deter-
mined that pulling elastic cuffs to 10–
20% of initial length achieved similar
reductions in brachial artery blood flow
as that of a pressurized nylon cuff in-
flated to 40 and 80% of resting arterial
occlusion pressure, respectively. Simi-
larly, Thiebaud et al. (89) reported that
elastic knee wraps, either stretched by
2 inches or to a length of ;85% of
thigh circumference, provided a valid
alternative to pneumatically inflated
cuffs. It should be noted that these
studies used specially designed elastic
cuffs that allow for precise determina-
tion of the magnitude of stretch; this is
a more difficult task with standard elas-
tic wraps, rendering their practical util-
ity somewhat limited.
Ideally, pneumatic devices are recom-
mended in the gym setting because
BFR Training and the Physique Athlete
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they are able to provide a more con-
sistent restrictive stimulus for BFR
application, minimizing safety risk
despite the higher cost to the
consumer. Newer technology has been
recently released for consumer pur-
chase that removes some of the pre-
vious barriers of using pneumatic
cuffs in the gym setting. These cuffs
can determine individualized suboc-
clusive pressures without use of an
external Doppler (the current gold
Table 2
Considerations for the practical application of BFR
Application variable Recommendation Research notes
Practical (knee wraps) using a perceived “7/10”
tightness versus pneumatic (tourniquet) using
limb occlusion pressure (LOP)
a
Pneumatic using LOP Although KW have shown efficacy in a number of studies
(8,60,102), they do not allow the individual to obtain
a standardized pressure from session to session (7). Bell
et al. (2019) showed that when individuals were asked to
pump the cuff pressure in the arms and legs to a “7/10”
tightness once each day over 3 d, it resulted in
overestimation/underestimation of LOP in the arms by
25% and legs by 20%. This suggests that setting pressures
relative to LOP may provide a more standardized
stimulus.
Cuff width—narrow or wide (5–17 cm) Depends—both are
acceptable if using %LOP
All different cuff widths have been shown to have efficacy
(71), but narrow cuffs require higher pressures to obtain
LOP, potentially increasing risk to underlying
neurovasculature (55). However, use of wider cuffs may
attenuate hypertrophy underneath the restriction site
(26), although setting to individualized LOP may mitigate
that chance (51). Narrow cuffs have also been shown to
be more comfortable compared with wider cuffs when
set to the same relative LOP (83).
Cuff position Proximal limb Safety concerns for a nerve injury arise with external
compression directly over vulnerable regions at the
elbow (ulnar nerve) or knee (common fibular nerve)
tractions the nerve and increases risk of demyelination
with muscular contractions. The neurovasculature is more
protected closer to the trunk due to increased soft tissue;
so application is best suited proximally.
Maximum no. of cuffs at one time 2 (2 upper body or 2 lower
body)
Although there is no research comparing the acute or
chronic safety of BFR applied to 4 limbs simultaneously,
bilateral BFR has been shown to increase heart rate to
compensate for loss of stroke volume during exercise,
increasing rate pressure product
b
threefold compared
with free-flow exercise (74). In individuals exercising with
more than 2 cuffs on simultaneously, it may unnecessarily
increase risk of adverse cardiovascular events and is
therefore not recommended.
Body position and LOP Determine LOP in the
position (standing/sitting/
supine) of the exercise
LOP has been shown to vary based on the position of testing
(38,78). Underestimating or overestimating LOP may
decrease effectiveness of nonfailure BFR exercise or safety
(71).
Determining LOP (frequency) Once every 4–8 wk LOP has not shown to change significantly in healthy
individuals over the course of 8 wk (61).
a
LOP 5limb occlusion pressure, is determined either with an automatic BFR device or manually with an external Doppler and a pneumatic cuff.
LOP is preferably determined in the position of the exercise, where the individual is relaxed, and an external Doppler is positioned at the level of
the radial or posterior tibial artery. The cuff is gradually inflated until there is no audible sound heard from the Doppler. The cuff is gradually
deflated, and the first sound heard is the individual’s LOP. Recent research also supports the use of a pulse oximeter in the upper but not lower
extremities (111).
b
RPP 5rate pressure product is calculated by the equation, “RPP 5heart rate 3systolic blood pressure” and is a measure of the workload on the
heart.
BFR 5blood flow restriction.
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standard in clinical application). The
wireless nature of these devices also
makes them more “gym-friendly” than
clinical models that are tethered, ex-
panding their ability for widespread
gym use. That said, practical BFR
using elastic knee wraps remains a valid
option for promoting an anabolic stim-
ulus. Individuals choosing to use this
option should do so with caution and
reduce restrictive pressures if any
numbness, tingling, or excessive bruis-
ing underneath the restriction zone
occurs.
PRACTICAL RECOMMENDATIONS
FOR INTEGRATING BLOOD FLOW
RESTRICTION RESISTANCE
TRAINING
Implementing BFR into the RT pro-
gram for physique athletes requires
some basic programming considera-
tions. Shown in Table 3 are some gen-
eral programming guidelines to
maximize hypertrophic potential with
BFR training based on the current
research.
Physique athletes can program BFR
RT to increase muscle hypertrophy in
a number of ways. The most practical
way to include BFR RT into a program
would be to add on 1–2 exercises per
target muscle group at the end of
a heavy-load training session to prefer-
entially stress muscle fibers that may
not be sufficiently stressed at higher
loading intensities (i.e., type I fibers)
(8,69). The combination of heavy-
load and low-load BFR in a single
training session provides both meta-
bolic and mechanical stress to the mus-
cle, which have been hypothesized to
positively contribute to maximal in-
creases in hypertrophy (69). Studies
have also shown that the additional
volume provided by nonfailure BFR
RT (i.e., 30-15-15-15) does not nega-
tively impact recovery from training
(57,87,88). However, incorporating
multiple sets of failure training may
prolong recovery and increase
delayed-onset muscle soreness, espe-
cially during unaccustomed bouts of
exercise (28,93). This may reduce
weekly training frequency and lead to
suboptimal hypertrophy over time.
Despite the potential for increased
recovery time performing failure rou-
tines, physique athletes may require
this approach occasionally to maxi-
mize long-term hypertrophy, espe-
cially if type I fiber hypertrophic
potential is limited by chronic training
with heavier loading protocols (8,9).
The best evidence-based approach
seemingly would be to program multi-
ple sets (2–4) of failure training period-
ically, most likely in exercise sessions
where there are scheduled rest days
afterward, so as to not provide a perfor-
mance decrement to subsequent lifting
sessions. Since unaccustomed failure
training tends to increase recovery
time, failure training should be per-
formed after an initial acclimation
period (2–4 weeks, 2–33/week) of
BFR RT has been completed. BFR
failure training also is more perceptu-
ally demanding than high-load training
despite significantly less overall vol-
ume, making it challenging to contin-
ually perform in practice (94). Finally,
single-joint exercises (i.e., leg exten-
sions and biceps curls) tend to be able
to drive more localized fatigue to the
muscles compared with compound ex-
ercises (i.e., squats and bent-over rows),
so these should be prioritized in train-
ing when heavy-load variations of the
same type of exercise are used concur-
rently in the lifting session (41).
Another unique application for BFR
RT could be during a planned deload
phase or when a competitor is deep in
contest preparation, and the likelihood
of musculoskeletal injury theoretically
increases. Two recent studies polling
elite physique athletes reported that
40+% of respondents train through
musculoskeletal pain (81,82). Short
blocks (1–2 weeks) of BFR RT could
reduce the stress on the joints of the
elbows and knees while providing sim-
ilar hypertrophic benefits as heavier
training (71). There also is evidence
to suggest a significant hypoalgesic
effect during and after BFR (45), which
may last up to 24 hours (39). This may
enable the physique athlete to continue
training despite injuries that would
otherwise hinder training intensity
(58). Taken together, low-load BFR
RT could help physique athletes main-
tain their physique during periods of
relative deloading while also decreas-
ing pain during and after exercise. Fig-
ure 1 displays the potential applications
for BFR during an RT program for
a physique athlete.
BFR RTexercise (20–50% 1RM) seems
to elicit similar benefits in muscle
hypertrophy when directly compared
with moderate-load (70% 1RM) and
heavy-load (80% 1RM) protocols
(21,46). However, heavy-load RT may
confer additional neuromuscular and
musculoskeletal benefits including
greater increases in dynamic strength
measures (i.e., 1RM), central activation
(a measure of neural drive to the mus-
cle), and greater muscle retention dur-
ing periods of detraining (12,109),
which may be of relevance to those
aspiring to maximize muscle develop-
ment over the long term. Thus, it is
recommended that BFR never com-
pletely replace heavy-load RT in
a long-term periodized program in
physique athletes.
There seems to be a difference in re-
sponses between men and women
with respect to submaximal BFR exer-
cise tolerance. Women have been
shown to have greater submaximal
endurance at lower loads (20–40%
1RM) than men (48,101). Accordingly,
women physique athletes may need
either additional loads and/or repeti-
tions to achieve a similar hypertrophic
stimulus as men using lower load, non-
failure BFR protocols.
From a loading standpoint, there likely
exists a floor beneath which optimal
hypertrophy can occur during BFR
training. Buckner et al. (14) random-
ized participants into 1 of 4 groups:
70% 1RM without BFR, 15% 1RM
without BFR, and 15% 1RM with 40
and 80% limb occlusion pressure
(LOP). Each participant performed
up to 4 sets of elbow flexion exercise
to volitional failure (or 90 repetitions)
twice a week for 8 weeks. Results
showed nonhomogenous increases in
muscle growth of the elbow flexors in
BFR Training and the Physique Athlete
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Table 3
Evidence-based practical recommendations for BFR resistance training
Programming variables to consider Recommendation Important notes
Frequency 2–33/wk for .3 wk, 1–23/d ,3 wk BFR training can be performed chronically 2–33/wk in combina-
tion with HLT or used to “shock” the musculoskeletal system for
a short period (,3 wk) for 1–23/d in the absence of HLT (like
during a deload week) (71). Of note, despite the low-load nature
of BFR, 1–23/d is very stressful and likely requires considerable
recovery (10 d) to observe benefits (9)
%LOP
a
Arms: 40–50%
Legs: 60–80%
In nonfailure exercise, metabolic stress is shown to increase with
higher pressures and in the legs, 40% LOP produces a similar
metabolic environment as free-flow exercise (42,73). However,
in the arms, 40% LOP produces similar outcomes as 90% LOP
(23).
No. of exercises per session Variable Most studies use either 1 exercise (i.e., leg extension); some use 2
exercises per muscle group performing a multijoint and single-
joint variation (i.e., leg press/leg extension) (21).
Repetition scheme 30-15-15-15 or failure training 3
multiple sets
Both routines show efficacy in numerous studies, but failure
training tends to increase recovery time (97). Failure may be
needed to maximally fatigue target muscle groups, especially in
advanced trainees.
Maximum wear time 10–20 min Recommended to reduce risk of adverse events. Deflate after every
1–2 exercises and wait at least 1 min before reinflating (71).
Loads 20–50% 1RM Loads greater than 50% 1RM do not seem to augment the benefits
of BFR exercise (50). Loads less than 20% provide suboptimal
outcomes with respect to hypertrophy (14).
Tempo 1–2 s concentric/eccentric Lifting tempo should be between 1 and 2 s because most research
have used these numbers (71).
Interset rest 30–60 s Shorter rest periods augment metabolic stress to a greater degree
than longer rest periods (150 s) (54).
Continuous (CON) or intermittent
application (deflated during
rest)
b
Continuous CON application shows superior metabolic stress (84) and muscle
fatigue (107) despite similar levels of perceptual effort during
exercise (31). Of note, when BFR is removed (or not applied)
during the rest periods, tissue oxygen levels tend to recover,
reducing metabolic stress (73).
Before or after HLT? After, unless no HLT performed
(deloads)
After HLT, as maximizing hypertrophy likely needs a combination
of high mechanical and metabolic stress, which could be
sacrificed long term if BFR is performed before HLT due to acute
fatigue response with BFR exercise (69).
Multijoint or single-joint exercises? Both
a
Both types have shown to increase hypertrophy, but single-joint
exercises likely superior to drive growth to muscles distal to the
cuff due to higher local fatigue tolerance (41).
Exercise order in BFR—multijoint or
single-joint?
Either, although single-joint may stress
muscles distal to the cuff to
a greater degree
Both have shown to be effective, but likely excessive fatigue
accumulation during single-joint movements may impede
completion of multijoint exercise performance.
a
LOP 5limb occlusion pressure is the minimum pressure needed to completely restrict both arterial and venous flow to the limb. Exercise is
performed at a percentage of this value.
b
CON 5continuous application describes when the BFR cuff is left inflated throughout the duration of the exercise versus deflated during the
rest periods.
BFR 5blood flow restriction; HLT 5high-load training (70+% 1RM); RM 5repetition maximum.
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the 15% conditions irrespective of
BFR, with lesser absolute increases in
hypertrophy compared with the 70%
1RM condition. Therefore, it seems
that metabolite-induced fatigue and
cell swelling act to augment the hyper-
trophic response to BFR RT in
response to external loads above 15%
1RM, but not lower. When integrating
BFR RT into exercise prescriptions,
loads corresponding to at least 20%
1RM should be used to ensure maxi-
mal benefit in work-matched or failure
exercise protocols.
An observed benefit to BFR RT in
untrained or injured populations when
performing multijoint exercises such as
the back squat or bench press involves
additional hypertrophy of the proxi-
mal muscle groups (i.e., gluteals and
pectorals) (1,10,105). However, the
gains in hypertrophy are variable and
tend to be greater with individuals who
are more deconditioned (10,105). In
the physique athlete who can tolerate
additional loading (70+% 1RM), BFR
may not provide enough of a hypertro-
phic stimulus to the muscles proximal
to the cuff to warrant its inclusion in
a training program. This is attributed to
decreased muscle activation secondary
to reduced training loads (especially
during nonfailure, multijoint exercise)
(1). It is recommended that muscles
proximal to the cuff be directly trained
with heavier loads without BFR to
maximize hypertrophy of these
muscles.
Figure 1 highlights the gradual intro-
duction of BFR RT into a heavy-load
RT program over 12 weeks. Although
applied pressure is not specified,
research has shown that a wide variety
of pressures can be used to improve
muscle hypertrophy at various loads
(52). However, it seems that when
using lighter loads closer to 20%
1RM, higher relative pressures (50%
LOP in the arms and 80% LOP in
the legs) may be needed to maximize
muscle gains (52). In nonfailure
Figure 1. A hypothetical mixed-method approach that integrates BFR training into a traditional RT program for the physique
athlete. BFR 5blood flow restriction; HLT 5heavy-load training; RM 5repetition maximum; RT 5resistance training.
Table 4
Possible ways to progress BFR resistance training
Difficulty Range of motion Miscellaneous variables BFR variables
Easier Partial range of motion
Single-joint exercises
Multijoint exercises
Bilateral (i.e., squats)
Avoid lengthening two-joint muscles (i.e., calf raises on the
floor versus off step)
Nonfailure (30-15-15-15)
Lower pressure (40% arms,
60–70% legs)
Lower %1RM (20–35% 1RM)
1–2 exercises/session
Harder Full range of motion
Single-joint exercises
Long-lever exercises (i.e., Straight leg
raise flexion)
Multijoint exercises
Single-leg biased (i.e., lunge)
Single-leg dynamic (i.e., walking
lunge)
Intensification techniques (drop sets, compound sets, etc.)
Full 2-joint muscle excursions (straight leg calf raise off step
into full dorsiflexion)
Failure (2–4 sets)
Higher pressure (50% arms/
80% legs)
Higher % 1RM (35–50% 1RM)
3–5 exercises/session
BFR 5blood flow restriction; RM 5repetition maximum.
BFR Training and the Physique Athlete
VOLUME 00 | NUMBER 00 | APRIL 2020
10
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routines (i.e., 30-15-15-15), metabolic
responses (i.e., rise in lactate and mus-
cle deoxygenation) seem to be aug-
mented in a pressure-dependent
manner above 40% LOP (80% .60%
.40% 5low load-free flow) (42).
Conversely, higher relative pressures
(i.e., 50% LOP in the arms and 80%
LOP in the legs) may not be required
at loads approaching 50% 1RM
because the intramuscular pressure
may be high enough from the contrac-
tion itself to produce occlusion during
the exercise bout (37,50,75). There also
seems to be no additional acute or
chronic benefit for adding BFR to
heavy loading as the muscle activation
is already high (50,64). Finally,
although BFR has been shown to be
relatively safe and promote benefits in
both muscle and connective tissue (17)
despite the low loads, not much is
known about effects from long-term
continuous (16+ weeks) application.
Therefore, a periodic removal of BFR
from the RT program is advised
to minimize the risk of potential
chronic adverse events currently
unknown.
Table 4 provides BFR evidence-based
progression guidelines for the use of
BFR training with athletes and body-
builders. The same principles of inten-
sifying strength training may apply to
BFR at lower loads (i.e., drop sets,
compound sets, etc.), but potential ben-
efits over traditional approaches with-
out BFR warrant further research.
SUMMARY AND CONCLUSIONS
BFR RT seems to be a novel way to
enhance muscle hypertrophy in phy-
sique athletes, especially when used
in conjunction with heavy-load RT.
Although the benefits of BFR AT are
less conclusive, the strategy does mod-
estly increase EE, cell swelling, and (in
some modes of exercise) metabolic
stress compared with work-matched
free-flow exercise, all of which can be
beneficial to the physique athlete by
either aiding in maintaining/produc-
ing a caloric deficit or by creating an
anabolic environment to aid in muscle
growth. Both of these applications
may be used in tandem to maximize
the hypertrophic potential of a com-
bined exercise session, but caution is
warranted with long-term continu-
ous use.
Despite the fact that BFR generally has
been shown to be safe to use in healthy
resistance-trained adults, not much is
known about the long-term effects
(16+ weeks) on vascular function, espe-
cially during RT where intramuscular
pressures from muscle contractions
may excessively stress the structure of
the arteriovenous system (i.e., stiffness/
compliance etc) (24). Therefore, it is
strongly advised to schedule a pro-
grammed 4-week period where BFR
is completely removed from training
to account for any potential as-yet-
undetermined adverse events.
With respect to the physique athlete,
there are numerous avenues for future
research that could help elucidate the
effectiveness of BFR within this popu-
lation. There are currently no studies
comparing heavy-load RT to heavy-
load RT plus low-load BFR RT in
highly trained physique athletes nor
are there any studies showing the
effectiveness of low-load BFR RT in
maintaining lean body mass during
contest preparation.
Conflicts of Interest and Source of Funding:
Nicholas Rolnick has received compensation to
provide educational lectures about blood flow
restriction training on behalf of Mad-Up,
a company that manufactures blood flow
resistance training systems. Otherwise, the
authors declare no other conflicts of interest.
Nick Rolnick is
the founder of the
BRF PROS, and
operates a physi-
cal therapy prac-
tice in New York.
Brad
Schoenfeld is
an associate pro-
fessor in the
Department of
Health Sciences
at CUNY Leh-
man College.
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