Blood Flow Restriction Training

by Brad Schoenfeld, PhD | 09/16/13

Here's what you need to know...
Blood flow restriction training involves wrapping a restrictive implement
around the limbs while lifting. Studies show increases in muscle growth
when low-load lifting is combined with flow restriction.
You don't need costly implements to perform BFR. Elastic knee wraps will do.
The best approach is to use this as a "finishing" technique. Perform a
moderate to heavy-load hypertrophy protocol first in a session and then
finish up with several sets of BFR training using single-joint movements.
Resistance training articles often explore variations on the same old theme.
That's because there just aren't many new techniques to report on... at least
few that actually work. Occasionally, though, there are exceptions. If you've
been searching for a novel way to ramp up muscle growth, here's a strategy
that you might not have considered blood flow restriction (BFR) training.
BFR isn't really a new technique. It's been used for years in Japan and
research on the topic dates back to the 90's. Despite emerging evidence of
its effectiveness, most lifters have only a vague idea of what BFR involves
and how it can be applied within a resistance-training program to enhance
results.

BFR Basics
BFR entails occluding circulation of the working muscle. This is
accomplished by wrapping a restrictive implement around the limb(s) while
carrying out dynamic exercise. The objective of BFR is to occlude venous
flow without significantly affecting arterial circulation. In this way, blood
goes into the muscle but can't escape.
Research on the hypertrophic effects of BFR is compelling. Studies show that
simply occluding blood flow to bedridden patients can prevent atrophy and
weakness, without performing any training at all (1)!
Moreover, walking with blood flow restricted to the legs not exactly your
classic muscle-building activity has been found to significantly increase
muscle strength and size (2). But the real hypertrophic benefits of BFR occur
when it's applied in concert with resistance exercise.
Numerous studies show substantial increases in muscle growth when low-
load lifting (~20-30% 1RM) is combined with flow restriction (3). Gains are
often on par with traditional heavy-load training during early-stage training,
sometimes even greater.
How Does BFR Increase Hypertrophy
What is the "magic" behind BFR? The exact hypertrophic mechanisms aren't
entirely clear but it's believed that metabolic stress plays an important role
in the process. Simply stated, metabolic stress is the buildup of training
byproducts called metabolites, and is particularly prevalent when training is
carried out in an oxygen-limited state, as is seen when circulation is
restricted. Metabolites implicated in promoting a hypertrophic response
include lactate, inorganic phosphate, and hydrogen ions.
These byproducts are theorized to enhance anabolism by a variety of
mechanisms, including mediating the release of growth factors, reactive
oxygen species, and cell swelling, and/or systemic agents. Alone or in
combination, the production of metabolites drive cellular signaling in a
manner that enhances protein synthesis and satellite cell activation key
elements needed for muscle growth (4).

What Should You Use to Wrap?

Well-controlled BFR studies use a variety of pneumatic cuffs and belts to
occlude flow. These devices are usually inflatable to a given pressure so that
researchers can standardize the amount of occlusion applied to the limb
(usually based on systolic blood pressure and set at anywhere from 160-200
mm/Hg). The problem is the cuffs used in research are quite expensive, in
some cases costing thousands of dollars.
Fortunately you don't need costly implements to perform BFR good old
elastic knee wraps do the trick very nicely (5). The wraps must be long
enough to circle your limb several times. However, that's the only
requirement; the brand or type of material really doesn't matter.
Placement of the wraps is crucial. You must position them as high as
possible on the limbs being trained. For the upper arms, they should be
wrapped as high on the biceps as you can get. For the thighs, they should
be wrapped just beneath the gluteal fold.
If the wraps are positioned too low, you won't achieve optimal venous
occlusion and the beneficial effects of the strategy will be compromised.

How Tight Should You Wrap?

The goal should be to secure the wraps so that they're snug on the limb but
not to the point where there's excessive discomfort at rest. On a scale from
1-10, pressure should be about a 7 or so. It generally takes some practice to
accurately quantify the pain-pressure connection, but after a few sessions
you should have a clear sense of just how tightly to wrap.
It's important to remember that the purpose of BFR is to impede venous
return, not arterial flow into the muscle. Wrap too tightly and all local
circulation becomes occluded. This increases the perceived exertion of the
exercise with a corresponding reduction in total training volume. And if
there's one thing that's clear in the literature, higher exercise volumes are
positively associated with increases in hypertrophy.

Cuff width also is an important consideration. Research shows that a wide

cuff cuts off arterial circulation at a lower pressure than narrower cuffs (6),
thereby impairing your ability to resist fatigue. It should therefore come as
no surprise that the use of a wide cuff during BFR has been found to reduce
the extent of hypertrophy (7).
The best solution is to aim for a width of a couple of inches or so, which is
approximately the size of most knee wraps. From a practical standpoint, this
means you should bind the wraps as closely over one another as possible so
there's maximum overlap.

Integrating BFR into Your Routine

In the vast majority of studies, BFR has been carried out in isolation so that
it's the sole training stimulus used over the course of a given research
protocol. Training in this fashion may be okay for elderly individuals or those
rehabbing from an injury, but if you're an experienced lifter, doing just BFR
training alone isn't going to cut it. Your best results are achieved by
integrating the technique into a traditional hypertrophy training program.
There are a number of different ways to go about incorporating BFR into
your workout regimen. After much experimentation, the best approach I've
found is to use it as a "finishing" technique. This involves performing a
moderate to heavy load hypertrophy protocol first in a session and then
finishing up with several sets of BFR training.
Here are the specifics. Although BFR can be employed with pretty much any
exercise, it seems to work best with single-joint movements. Biceps curls,
triceps pressdowns, leg extensions, etc., are all excellent choices here.
Perform multi-joint exercises such as squats, rows, and pressing movements
in the traditional fashion.
The weights used during BFR should be light. As a rule, keep the loads at
~20-30% of 1RM for a given exercise. Combined with occlusion, you should
get about ~20-25 reps on the first set.
Thereafter, perform a few additional sets of the chosen exercise while
keeping rest periods at about 30 seconds or so. The short rest interval helps
to heighten metabolic stress and pooling of blood in the working muscle. It
also necessarily reduces the number of reps you're able to perform on
successive sets.
By the final set, assuming you maintain the same load, you'll probably only
get around 8-10 reps. That's okay. As long as you follow the protocol as
described, you'll achieve optimal anabolic benefits.

It's also important to keep the limbs continually restricted for the duration of
the exercise. Research shows that untying the wraps between sets
significantly reduces metabolic stress, thereby inhibiting the growth
stimulus (8). Remove the wraps only after you've finished the final BFR set.
Do it right and you'll get a skin-splitting pump like you've never experienced
in your life.

At least some of your sets should be taken to the point of muscular failure.
Understand, however, that going to failure in BFR requires a different
mindset than during traditional resistance exercise.
With BFR your limbs get heavier with each successive rep. After a point,
you'll feel as though they simply can't move. This is where mental fortitude
comes into play. Because the loads are so light, you can will yourself to push
through the sensation and pump out a few additional reps. Dig deep and
squeeze out every last rep possible. Ultimately this is how you maximize
metabolite accumulation and its associated anabolic response.

Final Thoughts
Integrating BFR into your training can really ramp up your muscular gains.
With continued implementation into a well-designed resistance training
program, it may well be the strategy that takes your muscular development
to new heights.

References
Kubota A, Sakuraba K, Sawaki K, Sumide T, Tamura Y. Prevention of disuse
muscular weakness by restriction of blood flow. Med Sci Sports Exerc. 2008
Mar;40(3):529-34.
Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following
walk training with restricted venous blood flow from the leg muscle, kaatsu-
walk training. J Appl Physiol. 2006 May;100(5):1460-6.
Loenneke JP, Wilson JM, Marin PJ, Zourdos MC, Bemben MG. Low intensity
blood flow restriction training: A meta-analysis. Eur J Appl Physiol. 2011 Sep
16.
Schoenfeld BJ. Potential mechanisms for a role of metabolic stress in
hypertrophic adaptations to resistance training. Sports Med. 2013
Mar;43(3):179-94.
Wilson JM, Lowery RP, Joy JM, Loenneke JP, Naimo MA. Practical blood flow
restriction training increases acute determinants of hypertrophy without
increasing indices of muscle damage. J Strength Cond Res. 2013 Feb 26.
Loenneke JP, Fahs CA, Rossow LM, Sherk VD, Thiebaud RS, Abe T, et al.
Effects of cuff width on arterial occlusion: Implications for blood flow
restricted exercise. Eur J Appl Physiol. 2011 Dec 6.
Kacin A, Strazar K. Frequent low-load ischemic resistance exercise to failure
enhances muscle oxygen delivery and endurance capacity. Scand J Med Sci
Sports. 2011 Dec;21(6):e231-41.
Suga T, Okita K, Takada S, Omokawa M, Kadoguchi T, Yokota T, et al. Effect
of multiple set on intramuscular metabolic stress during low-intensity
resistance exercise with blood flow restriction. Eur J Appl Physiol. 2012
Nov;112(11):3915-20.