Novice Guide to Blood Flow Restriction Therapy

Novice Guide to Blood Flow Restriction Therapy

Technology has impacted almost every industry across the globe, and athletics and rehab are no exceptions. Over the last two decades, the science of athletic assessment, training, performance and rehabilitation has taken a quantum leap, with a plethora of new technology-driven tools that totally revolutionize our diagnostic and treatment approaches.

One exciting new treatment technology that holds promise for a broad range of applications is blood flow restriction therapy, or BFRT. This guide gives an overview of BFRT for novices who want a deeper understanding of what it is and how it works.

Before we dive deep, here are some basic factors about BFRT:

  • BFRT is a form of resistance training that uses a pneumatic compression device to constrict venous blood flow
  • BFRT stimulates muscle tissue repair and growth at much lighter training loads — 70-80% lower than traditional resistance training
  • BFRT is used to rehabilitate atrophied and damaged muscle tissue after an injury or illness, sparing the joints and other structures from excessive overload during recovery

BFRT has been used for injury rehab and muscle hypertrophy for several years now, but early BFR equipment was somewhat primitive and not at all precise. Today, BFR devices have become high tech, allowing for quantitative precision in occlusion regulation and limb loading, to ensure safe and effective outcomes.

The Science Behind BFRT

The Science Behind BFRT

It is often the case that new therapies and technologies emerge before their underlying mechanisms are fully understood, and that is definitely true with BFRT. We know that BFRT does in fact promote muscle hypertrophy and tissue regenesis, but there exists more than one theory about why and how.

There are three main theories about the science of BFRT:

  • As blood circulates, arteries carry blood to working muscle cells where they extract oxygen and nutrients, and veins carry away CO2 and waste products. According to our first theory, when subjected to compression during contraction, veins are constricted, causing arterial blood to pool in the muscle cells. The cells become filled with fluid to the point where they are forced to either burst or grow. This theory proposes that the pooling of blood is what prompts the muscle cells to grow larger and stronger. When muscle fibers become damaged from resistance overload, satellite cells are activated, triggering a cascade of responses that promote tissue repair and growth.
  • A second theory proposes that the mechanism of muscle repair and growth resulting from venous constriction is a buildup of metabolites in the muscle cells, including human growth hormone (HGH). Elevated cellular metabolites are a normal response to weight training, but they do not linger in muscle cells for long, as they are carried away with circulating blood. With BFRT, venous constriction prevents metabolites from escaping the cell, creating an abnormally high-HGH environment that stimulates accelerated muscle tissue repair and growth (Kwon, 2004).
  • A third theory suggests that when veins are constricted, deoxygenated blood is trapped in the muscle cells, creating an anaerobic (oxygen-free) environment that deprives Type 1 muscle fibers of the oxygen needed to contract. This in turn forces the body to recruit Type 2 fast twitch fibers that are much larger and are not oxygen-dependent for contraction. Since Type 2 muscle fibers are mostly responsible for muscle strength and hypertrophy, reliance on them for contraction at lower loads under BFR still stimulates tissue repair and growth. (Penny, 2015).

Effects of BFR on Athletic Performance and Recovery

Effects of BFR on Athletic Performance and Recovery

BRF has become a mainstay in training for elite sports performance and recovery. The method has been shown to be a safe technique for quickly enhancing muscle size, strength, endurance, and athletic performance. BFRT uses light weights to generate rapid strength and fitness gains in a short time span.

BFRT is used to help heal muscle strains and ligament sprains, and it speeds the rate of healing after knee and shoulder surgery, and even after total joint replacement. The BFR occlusion bands let you work out with substantially less weight, reducing stress on healing joints and connective tissues while speeding up muscle recovery. BFRT is ideal for athletes who need to quickly return to play after an injury.

BFR Therapy and Tendon Healing

BFR Therapy and Tendon Healing

Tendon healing has always been a long game, simply because the sparse vascularity of tendon tissue limits the amounts of oxygen and nutrients that can reach damaged cells.

For athletes, that means that even if damaged muscle fully heals and regains its size and strength, the associated tendons often lag behind. In many cases, athletes are released to return to play prematurely based on muscle recovery alone, setting them up for re-injury when tendons underperform.

A recent study by Centner et al. (2019), set out to determine if BFRT would accelerate the healing of both muscle and tendon tissue.

Over a 6-week period, researchers compared BFRT to traditional resistance training, beginning at 75% 1RM (one rep max) and progressing to 85%. The BFR group began at 20% 1RM and progressed to 35% over the same time period — much lighter weights than the traditional group.

The results?

Similar improvements in muscle size and strength were observed in both groups, and also in tendon stiffness and thickness.

This is great news for athletes who want to return to play as quickly as possible after an injury, or for anyone with tendinopathy who wants to get back to pain-free movement.

BFR Rehab Combined with Neuromuscular Electrical Stimulation

BFR Rehab Combined with Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) has long been used to help maintain muscle mass and strength during prolonged periods of immobilization. NMES devices have also been sold to gullible consumers as a gimmicky solution for flabby abs.

NMES works by delivering an electrical charge to nerves, stimulating their associated muscles to involuntarily contract. It is often used to preserve and rehabilitate muscles after injury or reconstructive surgery.

There is a growing body of research to suggest that combining NMES with BFRT creates a dynamic duo that enhances HGH secretion and significantly enhances muscle strength and size, compared to NMES without BFRT.

BFRT to Combat Aging

None of us wants to get older, but time, gravity, wear and tear and hormonal changes take their toll. Regular exercise helps, but even healthy adults who exercise regularly lose about 10% of their lean mass with every passing decade, a condition called sarcopenia.

Loss of lean muscle mass impacts older adults in multiple ways:

  • reduced strength
  • impaired balance
  • lower metabolism
  • increased risk of metabolic disease
  • unwanted weight gain
  • reduced bone mineral density
  • reduced mitochondrial function
  • impaired movement
  • increased injury risk
BFRT to Combat Aging

BFRT offers an ideal solution for older adults who want to gain muscle mass without overloading joints or lifting heavy weights. BFR therapy can aid in post-surgery recovery, to restore strength and stability, and reduce injury risk. BFRT also improves mitochondrial function, a key marker for longevity in older adults.

Contraindications for BFRT

While BFRT is generally safe for most people, it is not recommended for certain individuals, including:

  • Pregnant females
  • People taking blood thinners
  • Individuals with circulatory conditions like acute thrombosis and peripheral vascular disease
  • People with serious heart and pulmonary disease
  • People with pacemakers
  • Patients with Type 1 diabetes
  • Those with a range of less common conditions
Contraindications for BFRT

A thorough health and medical history should be conducted prior to administering blood flow restriction therapy.


At NYDNRehab, we are always adding the best new therapies and technologies to our growing menu of services. For BFRT, we use Mad-Up, the best personalized BFR device on the market.

BFR therapy is beneficial for:

  • Pre-op, to inhibit muscle loss after surgery
  • Post-op, to restore strength and promote healing
  • Older adults, to build strength and prevent sarcopenia
  • Injury rehab, to accelerate healing and restore strength while protecting joints
  • Performance enhancement, for rapid gains in lean muscle mass and strength

Contact NYDNRehab today, and see how BFRT can help you attain mass, strength, healing, and the very best quality of life.

Range of Available Unique Physical Therapy Treatments at Nydnrehab


  • Centner, C., Lauber, B., Seynnes, O. R., Jerger, S., Sohnius, T., Gollhofer, A., & König, D. (2019). Low-load blood flow restriction training induces similar morphological and mechanical Achilles tendon adaptations compared with high-load resistance training. Journal of Applied Physiology, 127(6), 1660-1667.
  • Kwon, MS, and Len Kravitz. “How do muscles grow.” Physiological Reviews 84 (2004): 209-238.
  • Loenneke, J. P., Wilson, J. M., Marín, P. J., Zourdos, M. C., & Bemben, M. G. (2012). Low intensity blood flow restriction training: a meta-analysis. European journal of applied physiology, 112(5), 1849-1859.
  • Penney, S., Comana, F., Lecovin, G., Miller, K., Gonzalez, J., Stull, K., . . . National Academy of Sports Medicine. (2018, March 23). Fast-Twitch, Slow-Twitch: What’s the difference and does it matter?
  • Waller, Tom, Mike Caine, and Rhys Morris. “Intermittent pneumatic compression technology for sports recovery.” The Engineering of Sport 6. Springer, New York, NY, 2006. 391-396.

About the Author

Dr. Lev Kalika is clinical director of NYDNRehab, located in Manhattan. Lev Kalika is the author of multiple medical publications and research, and an international expert in the field of rehabilitative sonography, ultrasound guided dry needling and sports medicine Dr. Kalika works with athletes, runners, dancers and mainstream clients to relieve pain, rehabilitate injuries, enhance performance and minimize the risk of injuries. His clinic features some of the most technologically advanced equipment in the world, rarely found in a private clinic.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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