BLOOD FLOW RESTRICTION TRAINING: THE GOOD, THE BAD, AND THE UGLY

By Peter Mraz

Now, in the time of spaghetti westerns, you used to always have the protagonist (the good guy) and the antagonist (the bad guy). Life was simple. The antagonist was ugly, rude, and mean, while the protagonist was tall, dark, and handsome. The roles were set in stone, and the story didn’t deviate from that. Kind of like the rehab social media space. BFR is either good or bad, either our handsome protagonist or our ugly antagonist.

But with the advance of cinema, we got our anti-hero. The anti-hero is a person who is bad, but you just can’t help yourself rooting for him. He has both good and bad in him. Being both the protagonist and antagonist in one. Picture Tony Soprano or Pablo Escobar. Now I want to present BFR in the same way. It’s neither totally good nor totally bad. It is our anti-hero for today’s blog.

BFR is currently a very hot topic. Some people think it’s the best thing since sliced bread, while others absolutely hate it. BFR was actually the topic of my Bachelor’s degree, and I work with it quite a bit in the clinic. It definitely has some advantages and drawbacks, as well as a lot of room for misapplication

THE GOOD

To be honest, I only use it with a younger athletic population and almost never with older individuals—almost exclusively with post-operative patients. I also don’t always use it as a main component of my rehab program but more as an add-on to achieve specific rehab goals. So, in my mind, it’s quite a niche thing.

As I mentioned, I use BFR almost exclusively with post-operative patients, the most common indication being ACL reconstruction. One of the best applications in this population is early in rehab when quadriceps activation is poor due to arthrogenic muscle inhibition. At this stage, BFR can be used as a warm-up with simple movements like an SLR (straight leg raise) or a quad set, helping to pre-activate the muscle before other exercises.

Then, when the patient can start riding the stationary bike, I like to use it as a tool to keep their aerobic condition high. Aerobic training with BFR, even at low intensities, significantly improves VO2 max and strength in as little as two weeks. In this case, it can also serve as a warm-up for your main work, keeping things time-effective. Now you can probably see why I think it’s a niche thing. Does your average middle-aged man really need to keep up his VO2 max? Probably not.

I also use it with resistance training because there is some data that it leads to faster hypertrophy after ACL reconstruction than your classical resistance training. But honestly, for me, that is not as important. And I never use it exclusively. I always combine some BFR training with some exercises without it.

Later in rehab, when introducing plyometrics, BFR can enhance post-activation potentiation (PAP), making patients more explosive and improving jumping performance. Traditionally, PAP was done with heavy deadlifts or squats before jumping, but with BFR, you can achieve a similar effect by doing one cycle (30/15/15/15 reps) of a lower-limb bodyweight exercise, resting for 2 minutes, and then starting the plyometric workout. In this case, BFR also serves as a warm-up.

Now, if you work a lot with the athletic population after surgeries, BFR can be a useful addition to your rehab program. The main reason being that it speeds things up. Athletes are usually impatient and want to get back on the field as soon as possible. BFR can help you shave a couple of weeks off the rehab plan when used correctly. Can it be done without it? Yes. Is it an important component of rehab? Probably not.

THE BAD

When they started researching BFR, there was a lot of talk about using it in older and frail populations. The rationale behind it was that you can use lighter weights and make it easier on the patient. That is not the case at all. While it is true you can use lighter weight, BFR is a very demanding type of exercise. The feeling is similar to the intense burn that you get when you’re exercising close to failure.

So, unless your granny has been hitting the gym and eating her protein, maybe just leave the cuffs at home, buddy.

There were even some reports of rhabdomyolysis after BFR training. Now, rhabdomyolysis is a condition where rapid muscle breakdown causes acute kidney damage, and unless you want your granny dying of a particularly “sick pump, brah,” maybe find some other exercise modality. Now, I think that a lot of the cases of rhabdomyolysis were caused by excessive cuff pressures. In early research, 200 mmHg was a common pressure prescription, which probably led to total occlusion of the limb. The research by Medrano et al. found that for the average person, 130% of systolic blood pressure equals the absolute occlusion pressure of the limb. If we take that the average systolic blood pressure is 120 mmHg, 130% of that would equal 156 mmHg, which is quite a bit less than 200 mmHg.

In my experience, I have found that it’s just not a good fit for your average older population. Or even middle-aged population. Most people are detrained and just not that used to working hard in the gym. By no means am I saying that they are lazy. Just maybe they haven’t really done exercise close to failure in a long time. I find that BFR overwhelms them, and they just can’t stick to that intensity of effort. Now, if you force them, that is just going to get them to resent their rehab, or it’s going to cause you to underload them by reducing the intensity (which is possible even with BFR). You have loads of options that offer the same or even better results than BFR. One of them is just your standard resistance training with intensities over 70%. There is also no need for fancy equipment with that style of training.

THE UGLY

The biggest mistake I see when people don’t use auto-calibrating BFR devices is applying WAY TOO MUCH PRESSURE. You should use a pressure between 100 mmHg and resting brachial systolic blood pressure, which typically falls between 60-80% of LOP (limb occlusion pressure). If you have an auto-calibrating device, use pressures between 40-80% LOP. Personally, I never go above 60% LOP because higher pressures are more uncomfortable with no added benefit. If BFR hurts, you are doing something wrong. The sensation should feel like a muscular burn, similar to lifting weights close to failure. If the limb turns white, that’s a sign you have completely occluded blood flow, which is unnecessary. This is not a tourniquet, and you are not performing surgery, so there is no need for that.

Now, let’s talk about another factor that makes BFR training way more uncomfortable than it needs to be. The most common set and rep scheme for BFR is 30 repetitions in the first set, followed by 15 repetitions in each of the three consecutive sets. This is called a cluster set, and the rest period between these mini-sets is usually 30 seconds. In rehab, we typically do several of these cluster sets, with a 1-minute rest interval between them. During this 1-minute rest, the cuff is often left inflated, based on the false belief that this increases growth and strength gains due to metabolite accumulation. However, this is not a fact—the results are the same whether you deflate the cuff or leave it inflated. But deflating the cuff makes the experience more comfortable for the patient, improving compliance. Again, BFR should not hurt.

The one rule that you must not break is the correct pressure. Never fully occlude your patient. Otherwise, the consequences may be severe. Like in the spaghetti westerns, Clint Eastwood is going to come and shoot you. Because in this scenario, you are the antagonist.

 The main takeaway that I think is important is this. When I was talking to Ben, I asked him what he thought about BFR and he replied: “I don’t really think about it much”. And after some reflection that is a very profound statement and, probably the best way to wrap this up. If you are not working with a specific subset of the population (athletes after surgery), my advice to you is what Ben said. Don’t think about it. For the majority of your patients, it doesn’t matter. But that does not mean it doesn’t make for one hell of an anti-hero. BFR will probably intrigue the imagination of young physios for a while to come. 

Now, in the words of Tony Soprano:

“Fuggedaboutit.”

Sources

Chulvi-Medrano, I., Cortell-Tormo, J. M., Hernández-Sánchez, S., Picón-Martínez, M., & Rolnick, N. (2023). Blood flow restriction training in clinical rehabilitation: Occlusion pressure methods relative to the limb occlusion pressure. Journal of Sport Rehabilitation, 32(4), 361-368.

Wang, J., Liu, H., & Jiang, L. (2023). The effects of blood flow restriction training on PAP and lower limb muscle activation: a meta-analysis. Frontiers in Physiology, 14, 1243302.

Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., ... & Loenneke, J. (2019). Blood flow restriction exercise: considerations of methodology, application, and safety. Frontiers in physiology, 10, 533.

Sinclair, P., Kadhum, M., & Paton, B. (2022). Tolerance to intermittent vs. continuous blood flow restriction training: a meta-analysis. International journal of sports medicine, 43(01), 3-10.

Gao, Z., Li, Y., Zhang, J., Li, L., Wang, T., Wang, X., & Wang, H. (2025). Effects of aerobic training with blood flow restriction on aerobic capacity, muscle strength, and hypertrophy in young adults: a systematic review and meta-analysis. Frontiers in Physiology, 15, 1506386.