Blood flow restriction training has been such a great addition to what we do in physical therapy.
Just like everything else, the more we use it, the more we refine what we are doing.
Here are our latest thoughts on how we are using BFR at Champion.
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#AskMikeReinold Episode 347: BFR Update for 2025: How We’re Using Blood Flow Restriction Training
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Show Notes
• My online course teaching you how to use BFR
• The Best Blood Flow Restriction Bands
• Ultimate Guide to Blood Flow Restriction Training
Transcript
Devin Limerick:
Christine from the UK says, “I have been using BFR for a few years now and always wondering if I’m getting the most out of it. How do you use BFR at Champion, and for what type of patient and how do you use it?”
Mike Reinold:
I think that’s a good question, and I think obviously we talk about blood flow restriction training a decent amount here on the podcast and on the website stuff. But I actually think it’s good to just have this periodic conversation because I do think how we use it is evolving. We’re changing. How we use it, when we use it, why we use it. There’s lots of stuff coming out. Even research coming out saying the 30/15, 15/15 may not be the best. Ischemic preconditioning is shown to have some potential benefits, that I think were a little bit more theorized in the past, that are now starting to come out in some of the research.
So I think there’s some neat new stuff or maybe we’re just, I don’t know, we’re just maturing with it. Is that a good way to say it? We’re starting to figure out… Any time you get a shiny new toy, I think we overuse it and then we kind of find out where it works best for us. And it might work a little bit different for you, but I don’t know. Len, I mean, you do a ton of our lower extremity and our post-ops and stuff like that. I don’t know. Why don’t we start with you? And just how are you using BFR nowadays, just in the clinic?
Lenny Macrina:
Right. I use BFR. I see a bunch of ACL patients and that’s kind of my primary, well actually ACL and UCL. I see a lot of ACLs and I use it early on. I tend to wait two weeks after the surgery, let the wounds heal, let the knee calm down. Some people use it earlier than that. I just don’t, just because that’s me. I think there might be some papers that say to wait two weeks, so I just kind of wait. Talk to Dan Lorenz, who you and Dan have a BFR course, that’ll be in the show notes. Just kidding.
Mike Reinold:
I mean, why not?
Lenny Macrina:
Right. And so I kind of use the two-week window, kind of do stim early on, and then shift to BFR or biofeedback as well. And so BFR for two weeks while they’re doing the leg raises, while they’re doing some basic weight-bearing type stuff. In my head, BFR is used if somebody can’t lift heavy weights. It replaces that ability so if they can do a two-pound ankle weight while they’re doing stuff, I use BFR. Once they can get out in the gym, say four to six weeks out of surgery, BFR is still used, but kind of used less, and now they’re trying to lift heavier weights, kettlebells, things of that nature.
And then from there on, they basically get it towards the end of a session for me. I want the weight training to be the primary source of the strengthening, and then at the end, I may lock in some knee extensions. I talked to Scott Morrison out in, I think Oregon, speaking of Oregon, who used it a lot in supine with a flexed knee and working knee extension that way, instead of just a traditional seated 90/90 knee extension.
That’s how I finish a lot of my programs, just a big burn to the quad, isolate the quad as much as possible in an elongated position. And I do that for the duration. Otherwise, BFR is a lot at the beginning and then only at the end of a session, otherwise, they’re just lifting heavy, heavy weights. Maybe I’ll put them on if they’re going to do bike sprints or something like that to really freak them out and really get that ultra training to the quad and overall to the lower body because there is a systemic effect. It’s not just going to the quad. There is a systemic effect that goes on when you have the cuffs on, so I’m trying to capitalize on that when they’re doing certain stuff.
But otherwise, it’s kind of utilized as I progress in ACL. It’s a little less, but I still use it a bunch. And like you said at the beginning, it’s evolving. How I’ve used it a year or two ago is different than how I use it now, and it’ll continue to evolve in my head, so I’ll have updates as I shift my thoughts.
Mike Reinold:
We’ll do another episode in six months…
Lenny Macrina:
Right, exactly, almost.
Mike Reinold:
Which we should. I mean, I think that’s what you want to do. But I mean, I think you’re right. What I really like about how Lenny’s talked about shifting right here is I think when we first started thinking about BFR, we’re like, “Oh, we’ll put it on during the whole rehab session and do a bunch of stuff and we’ll do it on a bunch of exercises.” And I think what we’re finding, and I think this is one big tip with what we’re doing different here, is that this does not replace load. If you have the ability to try to load somebody, load them. This is an adjunct when they can’t load, and I think it’s a good way of doing it though. And that doesn’t mean… So Lenny’s talking about three, four weeks after an ACL, he does both.
Because you still want to try to load without the BFR, but then still make sure that you’re using the BFR. Again, you get the effects of BFR, you get to work them at a fatigue state towards the end and I think that’s a little bit of the benefit. I think that’s really neat.
Dan, that’s how Lenny’s evolved a little bit with his post-ops. You have a lot of people that aren’t necessarily just post-op, right? You have people that are just an injury or in pain or something like that. People getting back to their sports. I know there are people that can deadlift with full load right now that will say, “Should I BFR?” And you’re like, “Well, we’d have to decrease the load to do that.” So it’s interesting. So how have you evolved your why and how you’re using BFR in that setting?
Dan Pope:
Yeah, I think just like Lenny said, we’re largely trying to load folks if they’re able to tolerate it. You will find some studies that blow my mind where they will do BFR training versus regular loading and one rep max test, like their squat afterward, and have a very similar improvement in strength, which is kind of crazy, which doesn’t make any sense to me. I would expect that heavier loading is going to be better for building strength. I’d also expect it’s better for power. So if you’re looking for strength and power, then I think you probably want to do a little bit more of the heavier loading.
What I find a lot, and we’re physical therapists, so I always say we’re injury magnets. We see folks that are having a hard time tolerating their activities because of injuries. And you see a lot of athletes, let’s say you have a powerlifter and they like heavy deadlifting like you said, and they just kind of run this yo-yo effect of like, all right, their back was hurting. They get a little bit better, they start loading up again, they’re having some success for a little bit, and they hurt themselves again and they have to go back to rehab. They de-condition, they ramp back up again. They’re making some progress and they get hurt again and they just go back and forth with this.
And we also know that volume is a big factor in building muscle mass and strength, two of which are really important for powerlifters. So one of the things I’ll use BFR for is that. It seems like the athlete’s not tolerating the training program well, that’s my thought. It’s probably too much of something. So one of the things that we can continue to do is we can add some additional volume in the form of BFR training when the loads are a lot lighter. And this is a personal opinion, but I think a lot of powerlifters and people in the gym in general, although this is not parsed out in studies and research, but I think they get into hot water because they do too heavy weights, too much, too frequently. I think it’s just the heavy load that ends up hurting people. Unpopular opinion, I’m sure, but I see this time and time again. It seems like when folks go a little too heavy for too long, that’s when they get into trouble.
So I will supplement people’s program with some BFR. The other place I see it a lot is older folks who have arthritis where if you have a younger individual with low back pain, my expectation is mostly you’re going to get back to feeling pretty good and we’re going to be able to load you heavy. If I have someone that has bad knee arthritis and it’s been hurting for the past 20 years and every doctor tells them, “Hey, you need a knee replacement,” I’m not expecting this person to get back to the point where they can back squat 500 pounds. It’s probably not going to happen.
So I will use BFR as a main treatment option in order to help to build their squat or to help to enhance their strength, whatever joint needs it. The quad is a big one for knee arthritis. Those folks tend not to be able to tolerate a whole lot of knee intensive exercises. I’ll maybe do the majority of their knee intensive exercise with BFR and maybe some sort of squat modification. So that’s kind of how I’ll use it in those folks. But largely I agree with Lenny. It’s the same idea, just to a different population, right?
Mike Reinold:
Yeah, and I’ll add a couple of points on recovery that I think is becoming a little bit more popular now too with recovery. So there’s some research coming out on ischemic preconditioning and using it in that fashion without exercise. And just having it kind of settled, it will actually help people with their recovery.
I will say we started using that more in our healthy pro athletes and they feel great and they love it. Now that’s the Journal of Anecdotal Medicine. I don’t know that, but again, it’s something that I’m excited about, that we can put it on our legs and do it as a refresh after a game. And I think that that’s a neat evolving progression. I want to see more research on that because it’s starting to come out and you’re starting to see something. I just read something and sent it to Dan Lorenz and said, “Oh, this is great,” on ischemic preconditioning, because I know we’ve been hoping that this was going to produce more and more research over the years and it’s getting there. So I do like that for recovery. But Jonah, what do you think?
Jonah Mondloch:
Similar to Dan’s first point, I think that sometimes when you’re working with, say, non-strength athletes, so baseball players, basketball players, especially older ones in college or professional athletes, where they’ve been working hard in the gym for 5, 10 years, and they might be people who quite frankly don’t enjoy the gym at all. In a typical training session, they likely have some speed power type work. They have some heavy lifting that’s meant more for the neural adaptations. Then they have some accessory work at the end that’s meant more for the muscular adaptations. I think that can be a great time to throw some BFR on where they’re capable of… Say they’re doing some step-ups or RFE split squats for higher reps and they’re capable of doing it with 80 pounds, but they just don’t really want to have to go pick up those heavy weights again.
I think it could be a great time to throw on some BFR cuffs, let them get a really good pump, have a different feeling of working hard, because it’s just not always fun for a non-strength based athlete to have to go pick up the heavy weights and grind in the gym. So I think it can just be a great option to throw in for something like that.
Mike Reinold:
I like that. I think that’s a really good perspective too. You’ve witnessed that in the gym with a lot of our clients, even our adult clients. That’s a pretty neat way of doing it. But again, I’ll just reiterate that Jonah’s not saying do your whole workout with blood flow, right? It’s an adjunct with that. So great stuff, Jonah. I like that.
I’ll add just because I have spoken about this, and I don’t think everybody agrees with me here, but I’ll add this: I’m still not using it in our baseball players. I still recommend that you don’t use it in your baseball players. We see way too many neurological issues and TOS type issues that I do not want to compress the brachial plexus or the brachium up there, and I still don’t see the need of it. I mean, I see baseball players after a game wanting to do BFR, and they’re the ones that maybe they can’t quite feel their fingertips.
They’re walking guys, two guys an inning, and have terrible command, and then they want to recover with BFR after. And during it, they’re like, “Oh yeah, no, this is great. I feel it in my hand. My whole hand’s tingling.” And you’re like, “That’s not good. That’s just not what we need.”
Plus the other fact that I think is really important with me on this is… Why are we using BFR in our overhead athletes? It’s for strength gains, right? I can honestly say, I keep saying this over and over again, I do not have trouble getting their forearm strong, do you? Right? I don’t think you do either. So don’t just do BFR because you think you’re supposed to do it. You use BFR because you have trouble getting strength after an ACL or something like that, or they’re unable to tolerate load.
So I continue to see not only not a reason in baseball players, but I actually see contraindications. Now that being said, Mike Scaduto, Mike, you’ve done some really great stuff on integrating BFR in our post-ops, like our Tommy Johns in our baseball players. Why don’t you speak on that a little bit here because I think it’s been a really great addition to what we’re doing in our rehab protocols for our overhead athletes after surgery.
Mike Scaduto:
Yeah, sure. I don’t want to speak for you, Mike, but just to clarify, I think you meant you don’t like to use BFR in the upper extremity for baseball players.
Mike Reinold:
Yes. Thank you for that. I got excited, yes. So we use BFR in the lower extremity all the time in baseball players, but we don’t use it on the arm in our baseball players. Thank you, Mike.
Mike Scaduto:
Yeah, for sure. So for shoulder and for elbow surgeries, when they’re in that kind of acute post-op phase with a UCL, they’re probably in a brace anywhere from four to six weeks on their arm. Obviously, we can load the contralateral and non-surgical arm, but there are some limitations as to how much weight they can hold if they’re having Tommy John surgery. They’re probably a high school or college professional-level athlete. So one of their primary goals after surgery is, when can they get back in the gym and start training? So we’ve started implementing BFR around that two week post-op mark for their lower body, as a way to at least maintain some muscle mass or hypertrophy. So when they get back into the gym, we’re not also trying to really build up their lower body strength or hypertrophy from scratch. We can try to maintain some of that while there are some limitations.
I think psychologically it also gives them the feeling that they’re working really hard and they enjoy that part of the Tommy John rehab. I think early on with UCL rehab, it’s honestly kind of boring for the client. We’re doing a lot of elbow range of motion, isometrics for their forearm and for their shoulder. If we can throw some lower body exercise where they feel like they’re getting a really good workout in and working towards their goal of getting back into the gym, I think it’s psychologically beneficial for them. So we’ll definitely use it. We’ll just do basic exercises, split squats, step-ups, lateral lunges, making sure that we’re being safe about them as a fall risk, not falling onto their surgical arm, but it seems to be a good tool for all those reasons.
Mike Reinold:
Mike, what do you like to do for the set rep schemes for somebody like two, three weeks out? That was four lower extremity exercises I think that you kind of said. What do you do for set rep schemes? Do you do 30/30/30 or 30/15/15/15, or do you just do it as a supplement to what they’re doing?
Mike Scaduto:
Yeah, I’ll just do it as a supplement. So I think for a more compound movement, like a split squat, I’m probably not going to do 30/15/15/15. I think that might be pretty brutal for them. So it’ll probably start in the two to three sets of 10 to 12 reps for those exercises, and then we will add some weight on their non-surgical arm if they can hold a dumbbell and keep that same set and rep scheme. I’ll leave it at that.
Mike Reinold:
I mean, I like that though because the total rep volume and all those exercises are still pretty high, but again, you’re getting movement variability. You’re not like we’re just going to do mini squats for 90 reps. I don’t think that serves a lot of the purpose of why you’re doing it. So I think it’s awesome. Obviously the systemic effects and the lower body effects on that, I think is great. But I got to admit, I think it’s the response of the athletes in that phase on how much they’ve enjoyed it, that kind of got me the most excited about it, like seeing Mike start to implement it in these athletes, it was that they loved it. And I think to his point, it’s a little bit of psychological that like, “Okay, I’m not just a slug laying on a table doing range of motion. I’m actually starting to get working out again.”
And then when they transitioned into the gym right around that time, their comfort level’s better. They just feel better about the movement. It’s a win-win-win. So I do think that’s a really neat way we’ve been evolving our BFR champion there too, is you have an upper extremity person, let’s put it on the legs and just do a lower body circuit at the end, for so many reasons.
So awesome. Great question, Christine. I hope that helps you as you’re getting started with that stuff. I mean, we’re going to continue to evolve our thoughts as we learn more, and hopefully, you will too. But if you enjoyed that, head to mikereinold.com, click on that podcast link, and fill out our form. You can ask us questions that we will answer on a future episode, and please rate, subscribe, Apple Podcasts, Spotify, and we’ll see you on the next episode. Thank you.
