Blood flow restriction training is gaining popularity, and new research continues to show benefits and potential new uses.
We review a brand-new randomized trial examining a brief BFR session before exercise in patients with knee pain. The question: Can a quick change before you even start your main work meaningfully alter pain during the session that follows? The results nudged us to rethink how we open visits for athletes with anterior knee pain. Want the exact setup—and when it’s worth trying?
Check out this week’s podcast for details on how we’re applying this paper to what we do at Champion.
#AskMikeReinold Episode 376: Using Blood Flow Restriction to Neuromodulate Pain During Exercise
Listen and Subscribe to Podcast
You can use the player below to listen to the podcast or subscribe. If you are enjoying the podcast, PLEASE click here to leave us a review in iTunes, it will really mean a lot to us. THANKS!
Show Notes
• Learn Everything You Need to About BFR in My Online Course
• My Favorite BFR Cuffs and Tools
Transcript
Mike Reinold:
Welcome back, everybody, to the latest episode of the Mike Reinold Show. We’re here at Champion PT and Performance up in Boston, answering your questions. Actually, we’re not answering your question this episode, sorry. We are doing another journal article review, which we’ve been getting good feedback, but let us know. I still want to hear. If you listened to the episode a couple of weeks ago, which I hope you did, we talked about some practice guidelines for patellofemoral. You may have got a sneak peek from Len Mac PT about this week’s episode, but we are talking about a recent BFR article that came out that talks about using BFR as an adjunct to therapy to neuromodulate pain beforehand. So, we got Lenny Macrina, Dan Pope, Kevin Coughlin, Brendan Gates here reviewing, and Anthony Videtto taking the lead this week. What do you got, Anthony?
Anthony Videtto:
Yeah, guys. So a cool article here. Title was, “Low-Load Blood Flow Restriction Exercise Training Prior to a Physiotherapy is Associated With Reductions in Anterior Knee Pain During Functional Tasks: A Blinded Randomized Sham-Controlled Crossover Trial.” This was written by Ogaili et al and Whiteley. This was published in 2025. So, the title gives away what’s going on here, but essentially, we’re looking at the use of BFR in patients with anterior knee pain and seeing if it can reduce that knee pain in functional tasks after the application of it.
So, crossover randomized control trial, and these participants were blinded and the assessors doing the study were also blinded. So, who was participating in the study? These participants were older than 18 years old, and they had to have a non-traumatic history of anterior knee pain that was greater than three out of 10 on the numeric pain rating scale during at least two of the three following functional tasks. There was a single-leg shallow squat and a single-leg deep squat. And then they also included a single-leg step down.
Patients were excluded from the study if they had a BMI greater than 28, if they had any systemic pathologies, any pain referred from the spine, any previous neurological conditions, received any injections in the past three months, had any infections, or underwent any previous BFR treatment, so they could not have used BFR before this study. Then they took these two groups of people, randomly assigned them to a BFR group, and this BFR group received 80% occlusion pressure, and then they assigned people to a different group, and this was the sham group, and they received about 10% occlusion. Now, each person that was participating in the study was told that they would be receiving 2% occlusion to see how it would affect their knee pain with low level exercise.
The other cool part about this study was that each participant was included in each group. So after the first visit, if one person was in the sham group, they came back 72 hours later, and they participated in the group with 80% occlusion. Each person in the study participated in both groups, which I thought was pretty cool. What were they looking for with this study? Well, like I said, they used the three functional assessments, so the single-leg squat to two depths and then the single-leg step down. And then they also used a mechanical pressure algometer.
I don’t know if I’ve used that before. I don’t know if any of you guys have, but it’s essentially… It applies pressure to the skin at increasing rates, and they can see if it’s causing pain in a specific spot. So, in this study, they used it in the knee at the most painful site, and then they also used it in the upper third of the anterior tib. And then they also used it in the lateral epicondyle at the extensor carpi radialis. And then they also included a couple secondary measures, sorry, secondary outcome measures, that included patient perceived pain changes and then RPE ratings for the session to see how intense it was. They performed these outcome measures at the very beginning of the session when they were doing the functional tasks, and then they performed the BFR session, and they performed them right after that.
And then right after they had the BFR session, they went through a typical PT session that included core training, lower body exercises, and all that stuff. Then they performed the functional tasks and the algometer right after that as well. During the BFR application, both groups performed two-to-two knee extensions, so that meant two seconds for concentric and then two seconds for eccentric, and they used a set of 30 followed by three sets of 15 with a 30-second break in between, and that’s kind of the standard protocol that we’ve all seen in the literature before. And then during this exercise, the patients were instructed to work up to a four out of 10 pain, but not go past that. So that was kind of the gist of the study. They had the functional exercises, performed the BFR, and then performed the traditional PT session afterwards, and they looked at the results to see how the 80% stacked up against the 10% BFR.
And what they found was that there was a significant reduction in pain in the BFR group compared to the sham group during the three functional tests immediately after the BFR intervention. And these improvements actually did persist after the 45-minute physiotherapy session as well. The participants also reported better global percentage change scores in the 80% group compared to the sham group. And then they also found that the 80% BFR group increased pain pressure thresholds locally at the knee, but this did not persist throughout the rest of the body to more distant sites like the anterior tib or the elbow, so that was really just a local effect there. So, that summarizes what they found with the study, and I’m interested to hear what you guys are thinking about the study as well.
Mike Reinold:
Great job, Anthony. Yeah, cool article, right? I’m trying to think… I know that we know BFR has this analgesic effect to an extent. I’m trying to think if there was a study conducted quite as well as this one. I think this one has some really good take-homes that I think… What an easy way to just add an adjunct to a treatment plan for something like patellofemoral syndrome, or just anterior knee pain, or maybe tendinopathy, or something like that. What a cool way to do it. So I thought this was really cool, but what do you guys think? Who wants to jump in? Anyone want to start? Dan?
Dan Pope:
I think it’s great. For a lot of the patients I work with, they want to get back to higher level stuff. A lot of athletes, same thing. If we can get their pain levels down a little bit prior to training or rehab, I think that’s great. Second part I think is a little tough is a practicality. If you only have 30 minutes of work with a person, sometimes it’s tough to throw those things on before we start the whole rehab program. And the other thing I would like to see in the future… We have a lot of these studies now where they try isometrics, or they try isotonics prior to exercise, and most of these studies are in tendinopathies, but now you’re starting to see patellofemoral pain. I’m curious if it’s the same across all different pathologies. You see this in the gym all the time. When people hurt, they just warm up for longer, and then they feel better, and they can train.
There’s another study from Li et al. I was looking it up while Anthony was going through this, but in 2020, and they had runners’ anterior knee pain, and they did stretching as well as foam rolling. And in the group that combined those two, they had a 90% reduction in symptoms. So I don’t know what’s best, but it seems like we have options. So a patient comes in, and their knees are killing. We can probably make them feel quite a bit better prior to them going out in the gym and trying a bunch of stuff, and that will maybe improve our outcomes. So I just thought that was kind of cool. Another neat option that we can try.
Mike Reinold:
And an option that you could argue has a potential benefit, too. Not that foam rolling doesn’t, but the transient effect of something like that versus a strengthening exercise with BFR going into it, which is cool. But, Dan, to your point, even just PT. Man, BFR cuffs and stuff, the ones from Suji, SmartCuffs, AirBands have evolved, like gosh, those are so easy now for people to use on their own. That’s almost something you can say like, “Hey, you don’t have my manual therapy or whatever pre all your training sessions, but you can do this quick little BFR thing before you hit the gym, and that might be pretty cool.” So I thought of it more than just rehab, but more independent. They can do that too nowadays. But, Kev, what do you got?
Kevin Coughlin:
Yeah, I was impressed overall with the study design and how the authors really tried to explain in detail everything they did up to getting the proper power to list the outcomes, and then just a very detailed protocol of what they did, so it makes it easy for us to replicate. They even had a list of the diagnoses that were included, which are things we see all the time. So I thought that was really good as well. And I like what Dan said. It is interesting. Some warm up effect for sure. But I thought what was good about this is, with the crossover approach, these patients had a clear benefit training at that 80% occlusion versus the 10% occlusion. So there is something about the intensity of the warm up that seems to be helpful in reducing pain. So I thought that was pretty good too. Overall, it’s not something I tend to do.
I tend to use BFR in phases when they’re not tolerating regular loading much, but maybe using it as a warm up for a certain patient could definitely be helpful. And then you go ahead, and you can get the actual training effect that you’re after sometimes, which is getting heavy loads. Because I think one of the included things was like patellar tendinopathy, and we know we need to load heavy to induce enough strain on the tendon to help it remodel. So I think that’s pretty cool. And then when they did their training session, they followed the pain monitoring model, which was also pretty nice. So I think the authors did a really good job. It was a super thorough paper, and they did a lot that we can just apply right away.
Mike Reinold:
Yeah, I completely agree. And the thing that jumped out at me, just while you were talking… I was thinking that it’s just another reason why you have to follow limb occlusion pressure. And Kev was talking about, “Man, I’ve always done this as a big application during an exercise session, but what about as a quick adjunct?” We can do that nowadays because the technology of the BFR cuffs has improved, and they have auto regulation that is so quick and easy now, and built into some of these bands that we mentioned earlier, that it’s kind of a no-brainer. So I still think, if you want to be as precise and consistent as you can, you got to find limb occlusion pressure and prescribe the dose you want. This study showed 80% is what you want for the analgesic effect from this, at least.
But again, back in the day, man, remember we had the radar, not Doppler radar, the stethoscopes and stuff. You are trying to do blood flow restriction. Yeah, we’d never do that quickly, but nowadays, it’s just so much more accessible that I think there’s no reason not to. So, Gates, what do you got?
Brendan Gates:
Yeah, so I think anecdotally, we’ve all seen that there’s the analgesic component of BFR, and I think at first I was kind of just like, oh, maybe this is like the, “Oh, your back hurts, let me punch you in the arm so your back feels better, but now your arm hurts, where the cuff was just so uncomfortable, but it made the knee feel better.’” But it’s cool to see some evidence come out and say that there is some evidence to support the analgesic effect. I just wanted to share a quick story about an extreme case, I think, where this worked well for us. But when I was in my first job out of PT school, I got a person who had tried PT after her ACL reconstruction. She was a middle-aged woman. She had done PT elsewhere for about three months. She went back for her strength test, and she couldn’t even push into the dynamometer.
She was limited by anterior knee pain and weakness. She went through all of her nerve testing, EMG stuff, and her femoral nerve was fine. It was just so weak and painful that she couldn’t do anything without pain. So walking hurt, stairs hurt, all that stuff. When she came in, she’s kind of looking for a second opinion. I was probably three or four months out of PT school. I just finished up my rotation here at Champion, and I was like, “Let me just throw the BFR cuffs on her and see what happens, and maybe it’ll work.” And it was almost like magic to her. She was like, “Oh my gosh, my knee doesn’t hurt. I can do this step up.” And so I think again, it’s not a magic bullet. It’s a nice adjunct, but in this case, it was the only thing that let us do exercise with it without pain.
And so we use a ton in our sessions for months, and she ended up having a pretty good outcome despite where she started when she came in. So I’ve always kind of kept that experience as like, “Okay, if someone’s really irritable, the BFR cuff seems to be a nice entry point to exercise.” So it’s cool to see that there’s some evidence on it now.
Mike Reinold:
I like that. I like your rationale, too. We might as well dry needle them, too. Let’s just make them hurt, make everything uncomfortable, so that way, they forget about their knee.
Brendan Gates:
Exactly.
Mike Reinold:
Shockwave, everything. But what do you got, Anthony?
Anthony Videtto:
Yeah, so after reading it, noticing just how applicable this could be in the clinic is awesome. So we have BFR cuffs. A lot of clinics have BFR cuffs now. They don’t take very long to set up and get the patient going with, and then all they did was four sets of knee extensions and then their pain got better. If someone comes to our clinic in pain and we can provide them with something that can reduce their pain so drastically and so quickly, that just allows for so much buy-in right off the bat, too. And then they get back to training, they feel better, and then they’re off and running. So, I think this is such an applicable study to any clinic out there, and it really, in my opinion, doesn’t take very long to get someone set up on the BFR, perform some knee extensions, and then they can get them going with the rest of the session. So I think that was awesome to see with just one exercise. You can really provide a ton of benefit.
Mike Reinold:
Yeah. And if you do that on your first session with the beginning of treatment, and they have that quick noticeable reduction, you just won that patient over there. The buy-in for the rest of your plan is great, but…
Anthony Videtto:
Yeah, there really aren’t many options that we have that provide that immediate pain relief. So I think that’s just a really cool tool that we could use for sure.
Mike Reinold:
Yeah. Dan?
Dan Pope:
I was going to say this is just maybe the strength coach in me, you know what I mean, from a program perspective. But if I was writing a program to try to increase someone’s strength, the last thing I would do is BFR first. You know what I mean? So I think sometimes as a physical therapist, we’d look at this paper and like, “This is amazing.” I think it is. But the other parts, like if you have a later stage ACL and you’re really trying to build power and strength and that type of thing, and you’re doing a whole bunch of BFR beforehand, the ordering of the workout might be a little bit off. So I don’t know. That was my only thought there.
Mike Reinold:
No, you know what? It makes sense. I think it goes back to the basics. Why would you do this, Dan? You would do this because you have acute pain that is limiting your ability to exercise. If you don’t have that, don’t do this. I think what a great way to wrap up the episode too, Dan, because it was… That really is a really good point here, you do see people take things too far, but simple, effective adjunct to knee pain, especially when you’re limited, start this first. It’s another way of using BFR. What a good win-win. Awesome. Great stuff.
Good job, Anthony. Good job on the review there. If you’re liking these, again, let us know. Let us know in the reviews, send us DMs on social media, reply to our comments, or whatever. Let us know if you’re enjoying this because we care about what the audience wants us to do, right? We’re here for you, answering your questions, helping you get better at your job. So let us know. Head to mikereinhold.com, click on that podcast link if you want to ask us a question. And please, please subscribe so you get more updates in the future. Thanks so much.
