Episode 14: Blood Flow Restriction (BFR) Training with Dr. Kyle Coffey

Episode 14: Blood Flow Restriction (BFR) Training with Dr. Kyle Coffey

April 12, 2022


All right, everybody. Welcome back to another episode of the barbell therapy podcast. I’m your host, Dr. Brett Scott. And with me here today is Dr. Kyle coffee. Dr. Kyle coffee is someone pretty special to me who has been one of the main people in forcing me off the ledge into the world cash based physical therapy. And as he said, I really took the bull by the horns here. So I’m very thankful for him. He’s was also a professor at UMass Lowell where I was. And I’ve been fortunate enough to do some learning from him about blood flow restriction training. And he’s part of the modern manual therapy, mentorship, in course offerings that we have there with our new incoming up to four, modern barbell therapy. So, Kyle, I’ll let you introduce yourself a little bit. What should you do? And you know, kind of what got you into the world of BFR?

Yeah, so my name is Kyle Coffey. I’m a physical therapist by trade. I always start with that even though I’m in higher education. And I still think like a PT act like a PT. I was treating patients for a number of years still treat patients but treating full time when I got an opportunity to go and start teaching full time at the University of Massachusetts all and been doing that for almost nine years now. I do have my own practice in Southern New Hampshire, just me solo cash based. Definitely don’t see as many patients as I as I would like to during the academic year but definitely upticks in the summer. So yeah. BFR BFR starts with me. When I was in undergrad, in college, I was playing summer soccer with a bunch of friends. We had a team and we actually say what BFR was, I don’t even know if I said blood flow restriction? Oh, yeah. This is where I’m kinda like, just speaking with acronyms. Yeah. BFR is blood flow restriction. Let’s start there. I got introduced the blood flow restriction. In college, I was a goalkeeper on a soccer team with friends. And I took a weird shot and shattered a couple of joints and my fingers had to have surgery on it. And I’m sitting at home trying to figure out how I can still work out and still train when I couldn’t do the other thing that I really liked, which is cycling, I couldn’t hold on to my handlebars. And do that safely. So I was watching the Tour de France, like any good cyclist does in the summer, and I started to do some research about literally googling ways to have high intensity exercise when you’re hurt, and blood flow restriction started coming up. And so I started diving into it deeper, and it kind of just jumped off from there. I mean, historically, blood flow restriction was used by power lifters and weight lifters, they weren’t doing anything in terms of the practical application in the individual application that we’re we do now. They were simply taking seat belts and tubing and wrap it around their arms and legs. And, and you know, as primitive as that might be, they knew they were there was a benefit to it, they would they would get a muscle pump, they would get, you know, a lot of fatigue and soreness from their exercise, but then they would not have that same high level of muscle soreness that they might have if they were lifting heavy. So I just kind of really dove in to it there. And it took off as I went into PT school. And I started to realize that, you know, the majority of the patients that we see at least in an outpatient, general population setting, they’re not able to lift at the levels, the intensities we need them to be at in order to gain muscle mass. And we were kind of stuck in this limbo of like, well, what do we do? You know, do we continue to do the same exercises and try to increase the number of reps and increase volume that way which, you know, research has shown that you can gain muscle mass that way it’s just going to take a heck of a lot longer or is there or is there a better way and so I started really just applying it on myself and figuring out how we could use it better. And then with the research that’s out there I developed a continuing ed course on how to you know practically apply it because when we’re talking about patients, we can’t do it like the power lifters do and just take seatbelts and tubing and wrap it around our limbs and hope for the best.

Yeah, absolutely. There’s a lot of us to goes back to like they used to do and I think sometimes it’s still gets confused with occlusion training, which is like an ancient Chinese medicine or something like that, where they would just try to occlude an artery and train that way, which is not the best idea for anyone trying to do that. But do you want to talk about that at all and kind of the history of BFR as a modality through its evolution here?

Yeah, I think that’s a good distinction to make, it is not blood flow occlusion, it is blood flow restriction, we are not fully occluding arterial inflow to an area, what blood flow restriction is, is we are trying to reduce venous return. So we’re trying to get venous pooling in the limbs in the exercising limbs. We know from a scientific standpoint, that venous pooling, increases cell signaling for a whole host of things that we want to happen with exercise, namely, muscle hypertrophy. But we’re not occluding it right? We can occlude blood flow to an area at rest. And we do that all the time in surgeries, we can’t do that with exercise because they the muscles require the nutrients coming in, and at least some removal of it during exercise. And what we know with blood flow restriction, when we do that, we actually create an anabolic environment within the muscle. In other words, we create an environment where the body is actively trying to increase muscle mass, all the good things we want with training, the kicker is, is we don’t have to train at the high levels as we normally would, right, we don’t have to get over or under a bar and lift heavy weights, which is great, we want to get there eventually. But as I alluded to earlier, especially post injury, post surgery, a lot of patients can’t lift heavy and so we this is a great opportunity for us to create that anabolic environment, still perform exercises at a lower intensity, get the benefits of higher intensity exercise, and then eventually transition out of BFR. I think that’s a really important statement too, is like BFR is not going to be a replacement for traditional high intensity strength training, I mean, get over get under a bar lift, heavy lift off and sprinkle in some cardio, you’re gonna have a healthy life, we eventually need to get people there. And so I think that’s where BFR is, is really, I hate using this phrase, but I’ll use it because I can’t think of anything else in the game changing, it gives us a really important tool for us to use to help people get to that point of, you know, getting back to their sport or lifting heavy and lifting often.

Yeah, absolutely. And I think there are some misunderstandings of it. And so, you know, I am a provider, too, that uses blood flow restriction training quite frequently. And I have a lot of patients that lift in clients that lift to that want to learn more about or have told me about their own self experimentation with it, and kind of what would you say the biggest things are that are misunderstood about BFR, and its application or use?

I think first and foremost, BFR alone is not necessarily going to increase your strength. Yes, with BFR, you’re going to get more muscle mass and the more muscle mass you have, the more force generation capability you have. But what we know is strength is also the central nervous system and how that controls our muscles. And the only way we can actually truly get stronger is by lifting heavy lifting often. So when we talk about BFR increasing strength, yes and no right in increases muscle mass. But to get really strong, we have to eventually transition away from VFR and get to that traditional high intensity strength training. With that BFR only really tackles muscle mass. It doesn’t affect neuromuscular application. So in the rehab world, you know, just I’ll give a a basic case study but you post op ACL post op meniscectomy and we’re doing the the the exercises that you know are allowed post surgery so that we’re not causing any damage to any of the repair. Yes, building muscles important there but we also have to get better control of the muscles. So let’s just hone in on the quads here and say quad sets are great and short. Our quads are great and all these things are great early on. BFR will help with increasing the muscle mass but it doesn’t do anything to help the coordination synchronization of Have those muscle fibers. So, you know, adding in neuromuscular electrical stimulation and MES is really where a lot of people miss the boat on that. Right? They forget that that’s not covering, covering that. And then I guess the other thing with BFR, and I’ve mentioned it already is, it’s not the be all end all, eventually, we have to transition away from it. What’s interesting is there’s there’s some research out there of athletes, higher level Gen pop clients, using BFR. As almost like a finisher, there was a study done that was like, if you’re going to do some power based training, high intensity training, what happens if you do a short session of BFR, directly after that training, and what was found was it doesn’t, there’s nothing necessarily detrimental that occurs. When you do it that way, however, you can have power output decreases for up to 48 hours afterward. So from a training standpoint, it’s like it has its place in, in just general training, not just rehab, but we have to implement it correctly. If that makes sense. Right? We have to thoughtfully put it where we want the most benefit.

Yeah, and I can add to that, too, from my own personal experience there is I actually got into BFR. I discovered it in college as well, but it was through bodybuilding. A couple of bodybuilders had started using it just for hypertrophy purposes. And you could get a ton of load and they’d get these huge pumps. And you know, they thought they would see benefit from it, which the data shows that you will get hypertrophy from it. And body builders don’t necessarily care about strength. So I was on the bodybuilding program A while ago, and I think I had to do like eight sets of 15 with BFR for like curls and triceps might have been a John Ross and program actually.
Yeah, sounds like a John Ross and FHT program, I think, yeah.

And I was the first couple of times I had done it, like I was super sore for days. And we’ll see that with people too is even like a little bit of work with this will make you can make you significantly surf, which isn’t a bad thing necessarily. It’s saying maybe there’s some type of biochemical thing going on where we’re creating some adaptation. But yeah, just realize that like when you’re doing this, like, you know, if you’re dealing with this for some chronic tendinitis, but you’re still going to play in your game tomorrow, it might not be the best time to use it. The day before that,
right. And exercise prescription is exercise prescription. I mean, just because you’re using something and you’re doing lower loads doesn’t mean you double down on the volume. You know, you still have to appropriately prescribe BFR, which, you know, any of the cases that we’ve seen in the research of of injuries with BFR. Which by the way, in the vast majority of situations, BFR is very safe. But the instances where we’ve seen it’s been a problem is when people over prescribe exercise under BFR. And they end up really damaging themselves, sometimes to the point of rhabdomyolysis, which is, you know, muscle muscle breaking down. That’s an extreme case, right? But but if we, if we program it correctly, it can be beneficial in rehab in training in and not just resistance trained individuals are people looking to increase muscle mass or, or what have you also in aerobic athletes. Because if we if we understand the principles of how our body uses oxygen during exercise, it needs two things, it needs the cardiovascular system to pump blood to those working muscles. So it needs a higher heart rate and it needs more blood pumped per B. But it also needs more muscle tissue that is going to need that oxygen and and that’s something called AV oh two difference. So the more muscle we have, the more oxygen will be used, the better off we are in terms of anaerobic capacity, as well. So you know, it’s got it’s got translation across many different things. However, it needs to be applied appropriately. And exercise prescription is really important.

So what would you say? Or let’s start with like, what are some of the common things? People out there that especially people that you know, train regularly, whether it be aerobic stuff running, or weightlifting? What if someone was going to start trying this? What would the common dosage and application be of rep sets how long should they do it? What intensities So it definitely is, is individualized. But like general thoughts here, we’re probably talking about in an athletic population, they don’t have any injuries, they’re not in rehab, and they’re using BFR, they’re probably using it somewhere between 15 to 20 minutes, no more, probably three to five different exercises, probably closer to three to four compound movements, multiple muscle groups, so your squat, your dead, your bench, your push ups, your your bigger compound exercises, and you’re doing probably three sets of for each exercise, here’s, here’s where it gets a little out of the ordinary in terms of how you would normally prescribe exercise, that first set, you’re going to be doing upwards of 30 repetitions. And the reason why you’re doing that is because you were intentionally trying to fatigue your body so that it will use and I’m going to generalize here, it’s going to use type two fibers more than type one fibers. Type two fibers are anaerobic power, strength fibers, again, to generalize, and our type one fibers are more of our aerobic endurance type fibers. So by putting that high number of reps in the first sets, we’re intentionally fatiguing the body, and then you back down for those subsequent sets, maybe 15, maybe 20, again, it depends on the individual. You don’t need a lot with BFR, you really don’t, if you are choosing exercises that are compound movements, multiple muscle groups, you’re gonna get fatigued pretty darn quickly. So you don’t need to overdo it at all. Now, what’s interesting, when we look at like, rehab versus training, rehab is going to use BFR, probably on a per visit basis, especially early on to build that muscle mass. Whereas in a training situation, you know, you may be using BFR, once a week, twice a week, not, not every time and you’re being strategic, a lot of people will use it on D load weeks or D load days, and they’re just taking a rest day, but they’re, you know, really passionate, really motivated, and they can’t do nothing, they have to do something. So they’ll put BFR on and maybe, you know, walk on a treadmill spin or just do really, really low load stuff. So there’s a dichotomy there, too, in terms of how it’s applied based on the setting.

Um, and would you say there is harm in trying to go outside of the norm of that prescription of doing less reps in doing like, you know, in the five to 10 rep range or anything, like, we don’t necessarily need to max out and like, yes, we can use minimal exercise and get some of these hard rests with like, some of my strength athletes and things like some people, you know, that they’re just not motivated by 30 reps, even if it’s gonna get them better. So is there any harm in doing, you know, in the BFR, can really make things tiring, harder than someone would expect. So, they might start out with their first few reps and be fine. And then by Rep 1012, like, on their first set, they’re like, Oh, crap, this is really hard. And like, I feel, you know, not pain, but discomfort of like, the pooling of the blood and the pump that people would get from it. Right? Yeah, yeah. And that’s where it’s like, you could say, start with 30 reps, start with 20 reps, whatever, monitor them, see what they’re doing. If they start really getting fatigued at 15? Well, guess what their first set is 15. And now you back it down to maybe 10, or eight for subsequent or whatever it may be. One thing I forgot to mention is, at least in my world, more in the rehab world, I’m doing BFR pretty much just bodyweight, or very minimal weight. You know, for instance, if you’re doing bicep curls with it, five pounds, we’re not. It’s very, very minimal. Now, in the training and athletic world. You have someone who has a good training history, they’ve been training for a long time, they’ve got good programming, they’ve got a great base of strength and in muscle mass and power. You can add in a percentage of their one RM. But even then, we’re talking 1015, probably no more than 20% One RM which we know without BFR would be like, what are we doing here? This is This is pointless. So there are ways to kind of modify it based on the individual’s certain circumstances. It’s just being mindful of that. And again, going back to the exercise prescription That kind of little tangent was, it’s the proper prescription here. We don’t have to overdo this. And if that cludes, as you were saying, Yeah, we wanted to do 20 reps, 30 reps on the first set, but we’re getting to 15 or 20. And we’re smoked. Well, that’s where we are. Right? And that may change exercise to exercise that might have been on a squat, but not on a push up, or what have you. And that’s okay. The key is high number of reps in the first set, and then back it down for subsequent sets.

Yeah, and there’s a lot of good things that we could go from go with from here. So I guess another thing and this is something, I actually have a interesting patient now who he just had a hip display as a surgery. And he had his labrum done before that, six months before that, and now he just tore his distal bicep again. So yeah, he’s he’s a big jujitsu guy. And he’s just like it, we’re doing well. And we’ve been doing BFR with his lower extremity. Now he can’t use his arm. And he’s like, this is he texted us the other day, and was like, This is my 911 call, like, I need a workout program. He’s just, he functions in life with exercise. So one of my first thoughts was, well, you know, and we’ve been using BFR for as low extremity anyways, but can we throw that on there? And I know, for some people, even just watching them anecdotally in the clinic, like, is there some type of cardiac response that happens as well? With the BFR? I know a lot of people like will be like, wow, like this is, you know, tiring and exerting and they’ll you’ll, I notice, and I can’t tell if it’s that they’re doing 20 to 30 reps, and they’re not used to it, even though it’s body weight, or is there an extra piece of a cardiac response that happens with BFR?

Oh, yeah, absolutely. your cardiovascular system will have to work harder, everything works harder at that those lower intensities using BFR. I mean, if you think about it, right, we are restricting venous return. And what venous return is, is the amount of blood that’s coming back to the heart so that your heart can then pump it out again, after it’s re oxygenated by the lungs. So if we’re restricting that venous return, we are not getting as much blood back to the heart, that means the hearts gonna have to pump a little bit faster, and a little bit harder to get whatever blood is coming back out as quickly as possible. So we generally see a higher cardiovascular response at lower loads than if we did if they were doing no BFR and slightly higher loads. So that’s that’s a, you know, consideration in terms of medical history for people. But it’s also something we can work with. Right? We know. And it kind of seems like this is what your your patient kind of needs, is that that mental health aspect of exercise that like that euphoria, is that endorphin release, right? Well, we know just exercise at higher intensities, gives that to us. Lower intensities, yeah, we get a little bit of it, but we need to be moderate, higher, higher intensity to really get that release. So in this case, this patient is I just need to move right? That’s really what he’s saying, I just need to move, I can’t sit here I can’t, I have to do something. Putting BFR on having him walk at a pretty not a jog, if he’s still got lower extremity issues going on. But at a high enough pace, and also on an incline can really have that cardiac response, which also drives a lot of biochemical stuff that happens in our brain from a from an emotional mental aspect as well. So yeah, I like to I like to say this, and it’s kind of corny, but I think it gets the point across BFR is like the spice in a recipe, not the main ingredient. And what I mean by that is anything we can anything that a client or a patient enjoys anything a client or patient needs to you because it makes them happy. We can still do that with BFR we just got to sprinkle in a little bit, sprinkle a lot in other instances, adjust the exercise prescription, and we can still get benefits from it. So in that case, I’m like yeah, let’s get that guy on the bike. Assault bike, let’s get him doing something. Getting his heart rate up getting him feeling like he’s doing high intensity stuff, even though he really isn’t that. It tricks the mind. It’s a very weird feeling right when you when you have a cuff on and you’re just doing five pound dumbbell curls 10 pound dumbbell curls, and you’re sweating your brain saying this, there’s there’s a mismatch going on here, we can use that to our advantage though in a case like that patient that you’re describing.

And things actually, like we did it in, in your course have, you put one arm one, a cuff on one arm and one arm doesn’t have the cuff and you hold like a 20 pound med ball. And it feels significantly heavier in the arm that has the cuff that’s being restricted. So that’s another aspect of, I guess, in a sense, it changes your perspective of load, it might be 20% of load, but it’s going to change your perspective of how heavy it feels, and be able to give you that sense of effort and fatigue a little bit more. But that brings up a question for me, too, is what does the because I haven’t really used it a ton in like a cardiac perspective. But what what would a cardio protocol look like with BFR?
Yeah, so similar to what we have our guidelines from the National Strength and Conditioning Association, ACSM, American College of Sports Medicine, you know, they say we have to be at like 70% of one RM to, to see muscle hypertrophy, obviously, we can be lower, it’s just going to take a longer time, but that’s kind of the optimal range. For aerobic we have to be at about 40% of our vo to max or higher. And now most people in facilities don’t have a metabolic cart to to get accurate vo two measurements, nor do they want to take the time to do a submaximal field test for vo two max. So we can translate that because there’s a linear relationship between heart rate and VO two Max, essentially what we’re saying is 40% of heart rate max or higher. And when when I when you take that into perspective, again, 40% of heart rate Max, without BFR wouldn’t do anything, it would be like the most boring, slow run you’ve ever done in your entire life. But when you do that under BFR. Now Now we’re cooking with with fire here we can, we can change some things around. So the way I love to do it, regardless of whether it’s bike, whether it’s treadmill, whatever rowing, is I like to do interval training. Because underneath that, with that BFR on, you’re not going to be able to run as fast as you’d like to, you’re not going to be able to bike as fast or as hard as you can. So doing whatever interval ratio you want to do, whether it’s the classic two to one, three to one, three to two, you are pushing that getting that cardiovascular response, you’re backing it down a little bit, you’re only going to be able to do that, again, probably for 15 to 20 minutes, it’s going to fatigue you out pretty darn quickly. But it’s also an again, from an exercise prescription standpoint, a nice way to make cardio, I don’t want to say more effective, but more enjoyable write sometimes people just don’t want to do cardio, and they need that little kick. You could add that in if you wanted to, on a cardio, cardio, aerobic side of things as well, it doesn’t just have to be resistance training. And with some of the manual systems out there, the ones that aren’t tethered to any, you know, little computer or whatever, you could do swimming as well. If someone wanted to swim and do laps in a pool and do you know do that as your interval, they could do that as well.

Well, you fall upside down with them. Right? Everyone in the pool is gonna think you have floaties on for a while, you know it’s funny in the in the rehab world when I’m when I’m when I’m teaching my course to PTS, and we talk about aquatic therapy, I make the joke, but it’s so true. It’s like you can only flap your arms and legs and use as much Styrofoam. There’s a limit to all of that when you’re in the pool. Right? And BFR actually can help you get that next step if there really can’t transition from aquatic to land yet if they’re there in between.

Yeah. And so for the aerobic, would you say you’d still limit that to about a 20 minute session?

Again, depends on the person but I’m also looking at it regardless of what setting you’re in rehab or training. There’s other stuff you’re going to want to do. Yeah, it’s not gonna you’re not going to just do cardio, you’re not just going to do strength in rehab. I’m not just doing manual therapy and Fairfax. I added modalities they would get this I get there might be a whole you know, buffet of things that I want to do. So I say from a physiological standpoint, but also a practical standpoint, you’re probably not going to be doing it more than 1520 minutes.

Can people up their tolerance to it though, like we said like I did 20 minutes of it before like when I first started it was really sore. I never went and progressed it more than that because I just I felt it was sufficient enough and it was the spice at the end of my workout, whatever. But if someone wanted to, could they build up to like a 45 minute session? Would it be a bad idea to do that? No, it’s not bad. Again, as long as as they’re being monitored, they’re not having any symptoms that we would say, alright, we got to discontinue this. You can absolutely do that. Again, I would argue, if you’re going to be building up towards 30 minutes, 45 minutes, just lift heavy, just get under over a bar, do that instead. Now Now, having said that, there are there are reasons why you might do BFR instead of lifting. Again, maybe you’re maybe you’re tapering down, for whatever reason, towards an event towards a competition, and you still want to be active, but you don’t want to lift heavy, fine, I could see it there. But if you’re using that as your primary mode of training, and especially if your goal is strength, true strength, and your goal is true to power, that’s when I say, you know, let’s let’s move away from that. You’re right, though, it would take a long time to build that up. Because you would have to let the body adapt and build up the buffering capabilities of dealing with all the metabolites that get kind of pulled up in the lens. And that then that would take time, but you can certainly do it.

And then with that being said, one of the other things I remember from the course is nerve conduction velocity is actually slowed, isn’t it?

Yeah, it is. I mean, you’re not just putting this cuff on an inflating it is solely impacting the vascular system, right veins in the veins and arteries, it is going to, to compress nerves. Now, obviously, you don’t want numbness and tingling, that’s too much compression. That’s one of those things where we back off a little bit. But just by from a physiological standpoint, that compression of that nerve, you’re going to get a little bit of a slower nerve conduction velocity. So I don’t know if this is where you’re going with this. But I’m going to mention it now that it comes to my head is like, I don’t really see an instance where I’m going to be doing speed or velocity based stuff with BFI. I’m not going to be doing Olympic lifts. There’s just no point. To me. It doesn’t seem like it’s going to have a benefit for most people. Could I? Again, there’s always these what ifs, right? Could I see a scenario maybe where we have a very well trained athlete, someone who has that good base? Who has really good Olympic lifting form? Who maybe we’re trying to challenge the system in a slightly different way, and we do it very low weight? I don’t know, probably not. We’ll see. I would argue again, in that instance, very similar to the I can do BFR for 45 minutes. If you’re if your first inkling with Olympic lifts into progress it is to do BFR No, I don’t I don’t think that you’ve fully investigated all the opportunities to progress that person appropriately. Like that shouldn’t be your first thought.

Yeah, I’ve seen so I would. So as an Olympic weightlifting coach myself, I have never and never plan to do BFR with Olympic lifting.

I go on Instagram and see what’s out there.

Yeah, true. I can maybe I’ll try. My plan. My my thought and this was kind of a word of caution, anyone trying this is I vaguely remember to so for those that don’t know, nerve conduction velocity, basically, is the speed at which your messages travel from your brain for your limbs or body to move. And one day, I was doing BFR, and I was doing a landmine press. And I went to transfer my hands. And it was like my hands were just dumb and not attached to the rest of my brain. And I slipped and almost took my teeth out my bottom row teeth out. And I was like, I just didn’t feel that coordination to like grab the bar the right way. And I was like, I think this is just slow nerve conduction philosophy. So there’s that safety aspect there, too, because I’ll just piggyback off of that and say, let’s not use let’s not use BFR on more complex activities, if we haven’t already taught someone how to do those activities without BFR right, because there is that aspect of safety of it is affecting, especially as you fatigue, how to I don’t want to say coordinated you are but there is a the fatigue will not just be in the muscle it will be throughout everything that’s going on.
And if you can’t react as fast because the conduction velocity has slowed well, it because I saw someone doing like they had some athletes that were all doing BFR. And they were doing the agility, hurdles, and the ladders and everything else. And I was like, This doesn’t make sense to me. Like, we’re training in a slowed rate, like, why would we want to do that? And then, like, I’ve seen people try to train balance with it before and I was like, Well, if the conduction is slowed, you’re making? Why are you going to make someone worse at something? And then have them try to do it? Well, doesn’t make sense to me.

Correct. Now, I could see a scenario where you’re doing some, some BFR training, and then you take those off, and then you go into some plyometrics some agility stuff, and you are essentially training you know, strike while the iron is hot. You have you have really fatigued that system. Now you’re asking it to do it. Not with BFR on but your your training in that way a little bit. I could see that. But with BFR on. Again, it’s I can’t say that you’re necessarily doing anything bad or detrimental. I just don’t think you’re actually accomplishing what you think you’re accomplishing. If that makes sense. Right? Correct.

My other question to you here was in its application, and who almost as a better fit for this is, you know, I have a really cool case now where I have a 72 year old female. She’s masters national champion power lifter. And so she’s 71 or 72. And she squats over 200 pounds, she deadlifts 245 pounds, she benches 137. I think she’s very strong for her age. And she’s got a significant amount of muscle mass, but she just had a hip replacement. And we we actually use BFR preoperatively. Because she couldn’t load that, well. She’s going in for surgery, she’s going to be off that hip for a while. She was on loan, she had to use a cane like it got really bad really fast. It was a great application then to maintain while she couldn’t load. But now she’s back to loading and doing all these things. And I’m just kind of like, do I do I want to use BFR with her Still, she’s two months out of surgery, she’s back in, you know, she is a different. She’s my 2% out of the curve of norm, where she’s repping she was repping 20 reps, you know, a week and a half post op with BFR cuffs on she’s back to doing hip hinging and all this and step ups without any assistance. And she’s maintained most of her muscle mass. And I think part of it, she’s just neurologically, she’s, you know, innovated that way. And she’s kept most of her muscle more than you know, I have 45 year old women in the gym who can barely do a step up on their own and they’re considered healthy. So is there a population? Where is this actually more beneficial for people that might be a little more frail that we need to build mass with versus people that are stronger and have more muscle mass? Is there less bang for your buck with them at all?

Yeah, that’s an interesting question. I mean, I always joke and say, if you’re human, and you’re breathing, you can use BFR. Right? Again, there’s there’s situations there’s risk stratification, certain conditions where we probably wouldn’t use it. But when you start sub sectioning it out into strong versus weak individuals, we’ll just call it that. Yeah, I mean, it’s like any sort of training those who are or who are deconditioned are going to see the largest increases from exercise and training compared to someone who’s strong, right? They’re going to see it a lot quicker. So definitely in in weaker individuals, deconditioned individuals BFR is that like Goldilocks? It is. It allows them to get moving. It allows them to build strength. If they’re fear, avoidant, it allows them to do things that they are okay with doing and still build some muscle mass over time. If they’re painful. It helps with that. So yeah, I think if if I had to choose it probably is going to be more helpful for for weaker individuals. But with that being said, and that particular person you’re working with, you know if even though she’s strong, if she came out out of that, that total hip and she will wasn’t able to return to a lot of that stuff. Well, then yeah, that’s gonna be again, someone who needs that. endorphin release needs that exercise wants that exercise. BFR is perfectly fine in that instance. But again, transition out of that as quickly as possible and get them them lifting.
Yeah. And that was my thought is like, well, we’re, you know, her goal is strength, and we have an adequate amount of muscle mass, we kept it like we use BFR was a great application for her pre surgery preoperatively. But now it’s like, okay, she can do step ups, you can do all these things. She’s kind of already unrestricted at this point, it’s only been six weeks. Do I want to use BFR? Or do I want to get her stronger? Again?

No, I think actually use BFR with her where you should have and that’s prehab. I think that’s one area where we can really kind of push home the importance or helpfulness of BFR, you know, we know it’s a fact the more muscle mass you have prior to a surgery, the better off you will have as outcomes, end of story. Right? So even in someone like her who was already a high level of fitness for her age, doing that beforehand, so that she didn’t lose any of that muscle mass is probably what helped contribute to the fact that she didn’t need BFR on the back end, right, that she could go to back to those things. Again, obviously, the level of fitness the base that she had. But yeah, using BFR in a prehab. Oral setting is is really impactful.

Yeah, and we talked a lot about muscle mass. And that’s very important for a lot of us. But what are some of the other benefits to that we get are the adaptations we see from using BFR, whether it be cartilage, ligaments, does all that stuff grow, what happens there? Pain, right? Yeah. So growth hormone is released, along with some other happy field, good things for muscle hypertrophy and growth. And so growth hormone is is definitely our repair and regrow hormone. So you think in theory that if that is released in higher concentrations, that we could get some benefit with tendinitis, tendinopathies, you know, soft tissue type of of injuries. The evidence out there is is conflicting. I think it’s getting better, more supportive. I also think it’s a product of how we’re measuring things. I think that’s part of it. But again, I go back to this, what’s the alternative? If we had someone who had chronic tendinitis or tendinopathy? And they can’t do normal things that we want to do? Are we just going to do nothing with them? Are we going to try BFR and hope that, you know, again, even though the research isn’t 100% there yet, that it will be something that will benefit this person? I always go, let’s stay away from not doing anything and and work towards that. In terms of pain? That one’s always a challenging one. How do you measure pain, right, other than a subjective scale. But what I will say is, there’s a couple of good studies out there that show after using BFR, that and this was for, I believe, patellofemoral it was a knee related condition. I know that after doing a short session of BFR, that individuals reported reduction in pain for 24 hours, some up to 72 hours afterwards. Now, is that due to the BFR? Or is that the fact that we just got the moving, we got them exercising, and when we exercise, the body feels better? Again, not entirely sure there. However, if BFR is what got them to move, so that that could happen. That’s a positive in in, in my book. So yeah, hypertrophy, muscle mass, some, some research showing reduction in pain. Some research showing support for helping with soft tissue related stuff. But the big one is, is muscle mass gain. That’s something we know that the research there is is solid.

Yeah. somebody the other day came in and asked if we did ultrasound, and I was like I just pointed to the coffee was like, No, I do that. Like what’s that? I was like, it’s BFR they’re like, I was like This replaces the need for basically any passive modality. Besides soft tissue work, I still use a lot of that and I do the my fair share of dry needling and things too. But like, you know, just rubbing kumana with a machine that basically does nothing or a 10s unit like BFR does all that and more. So why are we Why don’t we choose something that someone asked? Lou can participate in, get the sense that movement is better, it’s an active solution to an active problem. Let’s use that all day.

It’s also an empowerment tool to I mean, what is our role as pts? Well, even as strength coaches, right, we, I mean, yes, we want people to come back, we want them to enjoy us and what we provide for our services and to refer people to us. But ultimately, when we when it really comes down to it, we want the people to understand how their body works and how they can take care of it. Ultrasound is not going to do that BFR is going to get you to realize that exercise is helpful that moving is helpful. And so to me, it’s like yeah, replacing, it doesn’t have to be BFR. Let’s just replace modalities in general, that are not effective with things that that are effective, but also actively engage the patient in their treatment. Yeah, exactly. And my last question, before we have to wrap up here is, is this something people should try on their own? Should they go try to find a provider that does this for them? And if so, how would they go about doing this on their own?

Yeah, I think in general, right, the majority of people should be consulting a clinician, a provider who has been trained in BFR. And using it with them, there are going to be some instances where, you know, someone’s had been using it for a while, and maybe that individual clinician or provider feels comfortable saying, yes, you can use it at home, but that’s going to be few and far between. When when you’re looking for somebody, or when you’re looking to do BFR Yeah, go ahead.
I was gonna say, What is the reason for that? Or what what would be some of your reasonings for that?

I think while BFR is safe, has been shown to be safe, the research shows that it’s it’s not really increasing the risk of adverse events that significantly in a vast majority of the population, I think, once you remove it and put it in a situation where there’s more variable for error, that safety risk is not as solid. And so for me, I just say, let’s keep this with us. And then let me give you things that at home that are also beneficial that I that I know, there’s less variability in error with, if that makes sense, right? Yeah, inherent inherently, I think people could be trained to use it at home. But as a clinician and a provider, I’m trying to minimize risk and maximize benefit, and I just see too, too much potential for that happening if it becomes an at home thing.
Yeah, I’ve seen a lot of guys just slapping these things on their legs at the gym, or whatever, and doing these ridiculous workouts sometimes. And it’s like, you know, that’s one thing. But we also have to keep in mind, for everyone out there, too, are you telling mom and dad that they should try this because they should put on muscle mass again, is like, we have to think about blood pressures, heart rates, heart condition, or cardiovascular conditions. Even you know, I’ve had a couple people, they kind of push themselves a little hard on it, and like, you know, got lightheaded and dizzy because the cardiac response isn’t what they expected, or was something they weren’t ready for. And, you know, in sometimes it’s like, I had a woman that did it in the morning, like she hadn’t eaten breakfast yet. And for whatever reasons, you had too much coffee, and it was just like all that together, you know, just made for a bad day for me, whatever. And I think there’s a whole host of complications and things we need to look out for. That we as just regular civilians that aren’t medically trained, need to think about and worry about a little bit more. You know, doing it to yourself as an experiment is one thing but telling others to do it, or even as coaches. You know, as coaches, we can be certified to do it. But I think there’s real importance in knowing knowing what you know, and what you don’t know. And if you don’t know something, and someone has any little type of comorbidity or medical complication, I might want to consult with a doctor first or a medical provider this trend in this first Yeah, absolutely.

Now, what I was gonna say was, you know, well, how do I know if somebody has been trained in it? How do I know if someone’s been certified? Well, there’s a bunch of different certifications out there. All the ones that I’m aware of are good in the sense of, they are evidence based, scientific based, and they teach people how to appropriately apply BFR with their patients and clients. There’s no set certification There’s a couple of ones out there. However, there is a new resource that is, I think, going to be helpful. And that is BFR proz.com. It’s It was created by one of the colleagues in the field. And he has kind of created this website of clinicians and providers who sign themselves up. And they show that they’ve been trained in BFR. So that, you know, if you’re a patient, if you’re a client and you’re looking to, to find somebody in your area that you can work with, this is this is a good resource for that.
I think I just got invited to that page too. And I didn’t know that’s what it was. So yeah, go sign up for that.

Yeah. Yep. Sorry, Nick, if you’re hearing this, I haven’t had the chance to do it either. But I will because cool. And rapidly Gauss. Is there anything else you wanted to add about? VFR? Kyle?

No, I think it’s let me just recap and say this it’s it’s a powerful tool when used correctly just like anything else. And so find people who are going to be in your corner and help you use it and and also know when not to use it. As we mentioned, if your goal is truly strength and power, it’s probably good for a little bit but it’s not the be all end all. Now other than that, I think I’m good man.

I column where do people find you if you can find me? On my website, MODIS PT performance.com, mot us. I do have some social but to be quite honest, I try to stay off of those things as much as possible. I just have better things to do with my time. But if you want to find me there at Modus, PT, Motus, PT, Instagram, Twitter, and Facebook.

All right, thanks for coming on Kyle. And if anyone has any questions feel, feel free to reach out to either Kyle or myself. And stay tuned for the next few episodes. We’ve got a few other really solid guests coming on talking about pain science, talking about functional medicine, and a few others that I can’t think of off the top of my head. So stay tuned and thanks for tuning in.

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