Designing Effective Blood Flow Restriction Training Protocols: A Complete Guide

A comprehensive guide on protocol designs and progression to maximize the benefits of BFR training

By Andreas Kjærsgaard Christensen, MSc Sport Science, Head of Education in Occlude

Being able to design effective blood flow restriction (BFR) training protocols is essential for physical therapists, trainers and other healthcare professionals to ensure a safe and impactful BFR exercise stimuli for patients and athletes. In this comprehensive guide, we will explore how to maximize the benefits of BFR training, tailored to different settings and individuals.

This blog post covers key aspects of BFR training including AOP-measurement, individual blood flow restriction training pressure, understanding the load-pressure continuum and the BFR exercise intensity ladder. The blog post also includes guidelines and practical tips for passive & very low-lad BFR training, aerobic BFR training, low-load BFR resistance training, run-in phases and progression in BFR training.

If you are new to BFR training I suggest you start with our blog post ALL YOU NEED TO KNOW ABOUT BLOOD FLOW RESTRICTION TRAINING that will provide you with a general presentation to BFR training, safety aspects and relevant cohorts to BFR. Let’s get started!

Individual Blood Flow Restriction Training Pressure

Before initiating BFR training, it is important to determine the individual blood flow restriction training pressure. This is based on the individual’s arterial occlusion pressure (AOP), in some studies also referred to as limb occlusion pressure (LOP). Measuring AOP can be achieved using either a Doppler ultrasound or a handheld Doppler device [1].

To perform the AOP measurement, gradually inflate a cuff while carefully monitoring the arterial pulsation with a doppler. When pulsation no longer can be detected (due to the increasing arterial restriction by the cuff), the pressure is read and set to 100 % of AOP for the individual. In general, BFR training protocols use cuff pressures between 40 and 80 % of AOP[2].

On average, individuals using the Occlude cuffs will experience complete arterial occlusion (100 % AOP) around 200-220 mmHg with our leg cuffs and 160-170 mmHg with our arm cuffs. However, we experience large variation in pressures for complete arterial occlusion, especially in the lower limbs, with ranges from 170-300 mmHg (leg cuff widths: 11-12 cm), which emphasize the need to perform AOP-measurements for individualized BFR training pressure. Let me provide an example:

Patient A has an AOP of 200 mmHg. Exercise pressure set to 50 % of AOP equals 100 mmHg.

Patient B has an AOP of 280 mmHg. Exercise pressure set to 50 % of AOP equals 140 mmHg.

The difference in absolute pressures between Patient A and Patient B exercising at 50 % of AOP is 40 mmHg. If Patient A and B were to exercise with a cuff pressure of 80 % AOP the difference would increase to 64 mmHg (160 vs 224 mmHg)! This is a substantial difference in the absolute pressures applied, highlighting the importance for individualization.

A seated lower limb measurement of AOP with the Occlude leg cuff and a handheld doppler. The posterior tibial artery is used to detect pulsation.

AOP can be different between the dominant and non-dominant lower limbs, why it is recommended to measure AOP in both limbs if involved in exercise[3]. Body position also influences the AOP measurement. For absolute restriction of lower-limb arterial blood flow, higher pressures are required in a seated compared to supine body position, and higher pressures are required in a standing compared to seated and supine body position [4] why the AOP should be measured in the position that the restrictive stimulus will be applied. For practical reasons, we don’t teach nor measure AOP standing. Instead we recommend you to measure AOP seated and increase it with 10 % when calculating pressure for standing BFR exercises.

Here is an example: Patient C has an AOP of 220 mmHg, measured in a seated position. Patient C is about to perform squats at 50 % of AOP. First, we estimate standing AOP by increasing seated AOP with 10 % (220 mmHg * 1,10 = 242 mmHg). Then we calculate cuff pressure for the exercise: 242 mmHg*0,5 = 121 mmHg.

For a more in-depth presentation of the AOP-measurement and how it is performed in practice we recommend you to sign-up one of our BFR courses or contact us directly

Establishing a personalized BFR training pressure ensures consistent exercise stimuli[5], reduces the risk of peripheral nerve compression[6], and enhances comfort without compromising training efficacy [7]. It also minimizes the likelihood of adverse events[8] and allows for accurate documentation in patient records. Using non-individualized methods to set BFR pressures can lead to unsafe conditions, unnecessary high pressures increasing discomfort [9, 10], inconsistent exercise responses, and inadequate training stimuli [5].

For these reasons, determining personalized pressure is a critical step in designing effective BFR protocols.

A seated upper limb measurement of AOP with the Occlude arm cuff and a handheld doppler. The radial artery is used to detect pulsation.

The Load-Pressure Continuum

The load-pressure continuum explains the inverse relationship between the load, expressed as a percentage of one repetition maximum (% of 1RM), and the cuff pressure, expressed as a percentage of AOP or LOP (% of AOP), used in BFR training. When working with very low external loads (<15 % of 1RM), or during passive BFR application, higher cuff pressures of 60-80% AOP are needed to ensure sufficient local muscle fatigue. In contrast, when using higher external loads ranging from 20-40% 1RM, lower cuff pressures of 40-60% AOP are adequate to induce muscle fatigue. The reason for this is because the relative pressure affects local limb ischemia and microvascular oxygenation [11] hence the level of local muscle fatigue important for muscle adaptation [12]. To summarize, when training with a very low external load (0-20 % of 1RM), pressure should be increased towards 80 % of AOP and when training with a higher external load (20-40 % of 1RM) the pressure should gradually be decreased towards 40-50 % of AOP if a high level of muscle fatigue can be maintained. This concept is illustrated by the graphical presentation of the load-pressure continuum.

Other reasons to avoid unnecessary high pressures are increased discomfort, increased percieved exertion and a possible lack in training adherence.

A study by Counts et al., from 2016 showed that training with 40 % and 90 % of AOP led to similar gains in muscle mass, strength and endurance after 8 weeks training of the elbow flexors [7], indicating that high pressures don’t lead to superior results when performed in combination with exercises in the upper range of the exercise intensity for BFR training (20-40 % of 1RM).

Not only will a decrease in pressure reduce the discomfort experienced with BFR but also enhance the overall training experience, particularly for older or frail populations. Lower pressures could therefore potentially improve long-term adherence to BFR training [13] while maintaining maximal training outcomes.

Practitioners can experiment with the load-pressure continuum and the perceptual response to different cuff pressures. Try inflating a cuff on one leg to 40% AOP and a cuff on the other leg to 80% AOP while performing the same exercise with same external load for both (cycling for instance). Observing the difference in perceived exertion and muscle fatigue provides valuable insight into the effects of varying pressures and its practical use. This test is something we always perform at our BFR training courses.

In conclusion, the load-pressure continuum provides a flexible framework for tailoring BFR protocols to individual needs, ensuring optimal adaptations while minimizing discomfort. Practitioners are encouraged to personalize these variables to enhance training outcomes and long-term adherence.

Testing different pressure with same external load: 5 sec quadriceps contraction with 5 sec rest for 6 minutes. Right leg (left side for the viewer) inflated to 80 % of AOP. Left leg (right side for the viewer) inflated to 40 % of AOP

The BFR Exercise Intensity Ladder

The BFR exercise intensity ladder categorizes protocols based on the mechanical loads and intensities used in training and its progression from passive/very low load (with higher pressures) to higher external loads (with lower pressures). This concept is illustrated by the graphical presentation of the BFR Exercise Intensity Ladder.

Low-Load Resistance Training 

Low-load BFR resistance training, often performed at intensities between 20-40% of 1RM with cuff pressures ranging from 40-60% AOP, is the most frequently used BFR training concept. Traditional protocols typically involve fixed repetition schemes, such as 30-15-15-15 or 30-20-20-20 with 30-60 seconds of set-rest between sets, and the cuff pressure maintained during rest periods [14]. In some studies, 3-4 sets to voluntary concentric failure are also being used but this should only be integrated in training for the highly trained athlete. If you are to perform several exercises with BFR, take 3-5 min rest with deflation to allow reperfusion.

When performing the 30-15-15-15 protocol, the first set of 30 reps works as a “fatigue build-up” set and it should be relatively easy to complete. In the second set of 15 reps, the prominent feeling of muscle fatigue and percieved exertion sets in and completing the third (15 reps) and fourth (15 reps) set only becomes harder. In practice, repetition schemes of 30-15-12-8 are not uncommon meaning that third and fourth set actually are performed to failure.

Recent research has proposed an alternative protocol involving multiple sets of 15 repetitions, which has demonstrated similar efficacy in increasing muscle mass as higher-volume protocols and even heavy-load resistance training [15]. This approach is particularly valuable for pain-sensitive patients and non-athlete populations, as it reduces discomfort and percieved exertion while maintaining robust training responses. This could remove on of the proposed barriers to BFR training [16] thus improving long-term adherence and training compliance.

If we were to rank low-load BFR resistance training protocols from “hardest to easiest” it follows this order:

• 3-4 sets to voluntary concentric failure
• 30-15-15-15 reps
• 4 x 15 reps

Exercise selection

When selecting exercises for low-load BFR training, prioritize movements that emphasize muscle fatigue while minimizing complexity and the need for balance while performing the exercise. For this reason, both open- and closed kinetic exercises in machines are great training options to combine with BFR, especially in rehabilitation. Complex exercises like squats, bench press, lunge/split squat and row variations using barbells and/or dumbbells can be performed but would require experience with lifting. More advanced and time-efficient strategies such as antagonist supersets can also be implemented in a rehab or performance program for athletes.

Unilateral knee extension / leg extension after Jones fracture                                           Bilateral leg press 4 months post-op ACL reconstruction

Aerobic Training 

BFR combined with aerobic exercise provides a versatile alternative for individuals unable to perform high-intensity training due to pain, discomfort, or psychological barriers. BFR with aerobic exercise can improve muscle mass and strength [17] and potentially also benefit athletes depending on anaerobic and aerobic performance [18]. The latter is beyond the scope and we recommend you to read our post series on Instagram if you are interested in the impact from aerobic and anaerobic BFR training on athletic performance.

In practice, we generally work with two groups of aerobic BFR users:

• Individuals who cannot perform high-intensity training due to discomfort, pain, psychological barriers, or those who prefer not to engage in regular resistance training exercises.

• Individuals recovering from injury or surgery unable to perform higher-intensity training.

Unlike low-load BFR resistance training, the intensity of BFR aerobic training is dictated by the internal training response, with a target intensity of approximately 50% of VO2max or a rating of 12-13 on the Borg scale. The exercise can be continuous (5–20 minutes) or intermittent.

Intermittent sessions can vary from shorter exercises where cuff inflation is maintained during rest periods (e.g., 5 x 2 min – 1 min rest [14 min restriction] or 3 x 5 min – 1 min rest [17 min restriction]) to longer intervals (e.g., 2-3 x 8-10 min, 3-5 min rest), where the cuff pressure is released during rest periods.

Cuff pressures for aerobic BFR training generally range from 60-80% AOP, and training frequencies vary between 2-4 times per week, or daily for shorter exercise blocks of 1-3 weeks.

Aerobic BFR training can be performed using various modalities, including walking, ergometer-cycling, stair climbing/stair master and cross-trainer. Ergometer cycling is highly beneficial due to its low barrier to entry, non-impact exercise, non-weight bearing, ease of instruction, and different adjustments such as seating height that dictates hip and knee range of motion, which could be important in rehabilitation or with patients experiencing pain in different positions. Walking also offers benefits, as it does not require specialized equipment and promotes accessibility for a wide range of users, including the elderly [19].

Ergometer cycling and ergometer rowing with blood flow restriction

Passive BFR and Very-Low Load Exercises (< 15 % of 1RM)

The recovery from illness or injury can require otherwise healthy individuals to undergo a period of muscle disuse (e.g. bed rest or limb immobilization). A major consequence of disuse is skeletal muscle atrophy with evidence showing a substantial decline in muscle mass and strength after only 5 days of limb immobilization [20]. The rapid loss in muscle mass with immobilization is particular for anti-gravity muscles such as the quadriceps and occurs with a faster rate after surgery compared to “controlled immobilization” of healthy individuals. Passive application of blood flow restriction is a proposed method to minimize loss in muscle mass and function in these cases [14, 21].

Early papers of Takarada [22] and Kubota [23, 24] support the use of passive BFR to minimize loss in muscle mass and/or function with a [5 x 5 min, 3 min rest, 2 x day for 2 weeks, pressure; 50-260 mmHg], however later research from Iversen[25], who also used post-op patients after ACL reconstruction as Takarada, failed to find improvements with the same BFR protocol added to a standard-care treatment.

Indirect evidence from Nyakayiru 2019, found that only BFR with exercise increased myofibrillar protein synthesis rates at 5-hour post stimuli, compared to a passive BFR application in resting conditions, indicating a need to add muscle contraction to utilize the effect of BFR[26].

In a recently published study a group of researchers measured the impact of BFR on muscle protein synthesis rates, muscle mass and strength during 2 weeks of strict bed rest in 12 healthy male adults. One leg received passive BFR (3 x 5 min inflation with 1.5 min rest, 3 times/day, pressure: 200 mmHg, 45 min total BFR/day for 14 days) while the other leg served as control. The results showed that both legs had significant loss in muscle mass and strength and there was no difference between conditions[27].

On the other hand, the use of passive BFR has been found to reduce muscle atrophy in elderly coma patient in the intensive care unit[28]. Like Fuchs, Barbalho also used a with-in patient design, where one leg received passive mobilization + BFR (intervention) and the other leg only received passive mobilization (control). The authors found that both legs atrophied during ICU but the loss in muscle mass was lower after BFR + passive mobilization.

With conflicting results in the litterature it remains unknown if passive BFR alone can protect against muscle atrophy. We support that some sort of muscle contraction leading to single fiber mechanical tension is needed, as it is proposed to be the primary mechanism driving muscle hypertrophy [12].

One way of adding involuntary muscle contraction is with Neuromuscular Electrical Stimulation (NMES). NMES is commonly used as a rehabilitative technique for preventing muscle atrophy during immobilization periods. It is proposed that the combination of BFR and NMES provides a synergistic effect in which hypertrophy may be possible as a passive intervention. In a with-in patient design, a high frequency training protocol; twice daily, 5 days/week for 2 weeks consisting of involuntary NMES combined with BFR (NMES-BFR leg) improved isometric and isokinetic quadriceps strength and muscle mass. The control leg (NMES-only leg), only had a negligible effect on isometric strength [29].

Likewise, the use of synergist exercises (hip abduction, adduction or flexion) or early very-low load exercises with limited range of motion (seated quadriceps contractions and closed chain knee extensions) can be ways of adding muscle contraction with the limitations set by and injury or early post-surgery. 12- and 16-weeks protocols including these exercises can be found in Ohta 2003 and Jack 2022 who both found improved long-term outcome following BFR for patients recovering from ACL reconstruction [30, 31].

Thus, using passive or very-low load BFR should only be considered if the patient or athlete is unable to do aerobic or low-load (20-40 % of 1RM) strength training with BFR. As soon and safe as possible the patient or athlete should be encouraged to progress the exercise intensity ladder, with the next and more intense step on the ladder being aerobic BFR training.

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Quadriceps contract with BFR following ACL, PCL and MCL injury                                                                                       Passive BFR with NMES

Progression of BFR training and run-in phases

In order to continously improve muscle function, hypertrophy and/or strength with blood flow restriction training we have to progressively overload as the patient or athlete adapt.

Looking aside the Exercise Intensity Ladder and the different modes of exercise that can be combined with BFR, we have three different parameters that we can manipulate:

– Intensity (% of 1RM)

– Volumen (set x reps / duration)

– Pressure (% of AOP) 

Progression of the exercise intensity should be first priority whenever the current BFR training regime becomes too easy, as and increase in exercise intensity will benefit improvements in strength the most (rule of specificity). You can increase exercise intensity up to 50 % of 1RM and still combine it with BFR. When able to, progress to training with higher intensities. When performed above 50 % of 1RM, this should be without BFR. 

If the exercise intensity cannot be increased either due to pain or loading restrictions following an injury or surgery, we can instead increase volumen or the restriction pressure. The decision comes down to personal choice depending on what the patient or athlete prefers, what type of protocol you are using and how you attain a high level of muscle fatigue the easiest. Both training with higher pressures and more reps in proximity to muscle failure increases the discomfort experienced with BFR.

Personally, in most cases we start by increasing the volume up to a maximal of 100 reps in the rep-based protocols. If this is still insufficient to reach a high level of muscle fatigue we increase the cuff pressure. Increasing cuff pressure should be performed gradually with a 5 % increase in pressure (% of AOP) per session but never above 90 % of AOP.

Run-in phase

To reduce initial muscle soreness and damage, pain and discomfort, we encourage you to use a run-in phase where patients and clients are gradually exposed to BFR training and are provided time to adapt. We recommend the following run-in protocol for new users of BFR training:

Progression of pressure and intermittent BFR for new users

For some new users of BFR, the restrictive pressure maintained in rest periods can so also be uncomfortable. If the applied pressure is the biggest barrier to BFR consider either:

1. Lower the pressure to less than 40 % of AOP. Start with 20 % of AOP, and gradual increase towards desired pressure. If tolerable, increase pressure with 5 % of AOP per session.

2. Use intermittent BFR where you release the pressure in between sets. BFR is only applied while work is performed. 

Summary

Designing effective BFR training protocols requires careful consideration of individual pressures, the load-pressure relationship, and the appropriate exercise intensity. By understanding and applying these principles, healthcare professionals and fitness practitioners can safely optimize training outcomes for patients and athletes across various rehabilitation and performance settings.

Whether you are working with injured athletes, elderly patients, or general fitness enthusiasts, the adaptability of BFR training makes it an invaluable tool for improving muscle strength, hypertrophy, and overall function. Start incorporating these guidelines into your practice to unlock the full potential of BFR training.

References

1. Vehrs, P.R., et al., Use of a handheld Doppler to measure brachial and femoral artery occlusion pressure. Front Physiol, 2023. 14: p. 1239582.
2. Patterson, S.D., et al., Blood Flow Restriction Exercise: Considerations of Methodology, Application, and Safety. Front Physiol, 2019. 10: p. 533.
3. Tafuna’i, N.D., et al., Differences in Femoral Artery Occlusion Pressure between Sexes and Dominant and Non-Dominant Legs. Medicina (Kaunas), 2021. 57(9).
4. Hughes, L., et al., Influence and reliability of lower-limb arterial occlusion pressure at different body positions. PeerJ, 2018. 6: p. e4697.
5. McEwen, J.A., J.G. Owens, and J. Jeyasurya, Why is it Crucial to Use Personalized Occlusion Pressures in Blood Flow Restriction (BFR) Rehabilitation? Journal of Medical and Biological Engineering, 2018.
6. Patterson, S.D. and C.R. Brandner, The role of blood flow restriction training for applied practitioners: A questionnaire-based survey. J Sports Sci, 2018. 36(2): p. 123-130.
7. Counts, B.R., et al., Influence of relative blood flow restriction pressure on muscle activation and muscle adaptation. Muscle Nerve, 2016. 53(3): p. 438-45.
8. Jessee, M.B., et al., The Influence of Cuff Width, Sex, and Race on Arterial Occlusion: Implications for Blood Flow Restriction Research. Sports Med, 2016. 46(6): p. 913-21.
9. Mattocks, K.T., et al., The effects of upper body exercise across different levels of blood flow restriction on arterial occlusion pressure and perceptual responses. Physiol Behav, 2017. 171: p. 181-186.
10. Jessee, M.B., et al., The Cardiovascular and Perceptual Response to Very Low Load Blood Flow Restricted Exercise. Int J Sports Med, 2017. 38(8): p. 597-603.
11. Reis, J.F., et al., Tissue Oxygenation in Response to Different Relative Levels of Blood-Flow Restricted Exercise. Front Physiol, 2019. 10: p. 407.
12. Wackerhage, H., et al., Stimuli and sensors that initiate skeletal muscle hypertrophy following resistance exercise. J Appl Physiol (1985), 2019. 126(1): p. 30-43.
13. Spitz, R.W., et al., Blood Flow Restricted Exercise and Discomfort: A Review. J Strength Cond Res, 2022. 36(3): p. 871-879.
14. Patterson, S.D., et al., Blood Flow Restriction Exercise Position Stand: Considerations of Methodology, Application, and Safety. Front Physiol, 2019. 10: p. 533.
15. de Queiros, V.S., et al., Hypertrophic effects of low-load blood flow restriction training with different repetition schemes: a systematic review and meta-analysis. PeerJ, 2024. 12: p. e17195.
16. Rolnick, N., et al., Perceived Barriers to Blood Flow Restriction Training. Frontiers in Rehabilitation Sciences, 2021. 2.
17. Teixeira Filho, C.A.T., et al., Effect of aerobic training with blood flow restriction on strength and hypertrophy: a meta-analysis. Int J Sports Med, 2024.
18. Davids, C.J., et al., Where Does Blood Flow Restriction Fit in the Toolbox of Athletic Development? A Narrative Review of the Proposed Mechanisms and Potential Applications. Sports Med, 2023. 53(11): p. 2077-2093.
19. Clarkson, M.J., L. Conway, and S.A. Warmington, Blood flow restriction walking and physical function in older adults: A randomized control trial. J Sci Med Sport, 2017. 20(12): p. 1041-1046.
20. Wall, B.T., et al., Substantial skeletal muscle loss occurs during only 5 days of disuse. Acta Physiologica, 2014. 210(3): p. 600-611.
21. Scott, B.R., et al., An Updated Panorama of Blood-Flow-Restriction Methods. Int J Sports Physiol Perform, 2023. 18(12): p. 1461-1465.
22. Takarada, Y., H. Takazawa, and N. Ishii, Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles. Med Sci Sports Exerc, 2000. 32(12): p. 2035-9.
23. Kubota, A., et al., Prevention of disuse muscular weakness by restriction of blood flow. Med Sci Sports Exerc, 2008. 40(3): p. 529-34.
24. Kubota, A., et al., Blood flow restriction by low compressive force prevents disuse muscular weakness. J Sci Med Sport, 2011. 14(2): p. 95-9.
25. Iversen, E., V. Røstad, and A. Larmo, Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction. J Sport Health Sci, 2016. 5(1): p. 115-118.
26. Nyakayiru, J., et al., Blood Flow Restriction Only Increases Myofibrillar Protein Synthesis with Exercise. Med Sci Sports Exerc, 2019. 51(6): p. 1137-1145.
27. Fuchs, C.J., et al., Daily blood flow restriction does not preserve muscle mass and strength during 2 weeks of bed rest. The Journal of Physiology, 2024. n/a(n/a).
28. Barbalho, M., et al., Addition of blood flow restriction to passive mobilization reduces the rate of muscle wasting in elderly patients in the intensive care unit: a within-patient randomized trial. Clin Rehabil, 2019. 33(2): p. 233-240.
29. Natsume, T., et al., Effects of Electrostimulation with Blood Flow Restriction on Muscle Size and Strength. Med Sci Sports Exerc, 2015. 47(12): p. 2621-7.
30. Ohta, H., et al., Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthop Scand, 2003. 74(1): p. 62-8.
31. Jack, R.A., 2nd, et al., Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction. Sports Health, 2023. 15(3): p. 361-371.