Blood Flow Restriction for the Able-Bodied Lifter Dr. Jeremy P.

Loenneke Introduction Muscle hypertrophy is traditionally thought to occur only after repeated exposure to higher loads (e.g. 70% maximal effort) (2). While it is clear traditional training works, it is not the only way to achieve increases in muscle size and strength. Research over the past decade has demonstrated that exercising with loads as low as 20/30% maximal effort under blood flow restriction (BFR) is capable of inducing changes in muscle size and strength similar to that seen with traditional training (4). This is of obvious benefit to those who are injured or deloading, as it elicits adaptation without the mechanical stress that accompanies higher loads. It is acknowledged that the effects of BFR resistance exercise are similar and not superior to traditional training (3). This has led many who are not injured or deloading to question how this type of training may be useful to the healthy lifter wanting to increase maximal strength as quickly as possible. The purpose of this article is to briefly discuss the mechanisms and safety of BFR while providing context on how best to utilize BFR in combination with a traditional training program.

Mechanisms Low load resistance training in combination with BFR stimulates muscle protein synthesis which may occur from a reduced oxygen environment and/or through metabolic accumulation which may increase the recruitment of fast twitch fibers (5). Short term increases in muscle size (cell swelling) has also been suggested and descriptively shown to possibly be playing an important role in muscle adaptation with BFR (6, 7, 12). However, research from our lab and others suggests that muscle cell swelling may be important for muscle adaptation, but by itself is not enough to increase muscle size. A few studies have also found decreases in myostatin as well as

other markers associated with muscle breakdown (3, 10). It should also be mentioned that active muscles not distal to BFR also increase muscle size and strength (e.g. chest from bench press) . The mechanisms behind this effect are not presently known but may be due to muscle cell swelling and/or fatigue induced increases in muscle activation (1).

Safety The safety of BFR has been examined on several occasions and thus far has been shown to be no more dangerous than higher load resistance training (8). This is obviously under the assumption that moderate blood flow restriction is used in combination with a low load. Early on, several concerns were raised about BFR causing blood clots and muscle damage. Despite these initial concerns, little to no evidence exists to suggest that BFR in combination with low load exercise does either. In fact, the minimal to no muscle damage response observed with BFR is beneficial in that it allows a person to train much more frequently than they otherwise could with more traditional training.

Implementing Low Load BFR with High Load Training There is published and preliminary data from our group and others that suggests that the muscular adaptions from low load training with BFR are different than that observed with traditional resistance training (13). For example, both training modes increase muscle strength but with traditional training this increase is coming from both neural changes as well as changes in muscle size. With low load training in combination with BFR, the increase in strength is predominately coming from rapid increases in muscle size. This suggests a combination of both training methods may produce the most optimal training stimulus; especially given that low load training with BFR does not require as much recovery as higher load training.

There are a couple of different strategies one could use to try and obtain an optimal training stimulus using both low load and high load training. One is to include low load BFR training at the end of your normal workout. This has been previously demonstrated to increase muscular strength in American football players (11). With this strategy it is important to understand that a muscle has a finite anabolic response to a training bout. In other words, there is a point where more work is just delaying recovery but not necessarily mounting an anabolic response. This means that if you perform a sufficient volume of work with high load training, adding BFR at the end is unlikely to produce a favorable response. Thus, with this strategy it is important to keep overall volume in mind to ensure that the low load BFR training at the end of your workout is actually producing a beneficial effect. Another strategy may be to train a body part one time per week with traditional resistance training and two times per week with low load BFR (13). This strategy allows a physical/mental break from continuous high load training while producing increases in muscle size and strength. How to apply BFR BFR should be applied tight enough to cause a visual fluid shift but not so tight that it causes complete arterial occlusion. In a gym setting, it isnt practical to use the specialized blood pressure cuffs that we use in the laboratory. I recommend using elastic knee wraps and this method has data suggesting that it is useful for increasing muscle size and strength in advanced lifters (9, 11). The wraps should be applied either at the top of the leg or the top of the arms and left on for the entire exercise bout. Since pressure is not known using this method, the following guidelines can be used to make sure that the restrictive pressure is appropriate: If you are in great discomfort before the wraps are applied, the wraps are too tight.

If you are unable to complete a sufficient volume of work (30 reps, 3 sets of 15 for single joint exercises, 4 x 12-15 for compound lifts), then the wraps are too tight or the load is too high. If you are sure that the load is 20-30% of your maximum, then the wraps should be loosened. It is not uncommon to fail short of the goal amount of repetitions, but if you are not getting close, the wraps should be loosened.

Conclusions Low load resistance exercise in combination with BFR produces increases in muscle size and strength. The increase in strength with BFR occurs primarily from rapid muscle hypertrophy. The increase in strength with high load resistance training occurs from both neural changes and increases in muscle size. It may be a useful strategy to implement low load BFR resistance training with high load resistance training to produce a more optimal training stimulus. This strategy would allow for both neural and muscle adaptation, resulting in improved muscle function with an overall lower mechanical stress to the body.

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