Oct 1, 2018

Three Takes on BFR

Blood flow restriction therapy and training has emerged in recent years as one of the most talked about sports medicine practices of the decade. With what seems like endless benefits, it’s no surprise that there are a number of different ways to approach this trend.

By Nicole Sorce

By now, you’ve probably heard of blood flow restriction, also known as BFR, the latest wave in the sports medicine world. This training and therapy strategy involves the use of a tourniquet that is inflated to a specific pressure and reduces blood flow into the limb during light exercise. In return, patients experience results that coincide with a high-intensity strength program but without the corresponding stress to the limb.

As more is learned about this emerging practice, sports medicine professionals are discovering its many benefits. “The latest trend in sports medicine is simply that everyone is utilizing BFR, even the elite sports that are typically very resistant to change,” says JoHan Wang, ATC, CSCS*D, SNS, Sports Science Advisor for RP Sports. “One thing that almost every client reports is that our BFR devices allow for a full range of motion and do not create pain during the treatment. The benefits are really kind of infinite.”

BFR’s appeal to a wide variety of athletes and activities also makes it a desirable modality. “It seems like it can treat everything. Especially if an athlete is injured, just spinning lightly on a bike or walking on a treadmill with a tourniquet on the limb is key for an athlete to maintain endurance,” says Johnny Owens, PT, founder of Owens Recovery Science, which is a one-stop shop for medical professionals seeking certification in personalized blood flow restriction (PBFR). “We’ve never heard any practitioner say it’s a waste of their time, and it will change the way they look at muscle physiology and do their jobs.”

Its crossover appeal into the strength training realm provides further benefits. “Especially with teams that travel a lot, you only get a couple days of rest, and usually those days are spent flying between cities and fitting in practice,” says Owens. “That makes it really hard to factor in your strength training program because if you lift a guy heavy on Tuesday with a game on Wednesday, they might still be sore and down in terms of their force output. By using BFR, you’d get the same effects as you would see from lifting heavy—without the downside effects of lost performance or muscle soreness.”

As more is learned about BFR, the possibilities expand. With so many options, the future looks bright for BFR—no matter how it is used.

SAFETY FIRST

When Wang joined RP Sports as Director of Innovation and Technology in 2016, he was responsible for improving current products and researching new technology for the company’s portfolio. Every new product had to meet several important criteria, based on the company’s core values. “I made sure that every product was efficacious and evidence-based with significant scientific research demonstrating validity. The devices also needed to have a track record of safety and efficacy,” Wang says. “These are the things that our company values in all of our products.”

That’s how the company decided that distributing KAATSU and B Strong BFR devices would be the right fit for their clientele, which is comprised of more than 400 elite, college, and professional team clinicians across the NBA, NFL, MLB, NHL, MLS, and NCAA. “Our client list is pretty extensive across the United States,” says Wang. “We provide them with consulting services, as well as education programs for their entire staff.”

Although RP Sports specializes in the elite performance sector of athletics, Wang ensures that both KAATSU and B Strong BFR products are safe for use by people of all ages and from all walks of life. “That’s one of the great things about these modalities—they really fit everybody, and they’re not exclusive to a certain population,” says Wang. “There’s no ‘age minimum,’ but the specific population that we sell them to are clinicians, who ultimately make the decision. In terms of utilizing the technology, age is not a limiting factor.”

According to Wang, RP Sports first became associated with BFR products by distributing KAATSU, which he refers to as “the originator of BFR.” In order to purchase and obtain access to a KAATSU device, customers must complete an online certification course that instructs on how to utilize the equipment properly and safely. Once they pass the exam, the machine’s access code is provided. On the other hand, B Strong does not require a certification but does provide instruction and education through their guidance app. An optional live course is also available.

Wang says the difference in the policies of these two brands comes down to a simple fact. “The reason why is that our BFR devices are considered training modalities,” he explains. “They’re not classified as medical devices. It would be the same rationale as saying you need a certification to use a barbell at a gym. Can you get hurt using a barbell? Absolutely. But at the end of the day, it’s considered a tool to help you get the job done.”

While there are some slight differences in the technology of the B Strong and KAATSU devices, the ultimate outcome of the BFR treatment isn’t affected. “B Strong uses manual inflation, so it’s hand-pump driven with no automation,” Wang explains. “KAATSU is digital. It has a computer that controls the compressor and self-regulates the pressure. If there’s too much or not enough, the computer will self-adjust. It allows for automation and precision, and it has the ability to store treatments.”

Wang also warns to not just buy any BFR product on the market. A BFR device should be one that is safe and intended for this specific type of application. “When it comes to manipulating the body’s circulatory system, you want to use something that is actually designed and intended for BFR,” urges Wang. “Our products have safety in mind and are specifically designed for BFR. There are other devices on the market that are repurposed medical devices of some sort, intended for other purposes. It would be synonymous with using a blood pressure cuff to practice BFR instead of using a modality that’s specifically made for that type of application.

“Both KAATSU and B Strong are actually designed so that when you inflate them to a significant pressure, the devices make it nearly impossible to occlude the blood flow, which is key to getting a desired result—as well as safety,” he continues.

RP Sports has recognized that its clientele has placed a much higher emphasis on recovery as a whole, especially in recent memory. Aside from educating teams and organizations on how to use KAATSU and B Strong devices, the company has been assisting its clients in redesigning athletic facilities to dedicate a space just for athlete regeneration. “We may perform a needs assessment in terms of equipment, or it may be figuring out how to incorporate a recovery or regeneration room into an existing or new facility design,” says Wang. “All of the new facilities have a dedicated regeneration room, which is relatively new in the last two or three years. It hasn’t become a standard yet, but it’s sure moving that way.”

Based on Wang’s professional experience prior to joining RP Sports, he’s not surprised about the influence BFR has been having on the sports world. He spent a combined 12 years in sports performance roles with the Golden State Warriors and Los Angeles Clippers and was chosen as the Athletic Trainer for the 2011 NBA All-Star Game. “I was introduced to BFR very early on in 2014, when it was essentially introduced to the United States,” Wang recalls. “I had been chasing the technology for 10 years before that, and it all stemmed from an interest based on research I originally read on KAATSU. Once I was introduced to the technology, I quickly adopted it because the research was so strong.”

As far as Wang is concerned, BFR technology is only just beginning to evolve. “The one thing that all devices lack right now is attention to individuality, so there’s currently no way of creating prescriptions that account for individual physiologic differences and having the computer adjust to those,” says Wang. “In the future, I think the devices used for BFR treatments will become smarter and utilize individual patient metrics to drive prescriptions to make the process more automated.”

A MORE MEDICAL APPROACH

Before founding Owens Recovery Science in 2014, Johnny Owens first experienced the power of BFR therapy firsthand as the Chief of Performance Optimization at the Center for the Intrepid in San Antonio, Texas. Owens faced difficulty reaching ideal muscle quantity and quality changes in injured soldiers, so he and a team of scientists and surgeons began applying BFR treatments to them, and the results did not disappoint. “A lot of those involved delayed amputations from service members who were trying to salvage their limbs, but we also were seeing lost muscle due to blast injury. And in a 10 year window, we had over 50,000 ACL injuries from the war,” says Owens.

Finding positive results with those three populations, Owens began to apply his decade of experience working with the military to his new venture with Owens Recovery Science. “We published some early papers and went after large grants to start randomized clinical trials,” says Owens. “We eventually received some exposure on ESPN, and then all of a sudden, NFL teams started asking me to come out and teach BFR to them. Before we knew it, we were presenting at the NFL Combine, and we now work with a number of NBA, MLB, and NHL teams, as well.”

For the past three years, Owens Recovery Science has been providing medical professionals with the necessary education and training to safely practice BFR therapy. The courses include teaching the proper way to apply tourniquets, how to use the devices, and the clinical and sports performance protocols behind BFR.

According to Owens, the company offers two paths to BFR certification. “We have open courses where clinicians can just sign up and attend to get certified. Those are typically on a weekend, and we pick a fairly large location, like a university,” he says. “We also do private trainings. That’s when a team will call and ask us to train their entire athletic department or sports medicine staff, and our trainers around the country will go train them on-site.”

In both cases, the certification course is a daylong process with half of the time being spent in the lab. “It’s pretty intense on the physiology and science side, and once our clients receive their certification, we provide a lot of backend support,” says Owens. “We have a private advisory board that only certified BFR providers have access to, and they are able to ask questions between each other. Our board includes a cardiothoracic surgeon, sports medicine doctor, and dietitian, who all answer questions and keep everyone updated on any changes they should be aware of as the research continues to advance.”

However, not just anybody can become certified in BFR through Owens Recovery Science. “You have to have a medical license to be able to purchase our BFR device or get certified,” he says. “If a team wants to purchase it, they must take all the regulatory steps and show us they have a medical license that would pertain to the rehab of injuries—MD, PT, ATC, DC, and OT.”

The PBFR system that Owens Recovery Science distributes is developed by Delfi Medical Innovations, based in Canada. Owens’ relationship with Delfi began during his tenure at the Center for the Intrepid, where he first witnessed how well the technology worked. “They have modern microprocessor tourniquets that stay tethered, allowing the machine to constantly ensure that the numbers displayed on the device represent the exact pressure that’s coming out of the cuff,” Owens explains. “It also regulates the changes that need to take place to adapt the cuff to the limb.”

When the tourniquet is placed on the limb, the machine measures the limb occlusion pressure and the artery’s wave flow pattern until it stops completely. “Once that reading is complete, that’s how we know how much pressure it took to make all the blood stop in the limb. At that point, the clinician can decide what percentage to use,” says Owens. “We include protocols of what we think is the best evidence, but if the clinician fears an older patient may not tolerate BFR well, they can take the pressure down and choose which exercise to accompany it.”

With any form of exercise comes safety concerns, but Owens urges clinicians to use extra precautions when it comes to BFR training. “If you’re an athlete or patient looking to do this, find a certified provider and use a device you can trust will be non-harmful and give you the best effect,” he says. “Two recent commentaries in the Journal of Arthroscopy recommends the same thing and specifically listed the Delfi device as meeting safety standards.

“We often rely on this premise: if you can’t put a tourniquet on to have a surgery, then you shouldn’t put one on to do rehab,” Owens continues. “But as you can imagine, most people can have a tourniquet on for surgery, so we feel really comfortable for most types.”

One of the most frequently asked questions Owens’ clients have is the age at which it is safe to begin BFR training or therapy. “The youngest that we’ve had reported from one of our providers was a seven-years-old, who was post-op and tolerated it well,” says Owens. “Unfortunately, there is currently no research that suggests BFR helps younger kids recover any faster, but we’re really pushing for more as the gap in literature involves the younger individual. We are working with some large pediatric institutes, including one that is doing neurologic research, to look at safety and tolerance of BFR.”

Over the years, Owens has seen a shift in the culture of clinicians practicing BFR. “I think years ago, if you said that we’re going to put tourniquets on people after they break a bone, surgeons would have looked at you like you said you were going to barbeque a kitten,” says Owens. “That’s evolved big time and has become a huge part of clinical practice. Clinicians are now understanding the way to maximize a tourniquet by using good tourniquet technology, using Dopplers to understand blood flow, and really dialing this treatment in to a laser level.”

GAINS, GAINS, GAINS

While there’s still much to be discovered about the application of BFR in the muscle-building community, BFR Bands boasts impressive results among its clientele, which is comprised of bodybuilders of all skill levels. Whether used as a finisher on typical routines or a quick workout when pressed for time, BFR is rapidly becoming recognized as a means to achieve the next level of muscular fitness.

BFR Bands believes that in order to realize these types of results, BFR must be used consistently in lightweight sessions lasting roughly 10 minutes. Its bands do not involve mechanical inflation but are just as effective as other products on the market in blocking a limb’s veins without obstructing its arteries. When the blood is trapped in the muscle, muscle cells then are filled with fluid and nutrients that expand the cells to their limits, resulting in the subsequent expansion of surrounding tissue. In return, users report an increased burning sensation radiating through their muscles due to the steady accumulation of lactic acid and energy byproducts.

Unlike mechanical BFR devices, BFR Bands makes it possible to practice occlusion training on more areas of the body than just limbs. For example, wearing these bands on the uppermost portion of the thigh allows for intense glute workouts.

With any training program, individuals may hit a plateau if workouts are too tedious, and the same goes for occlusion routines. To avoid this unfortunate fate in bodybuilding regimens, BFR Bands encourages focusing on different parts of the body for a challenging new stimulation.

The company urges, however, that the use of BFR should not replace traditional training regimens—it’s only meant to enhance them when used safely and properly. And almost just as vital as consistent BFR use is an even more consistent post-workout recovery routine.

LOOKING AHEAD

It’s clear that the future of BFR therapy and training is brighter than ever. “I think in my opinion, BFR is one of the greatest innovations in the last two decades in terms of modalities used in the space,” says Wang. “People need to be aware of the differences in technology and choose devices that are backed by science, safe, and effectively restrict blood flow without increased risk of occlusion.”

Owens agrees. “I’ve been doing this for 20 years now, and this honestly has been one of the biggest game changers I’ve seen,” he says. “We hear that exact thing all the time from all of our providers—that this has changed the way they practice rehab.”

The need for more clinical trials and research is another area that both RP Sports and Owens Recovery Science support. “People are still learning how to use BFR. There are infinite possibilities, but at the end, it’s really through a lot of trial and error to figure out where exactly it fits into their rehab or performance continuum,” says Wang. “There are probably over 200 published studies in the area, which is significant because it proves its efficacy. But we still really don’t have a full grasp yet on its full potential.

“Utilize it according to your scope, but utilize it as a tool in your toolbox,” he continues. “It’s not the end all, be all. It’s just one piece of the puzzle.”

This article appeared in the September/October 2018 issue of Training & Conditioning.