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Ep 122: Blood Flow Restriction Training – Should You Do It?

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This week on the podcast, the entire Rebel crew and I sit down to talk all things blood flow restriction training. We specifically frame our conversation around: whether or not BFR training actually works, which outcomes may or may not warrant you to use it in your training, what the effects of BFR training are on hypertrophy, what the effects of BFR training are on strength improvements, and where BFR training fits into a rehab or in-season training setting. Listen in to learn some underlying mechanisms and protocols for how to best utilize blood flow restriction training if you choose to do so.

What You’ll Learn in this Episode:

  • [03:55] What is blood flow restriction training?
  • [07:45] The different ways to drive muscle hypertrophy
  • [14:32] Sarcoplasmic vs myofibrillar hypertrophy
  • [19:25] Where BFR training can be extremely useful
  • [22:30] Categorizing BFR in more of rehab setting versus a performance setting
  • [24:08] Loading the intended tissue
  • [28:10] Where BFR has the most impact on a trained population
  • [37:19] The three domains BFR training tends to work
  • [42:34] The importance of knowing your population
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Ryan L’Ecuyer: It’s so terrible. I love it.

James Cerbie: We did it. When I came down to Austin that first time, it was like, dude, James, I’m so happy you’re here, man. You want to go in the back where I have a legacy machine now, I’m going to conclude with you and let’s see how long you could last. Yeah, why not? Let’s do it.

Ryan L’Ecuyer: Yeah.  It’s just so good fun.  I love taking people through it because it’s like the first set, they’re always like, oh, yeah, this is cool. It’s like 30 reps. Who wants to do 30 reps? And then you finish, you’re like, oh, God, this is not going away. This feeling is not going away.

James Cerbie: Hey, friends. Welcome to Rebel Performance Radio, a weekly podcast for thinking athletes that want to be the total Package. I’m your host, James Cerbie, and each week on this show, we will distill the latest from scientific research and blend it with decades of practical under the bar experience to provide you with the no frills information and know how needed to turn yourself into a total package athlete. If you enjoyed the podcast, you can find out more about our coaching and training programs at jamescerbie.com. Thanks for tuning in. Hey there, team.

Welcome back to the show. This week, it is going to be the entire Rebel crew sitting down to have a conversation about blood flow restriction training. And in particular, we want to get after the following questions. One, does it actually work? Is there a significant outcome here that warrants you doing it or using it in your training? And so, we talk about, okay, what are the effects of blood flow restriction training on hypertrophy? What are the effects of blood flow restriction training on strength improvements? And where does blood flow restriction training fit in? Like a rehab or maybe an end season training setting? And then we obviously talk about some underlying mechanisms and then some protocols and how to actually best use blood flow restriction training if you do choose. So anyways, a really nice episode today. Top to bottom, answering the question, blood flow restriction training, should you do it? If so, how and why? Let’s dive in.

There we go. All right, we’re alive. The Five Horsemen are here to chat about blood flow restriction training today. And I think the biggest thing that we want to focus on is does it work? Is the outcome there? Because I think that a lot of times we start diving into research and literature, you can really get lost in the weeds. And so, I always want to start with what is the outcome or effect of these stimuli? And is there a positive outcome or effect that we are seeing? Research will then spend a lot of time trying to figure out why this thing gets the outcome. That’s mechanistic based research, which is very complex and very unclear. And then I want to focus on just giving you significant differences versus just doing like normal training? Is it worth adding to your training? What is it doing that just good training without BFR won’t bring to the table for you? And what are some protocols and practices and ways in which we can do this right? And I think one of the things that was actually funny in this when I was reading is that we’ll post some links to review papers and anything that we cite in the show notes here today.

James Cerbie: Is this something that you should consider using in your training? If so, how? Why? What should it look like? Because I think it’s a question I still get. Someone actually asked me about that the other day, one of my athletes. Hey, dude, what do you think about this blood flow restriction stuff like Chris Henshaw says he does it and gets a Jack Ryore. It’s like, okay, fair question, but let’s start here. Let’s just start like, what is blood flow restriction training? And I will defer to Mr. Wilson, because you’re the only human I know who travels and always has, you always have a blood flow restriction training device on you at all times. And so, I will let you kick off like, let’s just find this thing like, what is it?

What is Blood Flow Restriction Training?

Ryan L’Ecuyer: Yes, that’s not an exaggeration at all. I’ve read those fucking things with me everywhere. I read that when I go to visit my mom, just in case she wants to get Jack on the trip, like four. When I first heard about it, it was probably back in like 2010 or something like that. I think Wayne Norton was talking about it, and at that time, everyone was just wrapping elastic bands around their arms. And I did that, of course. And that worked to an extent, actually. I think that in terms of the effect that I was going for, which is mostly just discomfort, but there’s been a bunch of advances since then. They’ve definitely become easier to get a hold of. They’ve become cheaper. They’re still ridiculously expensive for what it actually is. If you want to get like a real pump and be able to know and monitor how much pressure you’re keeping in the cough and make it more educated than just do my fingers turn blue? Yes, or no? So, there’s a better way to do it now, which is cool. I can kind of let people know what I have. I have the H plus cuffs out of them that seem to work just fine.

They’re like the mid-range ones in terms of price. So, what is it doing? Basically, what we’re trying to do is just include the arteries to some degree. I’m sorry, not the artist really trying to include the venous flow. And we’re still trying to keep arterial flow to a degree. The question is, do you need to do that? Do you need cups to do that? The first thing I think to understand is that we’re always doing that when we’re doing weight training with a sufficient load and a sufficient intensity, we’re going to get restriction of those blood vessels and we’re going to restrict oxygen flow and CO2 flow out to a degree. So that’s the important thing first, and then it becomes in my mind more of like a practical discussion of when is it useful and is it useful, but just based off of. And of course, I’m going to approach this from my hypertrophy perspective, like I do everything in my life. And one of the things that we need for hypertrophy is we’re going to need sufficient tension and we can probably get some secondary effects potentially, or just like indirect effects with cell swelling and some of these metabolites that are produced and this low oxygen state at the local tissue.

And we’re definitely going to get all of those things with some type of blood flow restriction. We’re going to get the tension more in an indirect way because we’re going to end up fatiguing out a lot of those lower threshold motor units because they’re deprived of oxygen, essentially. And then we’re going to have to start recruiting the higher threshold motor units as we continue to carry out that exercise. So, we’re getting that mechanical attention in that sense. And then we’re most definitely getting this reperfusion and cell swelling effect, which has, I think, been noted to have an effect on hypertrophy in itself, just with that reperfusion of blood and what that does at the cellular level and the cycling pathways associated with that. So, we’re kind of getting all those things with this. But again, the question is, do we actually need to go out? Do I need to travel around with blood flow restriction cuffs every time I go to see my mother in order to actually get hypertrophy?

James Cerbie: Yeah. I think to summarize that up, really what we’re doing here, we’re taking some type of device and wrapping it around the proximal portion of your limbs, either your arms or your leg. Right. And we intentionally. Yeah, the most proximal thing we can get to. And if you have a cuff, you’re going to inflate that cuff. If you have bands or something else, you’re just going to tie in pretty tight. And we’re getting a little bit of arterial inflow. We don’t want to block that entirely. So, you’re going to have a little bit of arterial inflow. But the thing that you’re blocking is the Venous outflow. And so, when we think about hypertrophy, we know this exists on the spectrum and there are different ways to drive muscle hypertrophy. Right. We have metabolic stress, which is the accumulation of metabolic byproducts that build up in the local environment as you train things like hydrogen ions. So, we get PH change. There’s a ton of things that build up there. And so if you block the Venous outflow, and I’m not really bringing in much in terms of material, it’s like a trickle, then you have a very non oxidative acidic environment where all these things are really going to start to build up.

Right. So, you’re taking this metabolic stress factor and really jacking it up significantly higher potentially. Right. And then we also know we have tension maybe like damage, cell swelling, et cetera. But I think the thought originally with blood flow restriction training was maybe this is like an easy backdoor way into getting more high perturb than we would otherwise. Right.

Ryan L’Ecuyer: With really low loads.

James Cerbie: With really low loads. Right. We’re talking like 20% to 50% of your quote, like one rep Max type loads. Okay. And so, I think that if we were to start with the first question here, which is does it actually work? That’s the question that always matters. I think everyone wants to look at why this thing is doing this thing? But the first question that matters is does it actually work? Is there something here? Is there significant evidence that shows that this is doing something positive repeatedly? Right. And I think that there is. And so, it’s interesting, though, if we look at it, I think that you end up getting really similar outcomes and changes with regards to hypertrophy. If you do what we would consider more traditional hypertrophy training without BFR, and then you get the BFR approach where you went lower loads and higher reps and all that other stuff. It looks like the outcome where the gross type perjury is not really that different. They’re very similar. Right. Let’s maybe start there and see if that rings true to everyone else. Kind of based off of the reviews and things that we’ve read here, it looks like from a hypertv standpoint, we’re pretty similar.

It’s like you can either go heavier load eight to twelve reps, whatever it is, or you go lighter load with EFR, and you’re going to get about the same high perch fee outcome. It’s kind of what it looks like here. Is that a pretty fair statement?

Ryan L’Ecuyer: I would say so, yeah.

James Cerbie: Cool. Maybe.

Different Ways to Drive Muscle Hypertrophy

Lance Goyke: My question is so when I think about hypertrophy, I think about it in two different ways. I think about hypertrophy of the myofibrils and then hypertrophy of the surrounding fluids, the circle plasma hypertrophy. I would think BFR stuff would be almost exclusively circle plasma hypertrophy because of the cellular changes and fatigue that you’re learning to deal with. And so if you’re coming off of a training cycle where you’re doing heavier strength stuff, where you’re training six to maybe ten reps instead of eight to 15 reps, both of those are right in the wheelhouse of getting really good tension stimuli. But if I’m coming off of a mile fireball heavier thing, I’m probably going to see I would hypothesize at least that I would see more out of blood flow restriction stuff. And if I only did blood flow restriction stuff, I might hit this point of diminishing returns just like anything. It would be something to periodize. Does that ring true to any of you all’s experience?

Ryan L’Ecuyer: Yeah. We’re trying to keep this going for like under 3 hours.

Lance Goyke: So, I’ve never used it. And I had a professor in college right around the time you said 2010. He had just gotten back from Japan over the summer, and he had studied with the Katsu stuff. My understanding with blood flow restriction stuff is that it’s important to keep one the pressure of the resistance or the cuff, let’s say, to simplify it pretty standard so that it doesn’t change too much, though I imagine that might not matter all that much.

And it sounds like you get the more expensive system instead of wrapping a band around your upper arm just in order to do something like that. Is that true?

Ryan L’Ecuyer: Yeah, I think if you have access to those costs, that’s going to be a much more accurate tattoos, like the first person doing. And I think at that time it wasn’t even blood flow restriction. They were just calling it inclusion training, but I think that they were including both arterial and Venous flow.

Lance Goyke: Oh, really?

Ryan L’Ecuyer: Is that right, James?

James Cerbie: I would have to go back and read that. I think that if you look at something. Yeah, if you look across, I think the time scope of all the literature, you have a pretty wide range with regards to the protocol being used with how much the thing is being inflated. Because in a lab setting like that, in the lab that we had, we would totally stop RTO info. I mean, we weren’t doing blood flow restriction training. You would look at things like flow mediated dilation, which basically you throw a Doppler on a brachial artery and you put a pump on here, and you inflate it to super systemic blood pressures, and you totally stop all flow coming in, and you can see it on the Doppler. Like, there’s literally zero flow. And you watch the artery start to expand because it’s trying to be like, hey, bro, I need some blood and oxygen. Hook me up. And so, you literally watch the thing in Docker start to get bigger, and then you let the cuff off and you get this massive inflow of flow, and that artery just, like explodes. It dilates like crazy in a healthy population, at least if you look at how much it changes.

And that’s a pretty good indicator of cardiovascular health. But yeah. So, you have, like, in lab settings, you just tap a number on a thing and hit a button and just like, you get no arterial and flow. That’s not really, I think what we’re going for here with the blood flow restriction training, you’re really just trying to block the Venus. And the Venous pressure is pretty low compared to the arterial pressure.

Lance Goyke: So, is your cuff at like 80 90 then?

Ryan L’Ecuyer: So, what I’ve been doing, what I’ve read recently is more that you’re going to pump it up until you get an arterial restriction. And you’ll know that you have that by losing that. If you have a Doppler unit, you’ll lose that pulse, and then you’re going to do a percentage from there. And I think that can be a pretty wide range. So, say it takes you to pump it up to 200 Mercury, and that’s when you restrict flow, then you’re going to take maybe up to 70, 80% of that. And then that just kind of becomes your number, and you’re going to keep that on throughout the entire protocol. And then when you release it, you’re going to get that repercussion of blood. Just that shearing force against those arteries coming through. Like that might be hypertrophic just in itself. And I think that’s probably why we see some amount of hypertrophy and people that just put it in bed rest, like they’ll just put cups on people for 10 minutes or whatever, and at least some and they have less muscle loss during that period. I would guess that has something to do with that, along with just the metabolic production.

Because the question about Sarcoplasmic versus myofibrillar I look at Sarcoplasmic as and this may be inaccurate, but this is just kind of how I’ve constructed it in my mind. I think of the Sarcoplasmic stuff as being more energy related because it’s going to be more like glycogen and glycolytic enzymes and maybe even like Sarcoplasmic reticulum and that type of stuff that might be getting more into like a myofibrillar side at that point, I suppose. And then the myofibrillar adaptations are probably coming more from tension-based stuff. And when you’re like bedridden, you kind of have neither one of those things happening. There isn’t like a ton of energetic stress and there isn’t a ton of tension, but there is probably this reperfusion effect to answer that initial question. I believe that to be the case. I think that there probably is more of like, when I program it in for myself personally, I’m thinking of it as more of a metabolic stressor, and I’m getting some indirect myofibril stress for sure, because I am having to recruit those higher threshold motor units. But I think the energetic demand is probably higher than that. But I don’t have any way to prove that whatsoever. That’s just kind of how you think that literature really exists.

James Cerbie: I don’t know.

Lance Goyke: Go ahead.

Sarcoplasmic Vs Myofibrillar Hypertrophy

James Cerbie: I’m not aware of any literature that’s parsed out whether or not it’s coming from this more Sarcoplasmic or myofibrillar approach for hypertrophy and for people listening. If those two words like, what the fuck does that mean? We’re basically just saying, are you adding more muscle fibers or you’re just putting more fluid into the muscle itself? And I’m not aware of any. And I could be wrong because I haven’t spent a ton of time on PubMed really trying to go Ham on this. I’m not aware of the differences but I think as a potential mechanism, something that could be a counter argument to that is one way that they think blood flow restriction training is working is like the fact that I’m not really getting much oxygen in. And you have group three and four, a variant that feedback to the brain that starts shutting down these slow touch muscle fibers that fatigue faster. So, you start typing into these higher motor units quicker. And so, if that’s the case and I’m using the higher end motor units more than you could potentially be getting some of that myofibrillar hypertrophy from that. But I would think that if you asked me to have to sit down and make a bet on which of the two do I think is probably.

Ryan L’Ecuyer: Contributing more like Google Fiber and no, they don’t.

Lance Goyke: I was going to say the same thing, though. I thought the same thing that James was saying just based on what you said, Ryan.

James Cerbie: But if that right now is being proposed as a potential mechanism, then I could see it having a myofibrillar approach because you’re recruiting those higher end motor units that we know have capacity to have more of that type of response. But if I was going to have to make a bet, I would probably bet more of the sarcoplasmic just because when I think about the metabolic stress side of the coin, that’s where my brain goes. And so I’m sure you’re probably getting both right.

Ryan L’Ecuyer: Yeah, you’re probably getting both separate.

James Cerbie: It’s probably just like a dimmer switch. It’s like maybe you’re getting like a 70, 30, 60, 40 split off of it. And I don’t really know. I don’t think anybody does or no one can probably say that with enough confidence. But yes, because I think one of the studies here, it was like Lowry at all in 2013, Ryan, this one’s right up your alley. They were doing heavy bicep curls. Yeah, I’ve heard of them. They basically had two groups. They had a group like they took a baseline for biceps Brachii muscle thickness. They took a baseline measure, and then for the first four weeks, half of the group was doing blood flow restriction training. Half of the group was doing what we consider normal hypertrophy training. And then they remembered. And then for the second four weeks or eight weeks in total, they flipped the groups. So, one group went blood flow restriction to just like traditional higher intensity, and then the other group went higher intensity to then going to blood flow restriction. And both groups saw significant improvements in biceps Brachii muscle thickness compared to baseline. But there’s no difference between the two groups at either metric at four weeks or eight weeks.

And so that’s some of the evidence that’s looking to the fact that both of these things work. They’re both driving hypertrophy in one way or another. But it doesn’t look like there’s not a significant difference between the two approaches. I think that’s kind of an important thing for people to realize or understand. It’s just another tool. It’s just another way for us to help drive hypertrophy, because a lot of the people doing this research, like you’re trying to figure out how to take people who don’t like to lift and don’t want to have to lift heavy weight and don’t have to suffer it’s like how can you do this?

Ryan L’Ecuyer: Or they can’t because of an injury or some type of thing from doing that. That’s where I found it to be incredibly useful. And I think this is probably where like Kieran and Ryan Patrick could chime in because you’re going to have athletes that are injured. What do you do when you still want to get a training effect? Like this might be a reasonable option, yes.

Keiran Halton: Now that I’m outside, I have a brief window of no planes flying overhead. I’m also next to a local airport. It’s just like picking the worst spot today. To your point. I think that’s probably the biggest use for it is that return to play scenario where we got a couple of cross guys who just wrapped up the Championship and they’ve been kind of playing injured the whole time. And now you see them all in like the boots and things like that, where they’re out for probably most of the summer. So now we start having these conversations with some of our athletic trainers about how we continue to work through the summer and try to keep as much of the strength and hypertrophy as we can. And I think that’s a great way to start to implement it. Right. Just super simple stuff like that.

Lance Goyke: Ryan Patrick, do you have anything to add?

Where BFR Training is Most Useful

Ryan Patrick: No, I don’t. On top of that, the BFR admittedly is not my wheelhouse. So some of the things that I would probably encourage us to touch on would be kind of the pragmatic standpoint in terms of implementation. So I know we’ll probably dive into that before the end of the pod. But to the point, especially with athletes, they’re not just cleared from physical therapy is one thing when they’re able to train. But a lot of these athletes have a very short window in terms of them getting back to top tier performance. And we’re talking about the highest force outputs. We’re talking about extreme velocities and force through those tissues. So if there is a way that we can manage that or at least mitigate some of the downtime in the Atrophy, because I mean, disused, especially when we talk about somebody in a hospital that even just the ability to walk around and move retains so much more muscle mass. But when somebody is isolating a limb or they’re completely immobilizing it that Atrophy is so, so quickly. And then you’re trying to balance two things. You’re trying to bring one side up and still bridge that gap to performance so I think over time there’s going to be a lot of utility with this.

Keiran Halton: And now it’s definitely got me a lot more interested in how we can use that.

Lance Goyke: I haven’t used it a whole lot as a part of my prescribed training protocol. But if somebody has something like, I’ve got a rebel client who’s got them, I’m like, this is a great way for you to add some volume without wearing down your system so much. You’ll still get that sick feeling that will give you some sort of good stimulus. The other use case that I thought of was I had a guy that I trained at Google who could not bend his knees, like, could not do squats. He could do all of those things, and he probably wasn’t quite as bad as he felt like he was. But he’s just like, my knees are bad and I can’t do this. So it’s really hard to convince them to train quads and something like this would be much easier. I might even be able to get them to do some body weight stuff, give them an annoyingly long set, I think. But you could get some stimulus.

Categorizing BFR in More of Rehab Setting Versus a Performance Setting

James Cerbie: I think in rehab, we kind of like bucket this, right? I think there’s two ways we can have this conversation. It’s using blood flow restriction and more of a rehab setting. And then there’s trying to use it in a performance setting. I think we have to try to categorize it in one of those two worlds. And it’s like, okay, well, in the rehab setting, we do have some pretty positive evidence in the literature because you have stuff like showing that not even exercising, just throwing like, Ryan, you mentioned this already. Just throwing an Occlusion Cup on for 5 minutes without exercise, significantly decreased muscle atrophy of both quads and hamstrings and post operative ACL reconstruction. That’s pretty sweet. Like, you literally aren’t doing anything. You have a mobilized limb, and all I have to do is put a cup on and occlude you for 5 minutes a couple of times, and you’re going to lose weight. That’s pretty cool, right? And then you have stuff where you do, like, low load BFR training to get muscle and strength back faster and like a post ACL reconstruction environment as well. So I think there’s definitely tons of support here on that rehab side of the world.

It seems like a total no brainer. Like, if you’re injured, if you’re coming back, if you can’t go chase load for some reason, it just seems like a totally obvious low hanging fruit. Like, why is everyone not doing this in that setting? But then if we go to the performance setting, I think we’ve adjusted the fact that it’s another option for us to drive hypertrophy, but it doesn’t look like it’s going to be any better or worse than what would be more like traditional higher load hypertrophy training. Because at the end of the day, the metric that probably matters the most for hypertrophy is just like the number of sets you do that suck. That’s like a really rough cursory, right? That’s probably the greatest predictor of hypertrophy. We have. The number of total sets you do that suck, that are at an eight.

Ryan L’Ecuyer: RPE or above are probably intended tissue.

James Cerbie: Yes. With Loading the intended tissue. That’s where.

Ryan L’Ecuyer: Yes, that’s where I think the BFR can be really useful. So, the traditional BFR protocol that you’ll see in the majority of the research now people are starting to get a little bit crazier, which is super fun to watch. But the traditional protocol was like, take 30% of your oneRM of your leg extension and hit like 30 reps to start. Take a 32nd rest, hit 15 reps, 32nd rest, 15 reps. 32nd rest, 15 reps. Right? Yeah, that’s the traditional protocol.

James Cerbie: Yeah, that’s the protocol. Okay.

Ryan L’Ecuyer: So that’s cool. But who can’t do a leg extension? Pretty much everyone can do a leg extension. And you could do that with heavier weight or lighter weight or whatever. And I think it’s going to be a very similar response. I think the major thing that’s changing during that protocol is that you don’t get that kind of reprieve in between sets. Like, it’s almost worse in between sets. If you’ve ever done this protocol before, it’s so terrible. It’s so terrible. I love it.

James Cerbie: We did it. When I came down to Austin that first time, I was like, yeah, dude, James was so happy you’re here, man. You want to go in the back where I have a legislation machine now, I’m going to block you and let’s see how long you can last. I’m like, yeah, why not do it?

Ryan L’Ecuyer: Yeah, it’s just so fun. I love taking people through it because it’s like the first set, they’re always like, oh, yeah, this is cool. It’s like 30 reps. Who wants to do 30 reps? And then you finish, you’re like, oh, God, this is not going away. This feeling is not going away. And it kind of freaks people out, which I think is pretty cool for a lot of reasons. But in my mind, on the leg extension, that’s cool. That may be pushing us further than we would normally be able to go. And on a Lake extension, you could definitely make the argument that it’s a little bit of a weird hole on the ACL potentially. I don’t know if people still really believe that to be the case, but I can see that if you’re trying to really match leg extensions at some point, that could not feel good. But I think where it could actually really be interesting is with exercises where because when your leg extends, your quads are the limiting factor. It’s never like your back or something. Right? But a lot of our lower body exercises, it is something else. That’s the limiting factor.

Loading the Intended Tissue

Like, if we think of a squat. It’s typically not just the quads that are the limiter there. Just holding the position is the limiter or holding the thorax and pelvis in a way that the quads can actually work really hard. That becomes the hardest part of the squad. So, I might be able to squat four or five for ten reps, but the main thing is that which I can’t, by the way. But the main thing that’s limiting me is just being able to hold a position. Like my quads are kind of like they’ve been done since rep three or whatever. They’re not even able to really work that hard because I’m having to leverage my hips at this point. So, using something like BFR and a squat could be really cool because now you can reduce the load a ton to the point where holding the position is actually pretty easy. You could do that with 135, but now your quads are just getting no rest at any point in time. And I’ve done that. I have protocols that I’ve used with squats with BFR that are just so gnarly and at least from what we’re looking for in the acute sense, it’s like that feeling of working really hard and like the local tissue, working really hard and not getting a bunch of accessory muscles and discomfort in other places.

I think that could be really cool. So that’s something I’ve used myself a lot personally, especially when I’ve had, like, issues with other where I couldn’t load my back was fucked up or had any other thing going on. Yeah, that’s been really useful.

Where BFR Has the Most Impact on a Trained Population

James Cerbie: I think one of the things in the performance realm here to tack onto that when we start talking about our big lifts, this is actually surprising to me because I wasn’t fully expecting this. I remember when I first started thinking about blood flow Tricia a while ago. With the way the literature sits right now, if you actually look at trained populations, because you have to always take that into consideration. What population are they studying? Are we training? Is this like, well trained people, untrained people, sick people, bedridden people, that always totally changes the game. But if you look at a trained population, the place for blood flow restriction looks to actually have the biggest impact on strength, which is super interesting. There’s a pretty substantial amount of evidence that shows that when you add blood flow restriction to your heavy training, you see significant improvements in strength and squat and bench in particular. No one’s really looked at deadlift because it would be kind of awkward thing to look at, I think. But in the research, a lot of people looked at squat and bench and you see that they’ll do their typical do like three sets of five of typical heavy lifting and a big compound movement, and then they’ll hit back offsets with blood flow restriction.

Like a group will hit back off sets with blood flow restriction. Another group will hit the same back off sets with no blood flow restrictions. So, you at least are equating total work and volume. And then you have a control group that’s doing no back offsets. And you see pretty consistently that there’s at least a statistically significant improvement in strength in like a three or a five rep Max, for example, or even a one rep Max in squat and bench. And the group that does back off sets with blood flow restriction versus the group that doesn’t, or the group that does not back off sets. And we can link to all these Cook from 2013 showed something like that. Louvers, in 2014, trying to keep all my stuff over here, my iPad organized. Yes, we’ll link to a lot of these. That evidence is pretty substantial, which I thought was super interesting. And that’s like the way that I think about it and the way that I’ve seen it referenced that I like is it’s kind of like free training volume because you’re not going to get the really big muscle damage. You’re not going to have that crazy soreness the next few days.

It’s just a low hanging fruit free volume for people, which is dependent on how you do it. Yes, it’s going to suck, don’t get me wrong. But I think that hitting back offsets.

Ryan L’Ecuyer: At say, 30%, stomach fatigue is lower.

James Cerbie: Yeah, hitting back offsets that say 30% versus doing more very high-end work. I thought that it was super intriguing that you consistently see strength improvements across the board. So, from a performance standpoint, it’s like, okay, maybe that’s a tool worth really considering using during different phases of training. It’s like if we do say like an EDM protocol, for example, with that estimated daily Mac, it’s like, cool, maybe I’m going to do my EDM to my top set normal, and then I’m going to hit my back off sets of blood flow restriction, or half the back offsets will be author or half won’t. But that’s where it looks to be like the best tool is improving strength.

Ryan L’Ecuyer: Yeah. My first question would just be I would want to know what the proximity to the final testing day was, because it’s possible that it could just be carrying more fatigue in general going into the retest, but I would imagine that they probably haven’t looked into those ones. I probably have at some point. It’s just been a really long time. But that would be my first question. But I think at the very least for where we’re at right now, it seems that it’s not going to be any worse. When I’ve done these protocols and I’ve had people do them, it’s so terrible while you’re doing it. But to your point, you’re not carrying a ton of fatigue afterwards. You’ll get sore from it like the first few times you do it. But it’s not the same as doing another five sets of regular squats in terms of what that’s going to do to the rest of your body and just your whole system. The blood flow, the blood pressure restriction stuff can just be a nice way of really training hard in that moment but then not carrying so much of that with you for the rest of the session or for the rest of the week.

And yeah, I think that there’s a ton of value in that.

Keiran Halton: I think that’s going to have a lot of value for the athletes too, because they’ve got so many competing commitments in terms of where they have to allocate their output. So if we can get something that doesn’t have a huge systemic load but provides the effect that we want, I think that’s going to be really valuable for somebody who’s got to do running and competition and sport practice.

James Cerbie: That can make a lot of sense in season, folks. Dude, for maintenance, I got the first place my mind goes in this category. You got any competitive athlete that’s in season that seems like a really nice way to maybe maintain and hold on to things without them having to touch higher end loads potentially.

Ryan L’Ecuyer: Yeah. Very low cost.

Keiran Halton: This is kind of random, but I always think of the old school bodybuilders. They kind of seem to have found the fountain of youth with some of the higher rap traditional training where they’re really focusing on the muscles. I think part of it is they’re just not destroying themselves with weight all the time. And this could be another way that kind of enhances that effect. So I think about if you can get the same ROI and you have a periodic cycle where maybe you’re doing BFR for eight or twelve weeks, you’re using lower loads, there’s got to be some benefit in terms of joint stress or just overall kind of Ryan, to your point that’s systemic fatigue, that I think just really beats people up over time.

James Cerbie: Yeah, I would very much agree with that.

Ryan L’Ecuyer: Absolutely. If you guys are cool with going to a place that has zero evidence supporting literature at all, like I can give a few anecdotes.

James Cerbie: Yeah, I love anecdotal evidence. Anecdotal evidence is a leading indicator, dude. Research happens because enough people have anecdotal evidence.

Ryan L’Ecuyer: Yeah, fair, right. So the way that I’ve utilized it a lot of times in people and I guess this would be kind of more like a rehabby type of setting, I suppose in a sense. But I’ll use myself as an example. The two times that I’ve really utilized it a ton was because I couldn’t squat anymore. I was having this issue where my lateral quad was probably just from doing really powerless style squats where you end up rolling on the outside of your feet and really biasing a lot of that lateral quad tissue. And it would just get to the point where it was so painful, it just felt like it was just going to pop and I’ve actually had times where I would feel like a pop, and I was like, oh, wow, now I can’t bend my knees anymore. Like, this really sucks. I had a period of time where I couldn’t squat for, like, nine months. I couldn’t do any real direct squad training. And that was the thing that got me back into it. And I think that when you have an injury, maybe there is some type of physical damage that actually takes place.

Like, maybe you do tear a muscle, but eventually that thing, whether it’s through surgery or just kind of on its own, it kind of repairs itself or things work around. I don’t know exactly what goes on, but it gets better. But you might still have the pain, and a lot of that pain at that point is just really your brain holding on to that memory of that injury. It’s protecting itself from injury in that area again, but there might not actually be anything wrong with that tissue at this point. So after nine months of having this pain in my quad, it’s like I don’t think there’s anything really going on there anymore as far as there’s no bruising, there’s no swelling, there’s nothing that would appear to be wrong, but I still can’t do this thing. So using the blood flow restriction in my mind was kind of the only thing that I could do. But I think what it did is just created a more immediate threat for my brain than this memory of this painful thing. And so, you take away the majority of the oxygen of the tissue. And James, you said this plenty of times.

That’s going to send off some alarms. Like you’re going to have those affairs signaling going back, like the biggest alarm signals. Yeah, that’s the problem. You’re going to focus on that. So, it makes it very difficult to think about this other thing. And it’s like, as you’re doing these reps, it’s like, wow, I really don’t feel this lateral quad thing anymore now. I just feel like what I like feeling when I train, and it just reinforces that this is this thing that you can actually do and it doesn’t hurt and you enjoy it again, and you’re getting at the same time this kind of endorphin and catecholamine release. And that would be my theory of why it works so well. And I’ve used this with plenty of people, people with, like, knee pain or back pain, and that’s kind of the intervention. I don’t really think there’s anything wrong with your back. I just think every time that you do a squat, because we fix the squat, like, the squat looks good, and there’s nothing apparently wrong with your back. It’s just that every time you do it, it hurts. Let’s just provide a completely different stimulus and threat that’s way more immediate.

And all of a sudden, they start doing this squat again and reinforcing it with a ton of reps and then it’s like they’re off to the races and at the same time they’re still getting some hypertrophy and probably some strength along with that. So I found it incredibly useful for that. I think it’s probably more useful for lower body than it is for upper body for that reason, because you’re usually not like super limited upper body wise with positions and all that stuff. But I don’t know. That’s just my anecdote and why I’m unofficially a salesman for these BFR cuffs.

The Importance of Knowing Your Population

James Cerbie: Nice guys. This is good. Let’s kind of recap this. I think it may give the big takeaways for people listening. So, I think that there are three big takeaways here. On the first question, does it work? Is there an outcome here that’s even significant? And the answer to that question is yes. And I think it happens in three domains. I think one, it looks to be about as effective as more traditional heavier load hypertrophy training, but it’s not going to be any better. This will be about on the same plane, not as effective. It does look like it creates a significant improvement when added to strength training. So if you have like your heavier sets of strength training and you add back offsets with BFR, you are seeing significant improvements in squat and bench strength, which I think is super intriguing.

Ryan L’Ecuyer: Quick question on that. Do you have the protocol right there? What did they do for the back office? I’m just curious how many reps they’re doing, because I don’t think they were doing 3015, 1515.

James Cerbie: So, it’s not 30 1515. But I’ll send it to you.

Ryan L’Ecuyer: I don’t think you need to. No, it’s fine.

James Cerbie: Now I’ll pull it up here and I’ll send it to you afterwards. I don’t remember. We’ll link to all that in the show notes if people want to really dive in and go look at the specific protocols. But yeah, I can show that to you once we’re off air here. And then I think thing number three is that it definitely has great application in this more rehabby setting where if we have a pain issue, if we have an injury issue, we can’t train traditionally, then it’s like the Occlusion is playing a huge role in decreasing atrophy, which means that return to play is going to happen significantly faster. Right. Or in the anecdotal evidence using it. If I have some pain of some kind to continue to train and get me to a point to be able to do this thing again, pain free, baby. Right. So, I think those are the three big avenues where you feel like, hey, this thing’s definitely working in terms of mechanisms, why is this thing working? Who really knows? There’s like eight to ten different hypotheses of why this could be working. It’s probably a combination of all of them.

Metabolic stress, recruitment of type two fibers, growth hormone stuff. Obviously, like mTOR. Somewhere in here we’re changing signaling pathways and it’s like cell swelling. Who knows? Probably some combination of all these factors and the mechanisms gets super interesting. But it’s like it’s not going to change what I practice or what I do. Okay. And then I think that from a protocol standpoint, yeah. You got to dig into the research a little bit. The most classic protocol is at 30-15, 15-15. And again, I have to pull up the ones on the strength studies. I don’t remember what they were off the top of my head. I read those this morning, actually. Yeah. It’s kind of all I got here. So, it’s worthwhile to consider adding it to your training with the three things that we have mentioned. Did I miss anything?

Ryan Patrick: So, Monday, I want to walk in and I’m like, this all sounds pretty cool. I don’t have the Kaatsu cuffs, but I just want to play around with this practically. Would you be like, hit a drop set of bicep curls at the end of Monday’s workout and just like, use some knee wraps to like a six out of ten pressure or how would you approach somebody’s first time messing around with it?

Ryan L’Ecuyer: I would say if you’re using it in a training setting from a liability standpoint, I probably wouldn’t mess around too much with the reps. I don’t know. In that review, they were talking about potentially doing something where you can base it off of the discoloration of the hands. And if it’s like, if you get the response you’re looking for, then I don’t know that I’d mess around with that too much. You could also, if you had access to an ultrasound or even a stethoscope or something, you could take that brick already and then reduce from there just so it’s not like completely random. They do also make wraps that have numbers on them so you can at least somewhat keep it the same. But I don’t know. I think the better way to get that is like, you can still do blood flow restriction. You’re always doing blood flow restriction training when you’re doing hypertrophy training. So what I would do is just use a similar protocol and then just don’t go to full muscle lengths. So you’re doing a bicep curl, maybe just don’t go all the way down to the point where you’re getting any kind of relaxation at the bottom.

And yeah, you could use some type of drop set like that and just keep tension on the muscle the whole time. Just keep it in that mid-range. And I think you’re going to get, like, a similar feeling from that. And I don’t know if it’s going to be the same outcome, but that’s probably how I use it. I don’t know, James, do you have any ideas on that?

James Cerbie: I guess a little janky sometimes that’s kind of tough. It’s like, I don’t know.

Ryan L’Ecuyer: You haven’t done it.

James Cerbie: Yes, I would do it for myself, but from a coaching standpoint, you got to really be tight with whoever you’re going to do this with because you could bruise out of it like there are some places that may not go so well. So probably try to find some cuffs or things you can inflate that are not going to rip skin and leave you terribly Blues and torn apart. You could definitely j.org it together potentially. I’m not going to recommend you do that, but you can use knee, sleeves, wraps, etc. Just get stuff tight wrapped around a limb like it’s going to be doing something.

Ryan L’Ecuyer: It’ll work. Yeah.

James Cerbie: I mean, I think the only other thing to mention here is and we haven’t said this because it’s not really the people that listen to this or our population. The only time I think that you have to keep an eye on the blood flow restriction type stuff like anything is when you have compromised populations. Right. If you have people that have some type of cardiovascular disease, if they’re heart concerns and issues, they’re not really who we work with, not people that listen to this. I’m just going to throw that in there as an asterisk anyways. Like knowing your population. A high-risk population is a high-risk population. Training for them is probably a risk. So, you just gotta keep that in mind and know yourself. If you’re hypertensive and you have really high blood pressure, this is something that you definitely want to go chat with the doctor about before you start using because you’re going to get a big exercise pressor reflex and all this other stuff happening. So yeah, if you happen to fall in one of those buckets, like do your homework to talk to a doctor. But for all the healthy folk listening, which is probably 99.9% of you, there’s nothing I see here from a health concern standpoint that would keep me from having anyone do it other than just having access to something to do it.

James Cerbie: That’s not going to be like wrapping a band around my arm and then I get like just bad bruising or whatever it potentially would be from the implement used.

Ryan L’Ecuyer: Yeah, I don’t think there’s a huge consequence. I just don’t think you want to get yourself into any issues working with clients or coaches or athletes.

James Cerbie: All right. Sweet. I hope everyone found this useful. Found it helpful. We’ll throw links to references and stuff like that and show notes. If people want to go read that stuff and look into it more, they can. But yeah, it’s all we got for you guys and gals this week. Hope you have a fantastic rest of your week and we’ll talk to you next Monday.

Ryan L’Ecuyer: Thanks, guys.

Keiran Halton: Thank you.

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