Personalized Blood Flow Restriction Training In Rehabilitation

What’s BFR and why is everybody talking about it? Can it help you reach full recovery after injury faster? Can it help you prevent muscle wasting after surgery?

In a nutshell, Personalized Blood Flow Restriction Training (PBFR) is a way to increase strength or endurance without stressing the injured tissue, using light weight or slow movement. It uses a special tourniquet system on the arm or leg which, when inflated, limits arterial blood flow and significantly reduced venous return of blood. This occlusion stimulates muscle hypertrophy and endurance. Sounds like magic, right?

I have been hearing about PBFR for a couple of years now, being skeptical and careful because even a small mistake while working with elite athletes can set them back and negatively affect their career. I did not want to jump on just another fad in physical therapy and rehabilitation. 

So, I have been resistant to use it with my clients until I felt I understood it, it’s rationale and research behind it, background, implications, and precautions. If we can improve the rehabilitation process for a lot of people while minimizing overall stress on their bodies, it made sense for me to explore PBFR into more depth. I was ‘cautiously optimistic’ until I met Johnny Owens of Owens Recovery Science ( and the brain behind Personalized Blood Flow Restriction training. From then on, I went all in and saw an excellent response in rehabilitation progression – including decreased pain, excellent muscle mass gains and strength, and a gradual return to pre-injury sporting activities. 

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What is personalized blood flow restriction rehabilitation? 

It is not a new concept; it has been used for many decades in Japan. Only recently, orthopedic surgeons, physical therapists, and athletic trainers began to utilize it to help patients to heal faster and return to sports and physical activity. The concept is surprisingly simple, but the equipment is advanced to make the process safe. Practically, a wide cuff with is placed on the arm or leg, as close to the body as possible and inflated. These tourniquets have an internal Doppler sensor, that keeps the inflation on a precise, predetermined level to receive the best and safe benefit. The system is personalized to the individual. When inflated, the tourniquet limits arterial blood flow to the extremity and restricts venous return. The person then performs several sets of light resistance exercises or does a light aerobic workout. Because of the limited blood supply, the brain (and glands producing hormones) is triggered to respond to this situation of hypoxia and produces hormones that promote protein synthesis and muscle hypertrophy.  

​It is a way to allow the body to adapt – physiologically and metabolically to the imposed load, without the detrimental effect of heavy lifting and high load (when precautions are present after surgery). The exact mechanism behind the positive results seen with PBFR is still being extensively researched. Theories range from a significant build-up of metabolites by anaerobic metabolism, a systemic anabolic response and cellular swelling. It is most likely a combination of multiple factors. It does appear that muscle protein synthesis plays a primary role as this has been consistently demonstrated in the literature. More to read here:

PBFR consistently demonstrates greater results compared to work matched controls exercising without PBFR. The positive results have been seen in patients after injury, in the elderly, and in athletes. It has also been applied extensively in a military rehabilitation setting on severely compromised patients.

Is PBFR Safe?

PBFR has consistently demonstrated to be a safe modality in the literature. It has been performed on thousands of subjects in the peer-reviewed literature with little to no side effects. The occlusion pressure and time of the occlusion is carefully monitored by the unit. It prevents from over-inflating the cuff while providing the best benefit.

What does this mean for physical therapists in clinical settings?

Several reasons: after surgery, the patient is usually on some type of precautions, whether weight bearing or lifting limit. According to American College of Sports Medicine, muscle strength gains and hypertrophy happen when lifting heavy (more than 65% of 1 RM) for a period of 12+ weeks. This is oftentimes impossible during the earlier post-surgery phase. With PBFR, the patient can create significant strength and hypertrophy gains with loads as low as 20% 1RM. PBFR allows the clinician to begin the strength and hypertrophy phases of rehabilitation much earlier. PBFR has demonstrated statistically significant improved patient outcomes after anterior cruciate ligament surgery both acutely and chronically.
Very compromised patients suffering inflammatory muscle wasting diseases such as polymyositis and dermatomyositis have also demonstrated positive results without any potential safety risks.
It has also demonstrated improved results in patients who have suffered severe musculoskeletal trauma
and in women with risk factors for symptomatic knee osteoarthritis

What kind of device can be used for Blood Flow Restriction Training?

The Delfi BFR unit with cuffs. Image credit:

The Delfi BFR unit with cuffsSafety is always first. There are BFR cuffs and devices that are being used in gyms, such as straps or thin inflatable wraps. While these devices provide some compression and blood flow occlusion, it is difficult to regulate the exact pressure. Pneumatic tourniquets are classified and regulated “Class I” devices by the FDA. It is strongly recommended, that clinicians use a device that has been listed with the FDA and indicated for PBFR use specifically to ensure safety with use, especially when being applied in clinical settings where persons have comorbidities. Here, risks inherently increase and using a device such as the Delfi PTS System helps to reduce that risk to both patient and clinician.

Bottom Line

Can this be the future of rehabilitation? Can BFR help everyone? Likely not, but it is a promising tool to help people who are ‘stuck’ in their progress, who are unable to use other rehabilitation tools to the full extent because of pain and/or weakness. PBFR is now widely used in Lower 48 for rehabilitation after orthopedic surgeries and to prevent muscle atrophy, but it is still barely making its way to Alaska. 

I urge clinicians to explore this option to be able to help our patients better.


What is PBFR? Personalized Blood Flow Restriction Training is a way to physiologically and metabolically stress the muscle using specialized blood flow occlusion cuffs to allow for safe adaptation and muscle gains. What are the benefits?

  • Potential to decrease musculoskeletal pain; the effect can last from several hours to about 2 days, creating a ‘window of opportunity’ for an athlete to progress in his/her rehabilitation or training with decreased pain. 
  • Provides anabolic (muscle synthesis) benefit with very low load – approx. 20% of 1 repetition max (1RM) will provide similar effect as lifting heavy. This is especially important when the athlete cannot lift heavy or weight bear due to postoperative precautions or pain. 
  • Slows down atrophy after surgery (disuse atrophy)
  • There is a potential to increase cardiovascular endurance
  • Potential with faster bone healing (big studies are going on at this time)

Do you want to learn more? Please contact us, we would be happy to answer all of your questions.
Helping recreational and elite Alaskan runners of all ages to return to running safely, effectively and pain-free …for life.


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