How Can Personalized Blood Flow Restriction Be Used Safely and Effectively to Accelerate Rehabilitation After Surgery?

Two significant peer-reviewed articles on Personalized Blood Flow Restriction (PBFR) were published this month in the Journal of Arthroscopic and Related Surgery. The Journal of Arthroscopic and Related Surgery is the official journal of the Arthroscopy Association of North America (AANA), and is read by many orthopaedic surgeons. The contributing authors are two well-respected and accomplished orthopaedic surgeons.

The first article is a guest editorial written by Dr. Brian Day, a past President of AANA, titled “Personalized Blood Flow Restriction Therapy: How, When and Where Can It Accelerate Rehabilitation After Surgery?” [1].

The second article is a paper entitled “The Role of Blood Flow Restriction Therapy Following Knee Surgery: Expert Opinion” [2]. The corresponding author of the second paper is Dr. Robert LaPRade, Chief Medical Officer at Steadman-Philippon.

The papers address current guidelines for clinical use post-surgery and highlight the existing gaps in the literature:

There is increasing amount of evidence showing Personalized Blood Flow Restriction (PBFR), in combination with low-load resistance exercise, may enhance and accelerate the recovery of muscle mass and strength after surgery or injury [1]. A key study has shown that short-term low-load resistance exercise with BFR leads to marked proliferation of myogenic stem cells and myonuclei, accompanied by substantial myofiber and hypertrophy [1]. Further, it has been theorized that “the use of BFR can lead to the preferential mobilization and synthesis of type II muscle fibers that are correlated with muscle hypertrophy and strength” [2].

The benefits of PBFR after arthroscopic knee surgery includes reduction of postsurgical pain, significant improvement of muscle girth, function, and quadricep flexion and extension strength [1]. “Case studies of patients whose initially prescribed rehabilitation programs were ineffective at returning full strength and function have similarly demonstrated significant improvements in quadriceps strength, peak torque, and knee flexion and extension, and successful return to their active daily living and work-related activities” [1].

However, while its effectiveness is well demonstrated, inconsistencies exist in how the therapy is delivered. In some instances, “equipment not meeting medical device standard is being used by non-healthcare practitioners with little or no training; in other instances, nonproven instruments and cuffs with non-personalized blood flow restriction pressures and inconsistent precools, are employed” [1]. “A recently published review of reported side effects and safety considerations concluded that the therapy can be used safely in most patient populations if surgical-grade tourniquet equipment is used, but that it is essential that the therapy is prescribed by a trained practitioner who uses clinical judgement, with knowledge of the appropriate protocols and possible contraindications, and who maintains personalized restrictive pressures” [1]. DePhilloipo et al. recommends [2]:

  • Use wider tourniquet cuffs. Narrow cuffs may increase complications such as increased pain post-treatment.
  • Use personalized restrictive pressures based on limb occlusion pressure to provide patient specific therapy. Non-personalized restrictive pressures may exert excessively high-pressures and high pressure gradients which may cause complications such as nerve injury and limb ischemia.
  • Use limb protection sleeves to prevent pinching and wrinkling of the skin under the tourniquet cuff.
  • Apply the tourniquet cuff to the most proximal portion of the limb to avoid applying pressure to the surface nerves around joints,
  • Use 4 sets of 30/15/15/15 with a 30-second rest between sets and a 2-second concentric and a 2-second eccentric contractions for metabolite response,

In conclusion, PBFR can limit muscle atrophy and aid in the recovery of strength and function. It has the potential to significantly reduce the morbidity from limb trauma and surgery, allowing a substantially earlier return to full activity [1]. Its effectiveness and safety have been demonstrated, as long as the safeguards and protocols discussed previously are followed.


[1] Day B. Personalized Blood Flow Restriction Therapy: How, When and Where Can It Accelerate Rehabilitation After Surgery?. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2018 Aug 1;34(8):2511-3.

[2] DePhillipo NN, Kennedy MI, Aman ZS, Bernhardson AS, O’Brien LT, LaPrade RF. The role of blood flow restriction therapy following knee surgery: Expert opinion. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2018 Aug 1;34(8):2506-10.