September 12 2024
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Welcome to the True Sports Physical Therapy Podcast with your host, Dr. Yoni Rosenblatt. Today, we dive deep into the world of blood flow restriction training with expert Dr. Nicholas Rolnick. This episode covers the science, benefits, and practical applications of BFR in both rehab and performance settings.Join us as Dr. Rolnick explains how BFR can enhance muscle strength, accelerate recovery, and improve outcomes for various patient populations, including athletes. Whether you're a clinician, athlete, or fitness enthusiast, this episode offers invaluable insights into the effective use of BFR. Let's jump right in.Thank you guys. Thank you. Thank you. Thank you for downloading this episode of the true sports physical therapy podcast Thank you to all our listeners worldwide. We get tons of feedback from across the globe of people listening to this So thank you so much for listening to it. Keep them coming Let me know who you want to have on what you loved about our conversations and what we could do better This conversation came as a direct request from a therapist all the way over in China.So thank you for listening. Um, it is Dr. Nick Rolnick. He is the blood flow restriction guru, as you'll hear us talk about. He refers to himself as the human performance mechanic. He's a world class physical therapist and performance enhancement specialist. This guy was an athlete, is still an athlete, bodybuilding, but played baseball, Franklin and Marshall, went on to get his master's degree.In health promotion management, uh, from American university, and then got his doctorate in physical therapy from Columbia university, where he currently resides in New York. He still teaches, which I love about him. He is the founder of the BFR pros, and I highly encourage everyone to take his course, BFR training.com. He talks a little bit at the end of this conversation about why it's such a unique course. It is highly applicable to what everyone listening to this pod does for a living. As a sports pt, he really distills it down and he's always updating it every year. We had a great conversation in which I learned a ton about what BFR does, the differences in cuffs and what you should look for if you're looking to get into the BFR world, as well as how to apply it, what patients to use this with, how to use it, and then how to progress even away from it.Nick did a great job of boiling all this down. We love your feedback. Keep it coming. You can DM us true sports BT on Instagram. That's the best way to get ahold of us. We're also constantly hiring and growing the hell out of this true sports physical therapy enterprise. So if you want to be a sports PT and treat patients one on one in elite level performance setting, shoot us a DM and just tell us you want to be with us.And we'll walk you through the interview process. Can't wait to hear from you. Without further ado, here's a great conversation with Dr. Nick Rolnick. Welcome back to the true sports physical therapy podcast. We got Dr. Nick Rolnick with us today. The BFR guru, not self proclaimed that's proclaimed by me. So Nick.Welcome to the show. I can't wait to learn from you about BFR. Well, thanks for the humble introduction. I do not consider myself a guru in any way, shape or of the word. It's more, I'm very fortunate that I get to come on, have conversations like this about a topic and an area that I'm very passionate about.And I think can change lives for the better and rehab. So. It's definitely changing rehab and I named you the guru for the record. So that's not you calling yourself the guru, but I want to dive right in because, um, a little bit of a backstory. I came to BFR probably about eight, 10 years ago. Um, I had an employee that wouldn't shut up about needing to get this BFR thing.I'm like, how much is it? They. Quoted me the price of like seven grand and I'm like, dude, that's double what my car is worth. So that's insane. Like, what are you talking about? We ended up doing it. And now BFR, man, it, first of all, it's super mainstream. Second of all, it's now all of a sudden very affordable compared to that seven grand.So I think we've come a long way, but when that first came into my view, it was all about 30 reps. 15, 15, 15. Um, that seems to kind of be going back and forth. Tell me where that came from. And what your rep scheme is when you're utilizing BFR? I think before we discuss any of that, it's important to just get on the same footing about what I feel is happening with blood flow, restricted resistance exercise.Cause it's not necessarily the same as aerobic, but generally the statements that are made in the research, um, are such that BFR, uh, because of the unique environment that it puts the working muscles in, um, it, It can, in essence, accelerate the, um, normally occurring fatiguing processes that happen with light load exercise and makes it happen a lot quicker.And as a result of that, we get an increase in muscle fiber recruitment. Due to the fatigue. Um, cause fatigue with low loads is a, is an essential ingredient. Um, if we don't get fatigued, we're not going to grow with light loads. That's not necessarily the same ingredient list for high load exercise. But, um, what BFR does is it, it really just gets us to the same end point quicker.And as a result of that, It's uncomfortable. It is something that if, if you're doing BFR and you're not uncomfortable, you're doing it wrong. Um, it's that discomfort feeling that, um, I know as a clinician, um, that is, is saying that there's enough metabolic stress that's built up within the exercising muscle that is causing this accelerated fatiguing process.Um, and, and I want my clients and patients to be able to get there at any means possible. So, with that kind of background on resistance exercise with BFR. And if we take it at face value, that when we look at exercise and we look at the, the molecular milieu, like lactate levels, um, pre, during, and post, um, we tend to see that they're basically identical when we have low load exercise to volitional failure, right?We're standardizing it there. That tells me that, again, this is a, operates firmly under normal strength training principles. That's really, really, really important because a lot of people, the narrative is that BFR is special. And I do think it is special. I think there are nuances in the application of BFR that are very unique.For example, I believe that with With light load exercise, we're, we're going to hit a threshold of hypertrophic or increasing in muscle size adaptation with, um, about 20 to 30 percent of the one rep max more so toward 30 percent than 20 percent with blood flow restricting. We already have research that shows that we can get a very comparable level of muscle hypertrophy with loads as light as 15 percent of the one rep max.So it lowers the, it lowers the floor. For the hypertrophic adaptations, which are really, really. Uh, exciting from a rehab perspective as a physical therapist. Now, getting back to the initial question of the rep scheme, the rep scheme literally came through, to my knowledge, that a group of researchers was like, Skip, alright, well, it's light load exercise.We're just going to try 30 reps followed by three sets of 15. They found that it worked. And then other researchers, because when you write projects, right, when you're trying to get IRB approval, um, when you're, when you're designing research experiments, you want to have some data that supports your methodology.Right. And so I envision, right, I don't know if this is, but my understanding is that the researchers kind of said, all right, well, 30, 15, 15, 15, it works. It's light load exercise. Okay. We're going to now just start replicating this protocol. And that to me has happened time and time again with all these protocols.So it's kind of, ingrained in the recommendations for blood flow restriction that we want to do, you know, 30 reps on the first set, followed by three sets of 15. And that is a terribly difficult protocol. Um, It's really challenging, especially if you're in the 20 to 30 percent range. And so for me, as somebody who's highly interested in, um, in the safety of BFR, in the tolerability of BFR, and in the way BFR is administered, it was And, and look using BFR now for eight plus years, um, in, in the clinic, I was, you know, I was a little skeptical and still I'm skeptical about how much volume we truly need to achieve in order to get comparable results to high intensity resistance exercise.So a group that I frequently collaborate, uh, Victor DeCaros, he's a all star Brazilian PhD student, and he's going to get his PhD in the next week or so. Um, him and I have collaborated on a number of different projects, um, which has been really, really cool because that, that relationship has been leveraged just through my Instagram and connecting with all these different researchers across the world.And that's a benefit of social media. Um, Although social media is pretty toxic these days, but that's definitely been a benefit. And we did a meta analysis that was like, okay, we wanted to update the pivotal Lixandro meta analysis that was published in 2018 that basically showed that the BFR hypertrophic stimulus was the same, um, as high load exercise.And then they also looked at strength and then they showed that the magnitude of strength adaptations are greater in high load exercise, which should make sense, right? If you're lifting heavier, you're going to become better at lifting heavier. It's a skill. We then said, okay, let's update that meta analysis because there was only, there was only 10 papers that fit the inclusion criteria for that, for that study, the Alexandra.And we ended up getting, uh, in our inclusion criteria, about 24. Okay. Um, and then we said, okay, we replicated that result. We found that across the, the body of literature that compared low intensity exercise with blood flow restriction, 20 to 30 percent of the one or at max to high intensity exercise. I think it was greater than 60 percent of the one or at max was our inclusion criteria.We found that the hypertrophic effects were similar and we used, um, What would consider the, the, the better markers of hypertrophy. So we used, uh, we only included study that did musculoskeletal ultrasound or imaging that looked at the, uh, amount of, of muscle growth. And then we did a subgroup analysis and we said, okay, is this based upon the repetition scheme that's adopted?Right? Because the Patterson et al paper that was published in 2019, um, stated that BFR can be done one of two different ways, exercise to volitional failure. So multiple sets to volitional failure or a non failure 30, 15, 15, 15 with 30 seconds of rest in between. Anybody who's done blood flow restriction, um, will, will, should, if they're doing it correctly, tell you that not everybody even finishes that protocol.It's brutal. So we're ending up and, and we're, I'm working on something right now, which is awesome and awesome side project that hopefully will get published, um, early next year. Um, comparing some of these protocols, but, um, it's not, it's not a, an easy protocol. So trying to get somebody to do that 30, 15, 15, 15, especially with a loading in between 20 and 30 percent is very, very, very, very challenging.So we then stratified. Are in our subgroup analysis. We just looked at papers that were comparing different rep schemes to high load exercise in general. So we base this on basically ecological validity, meaning that we didn't volume equate. We didn't, we didn't attempt to stratify those type of studies.We just said, all right, well, we look at high load exercise, whatever the study compared that to. And we looked at low load exercise. Okay. and with BFR and whatever that compared to. And we found identical patterns of muscle growth when we do multiple sets of 15 reps versus 15 versus multiple sets to failure.Now, there's a lot of fine. Let me cut you off for a second. How do you define multiple there? So it was, it was, some had three sets, some had four sets. Um, I think the, the failure aspect is just one of those things where, which I'm very interested in, um, because you know, there, there is failure from a metabolic perspective, like you just, you just get too, it's too painful to continue and then there's true muscular failure, um, where, you know, I don't necessarily think that we hit that with blood flow restriction because it just, it's a necessary ingredient.Yeah. So, so like. We, we need, it was just nice to be able to say, all right, well here are the multiple different repetition schemes that are adopted. And so we, we found that the muscle growth was similar across these various protocols. And since then, I've really been leveraging four sets of 15 instead of 30, 15, 15, 15.Now there's a couple of caveats here, right? Because they're, they're, they're like, If I, I am a, I am the BFR guy. That's going to tell you not to do BFR for the reasons that we've already discussed in the sense that it is painful there, there, there, you need to be in a mental state to be able to push yourself to the level of exertion.That's going to be needed in order to effectively build, build muscle and get that stimulus. And so. I am much more a fan of with patients that can tolerate it and knowing the impact that load has on muscle activation of increasing in fatigue. And the whole rationale that BFR is a bridge to high load exercise that we can, if we adopt the notion That BFR simply accelerates the normally occurring, uh, fatiguing processes with light loads, then we shouldn't have to be, um, limiting ourselves to those, those light loads, right?So I am much rather, I would much rather start out somebody. With four sets of 15, right? Making sure that they can complete the protocol and then starting to, there's two strategies starting to one, if they're load compromised, right? We can't put any more load in the tissue. Then the way that I would do that would be four sets of 15 plus meaning three sets of 15 and then the last set to failure.Yeah, right. So they're, they're going and then you go two sets of 15 and then the last two sets of failure. Right? So you're, you're building upon that. You're still achieving progressive overload, but you're doing it in such a way that's mitigating a lot of the perceptual discomfort. And even with the four sets of 15, If you use a load that really truly is between 20 and 30 percent it is extremely uncomfortable.And so the balance has to be with BFR providers that we need to get our patients that stimulus, but we need to do it in such a way that's not going to turn them off from the, the, the, the exercise approach or modality. I know Kyle Kimbrell would murder me with saying a modality BFR, but, um, you know, a way to perform that, uh, that exercise.Um, so that's one way. And the second way would be simply to progress load, right? So if our goal is going to be to using BFR to bridge them to high load exercise, then I can do four sets of 15 at 20 percent of the one right max. And then I'm going to add you know, three to five pounds and see if they can do it again.And you continue to add weight and you keep everything else the same and you're still getting progressive overload. You're achieving that bridge, um, to high load exercise. How are you? There's a lot of different ways. It's just like, it's like people, I'm very much not a rigid, you know, I don't think there needs to be a rigidity.to the BFR prescription. I think if you understand what you're trying to accomplish with the addition of blood flow restriction, you don't need to adhere yourself to these rigid repetition protocols. Yeah. Yeah. I, you know, it, it reminds me of like, um, the intermittent fasting protocols that came out of this like 16 hour window purely because that's what worked for the scientists then.And then it became gospel, right? It sounds like that's kind of where the 30 and three sets of 15 came from. And then no one really diverged from it. So what you're saying to sum up is we got to get these guys to maximal fatigue. Right. And however you get there, you get there. Is that, is that right? Is that okay.So that's a decent. Yeah. I mean, I, it really, it's just for me, I'm a big data and tracking person. So every single one of my clients has a little folder on my phone that I track everything that they're doing, right. We should be doing that as clinicians. So as long as I am achieving progressive overload, either through, An increase in reps at the same load, or I am increasing load and keeping reps the same, and they're still able to accomplish that, um, that same amount of reps, um, I'm good.Um, and I think the evidence is going to continue to support that. Um, that the BFR stimulus is going to produce very comparable results to high load resistance exercise in terms of muscle growth, not necessarily muscle strength. And so if we just, if we're comfortable with that and we know that metabolic stress needs, metabolic stress is not a mechanism of blood flow restriction, right?If it was a mechanism of blood flow restriction, it would be unique to blood flow restriction. And when we see. Uh, studies that have attempted to, um, map out the amount of metabolic stress that is, um, that is accumulated when, with low load exercise and low load exercise with BFR, they really haven't shown any differences.It's just, we need to embrace that the metabolic stress is going to create a fatiguing stimulus in the crossbridge cycling process. So actinomycin and it kind of clogs it. clogs up the force, uh, the, the force, um, uh, cycling, um, inside of the muscle fiber. And as a result of that, we are now needing to recruit more unfatigued type two muscle fibers.I mean, that's basically how I think about it. Hey guys, quick pause and a quick shout out to this new Masterclass that we just launched here at true sports, physical therapy, myself and Dr. Tim stone put together a masterclass of ACL rehab, and we call it from table. To turf. And the reason we call it that is because it's going to teach you exactly how to get your athlete all the way from post op day one with the nitty gritty of regaining all of that range of motion with the tips and the tricks that we use here at true sports, physical therapy that gets our athletes.better, faster and stronger. And that's early. And then how do you progress that athlete all the way onto the field with a ball in their foot or stick in their hand or whatever their sport is and teach them how to accelerate, how to do so, how to change direction, all the mechanics that go in there. What drills do we use to make that happen?To get our athletes exactly where they need to be back on the field and even better than before injury. And I want you to sign up for that class. Now you can find it on our website. You can shoot us a direct message and just say, Hey, send me the course. It's right now on sale. So make sure you sign up now.It is fully accredited to get you all of your continuing education hours. Sign up for the true sports masterclass ACL from table to turf. Thanks guys. Yeah. And I think that makes a lot of sense. And so let me ask you this. If you're moving them through to fatigue, what, what levers do you pull to increase that overloading stimulus?Like, do you usually err on the side of increasing reps? Do you usually err on, okay, you've been able to do four sets of 15 at 20%. Let's bump the resistance. Is there a better method? I mean, it really comes down to. the patient or the client that you have in front of you. Um, and, and that kind of gets into some of the BFR training personality types that I, you know, kind of talk about in my online course where you have, you have the, the, on one end you have like the quitter, which is the, this is the person that you, you have to be very careful with.Progressing BFR doing too aggressive of a stimulus because they usually don't have a long term resistance exercise history that is huge because with BFR, you're, you're, you're simply going to get a magnification of those metabolic, that metabolic stress feeling. And a lot of people that's uncomfortable.And when you have somebody who doesn't have that training history, you have to be a little careful, um, not saying that BFR is, is an unsafe, um, uh, approach. Cause I don't believe that. In fact, I gave a presentation, uh, last year at the NSCA national conference that basically said that if you're safe to exercise, BFR with a caveat, like, common sense applies here.Uh, even though I know common sense is not so common these days, but there is an increased risk in the beginning of a training program for people that haven't done resistance exercise. They've been sedentary for a while. Um, in our perceived barriers to blood flow restriction training paper that Kyle was, was on, and I was, I collaborated with Chris Brandner and Mikkel Sequeira, um, these are, uh, people, researchers in the space and, and Ben, um, Ben from ORS as well.Um, we. We basically said if you have a, if you don't have any resistance exercise history in six months, that is a yellow flag for us because when you resistance exercise, you, you now are creating an additional buffer zone for all of these normally occurring processes that happen to allow the muscle fiber to function in periods of duress.Those adaptations are not there. When you don't have a resistance exercise history, you have to be really careful with that. So those, the quitters are people that I might start off on a modified protocol. So I might even do like three sets of 10 reps, um, or I might now that the technology is a lot more affordable and we're able to, um, leverage, uh, cheaper technology that does very similar Uh, things than the more expensive devices.Maybe I'll do intermittent BFR. Um, so I will have it deflated in between the rest periods. Like there's technology out there that allows you to do that, um, from your phone. So those are the people that you really just want to get them comfortable as much as possible and confident. So I might even do passive applications there too, just so they can feel The cuff pressure, um, because that can in and of itself be uncomfortable, um, with a lot amount of pressure.And then you have the masochists. These are like my favorite type of BFR client patients because these, yeah, these are me. like bodybuilders, um, like people that crossfitters, like they're very used to high metabolic stress type exercise. So these are the people that you have to actually like rain back because they're like, Okay.If we're going to do 80 percent limb occlusion pressure on the lower extremity, then 90 percent is better. Um, or a hundred percent. And these people, I feel I have to educate a little bit on what we're doing and why we're doing it in such a way that More is not better. Um, for example, there is evidence to suggest that when we have ischemia or post exercise occlusion is how it's studied.But basically when we have this trapping of Uh, metabolites in one limb, we actually can increase the central nervous system fatigue such that if we're trying to exert our recruit muscles on the opposite, on the opposite side, that's not recruited. Our voluntary activation goes down. Um, so a lot of these people were like, Oh yeah, why can't I just superset like biceps and then do, you know, a leg exercise unoccluded or, you know, I've heard it all.It's really talking about the education that we're, we want to just isolate the stimulus as much as possible and intensifying the stimulus is not necessarily a better stimulus. Well, I think also, I mean, when you talk about another limb, that makes a lot of sense. I wouldn't have thought of it like that.I would think about what about the next time they come in for therapy. How much are you, how much are you going to get out of them? If you ramp that cuff up to 90 versus living at 70 to 80, right? Are they going to be able to come back and train at a high level? Or have you just guess their central nervous system where they're not gonna be able to come back in and get the max output in that second session?Would that make sense? Is that a reason not to bump it up all the way to 90? Yeah. I mean, when I think of CNS fatigue, I think of a, uh, processes that happen during an immediately following exercise that limit motor unit recruitment. Um, so I think the, the way that you were framing CNS fatigue is more like a systemic thing.And I guess that's kind of true, but like what, what, What I want to make sure when I am giving any sort of stimulus, um, to my clients with or without blood flow restriction is that I'm mitigating the accumulation of CNS fatigue as the exercise session progresses. Meaning that as we increase cardiovascular demand, as we increase the amount of muscles that are recruited, Um, we get this increase in inflammatory processes that normally occur.These inflammatory processes can cross the, the, the blood brain barrier and lead to reductions in voluntary activation, even with high levels of effort. So this is a systemic process that happens. So how do we mitigate that? Well, we mitigate that by in BFR, like I tend to do very much machine based work, um, because I have a.practice that's predominantly in a gym. So I just want them to focus on, on moving their, their limb. Through a predefined range of motion. Um, and I can closely track volume and intensity, um, multi joint exercises within machines as well. So we're mitigating the amount of skill requirement. Um, I'm sure if you've been doing BFR for a long time, you see these free weight exercises with BFR and the form just looks disgusting.Like it ends up being where instead of a squat exercise is that's targeting the quadriceps. Now you're starting to get this bastardized hip hinge that just looks terrible and it's not accomplishing what you've set out to accomplish, or you've accomplished it and you're just now putting volume in that, that is, you're not getting a, you're not getting a good return on your investment.Um, so these are all things that go through my mind with, with the programming. And you mentioned pressure too. I am, and I've, I've said this for years. Um, I was one of the first. BFR Educators to really come through and argue against the use of high pressure. Um, I am very much a moderate pressure, meaning 60 percent uh, of the limb occlusion pressure is pretty much the highest that I will go for any of my patients.Um, the caveat, because there's always caveats, right? Is if they're, they're doing no load exercise. where we can't add an external load it at that point, then pressure, you can turn that lever on pressure and use that as a way to accelerate the, um, the fatigue that's accumulated. But what we kind of know about the relationship between applied pressure and blood flow to the limb is that it's not linear.Um, there are, uh, stepwise changes that happen. So when we apply zero to 10%, there's a sharp reduction. And then when we get to about 40%, there's a sharp reduction. And then it kind of stays the same until around 90 percent we're talking about the legs. Um, so if we have this, period where of this 40 to 80 percent where it really kind of looks like blood flow is, is relatively the same.Why are we now pushing? If, if we know that perceptual demands are a barrier to long term adherence, I struggle. if you are able to lift between 20 and 30 percent of the one or max, I struggle to justify the use of higher pressures. Yeah. Um, so, so we have to tie it back to objective data, subjective data, and what we understand about the outcomes in a variety of different BFR training pressures.So when the loads are very low pressure can be higher. Although, again, I'm unsure that that. You know, even now, even worth it because it's like, it's just a lot. Um, it's a lot. Yeah. So, so that makes sense. Okay. So you live in that 60%, let's say for lower extremity, cause you want them to get as much bang for their buck as they can, and you want them to be willing to do it again to increase adherence.So I think that makes a lot of sense. What other, um, BFR personalities. that, that you see, you mentioned quitter, you mentioned masochist, what else lives in there? The battler, which is like the one that the vast majority of people are. Um, as I would say, that's probably like the 80 percent and then you have 10 percent on each side.And those are just the people that, You know, they're, they're, they'll do BFR because you tell them that it's, it's beneficial. They'll tough it through, but they're going to let you know about it. And these are the people that you could still progress. You can go through your normal, you know, progressions, but you still gotta, you know, be careful because It could be a couple of bad experiences with BFR and they might be turned off from it.Um, so these are the people that are the vast majority of people you're going to come into contact with. But again, it's still BFR. is very perceptually demanding. And so for me, I've been just hyper cognizant of the fact that I've built my practice on blood flow restriction, but I've found myself using BFR less and less, um, in my own clinical practice, just because if I have clients that can tolerate even moderate loads, right, we can get less cardiovascular demand.Okay. Get a little bit stronger and not have to worry about the perceptual demands of VFR and Accomplish all of the, you'd rather live there. Yeah. Yeah. I'd rather, I'd rather live there. Again, it's, it's funny. Cause like I am the BFR guy that doesn't, that tells you not to do BFR, but there are certain situations where you really don't have a choice and BFR can truly help, not just from a muscle building perspective, but also in unique ways, like reducing pain in, in achy joints.And there's other applications where I might want to turn that. Pressure lever up versus keep it at that moderate level. But what we do know is that the hypoallergenic effects of blood flow restriction are, are likely modulated by, you know, a similar capacity as normal training. Right. But with the more volume that you do, the higher, the intensity, right.Uh, that you're getting and the more you're going to get pain relief. Yeah. So it's, it's, it's, you know, I always try to just relate all this back to normal. Like I was involved in a study that we did, uh, moderate load exercise. So 50 percent of the one right max. And we had people do a single leg press and they did 30, 15, 15 failure.And the same thing with the low loads, uh, with 30%, 30, 15, 15 failure. And BFR actually created a little bit of a better hypoallergenic response than moderate load. load exercise. So there is something potentially to the BFR stimulus. We're still kind of parsing that out, but it really, again, comes back to it.It could be the best intervention on the planet, but if you have clients or patients that are not going to tolerate it and you can't do it anyways, then what good, what good is it? So it's very much, I'm very much approaching it from the camp of, Um, I understand the wealth of benefits that blood flow restriction can provide to an overall rehab program.We just have to consider the perceptual demands and I noticed by the way that I haven't really said safety because I don't think that we need to be as concerned about safety with blood flow restriction than we once thought. And I, and I think that's becoming more and more clear as the technology increases and we're actually able to, to read pressures more real time.Um, you know, long gone are the days of using the ACE bandage to totally occlude, and you're not really sure how much you're occluding. So I think that has been proven, um, how safe it is to read. Just walk me through nuts and bolts. When you're doing a knee extension, I deal with this a ton with patellar tendinopathies.You're getting your one rep max from your contralateral side. I do. So there, these are the things that people ask me in, in courses. And I'll give you the textbook example and I'll give you the real life clinical example. Um, the real, the textbook example would be contralateral 10 RM. Um, I don't really ever test again.I don't work with sport athletic populations where I would really feel the need to get a true one RM. Um, so I tend to do a five to 10 RM if I have the capacity to do that. But the real life example is I pick and choose a weight and then I see, Hey, Can you do the prescribed load? Okay, we're going to increase the weight next time or, Oh, wait a second.You might not, we might need to decrease the weight, right? I think this is where the research and practical experience leveraging, you know, loading parameters kind of diverge. Like in an ideal situation, if I'm working with a high level athlete that I know, like, that I know needs to get back and I want to be as precise as possible.And yes, I am going to use objective data to, to stratify the BFR prescription. But in my population and the population of a lot of the clinicians that I've educated, these are general outpatient ortho. These are, um, you know, athletics, but like, Not high, high level athletics where we don't need to be as precise with our prescription.And I'm comfortable with that. I mean, again, you have to go and you have to take it from the overarching perspective of I want my patients to experience progressive overload on a session by session basis. However, they do that. Yeah, sure. Some strategies might be more efficient than others, but do I really want to take that 55 year old, uh, you know, through a, a three to five rep max on a leg extension, just so I can prescribe to them the appropriate loads for their affected knee?Yeah. I think more times than not, I would say no. Yeah. Yeah. Well, it boils down to something we talked about so much on this pod, which is just reading the room, understanding who's in front of you and what your goals are, um, and using common sense. As you, as you said, talk to me about what BFR does to strength gains.As we talked a lot about hypertrophy, what do we think it's doing? Strength wise, when do you get away from BFR and just go into loading once a tissue can tolerate it? I mean, I try to get away from BFR as soon as possible. Um, for everything that we just discussed now, if we think about, I think, and this is where my online course, I take painstakingly, uh, important things, which is framing.how normal strength training likely works and then fitting in blood flow restriction within that paradigm. If you just go to BFR, you're never going to really appreciate the nuance associated with its application. So when we think about strength, right? Strength in the most basic of senses is just the ability to express force, right?And that could be done in a number of different ways. Okay. Right. But generally in the clinic, it's the ability to lift more weight. Um, now what we do know is that as you increase the complexity of a task, then it becomes more and more skill based, less and less, just doing it. base essence force production at the muscular level.Yep. Our brain becomes more and more important at coordination. So firing the muscles appropriately, um, antagonize antagonist muscle. reduction in coactivation, increasing involuntary drive. These are all things that happen. And the more complex the task, the more relevant they are. So when we're thinking about the evidence on blow flow restriction, it should come as no surprise that the vast majority of evidence shows that BFR does not produce as as fruitful of strength gains as high load exercise.Now, stepping back, if I'm lifting 80 percent of my one right max, and then you're asking me to lift a hundred percent of my one right max, right? The muscular processes that happen when we're thinking about a skill, right? It's more specific to the task. Then I am going to most likely be favored when I practice the test.Right, which is basically what's happening with low, low blood flow restriction, we will see an increase in strength certainly beyond low intensity exercise, particularly if we're using work matched protocols, so we're not reaching failure with a low load exercise where we're operating closer to failure.Um, which will stimulate the type two fibers and especially with isometric based tasks, really the, the two determinants of how much muscle force is going to be exerted is the muscle cross sectional area and the voluntary drive, right? So if we can increase the cross sectional area of the tissue with an isometric task, um, that is likely going to produce Meaningful increases in, in what we would consider strength.And that's what kind of the research has said. Like there's a paper that was a meta analysis, uh, Gronfeld in 2020. And they, they kind of looked at, um, the strength from a different angle. And they basically said that BFR does have the capacity to increase strength to a similar level, um, as high load exercise, uh, which was a more.Unique, uh, It, it had to do a little bit with their, their methodology and what they, what the studies that were included in that are. But I mentioned that only because there is some modicum of evidence that suggests BFR can produce similar amounts of muscle strength, but I would not hang my hat on it. I would much rather if I need to get an athlete or a person back, I want them to be able to produce as much force in as short of a time as possible.So that means bridging them to moderate to high intensity exercise as soon as possible and then beginning speed work, right? So now we have the, we're able to create the ingredients necessary to provide a strong foundation for these, for these athletes or these participants or clients or whatever, but then we still need to now.Create that additional bridge. So we have this muscle. Great. And then they can use it and that's where there's a skill and that's where programming comes into play. Um, where, where, you know, the strength and conditioning aspect of my role as. A physical therapist comes in. True Sports Physical Therapy is growing like wildfire.We have 14 locations, soon to be more. We are throughout the state of Maryland. We're in Pennsylvania, in Lebanon, in New York, Pennsylvania, as well as in Delaware, in Newark and Wilmington, Delaware. Like I said, So many more practices to come and we always need outstanding sports physical therapists. Our treatment style is unique.We are one on one with your athlete for 45 minutes every single session. You do the entire treatment. You do the entire evaluation. And they are in state of the art facilities where you have room to run, throw, and jump and really get your athlete all the way back to on the field and better and stronger than they were.We also have outstanding salaries, comp structures, bonus abilities, 401ks. As well as a very strong continuing education offering, including in house continuing education, and we're looking for you now is the time as we are growing like crazy, just shoot your resume over to Yoni Y O N I at true sports PT, or shoot us a DM and we will hit you back.We will get you in for our unique tried and true interview process and really make a determination. That this is the right place for you to grow your career and get your athletes better than ever. We can't wait to hear from you. Yeah. So, so it sounds like you would start, um, let's say as a Patel or tendinopathy case, you can use BFR early as hypoalgesia.It's going to calm down that pain response. You're going to be able to load more effectively throughout the session. You graduate away from that. Then as pain levels come down overarchingly, you get them more into, um, unrestricted training. You get them more into timing mechanisms. You get them more into sports specificity as they graduate through it.So it could be your BFR is done after you get them through that initial pain response period. Would that be a good summation? Yeah. Okay. Okay. So that makes a lot of sense. Now, looking forward, there's so much, there's an explosion of research right on this around BFR. What do you see as the gaps in research that you're most excited about and how are you going to address those?I, I am very interested in the continued widespread adoption of blood flow restriction. Um, I know that I am the BFR guy that says not to do BFR, but I think it's, it's really important to recognize that it is a very powerful tool in our proverbial Toolbox. I know. I hate that. I hate that. Um, I hate that. I hate that analogy as well, but it is a powerful weapon that we have to combat disuse atrophy and the sequelae following orthopedic surgery or injury.Um, now my interest, believe it or not, right. When I first came into the BFR space, it was very much aligned with what we talked about. right? Muscle mass and muscle strength. Um, and then as I've kind of the totality of evidence has continued to support that we're going to get very comparable results with muscle growth as high load exercise and slightly less, although still pretty robust, uh, increases in muscle strength.Great. That bores me now. I am not interested in that at all. I, I'm actually not interested in clinical research. At all. Um, what I'm interested in is, and this has been borne out through my education, um, company, the BFR pros, where we've used for years and years, a number of different devices. And these different devices have features.that are marketed to clinicians that this either improves the safety or the tolerability of blood flow restricted exercise or increases the outcomes associated with blood flow restriction. But when you take that at face value, Oh, that's great. But the research does not, um, is very new in that. So I'm very much interested in what features are marketed to clinicians.Um, that may have an impact on the acute and or longitudinal response, the blood flow restriction exercise. What are they? Tell me what's that? I am. I am highly interested in auto regulation. Um, auto regulation is the, um, the cuff feature whereby a cuff automatically adjusts to the, uh, phase of muscular contraction in, um, in the, the, the range of motion.So for example, a cuff will inflate. air around the limb as the limb goes into the eccentric phase or the muscle lengthening part of the contraction. And then as you transition from the eccentric to the concentric phase, this air gets dumped out of the, of the cuff to maintain a, what we call a set interface pressure.So the set pressure, which is a hundred millimeters of mercury, for example, That pressure oscillates depending on the phase of contraction, whether that matters is another, um, is another Pandora's box. Definitely. Listen, it definitely matters. Anecdotally. Like when you look at that first system that I bought for seven grand from Delphi, it's doing that.Right. And it is hell. Let that, and I love, I really do like the Delphi device. Um, I have their gen three, um, device and. It has a, and this kind of gets me into my area of research. So. Um, with, with auto regulation, there have been a number of costs that have come on the market, um, that, that have auto regulation, um, as part of their marketed, um, value proposition to, to clinicians.And so, I'm so auto regulation has been one where I've taught with a number of different cuffs. And if you have a number of different costs in front of you and you try them and you see that the auto regulation function is very different on a cuff to cuff basis for me, that means, so think about this. If you have a cuff that's not responsive, like the Delphi, for example, is very tightly regulated.It is a retrofitted surgical tourniquet device. That's why it's so expensive. Um, That auto regulation feature is pretty tight and I've known that for years. Um, but other costs that are more affordable, their auto regulation feature is not as tight. And so what, what you can see is if the air is not able to be compressed or released in different phases, you can actually, um, No, the, like, feel the difference because blood is escaping the limb that's exercising.So the BFR stress per repetition is not the same as a more tightly regulated, uh, regulated cough. So we've done, I've done now. Uh, three papers, two of which are published one that is hopefully going to be published by, by the end of the year, um, on auto regulation, um, one using a less responsive device, the more affordable device, the generation three smart costs, we found that, um, in that paper, That auto regulation allowed participants to perform like 29 percent more volume when we had them exercise the failure than a non auto regulated cuff where that we just the, the, the limited body of research basically is, did not standardize the actual cuff with, um, my colleague Luke Hughes has done a couple of papers on that.Um, but they weren't standardized according to cup width. So I made sure that the devices were standardized to allow an apples to apples comparison versus an apples to oranges comparison. So we found that auto regulation, when you had these individuals, we had them do a fixed and then a failure repetition scene.So we had them do the 30, 15, 15, 15, and then randomize them after they've done, uh, not, Oh, so non auto regulated and auto regulated condition. Then we randomized them again into a failure routine. And this was published in the British Journal of Sports Medicine. So it's a pretty, pretty solid, uh, journal, which is awesome.But we, what we found was that auto regulation allowed, uh, for a more safe stimulus. So the, the, the amount of minor adverse events were, uh, significantly less in the auto regulated cough condition. Compared to the non auto regulated cuff condition. Um, and the majority of those minor adverse events were actually first time exposure and the fixed BFR repetition scheme.So when you actually had them exercise the failure, the, they already had some previous BFR exposure and they didn't, um, have a significant difference in adverse events, but, um, The failure auto regulated condition were almost 30 percent more volume, um, than the non auto regulated and that has to likely do I hypothesize with a less responsive auto regulation feature.So then we then said, okay, I kind of knew that and going into it, I knew that there was a less responsive device, practical knowledge kind of informed me of that. So then we designed with my colleague, Tim Werner at Salisbury university, we then did a, an auto regulated versus non auto regulated, uh, versus low intensity exercise.So we added a comparator group and we wanted to look at the magnitude of difference in volume workload, uh, as well as what about hypertrophy? I want to know about outcomes. Does it matter? Yeah, well, so I'll, I'll get to that. Um, but, but we use with the Delphi. Which is a very more responsive. And we actually found that the perceptual responses between auto regulated and non auto regulated using the Delphi device.So they manufacture, they specifically allowed us to, um, have a feature that basically doesn't auto regulate, but allows the cuff pressure to stay. So we can isolate the auto regulation variable. Um, we didn't find any difference in the amount of volume that was performed. So about 52 to 53 reps and four sets to failure, which is, you know, Think about it.On the lower side, these participants were not able to, in a wall squat exercise, able to perform even the 75 reps because it's such a, a brutal protocol with the wall squat at least. We also found that BFR accelerated fatigue similarly, whether the presence of auto regulation or not, compared to low intensity exercise.So, So that was that. Um, and then, you know, for us, we're building toward a longitudinal trial, but one of my colleagues, um, Matthew Clarkson, he just published in journal clinical rehabilitation. He did a massive meta analysis. I think it's actually the largest meta analysis, um, in BFR in the space that looked at the presence of regulated versus unregulated Protocols longitudinally and found that they were really no difference in outcomes.And that's really, um, it's a tough paper to do because A lot of these cuffs, we're not a hundred percent sure that they have the ability to regulate or not. Like we know that the Delphi as a consumer, as a researcher, that autoregulates, but some of these other cuffs are kind of all over the place. Yeah.My personal, my personal opinion is that BFR doesn't what, like the presence of autoregulation won't impact outcomes if the autoregulation, uh. Is very tight, like the Delphi device. If you use other cuffs, particularly with a non failure repetition scheme. So you're not working them to a high level of effort.Um, and you're just having them complete the protocol. I'm not so sure. Do I think that it's a variable that we should absolutely consider? Yes. Um, but that's kind of where, for me, that's one area of. Of interest. Um, and, and we'll know more, um, we hope we did the lower body. Now we're waiting on, on getting published, uh, in the upper body, but that should be hopefully released soon, which would provide some interesting new perspectives on upper body auto regulation.Yeah. I think there's this narrative that auto regulation is more comfortable. Um, and I, I, I disagree it's less comfortable. Yeah, it's less comfortable. And so that's where, you know, it, and that's actually what we found, um, in the upper body, actually, that, that, that it was slightly more uncomfortable with auto regulation and bicep curls in the upper body than it was non auto regulated.And again, This is practical experience informing research, right? Like it was pretty easy. Um, to, to, to kind of predict what was going to happen. Yeah. I'm not surprised by that. I mean, when you get with the, with the good auto regulation systems, those rest breaks are terrible. Cause it's, it's choking you out.Yeah. I mean, it's, it's. Sorry, my coffee, you know? Yeah. Um, yeah, so I'm interested in autoregulation because if we, for example, don't need autoregulation to, it's more affordable and more tolerable. More affordable, and it allows for more access now. Then I'd be remiss to say my second interest is this, this, this concept of a multi chamber bladder system.Yeah. So I don't know if you're familiar, but there's a, there's a company called be strong that has a multi chamber bladder system. So instead of a single bladder whereby the air is circumferentially around the limb. These are, are marketed as not being able to occlude arterial inflow, but restrict venous return because of the fact that these bladder, these multi multiple little bladders are not providing an extreme amount of compression on the limb.And what's happening is that researchers are not respecting that this design is specifically marketed for the fitness professional, um, or the, the rehab professional that really just wants a less precise device. Um, but does, it's very hard to standardize the amount of applied pressure when you can't relativize the pressure.A very minority of studies have, have been able to relativize the pressure. Using these devices. So researchers now are, and I hate to generalize, but I've seen a ton of research out of Asian countries that are not respecting the fact that a multi chamber bladder system is a fundamentally different stimulus than a single chambered system.So they're now coming in to publishing these studies that are not helping us inform on the relative effectiveness of these devices because they're not able to. to, to relativize the pressure. So another area of interest for me is trying to determine how relevant do we need, uh, how relevant is personalizing the pressure in terms of the adoption of and safety of blood flow restriction.So for example, we know, and this is another paper that we have under review right now, um, where, It, it appears that when we use a multi chambered system, that the stimulus to reduce repetitions to fatigue based on our research right now, actually is equivalent to the Delphi during set one. And this is unpublished.We are in peer review right now. So hopefully at some point this will be published, but what we found was in comparison to low intensity exercise, that as you go into sets two, three, and four, That the B strong cough acts more like low intensity exercise in that the Delphi continues to reduce the amount of repetitions to fatigue and.Um, and overall has more, um, reductions in total reps performed. So there might be a, a, a very relevant finding there in that if we're not exercising people to volitional fatigue with a cuff, like a multi chambered cuff, then we're probably not going to get longterm similar benefits. So these are, are, are questions that I am, I'm looking to.Help address through research. And in fact, I was asked to host the special topics in frontiers and physiology and act and sport and active living that is literally calling for papers like these to address the. Gap in this research because people are just adopting BFR, which is great. But now let's try to make it more precise and let's try to create good research that reflects practice what's done, but also helps us answer some questions.So I have a lot of really. Really cool projects that are in review that should be out hopefully, you know, later this year, early next year, that are going to help answer some of the methodological questions that we need to, uh, consider when we're studying BFR, but also when we're implementing it in practice.So I'm super excited about that. And the reception to this special topic so far. Has been outstanding. So it should be a massive, um, addition to the overall body of, of BFR knowledge, you know, mid middle of next year. We got to get back on it after that, because I'm, I'm fascinated by the outcomes of that. I specifically want to know what it looks like longitudinally or regulation, um, verse.Uh, non auto regulation, I guess. And that wasn't really interesting to me. It just makes sense to be strong with a multi black system. It's not going to get the level of the same level of compression that like you said, it's just common sense. Um, okay, Nick, God, I could talk to you forever. I feel like you could talk forever about this and I really appreciate that.So, um, tell me about your course. It's the only one listening sports PTs across the country, how they can find you and why the hell they should take your course at BFR training. com. Yeah. I mean, I, if you're interested in understanding how BFR likely operates from a resistance and aerobic capacity, and from somebody who, you know, I've published over, you know, 35, 40 articles in the space, um, and I've distilled all of the, the vast amount of, of information into the absolute need to know, um, Um, that's, that's my course, basically, you know, I I've, I've given more than 60 in person courses and, um, very fortunate to bring all that knowledge online in a highly, uh, I spent a lot of money on this production of the course, but it's been, um, it's been a lot of fun to, to be able to, impact a lot of lives indirectly just through the online course.So, um, it's on bfrtraining. com. I actually own bfrtraining. com. I own bloodflowrestriction. com. I own chasethepump. com. Um, I, uh, you know, I basically own blood flow restriction, but I do think that the course offers. a no nonsense, um, version of BFR coming from somebody who's studied, uh, strength and conditioning and understand its place in rehab.And then we get to talk about cuff features too. So one of my, the recent every, every year I update the course for free for people that have, um, Have purchased and our student of mine, I do it for free. Just so you understand the latest and greatest in BFR knowledge. So this year's update was exactly what we just talked about cuff features, what the, what the most up to date research has on that.And then I'll update it again next year. So, and you know, you mentioned all your expertise in BFR research. Your background, strength and conditioning also equally as important, if not more important, is you're a, you're a sports PT. I mean, you're a physical therapist using this every day, understanding how to use it, who to use it with.I love the way you outline. patient feedback in their disposition or, um, their personality type and how to approach them. I think there's a tremendous amount of value there. So I highly recommend everyone kind of going over to BFR training. com. Take your course, Nick, you have been awesome. I'm going to get you on again.Middle of next year. So we can talk about that research. Thank you for all your work and thank you for your time today. Yeah. People want to find me on Instagram. They can follow the BFR pros for a lot of the BFR related stuff or the HPN. Sure. For the human performance mechanic on, on Instagram. And then, yeah, if you send me a DM, uh, I'd be happy to give you a discount to the course, just mention, mention this podcast and I'd be happy to hook you up with, uh, 50 bucks off.Hell yeah. Go take it guys. Go take it. Thank you for your time. Thank you for your knowledge. You taught me a ton. Appreciate it. Thanks for having me. All right. We'll talk soon. Bye. Bye. Bye.
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