Relative Safety of Personalized Blood Flow Restriction in the Aged Client
April 20, 2017
By Kyle Kimbrell, MPT
We've heard it time and again, whether it be a political season, a commentary on modern healthcare or you're stuck behind a conspicuously slow moving vehicle…America is getting older. Therefore, it should come as no surprise that we get quite a few questions regarding safety, benefits, and application of BFR in the “seasoned” individual. In this initial posting, we would like to tackle the safety question as thoroughly as we can.
Aged clients often have a number of comorbidities that the clinician must consider when prescribing any modality. BFR is certainly no different. In addition to the data we have, a good understanding of underlying causes of diseases and their mechanisms can help us make the most informed decisions possible.
Take, for example, Inclusion Body Myositis (IBM) , an inflammatory muscle wasting condition that occurs primarily after the 5th decade of life, affects primarily forearm and thigh muscles, causing those afflicted to lose muscle mass and thus vital functional abilities. Currently, there is no treatment intervention for these individuals and heavy load training to preserve or restore muscle mass may actually make their condition worse secondary to the increased inflammatory cascade. BFR on the other hand, with its ability to add size and strength in the absence of or minimal amount of muscle damage and inflammation, presents an interesting option for not only the IBM population but other diagnoses where load or muscle damage might be a confounding variable. Preliminary work has demonstrated that BFR may mitigate atrophy, improve muscle size, and improve functional and self-reported measures in this elderly muscle-wasting cohort.
Exercise is stressful! We know that our bodies typically respond to stressors in rather predictable ways. For example, when we restrict blood flow to a limb temporarily, a response is to release factors that aid blood flow and eventually can lead to increased vascularity. This has been shown to occur in the older client as well, resulting in improved venous and arterial compliance, and post-occlusive blood flow. The addition of muscle mass from BFR training can also result in the addition of new capillary beds. Therefore, chronic peripheral and central cardiovascular responses to BFR application in this population present some interesting possibilities for the elderly with cardiovascular compromise. In Europe, a randomized controlled trial is assessing the effects of BFR on coronary artery disease and pilot data collection assessing BFR’s role in individuals with cardiovascular risk factors is under way in the US.
The BP response to heavy loaded exercise is well documented, with intense lower extremity exercise increasing BP to as high as 480/350 mmHg. Takano examined the BP and HR responses to low-load exercise, and low-load occluded exercise. The result being the occluded group’s systolic pressure elevated 20 mmHg beyond the free-flow group, and the groups’ diastolic pressures remained equal. HR on average elevated about 20 beats per minute more in the occluded group. No studies have specifically examined BP or HR responses to BFR exercise in the elderly. Therefore, we would make two points: a number of BFR studies have been safely executed on both normotensive and hypertensive elderly subjects without adverse events; from the available exercise literature, we see similar BP responses to resistance exercise in the elderly as we see in younger subjects. Caution is certainly warranted in our elderly clients who are on drugs to alter their BP and HR, we, therefore, recommend taking BP before each session as well as clearing your plan with the referring MD.
Lastly some anecdotal and clinical experience to help guide you:
- We recommend caution when choosing to use BFR in the presence of varicose veins. There is no data to guide this recommendation other than experientially there has been an isolated case of rupture following BFR exercise. Certainly, not an emergency type situation, but neither a desirable one. Please make sure you inform your patient of this risk.
- The use of blood thinners will certainly pose a risk of bruising from the tourniquet use. Beyond that clinical reasoning, there is no data. Clear with the MD.
- Open wounds or infection in the limb would be a contraindication.
- The presence of a stent or a port in a limb would be a risk for cuff placement over the location of the device. Beyond that, it is still wise to clear with the MD.
- A history of clots is a tourniquet contraindication. BFR studies have demonstrated it activates the fibrinolytic system and is not associated with clotting factors so we “suspect” it poses no risk. This has not been confirmed. Get clearance.
- The presence of a clot=contraindication.
- The elderly may not tolerate as much Limb Occlusion Pressure (LOP) as a young healthy individual. Ongoing clinical trials including femur fractures and Total Knee Arthroplasty are using 80% Personalized Tourniquet Pressure (PTP) for the lower extremities. Clinical decision-making is imperative to assess the elderly person’s tolerance to the surgical-tourniquet cuff.
Performing BFR and dosing to the level of muscular failure, at which point we achieve the greatest potential for muscle adaptation is difficult, no matter one’s age. Asking someone who has never exercised a day in his or her life, or is significantly detrained, to get to that level initially is a mistake whether you’re using BFR or heavy load training. I recommend choosing a lighter load initially and getting them to complete the volume of 75 reps. I want my patient to be fatigued and feel the lactate burn, but I also need them to come back. As your client is acclimated and becomes a bit trained you can gradually add load and pursue the most effective point of muscular failure for exercise. Another means of introducing BFR might be, to begin with a cycling or walking protocol for a few visits. Those have demonstrated their effectiveness and could be a pathway for the introduction of an exercise task that will be most effective.
1. Loenneke, J. P., Thiebaud, R. S. and Abe, T. (2014), Does blood flow restriction result in skeletal muscle damage? A critical review of available evidence. Scand J Med Sci Sports, 24: e415–422.
2. Mattar, Melina Andrade, et al. "Safety and possible effects of low-intensity resistance training associated with partial blood flow restriction in polymyositis and dermatomyositis." Arthritis research & therapy 16.5 (2014): 473.
3. Gualano, B., C. Ugrinowitsch, M. Neves Jr, F. R. Lima, A. L. S. Pinto, G. Laurentino, V. A. Tricoli, A. H. Lancha Jr, and H. Roschel. "Vascular Occlusion Training for Inclusion Body Myositis: A Novel Therapeutic Approach." (2010).
4. Jørgensen AN, Aagaard P, Christiansen M, Frandsen U, Diederichsen LP. Effects of 12 Weeks Low-Intensity Blood-Flow Restricted Resistance Training on Knee Extensor Strength in Patients with Sporadic Inclusion Body Myositis [abstract]. Arthritis Rheumatol. 2016; 68 (Suppl 10). http://acrabstracts.org/abstract/effects-of-12-wee... Accessed April 11, 2017.
5. Santos AR, Neves MT, Gualano B, et al. Blood flow restricted resistance training attenuates Myostatin gene expression in a patient with inclusion body myositis. Biology of Sport. 2014;31(2):121-124. doi:10.5604/20831862.1097479.
6. Shimizu, R., Hotta, K., Yamamoto, S. et al. Low-intensity resistance training with blood flow restriction improves vascular endothelial function and peripheral blood circulation in healthy elderly people. Eur J Appl Physiol (2016) 116: 749. doi:10.1007/s00421-016-3328-8
7. Takano, H., Morita, T., Iida, H. et al. Hemodynamic and hormonal responses to a short-term low-intensity resistance exercise with the reduction of muscle blood flow. Eur J Appl Physiol (2005) 95: 65. doi:10.1007/s00421-005-1389-1
9. Clark, B. C., Manini, T. M., Hoffman, R. L., Williams, P. S., Guiler, M. K., Knutson, M. J., McGLynn, M. L. and Kushnick, M. R. (2011), Relative safety of 4 weeks of blood flow-restricted resistance exercise in young, healthy adults. Scandinavian Journal of Medicine & Science in Sports, 21: 653–662. doi:10.1111/j.1600-0838.2010.01100.x
10. Ozaki H, Miyachi M, Nakajima T, Abe T (2011a) Effects of 10 weeks walk training with leg blood flow reduction on carotid arterial compliance and muscle size in the elderly adults. Angiology 62(1):81–86
11. Julie E. A. Hunt, Dermot Galea, Graham Tufft, Danny Bunce, Richard A.Ferguson. Time course of regional vascular adaptations to low-load resistance training with blood flow restriction. Journal of Applied Physiology Aug 2013, 115 (3) 403-411; doi:10.1152/japplphysiol.00040.2013
12. Patterson SD, Ferguson RA (2011) Enhancing strength and post-occlusive calf blood flow in older people with training with blood-flow restriction. J Aging Phys Act 19(3):201–213
13. J. D. MacDougall, D. Tuxen, D. G. Sale, J. R. Moroz, J. R. Sutton. Arterial blood pressure response to heavy resistance exercise. eJournal of Applied Physiology Mar 1985, 58 (3) 785-790
14. Iida, H., Nakajima, T., Kurano, M., Yasuda, T., Sakamaki, M., Sato, Y., Yamasoba, T. and Abe, T. (2011), Effects of walking with blood flow restriction on limb venous compliance in elderly subjects. Clinical Physiology and Functional Imaging, 31: 472–476. doi:10.1111/j.1475-097X.2011.01044.x