When Should We Start Blood Flow Restriction Training Post Operatively?

That’s right, ladies and gentlemen!  Today we’re answering the age-old question…when should we start BFR training following surgery?  After adequate screening for DVT risk, when should we slap on some cuffs?  Let’s dive in!

BFR training can be performed as early as you receive physician clearance. This is especially important given the lack of literature regarding post-surgery BFR application in almost all populations. ACL reconstruction happens to be one of the most researched post-surgical orthopedic populations, so we have a bit more guidance with this population.  Studies in this population have begun BFR training as early as day 2 (Iverson et al, 2016) or day 3 (Takarada, 2000), with some waiting 2-3 weeks to begin (Ohta, 2003; Hughes, 2019). It is important to note that these initial clinical studies have rigorous inclusion and exclusion criteria, which further increases the safety of BFR application.

Some even had clinical criteria to begin BFR training. For example, in 2019 Hughes et al. required 2 weeks to pass following surgery as well as meeting 5 physical criteria along with orthopedic surgeon clearance. The clinical criteria were: demonstrating the ability to balance on the affected leg for 5 seconds, having a visible hamstring and glute contraction, 90 degrees of knee flexion, ability to perform multiple straight leg raise flexions without a quadriceps lag, and demonstrate no additional post-exercise swelling beyond what would normally be anticipated.

So what’s the answer?????  At the end of the day, we can’t provide any definitive guidelines yet as to when to begin BFR training for any post surgical population. What we can definitively say is that using your clinical reasoning on assessing relative risk of adverse events along with obtaining clearance for BFR are likely the two most important steps you can take as a BFR provider before proceeding to the pillars for application.

Factors to consider when weighing the risks versus benefits of BFR training related to the surgery should include: 

• The type of surgery performed – Common sense would suggest the more invasive the surgery, the greater the risk.

• How long since surgery? – Consider the healing state that the tissues are likely in. Between 0-3 days is the inflammatory state where the body’s reaction to the surgery is likely heightened and is identifiable by increased edema, reddening of the skin, increased heat, and pain. Compare that to 2-3 weeks out when the area is likely in the proliferative phase where the focus is to promote healing with less heightened local responses. Common sense would also suggest a greater risk immediately following surgery.

• The incision size- A rule of thumb is the larger the incision size, the longer the wait to integrate BFR training. There’s a distinct difference in incision size from a surgery like an ACL reconstruction compared to a total knee replacement.

• The incision site itself – Does the incision still have stitches or is it healed up? With the addition of post-surgical swelling plus the application of BFR training, there may be an increase risk of dehiscence at the incision site, which could complicate the recovery. This may impact the type of BFR training performed such as intermittent versus continuous application.

These all should be kept in mind when attempting to make a determination about the risk of BFR following surgery in conjunction with the patient’s medical state. 

Hughes, L., Rosenblatt, B., Haddad, F., Gissane, C., McCarthy, D., Clarke, T., Ferris, G., Dawes, J., Paton, B., & Patterson, S. D. (2019). Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial. Sports medicine (Auckland, N.Z.), 49(11), 1787–1805. https://doi.org/10.1007/s40279-019-01137-2

Iversen, E., Røstad, V., & Larmo, A. (2016). Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction. Journal of sport and health science, 5(1), 115–118. https://doi.org/10.1016/j.jshs.2014.12.005

Takarada, Y., Takazawa, H., & Ishii, N. (2000). Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles. Medicine and science in sports and exercise, 32(12), 2035–2039. https://doi.org/10.1097/00005768-200012000-00011

****Remember, the decision to use BFR, or any treatment for that matter, should be based on the pillars of evidence-based practice.

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