There is a recent trend among physical therapy providers treating their patients, including injured workers and plaintiffs, using Blood Flow Restriction Therapy (BFRT). While you may have recently heard about this trend during the Summer and Winter Olympics or have read about now-retired Washington Commanders quarterback Alex Smith’s road to recovery and use of this procedure, this therapy actually dates back to the 1960s. Yet, despite this treatment’s popularity for nearly sixty years, from a layman’s perspective, the therapy has remained largely unchanged.
What is BFRT, and what are its intended uses? What are possible issues to be aware of when handling workers’ compensation claims and reviewing medical records and medical bills? Lets take a look.
What is Blood Flow Restriction Therapy?
BFRT has been defined as the application of pressure over a body part, typically the arms or legs, by the use of a cuff while still maintaining blood flow to the cuffed body part in question. The aim of this technique is to allow patients to make greater gains while lifting lighter loads and, in turn, reducing the stress to that body part. To put it another way, BFRT restricts the blood flow to the body muscles in question through a tourniquet type device which then allows these muscles to strengthen through higher reps while using lighter weights. It’s a technique that has been quite popular with professional athletes, including Dwight Howard, Jadeveon Clowney, and actor Mark Wahlberg.
How Does it Work?
The theory behind BFRT is that by restricting blood flow from the area, a person can develop muscle more quickly while using less weight. For example, suppose an individual is performing dumbbell curls. In this case, as they execute the “pump” with blood flow restriction cuffs applied, the oxygen in that area continually decreases while the muscle-building parts of the body begin working in overdrive.
More recently, this therapy has been aimed to be especially effective in people who have atrophied or “eroded” muscle due to inactivity while bed-ridden or confined to a wheelchair for an extended period.
Does it Work?
The question of whether BFRT works is complicated. Research suggests that while lighter weights will spare your joints and allow you to perform more repetitions, it can prevent ligaments and tendons from further developing and is not conducive to building heavy muscle.
As referenced above, BFRT gained notoriety around the time an ESPN episode of “E 60” was aired on pro quarterback Alex Smith, who was rehabbing at the Center for the Intrepid, a rehabilitation facility owned by the United States Department of Defense. Alex Smith suffered a compound leg fracture while playing for the Washington Commanders in 2018, which ultimately resulted in 17 surgeries to fix his leg. Through his rehabilitation process, Alex Smith learned of Johnny Owens, owner of Owens Recovery Science, who was working out the Center for the Intrepid. Mr. Owens was using BFRT to assist blast injury victims from our military service to develop muscle without traditional weightlifting. Alex Smith implemented BFRT in his recovery, which led to him back to playing in the NFL in 2020.
While this is clearly a success story, a recent study performed with thirty-five subjects randomly assigned between implementing blood flood restriction and not implementing this technique found that “the B[lood] F[low] R[estriction] protocol used in this study did not augment strength for the rotator cuff in subjects.” In other words, there was no difference in strength gains between the groups.
Is it practical?
A few internet searches will tell you that a BFRT machine is available for purchase in the range of $119.00 up to $5,000.00. A continued search suggests a person can “DIY” the technique using resistance bands. However, this latter technique is heavily cautioned against by those who support this type of therapy.
Physical therapists who maintain practices where they treat patients involved in litigation say that the devices are relatively small and appear fairly easy to use, similar to that of a TENS unit, which can be “prescribed” for home use with a cost that can be wide-ranging. However, medical professionals caution it would be best to exercise care in issuing this equipment, given the associated dangers that can come along with them. Let us not forget that this is a therapy that cuts off blood flow to various parts of the body, and it would seem a professional’s application be necessary.
Where do we go from here?
Other than weightlifting and to aid in the development of muscle, BFRT is being experimented within a variety of areas to see the effect on workers’ compensation. For example, a clinical trial which began on January 15, 2019, and is expected to be completed by December 31, 2022, by the Duke University Sports Sciences Concussion Clinic is studying the effects of BFRT during post-concussion physical therapy and exercise to assist in a quicker recovery. Another area BFRT is being used is in blood platelet plasma treatment which uses BFRT to increase stem cells in blood to allow the muscles and joints to speed up the healing process.
Searches for physical therapy providers in Pennsylvania advertising the use of BFRT does not result in a plethora of positive hits. However, those that do come up all appear to advocate for its use for conditions such as fractures, inflammatory muscles, knee reconstruction, rotator cuff repair, osteoarthritis, and postoperative weakness.
Given the fairly general description of the uses for BFRT, we can expect to see an uptick in the implementation of this modality and having an understanding of what it is and how it is designed to be used, will go a long way in effectively monitoring workers’ compensation claims.
Discussions with numerous clients revealed that this treatment and associated invoices have not come across their desks yet. Still, with a large number of blood flow restriction systems being categorized as a “pneumatic tourniquet” under the FDA, the device in question needs only be listed and not approved by the FDA because it is defined as a Class I device and is 510(k) exempt. Given this, and that physical therapists appear to not be required to have any type of certification to implement these devices, we anticipate these devices will become part of injured worker’s training regiments sooner rather than later and will follow similar lines of take home TENS units.
This is still a relatively new type of treatment that needs objective case studies performed and the associated data analyzed. For insurers and employers across our Commonwealth, it is certainly something to monitor. If it happens to arise, the first line of defense would be to perform an investigation into the equipment being used and the costs associated with the same. Of course, the results from this treatment are a factor to consider as well. If you have a patient implementing this treatment at moderately little cost, then the fact that this treatment is relatively novel may not be the prevailing factor in denying the treatment.
 Brumitt J, Hutchison MK, Kang D, Alterado SGD, Berg T, Nguyen BP, Neumiller C, Reynoso R, Stickell J. "Rotator Cuff Strength is not Augmented by Blood Flow Restriction Training," Phys Ther Sport. 2021 Nov;52:305-311. doi: 10.1016/j.ptsp.2021.10.013. Epub 2021 Oct 23. PMID: 34742029.
 Briefly, a Class I device is a device that presents “minimal potential harm to the user,” while a 510(k) is a pre-market submission a medical equipment producer makes to the FDA to show that the device they are marketing is safe and effective.