Can Blood Flow
Restriction Used During
Aerobic Training Enhance
Body Composition in
Physique Athletes?
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Nicholas Rolnick, DPT, MS, CSCS1 and Brad J. Schoenfeld, PhD, CSCS, CSPS, FNSCA2
1
The Human Performance Mechanic, PHLEX NYC, New York, New York; and 2Health Sciences Department, CUNY
Lehman College, Bronx, New York
ABSTRACT
Emerging evidence indicates low-load
blood flow restriction (BFR) training is
an effective strategy to increase mus-
cular adaptations when performed
during resistance training. Yet, it
remains questionable as to whether
combining BFR with traditional aerobic
training can preserve or perhaps even
potentiate hypertrophic adaptations.
The purpose of this article is to provide
an evidence-based review of current
research on the topic and draw prac-
tical conclusions as to how BFR can
be applied by physique athletes to
optimize increases in muscle mass.
INTRODUCTION
lood flow restriction (BFR) has
B become a popular adjunct to
high-intensity resistance-training
(RT) and aerobic-training (AT) programs
in physique athletes due to its unique abil-
ity to produce comparable gains in mus-
cle size, strength, and aerobic capacity
despite the lesser relative exercise inten-
sity (33,38,51). BFR involves the use of a
compressive cuff (either elastic or
Address correspondence to Brad J. Schoen-
feld, brad@workout911.com.
Copyright Ó National Strength and Conditioning Association
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
pneumatic) that is applied to the proximal
portion of the limb to partially reduce
arterial flow and completely occlude
venous return (53). Application of BFR
alters the local metabolic environment
due to restriction of arterial flow, increas-
ing contraction demands of muscles distal
to the cuff. Researchers have theorized
that these responses are due to reductions
in oxygen delivery, producing earlier voli-
tional failure in RT and AT programs
compared to unrestricted exercise
(19,20,74). BFR RT exercise prescriptions
are commonly between 20 and 40% 1
repetition maximum (RM), providing an
alternative approach for individuals look-
ing to maximize muscle hypertrophy in
their training programs from the tradi-
tionally recommended 6–12 repetitions
at 65–85% of the 1RM (59). Although
the benefits of BFR RT have been dis-
cussed at length in other publications
(25,39), not much attention has been
focused on the potential for BFR AT to
enhance hypertrophy or other beneficial
outcomes (i.e., aerobic capacity or caloric
expenditure) in individuals looking to
maximize muscular adaptations in a com-
bined RT-AT program.
AT is commonly used by physique
athletes to increase daily energy
expenditure (EE) to maximize fat loss,
Strength and Conditioning Journal | www.nsca-scj.com
particularly during contest prepara-
tion. Typical physique athlete recom-
mendations for AT vary in intensity,
duration, and frequency (28), and
depend on whether or not the individ-
ual is in contest preparation. Helms
et al. (28) recommended that both
high-intensity AT and low-intensity
AT be performed within a concurrent
RT program to maximize fat loss but
cautioned against regular use of high-
intensity AT, especially during contest
preparation, due to the potential inter-
ference effects as well as impeding
recovery between RT sessions. This
makes low-intensity AT a more feasible
option for the physique athlete. How-
ever, high volumes of low-intensity AT
may negatively affect hypertrophic
adaptations despite the additional loss
of body fat, especially if longer dura-
tions (30+ minutes) are used (75).
Using other alternative approaches to
augment caloric expenditure, preserve
(or enhance) muscle mass,
and minimize recovery times between
RT may be a desirable alternative to
traditional AT approaches.
KEY WORDS:
occlusion training; cardio; body-
builders; Kaatsu
37
 BFR-AT for Physique Athletes
BFR AT is commonly prescribed at
aerobic intensities as low as 30% of
heart rate reserve (HRR) (53). Low-
intensity AT with BFR has been shown
to increase EE, improve maximal aer-
obic capacity, shift substrate utilization
toward fatty acid oxidation, and even
enhance muscle mass compared to
matched free-flow conditions
(2,18,55,66), making it a potentially
appealing approach to augment the
benefits of AT during contest prepara-
tion. This article provides an evidence-
based review of current research on the
hypertrophic benefits of BFR AT, and
draws practical conclusions as to how
the strategy can be used by physique
athletes to optimize results.
BLOOD FLOW RESTRICTION
TRAINING MECHANISMS:
OVERVIEW (HYPERTROPHY-
FOCUSED)
Muscle hypertrophy from chronic
BFR training seems to be mediated
by somewhat similar processes as
free-flow exercise. In short, for muscle
hypertrophy to occur, net protein bal-
ance must remain positive for longer
periods than when it is negative (17).
Although muscle hypertrophy after
BFR RT seems to be primarily medi-
ated by the mechanistic target of rapa-
mycin complex 1 (mTORC1), a
molecular nodal point in the anabolic
molecular intracellular signaling path-
way, BFR AT-induced elevations in
muscle protein synthesis responses
seem to be of less magnitude, if they
occur at all (26,48). Due to the low
intensities of BFR AT and the lack of
significant external resistance (i.e.,
load), the hypertrophic potential seems
to be less than BFR RT and likely takes
longer to occur relative to BFR
RT (63).
AEROBIC TRAINING:
MECHANISMS UNDERLYING
HYPERTROPHY
This section provides a brief, general
overview of the proposed mechanisms
underlying hypertrophy observed with
AT combined with BFR. The reader is
referred to our companion article that
provides a brief overview of the mech-
anisms thought to be mediating gains
38 VOLUME 42 | NUMBER 5 | OCTOBER 2020
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in muscle size after BFR RT—metabo-
lite-induced fatigue and cell swelling
(57). These mechanisms are relevant
when discussing the similarities and
differences between BFR exercise
modes with respect to muscle
hypertrophy.
Although BFR RT has shown to
increase hypertrophy to a similar mag-
nitude in old (9) and young (60), trained
(8,15) and untrained (68) participants,
BFR AT displays less robust hypertro-
phic outcomes (2,3,63). For example,
Kim et al. (33) reported no significant
increases in thigh hypertrophy after a
6-week BFR cycling program at 30%
of HRR despite an increase in lean leg
mass in the BFR group. Other studies
reporting hypertrophy with BFR AT
protocols used higher exercise intensities
such as 40% V̇ O2max (3), 40% V̇ O2
reserve, (14) or 45% HRR (47). It seems
there is a minimum intensity threshold
(;30% HRR) for BFR AT below which
hypertrophic gains are blunted, conceiv-
ably resultant to lower absolute meta-
bolic and musculoskeletal stress (33).
Similar to BFR RT, BFR AT can be
performed at low intensities (30–50%
HRR or V̇ O2max) (53). Numerous
studies have reported significant
increases in muscle hypertrophy after
low-intensity walking or cycling proto-
cols in a variety of populations
(2,4,14,46,58) but few have reported
on postexercise protein signaling
expression after BFR AT. One study
reported that walking with BFR at
55% V̇ O2max increases phosphoryla-
tion of p38 (a member of the
mitogen-activated protein kinase sig-
naling pathway) without correspond-
ing increases in mTORC1 or S6K1
phosphorylation levels compared to
free-flow exercise at the same work-
load (48). Conversely, another study
found no changes in postexercise
expression of p38 but showed
increased expression of downstream
mTORC1 substrates and myostatin
downregulation after a BFR AT inter-
val walking program (31). Of note, my-
ostatin is a negative regulator of
mTORC1 pathway and its decrease
has been theorized to lead to greater
long-term gains in muscle mass accre-
tion from RT both with and without
BFR (35). Compared to BFR RT, the
degree of post-exercise anabolic signal-
ing after BFR AT is significantly less
(22,23), albeit still greatly elevated
above pre-exercise levels. These obser-
vations support the notion that low-
intensity BFR AT elicits less of an ana-
bolic response compared to low-load
BFR RT. The differences in anabolic
signaling between modes of exercise
may be related to the relative fre-
quency, intensity of walking/cycling
relative to external resistance (such as
in BFR RT), and/or changes in post-
exercise cell swelling (45).
At lower exercise intensities, BFR AT
walking and cycling do not seem to con-
sistently augment metabolic stress
(13,32,40,50,65,73), nor increase post-
exercise muscle fatigue (32,45). How-
ever, when compared to the same mode
of exercise performed without occlusion,
BFR AT increases acute measures of
quadriceps femoris and triceps surae
muscle thickness over free-flow condi-
tions (45). Thus, it is possible that the
acute cell swelling response may be a
commonality linking BFR RT and BFR
AT, which conceivably would help to
explain the decreased magnitude of pro-
tein signaling pathway activation relative
to RT, because cell swelling in and of
itself is not a potent stimulator of muscle
hypertrophy (34,69). Indeed, recent
research has shown that cell swelling
can augment the force-producing capa-
bilities of contracting muscle by increas-
ing both active and passive force
production at longer muscle lengths
through heightened force transmission
to the local extracellular matrix, theoret-
ically enhancing the mechanical tension
experienced by the myofiber per con-
traction (64). Mechanistically, this may
provide some support as to the inconsis-
tent increases observed in muscle hyper-
trophy and protein signaling observed
after a variety of different BFR AT pro-
tocols. Namely, protocols using longer
durations, higher frequencies of training,
and/or greater intensities may allow
for a larger degree of cell swelling and
 therefore, a more potent hypertrophic
stimulus in the exercising muscles.
It is interesting to note the similar
responses in muscle hypertrophy after
BFR AT when comparing protocols of
different modes, frequencies, and
intensities of training. For example,
Abe et al. (3) elicited a 4.6% increase
in quadriceps cross-sectional area
(CSA) (assessed through magnetic res-
onance imaging [MRI]) and a 6.4%
increase in maximal aerobic capacity
using a 33/week, 15-minute cycling
protocol at ;59% HRR over 8 weeks
(;18 minutes of total time under
occlusion). The results from Abe
(2010) suggest that shorter-duration,
higher-intensity bouts of BFR AT
may be performed instead of longer-
duration, lower-intensity bouts to aug-
ment muscle hypertrophy and increase
aerobic capacity in young, healthy
adults. Importantly, the intensity of
the exercise performed falls under the
recommendations by the American
College of Sports Medicine to improve
maximal aerobic capacity and is not
considered low intensity (54). How-
ever, a high-frequency short-interval
BFR AT walking protocol (50 m/min
speed, 5 sets of 2 minutes; total time
under occlusion—17 minutes) per-
formed twice per day for 3 weeks also
improved quadriceps and hamstring
muscle CSA by 5.7 and 7.6% (assessed
through MRI), respectively, along with
increases in 1RM leg press and leg curl
strength (2). The relative intensity of
the BFR group was estimated to be
at approximately 19.5% V̇ O2max—
much lower than the recommended
50% V̇ O2max or 60% HRR intensities
required to elicit aerobic benefit or the
intensity of Abe’s cycling protocol (54).
Therefore, it seems that the increased
frequency of training made up for the
decreased relative exercise intensity
performed to produce similar levels
of post-intervention muscle hypertro-
phy (4.6 versus 5.7%, respectively).
Compared to BFR RT interventions of
similar durations, the resultant hyper-
trophy is considerably less in BFR AT.
For example, Abe et al. (1) had 16
young adults perform 12 days of
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
twice-daily squat and leg curl BFR
RT at 20% 1RM and produced a 7.7%
increase in quadriceps CSA (assessed
through MRI). Another long-term 8-
week study on BFR RT using 4 sets
of leg extensions performed at 50%
1RM to volitional fatigue in athletes
increased quadriceps CSA 12.3% (as-
sessed through MRI) (70). The fre-
quency of this intervention was twice
per week, emphasizing the hypothesis
that BFR RT may not require as high of
a frequency (2 versus 3 d/wk) to pro-
duce superior hypertrophic outcomes
as BFR AT as long as the external load
(above 20% 1RM) and effort (working
near or achieving volitional fatigue for
multiple sets) is sufficient (70).
In conclusion, BFR AT-induced hyper-
trophy can occur after short- or long-
term training, but is of lesser magni-
tude than BFR RT and likely requires
more training sessions compared to
RT to observe a meaningful accretion
of muscle mass. This difference may be
explained by a lack of significant
metabolite accumulation in BFR AT
despite higher levels of cell swelling
post-exercise in BFR AT versus AT
alone. There likely exists a minimum
threshold (;30% HRR) in BFR AT
under which negligible hypertrophy
occurs. As a general rule when pre-
scribing BFR AT exercise for the goal
of increasing hypertrophy, intensities
above 30% HRR should be used to
heighten the anabolic response to this
form of exercise, especially in
resistance-trained participants.
BLOOD FLOW RESTRICTION
RESEARCH ON ATHLETES, WELL-
TRAINED INDIVIDUALS, AND
PHYSIQUE COMPETITORS
To date, the research on using BFR
with physique athletes is sparse (1 case
report) (64). Furthermore, the subject
of this case report did not use concur-
rent use of BFR AT, limiting the ability
to draw inferences as to its efficacy. To
the best of the authors’ knowledge,
there currently are no studies that
investigated the hypertrophic potential
of BFR AT in athletes, well-trained
individuals, or physique athletes. A sys-
tematic review by Bennett and Slattery
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(7) suggests that BFR AT is a viable
approach to augment aerobic capacity
in a variety of populations, including
athletes, but do not report any studies
investigating hypertrophic outcomes.
There is evidence that BFR combined
with walking stimulates anabolic intra-
cellular signaling to a greater extent
than nonoccluded walking (48); how-
ever, subjects were not involved in a
structured exercise program, limiting
extrapolation to resistance-trained
individuals. Similarly, other studies that
do report hypertrophy with BFR AT
are in young (46,58) and old sedentary
adults (50), making any recommenda-
tions on the efficacy of BFR AT in the
physique athlete difficult, especially
when prior reviews have concluded
that older, deconditioned adults tend
to experience greater magnitudes of
hypertrophy with traditional AT than
younger adults (49).
Therefore, this section will briefly dis-
cuss the studies that investigated mus-
cle hypertrophy during BFR AT in
untrained or physically active adults
that were directly compared to
higher-intensity exercise (and/or RT)
and will draw parallels (when appro-
priate) to the physique athlete during
off-season or contest preparation.
Understanding the magnitude of adap-
tations relative to both higher-intensity
exercise and RT can provide informa-
tion to help physique athletes pre-
scribe BFR cardiovascular exercise for
their own programming.
To date, only 2 studies have compared
the chronic anabolic effects of low-
intensity BFR AT to high-intensity
nonoccluded AT (14,33). Kim and col-
leagues (33) compared the effects of 6
weeks of 3 times per week high-
intensity (HIT) cycling AT (20 minutes
at 60–70% HRR) versus low-intensity
cycling BFR AT (20 minutes at 30%
HRR with bilateral 160–180 mm cuff
pressure to thighs) on thigh CSA,
strength, body composition, and max-
imal aerobic capacity in physically
active college-aged males. Despite
the differences in total volume of exer-
cise, the BFR group increased knee
flexor strength and muscle CSA
39
 BFR-AT for Physique Athletes
(+2.24–2.67%) to similar degrees as
the HIT group and produced superior
gains in lean leg mass (33). Unlike
other BFR AT studies, maximal aero-
bic capacity did not change post-
training in either group, likely a
product of the methodology (arbitrary
pressures, relatively low exercise inten-
sity in the BFR group, and duration)
(33). This study provides support
for using low-intensity BFR AT cy-
cling to produce small increases in
muscle hypertrophy similar to, or per-
haps slightly superior than, HIT.
Another study compared the anabolic
effects of 4 weekly HIT-AT cycling ses-
sions (30 minutes of cycling at 60–70%
V̇ O2reserve), low-intensity BFR AT
cycling (30 minutes of cycling at 40%
V̇ O2reserve using 80% personalized
restrictive pressure), and high-
intensity RT (70% 1RM, 43 failure
leg press) in sedentary young adults
(14). After 8 weeks, only the RT and
BFR AT groups increased vastus later-
alis CSA (+12.5% in RT and +10.7% in
BFR AT) with large effect sizes (ESs)
(+1.24–1.41) and no between-group
differences, indicating the exercise
intensities in both groups were suffi-
cient to produce a large hypertrophic
stimulus (14). Muscle strength also
improved in both RT and BFR AT
groups but to a much larger degree
in the RT group (+35%, ES 5 2.17)
than the BFR AT group (9%, ES 5
0.58). However, caution must be taken
when extrapolating results to physique
athletes, given that the cohort was sed-
entary young adults and thus the mag-
nitude of effects likely would be much
lower in resistance-trained individuals.
It is interesting to note the differences
in frequency, intensity of exercise, and
duration of training in the Conceiçao
et al. (14) study compared to the Kim
et al. (33) study, which may provide
some insights into appropriate exercise
prescriptions for the physique athlete.
Specifically, the results of these long-
term studies suggest that meaningful
hypertrophy with BFR AT (if it occurs)
likely takes longer (8+ weeks), requires
higher frequencies (43/week), and
needs to be of sufficient intensity (at
40 VOLUME 42 | NUMBER 5 | OCTOBER 2020
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least 40% V̇ O2 reserve or HRR) to pro-
duce the stimuli required to elicit pos-
itive adaptations, especially in
resistance-trained individuals looking
to maximize hypertrophic potential.
In regard to the physique athlete, it
can be hypothesized that BFR AT
most likely will produce minimal if
any hypertrophy due to the advanced
training status of the individual,
although this hypothesis requires
empirical evidence. A more promising
possibility is that the use of BFR AT of
similar duration, frequency, and inten-
sity as traditional AT may mitigate
muscle loss generally observed during
prolonged periods of caloric restriction
(i.e., contest preparation). This hypoth-
esis warrants further research but, until
such research is conducted, the use of
BFR during AT would seem to have a
favorable upside with limited downside
for the physique athlete.
METHODOLOGICAL AND
PRACTICAL RECOMMENDATIONS
FOR APPLYING BLOOD FLOW
RESTRICTION
Implementing BFR into the AT pro-
gram for physique athletes requires
some basic methodological consider-
ations. These considerations can help
shape how BFR can be safely integrated
into the AT programming of physique
athletes.
BFR can be applied in practice to the
proximal limbs (arms or legs) using
either a pneumatic or nonpneumatic
device (i.e., practical BFR). Pneumatic
devices are cuffs that are either manually
(using a pump) or automatically (using
an automated computer or wireless
device) inflated to a personalized pres-
sure called the limb occlusion pressure
(LOP). LOP is the minimum pressure
required to completely restrict arterial
inflow and venous return, and exercise
is performed at a percentage of that
pressure to minimize risk of adverse
events and augment metabolic responses
to BFR training (53). For example, apply-
ing 40% LOP to a limb would be 40% of
the minimum pressure required to fully
occlude both arterial inflow and venous
return, ensuring arterial inflow during
exercise. LOP has been shown to vary
based on body positioning (29,61), and
thus it is important to assess LOP in the
position of the exercise because overes-
timating or underestimating pressure
could limit the effectiveness of BFR
AT exercise or increase risk of adverse
events (53). LOP is frequently assessed
in pneumatic cuffs with either an auto-
matic, tethered device that uses a pulse
pressure sensor, manually through an
external Doppler or with pulse oximetry
(in the upper extremities only) (37,77).
All 3 types of measurements to deter-
mine LOP have shown to be valid
despite significant differences in cost to
the consumer (36). Namely, the tethered,
automatic pneumatic devices are very
expensive, limiting their practical utility
in the gym setting, whereas nonauto-
matic untethered pneumatic cuffs plus
an external Doppler are more affordable
to the masses. For the upper body, pulse
oximetry provides a superior alternative
from both a cost and practical integra-
tion perspective because the barrier to
use is minimal. Even so, pneumatic cuffs
are still relatively costly from a practical
use perspective, but proper technology
allows for reproducible and valid mea-
sures of arterial occlusion on a session-
to-session basis, maximizing safety. New-
er technology uses wireless pneumatic
cuffs, although the validity of such
devices is yet to be determined with
respect to BFR training. Typically, exer-
cise is performed between 40 and 50%
LOP in the arms and 50–80% LOP in
the legs, with higher pressures likely
needed during BFR AT compared to
BFR RT due to lesser relative muscle
activation (53). Finally, LOP has been
shown to remain similar over the course
of 8 weeks, making prescription of indi-
vidualized pressures through use of an
external Doppler or wireless device more
practically feasible (and likely safer) than
nonpneumatic cuffs (42).
Unlike pneumatic cuffs, nonpneumatic
cuffs, such as knee wraps (KW), apply
pressure to the limb through increased
tension on the proximal limb applied
by the user. Although KW have shown
efficacy in a number of studies
(8,41,76), they do not allow for person-
alized pressures on a session-to-session
 basis (6). The results of Bell (6) suggest
that setting pressures relative to a “7/
10” tightness, as recommended in pre-
vious research, may overestimate or
underestimate applied pressures by as
much as 25% over a 3-day period. This
may significantly alter the effectiveness
of nonfailure BFR exercise and
decrease overall safety due to poten-
tially exercising under full occlusion.
Recently, to mitigate risk of excessive
application of cuff pressure using KW,
Abe et al. (5) showed that pulling
custom-designed elastic straps by 10–
20% of initial resting length reduced
arterial flow similarly to a pressurized
nylon cuff inflated to 40–80% of LOP.
Thiebaud et al. (72) provided addi-
tional support for the use of practical
BFR, stretching specially designed
straps either 2 inches or to 85% of thigh
circumference. However, it is impor-
tant to note that these elastic straps
were specially designed to allow pre-
cise determination of the magnitude of
stretch; consumer-bought elastic KW
are more difficult to standardize, mak-
ing practical BFR more challenging to
implement in practice when specific
pressures are required. Until these
straps become more widespread for
consumer purchase, pneumatic BFR
devices are the preferred choice for
use in the gym setting.
Pneumatic devices are recommended
for practical use over KW because they
are able to provide a more objective and
consistent restrictive stimulus, minimiz-
ing the risk of adverse events. Newer,
recently released technology has
removed some of the previous barriers
to practical implementation including
cost and need for an external Doppler
for LOP assessment. These devices are
able to wirelessly determine LOP using a
pulse pressure sensor, making them
more gym friendly for the physique ath-
lete. That said, if individuals still wish to
implement KW into their BFR exercise
routine, they should exhibit caution and
reduce applied pressure if any numbness,
tingling, or excessive bruising occurs
underneath the area of occlusion.
Given the aforementioned recommen-
dations (Table) for integrating BFR into
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
AT regimens, it is important to note that
BFR AT-induced hypertrophy is signif-
icantly less than BFR RT (63), similar to
what has been observed in research
comparing nonoccluded AT to tradi-
tional RT protocols (24). Therefore,
the most suitable role for BFR AT in
the physique athlete seemingly would
be to enhance caloric expenditure and
increase myocardial workload to sup-
port a caloric deficit as a supplement
to traditional RT programs, while
potentially helping to enhance the ana-
bolic milieu and thus preserve muscle
mass. Such a milieu may help to support
further anabolic gains through increases
in conduit artery diameter (12), anaero-
bic capacity (51), mitochondrial gene
transcription (10), and improvements
in Na+/K+ ATPase activity (11), all of
which can allow for higher volumes of
exercise to be accomplished by the
working muscle before significant
fatigue accumulation.
Several studies have shown the effi-
cacy of BFR AT in increasing total
EE of AT when compared to free-
flow exercise (13,43,55,62). One study
showed that BFR AT walking increases
V̇ O2 requirements by ;5% compared
to free-flow AT (46). Another study
reported that 14 minutes of BFR AT
walking at 50% LOP at 40% of personal
maximum running speed (;3.5 miles
per hour, mph) burned 90 versus 76
kcals in free-flow (+18.7% difference)
(55); further increases in pressure did
not augment the EE response to the
same degree but exponentially
increased perceived discomfort, poten-
tially limiting long-term adherence
using higher pressures. It should be
noted that the overall magnitude of
differences in EE is modest between
conditions, at least during the activity
itself, and thus of questionable practical
meaningfulness. Whether AT BFR
enhances post-exercise EE (excess
post-exercise oxygen consumption)
over and above free-flow AT remains
to be elucidated.
With respect to theorized hypertro-
phic mechanisms in AT, Ogawa et al.
(45) reported that neither fast (87 m/
min 5 ;3 mph) nor slow (56 m/min
Strength and Conditioning Journal | www.nsca-scj.com
5 ;2 mph) walking had any influence
on acute cell swelling values. However,
interval BFR cycling at ;80% LOP
with a 70 revolutions per minute
(rpm) cadence at 30% peak power pro-
duced lactate levels similar to 90–105%
peak power intervals (16). Although
hypertrophy was not measured in
these acute studies, the findings may
have implications for exercise prescrip-
tion to maximize EE and hypertrophy
after chronic BFR AT. Fast walking (3–
3.5 mph) or cycling (;70–80 rpm)
combined with BFR with at least 50%
LOP potentially could maximize the
EE and hypertrophic potential of BFR
AT in long-term training regimens.
There is a paucity of research on BFR
AT and athletes (and none on physique
athletes), limiting the ability to translate
research findings into practice. To the
best of the authors’ knowledge, only 4
studies have been conducted on athletes
using BFR during AT: 2 studies used
high-intensity interval cycling with
BFR applied during the rest period
(44,71); 1 involved elite rowers who
substituted some of their weekly AT vol-
ume with low-intensity BFR (;65%
HRmax) (27); and the other was a short,
high-frequency walking program in col-
legiate basketball players (51). None of
these studies reported relevant outcome
measures (EE, thigh muscle hypertro-
phy) for the physique athlete. Thus,
more research is needed to better gener-
alize conclusions as to the potential use
of BFR AT for the physique athlete.
BFR AT can be performed either con-
tinuously or in intervals. Continuous
BFR AT application involves perform-
ing a mode of AT (i.e., walking/
cycling/rowing/step mill) for a set
duration of time where the BFR cuffs
are inflated throughout. Interval BFR
AT application involves performing
smaller workloads (at a similar or high-
er intensity than continuous BFR AT)
for a set period followed by a short
interset rest (typically 1 minute) where
BFR is either released or maintained.
Research conducted on healthy adults
indicates that either method may
elicit hypertrophic adaptations, but
cycling intervals may produce superior
41
 BFR-AT for Physique Athletes

Table
Evidence-based practical recommendations for BFR aerobic training based

Programming variable considerations Recommendation Important notes

Mode Walking/cycling/ Walking and cycling are the most researched modes of AT using
rowing/step mill BFR training, but recent evidence has incorporated rowing
with significant maximal aerobic capacity benefits, although
hypertrophy was not a measured outcome (26). Step mill could
theoretically increase hypertrophy compared with other forms
of AT because of higher muscle activation. Minimizing the
degree of post-exercise muscle damage/soreness is crucial to
maximize the frequency of both AT and RT, so jogging/running
with BFR is not advised despite some evidence suggesting it
can augment thigh hypertrophy and reduce running-related
markers of muscle damage compared with the same exercise
performed without BFR.
Frequency 1–23/day up to 3 wk; There appears to be a dose-response relationship with AT cycling
2–43/wk . 3 wk and hypertrophy specifically with duration (49), and BFR
training may follow similar patterns. A recent review on
hypertrophy following cycling in young, untrained adults
showed large effects (0.91) in studies that performed
continuous AT training for greater than 40 sessions, whereas
significantly smaller effect sizes on hypertrophy (0.21) were
noted in studies using under 40 sessions of BFR AT. This may be
reflective of the lower absolute hypertrophic potential of AT
due to less muscle activation/protein synthesis signaling.
Programming BFR AT should be based on the seasonal status
of the physique athlete (i.e., in-season or offseason), but there
does appear to be merit in short, high-frequency blocks of BFR
AT to augment the hypertrophic response to AT, at least in
healthy, young and old participants (2,47).
Intensity At least 40% HRRa/ Some research has shown that intensities below 40% HRR/V̇O2R
V̇O2Rb do not promote significant hypertrophy during BFR AT (2,33).
When using HRR, there appears to be an underestimation of
relative intensity (with respect to %V̇O2max) in trained
individuals, likely requiring higher intensities of exercise to
achieve adequate muscle stimulation (54,65). V̇O2R is probably
more accurate to reflect research recommendations but
requires knowledge of V̇O2max, making HRR more practical.
%LOPc Arms: 40–50% LOP A minimum pressure of 50% LOP was shown in the legs to
Legs: 50–80% LOP produce significant increases in EE over free-flow work-
matched controls (55). Higher pressures increase EE but are
significantly more uncomfortable (55), potentially limiting
applicability. However, because of low muscle activation
during AT, higher pressures (i.e., 80% LOP in the legs) may be
needed to maximize hypertrophy, as this has been shown in
BFR RT with a lower % 1RM (38).
Continuous or intermittent application Either Continuous application during BFR AT augments the acute cell
(deflated during rest)d swelling response that may contribute to hypertrophy
observed with BFR AT (45). Conversely, short, high-intensity
bouts of cycling BFR AT between 60 and 80% maximum
tolerated workload improved performance and enhanced
Na+/K+ ATPase function in type I and II muscle fibers,
decreasing their fatiguability (11).

42 VOLUME 42 | NUMBER 5 | OCTOBER 2020

Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
 Table
(continued )
Continuous/intervals? Both Continuous application may provide a superior stimulus for
hypertrophy, whereas interval exercise may promote a
superior strength response over continuous forms of BFR AT
because of higher relative intensities of exercise and muscle
activation levels (49). Low-intensity interval BFR AT has been
shown to outperform interval training without BFR on V̇O2 max
and muscle strength (18).
Maximum wear time 30 min For safety reasons, limit continuous exercise duration to 30 min;
most studies on BFR AT do not exceed 30 min of continuous
application.
HIIT and BFR? Yes—but likely not BFR AT can be performed with HIIT, but it does not appear to be
optimal for effective at improving either type I or type II muscle fiber cross-
hypertrophy sectional area in trained cyclists over 4 wk despite increasing
V̇O2max (44). Practical bodybuilding recommendations vary as
to whether HIIT should be used as a strategy for creating an
energy deficit, with lower durations recommended to maintain
or improve hypertrophy (28).
%1RM 5 percent of 1 repetition maximum; AT 5 aerobic training; BFR 5 blood flow restriction; EE 5 energy expenditure; HIIT 5 high-intensity
interval training; LOP 5 limb occlusion pressure; RT 5 resistance training.
a
HRR 5 heart rate reserve. Calculated by the Karvonen formula (KF) to determine intensity of cardiovascular exercise; KF 5 ([220 2 age 2 resting
heart rate] 3 %HRR intensity) + resting heart rate.
b
V̇O2R 5 Similar to HRR values but based off of V̇O2 max equations. Defined as: V̇O2R 5 V̇O2max 2 V̇O2Resting.
c
LOP 5 limb occlusion pressure 5 The minimum pressure needed to completely occlude both arterial flow and venous return of a limb, typically
determined with a pulse pressure sensor, external Doppler, or pulse oximeter.
d
Continuous describes when the activity is performed for a set duration of time (i.e., 10 min). Interval describes a shorter bout of exercise
performed at a higher intensity with interset rest periods.

metabolic stress and muscle activation
due to larger range of motion excur-
sions of the knee, potentially increas-
ing the muscle-building potential
of BFR AT over walking protocols
(14,16). More research is needed to
directly investigate muscle mass accre-
tions after chronic use of these
protocols.
Finally, some evidence indicates that
BFR AT can be performed at rela-
tively high frequencies (1–23/day)
to help maximize aerobic capacity and
improve muscle hypertrophy albeit to
a lesser degree than what would be
expected during BFR RT (2,51). The
Figure illustrates how BFR AT could
be integrated into the training pro-
gram of a physique athlete. Note:
Despite the lack of post-exercise
fatigue produced by BFR AT, BFR
AT is recommended to be performed
after RT to maximize hypertrophic
results (32,45).
HRR is recommended in practice
because it is more practical than V̇ O2m-
ax or V̇ O2reserve. Although HRR is not
without limitations—namely that it tends
to underestimate the relative intensity of
exercise in trained individuals (56,67)—it
is the most practically useful way to pre-
scribe exercise intensity.
To determine appropriate target heart
rate (THR) for BFR AT training:
 Resting heart rate (RHR) is determined
by measuring heart rate in the position
that the exercise is to be performed
 Use the max heart rate formula—“220
2 age” to get max heart rate (MHR)
 MHR 2 RHR 5 HRR
 THR for BFR AT 5 HRR 3 desired
exercise intensity (0.3–0.5; 30–
50+%) + RHR
For example—THR during BFR AT:
Age—20; RHR—60; desired exercise
intensity—0.4 (40% HRR)
 {([220 2 20] 2 60) 3 0.4 + 60} 5
116 beats per minute
Short intervals of BFR AT during the
initial sessions of a BFR training pro-
gram may allow for individuals
to successfully acclimate to the exercise
and scale up to ;30 minutes
of continuous application (Figure).
Although current evidence suggests that
BFR AT is well tolerated, practical expe-
rience suggests that if individuals are not
accustomed to the increased effort
required to maintain THR relative to
normal AT, BFR AT becomes a less
effective strategy at influencing hypertro-
phy and/or caloric expenditure, espe-
cially when target HRR is low
(;30%). Therefore, programming
should account for a ramp-up period
where THR is met consistently and

43
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 BFR-AT for Physique Athletes
Figure. A 16-week hypothetical approach to BFR aerobic training for the physique athlete. The exercise could be walking, cycling,
or step mill. BFR is applied bilaterally. Pressure is 50–80% LOP. Goal time does not start until THR is achieved. Note BFR
frequency remains 2–43/week. BFR 5 blood flow restriction; HRR 5 heart rate reserve; LOP 5 limb occlusion pressure;
THR 5 target heart rate.
individuals are able to meet the prescrip-
tion levels before progressing to longer,
more continuous forms of BFR AT.
There also is a rationale for incorporat-
ing both continuous and intermittent
BFR AT protocols into a concurrent
training program. Intermittent BFR AT
routines could be performed at a rela-
tively higher intensity (i.e., 50+% V̇ O2m-
ax) for a shorter period (;2–5 minutes),
increasing muscle activation and con-
comitant hypertrophic stress. Further-
more, cuff deflation during the interset
rest periods could facilitate additional
vascular and/or muscle-fiber-specific
adaptations due to the reperfusion and
hyperemic response of the exercising
muscles (11,12). The combination of
both types of protocols in a long-term
training program could theoretically pro-
vide an additive effect for the physique
athlete, although this remains speculative
and warrants investigation.
Practical recommendations to maximize
hypertrophy for the physique athlete
during BFR AT should likely involve a
mixture of the aforementioned strategies
shown to be efficacious in this review.
The Figure describes a 16-week perio-
dized walking/cycling/step mill pro-
gram focusing on building up tolerance
to BFR AT using short (5 minutes) inter-
vals at a lesser THR (40% HRR) transi-
tioning into longer-form cardio
(30 minutes) at a higher THR (50+%
HRR). This protocol likely maxi-
mizes cellular swelling and metabolic
stress due to the prolonged time under
occlusion and higher relative intensities
(by the end of the program). Con-
versely, short bouts (i.e., 5–10 sets of
44 VOLUME 42 | NUMBER 5 | OCTOBER 2020
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
2–3 minutes on, 1 minute deflated rest)
of high-frequency (1–23/day for 14
days) interval BFR AT could be used to
maximize vascular stress from ischemia/
reperfusion and could likely be per-
formed at even higher exercise intensities
(50+ % HRR) than continuous BFR AT,
elevating muscle activation and aiding in
the upregulation of anabolic milieu such
as vascular endothelial growth factor and
nitric oxide. These factors support
angiogenesis, vascular dilation, and allow
for better oxygen delivery to the working
muscle fibers, theoretically enhancing
the effects of RT with or without BFR. It
stands to reason that a combination of
these 2 protocols could provide the
physique athlete with not only hyper-
trophic but also aerobic benefits that
could help in interset recovery.
Of note, a recent review reported that 2–
3 days a week of high-intensity (;80–
90% V̇ O2max) BFR AT exercise does not
seem to provide additional cardiovascular
benefits over free-flow exercise in V̇ O2m-
ax (21). Yet, in those included studies,
running and cycling were used and
hypertrophy was not an outcome mea-
sure so it is only speculative whether or
not the higher-intensity exercise could
provide further hypertrophic benefit
when used in conjunction with a tradi-
tional heavy RT program typical of phy-
sique athletes. Interestingly enough, both
studies (30,52) reported peripheral mus-
cular adaptations including improved
running economy and submaximal mus-
cle V̇ O2 usage (52) and peak power out-
put (30) that suggests the possibility of
increased capillarization of the working
muscles (although this was not measured
in either study). The presence of periph-
eral muscular adaptations in a variety of
BFR exercise protocols highlights the
unique potential ways in which the addi-
tion of BFR AT to a physique athlete’s
concurrent training routine could further
support and/or maximize hypertrophy.
Despite the potential for running to
induce favorable peripheral muscular
changes that may support further hyper-
trophy, we do not recommend it as a
BFR AT training approach due to the
larger demands on the lower extremity
and heightened risk of increasing mus-
cular and vascular damage from the
occlusive stimuli. The heightened
single-leg impact and the greater eccen-
tric component could negatively affect
recovery between RT bouts and reduce
hypertrophic adaptations as a result.
To reduce the risk of hindering recovery
between RT bouts, BFR AT should be
performed using modes of exercise that
do not further facilitate an increase in
muscle damage. Muscle damage can
impede the recovery process and reduce
hypertrophic potential by limiting fre-
quency or intensity of training—undesir-
able consequences for the physique
athlete looking to maximize hypertrophy
during an offseason or maintain muscle
mass during contest preparation. Exercise
modes such as walking and cycling are
most favorable due to their low eccentric
demands as well as the presence of evi-
dence supporting its efficacy in producing
muscle hypertrophy with BFR AT. Step
mill—a common AT choice for physique
athletes—is another viable alternative to
walking/cycling, but caution is warranted
with higher-intensity protocols due to
 the potential for increasing muscle dam-
age. Likely, Stairmaster exercise is the
better alternative because it is also
weight-bearing and can easily be intensi-
fied without significant impact on the
legs, minimizing the likelihood of addi-
tional muscle damage. Practice-based evi-
dence suggests that both continuous and
interval aerobic exercise of various inten-
sities can work to support hypertrophy in
the physique athlete, but careful attention
should be given to the time of season
(offseason/contest preparation), BFR
acclimation status (new to BFR or expe-
rienced), and goals of the AT program
(maximizing hypertrophy/aerobic
capacity/calorie expenditure) before
determining mode, frequency, BFR pres-
sures, and exercise protocols.
SUMMARY AND CONCLUSIONS
Although the benefits of BFR AT are less
conclusive than that of BFR RT, the
strategy does modestly increase EE, cell
swelling, and (in some modes of exercise)
metabolic stress compared to work-
matched free-flow exercise, all of which
may be beneficial to the physique athlete
by either aiding in maintaining/produc-
ing a caloric deficit or by creating an
anabolic environment to aid in muscle
growth. Both of these applications may
be used in tandem to maximize results
during pre-contest preparation; however,
caution is warranted with long-term con-
tinuous use.
Despite the fact that BFR generally has
been shown to be safe in healthy
resistance-trained adults, not much is
known about its chronic effects (16+
weeks) on vascular function (17). There-
fore, it is advisable to schedule a pro-
grammed 4-week period where BFR is
completely removed from training to
account for any potential as-yet-
undetermined adverse events. There
may be less potential for adverse vascular
responses with BFR AT compared with
BFR RT due to the differences in intra-
vascular pressures from decreased mus-
cle activation and mechanical load,
potentially allowing BFR AT to be per-
formed for longer continuous
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
longitudinal durations (8–12 weeks) than
BFR RT, although this hypothesis
requires empirical support.
With respect to the physique athlete,
there are numerous avenues for future
research that could help to better deter-
mine the effectiveness of BFR within
this population. There currently are no
studies comparing the hypertrophic
effects of a typical AT program to a
BFR AT program performed in highly
trained physique athletes in either the
offseason or during contest preparation.
There are also no studies using a com-
bined RT-BFR AT approach compared
to the same approach without BFR on
muscle hypertrophy. Finally, exercise
prescription and modes outside of
cycling, walking, and rowing are yet to
be investigated, making practical,
evidence-based recommendations
somewhat difficult and largely based
on experiential outcomes.
Conflicts of Interest and Source of Funding:
N. Rolnick has received compensation to
provide educational lectures about blood
flow restriction training on behalf of
Mad-Up, a company that manufactures
blood flow resistance training systems.
The remaining author reports no conflicts
of interest and and no source of funding.
Nicholas
Rolnick is the
founder of the
BFR PROS, and
operates a physi-
cal therapy prac-
tice in New York.
Brad J.
Schoenfeld is
an associate pro-
fessor in the
Department of
Health Sciences
at CUNY Leh-
man College.
Strength and Conditioning Journal | www.nsca-scj.com
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