Rehab & Performance Lab Ep 11: Blood Flow Restriction: Is it a Game Changer for Rehab Professionals?

Summary

Highlights

• BFR is a promising technique offering both hypertrophy and strength benefits without heavy lifting. 🔥
• Originally developed for military applications, BFR has transitioned into mainstream rehab practices. 🌟
• Research supports BFR's efficacy for a variety of conditions, making it a versatile tool in physiotherapy. 📊
• BFR not only builds muscle but also supports vascular health—an added bonus for patient rehabilitation. ❤️
• Proper training and understanding of BFR's contraindications are essential for safe application. 🚨

Key Takeaways

• BFR can mimic the effects of heavy lifting on muscles using lower loads, making it ideal for rehab settings where traditional heavy lifting isn't feasible.💪
• The technique has its roots in military rehab, especially for combat injuries, and has now expanded into general rehab due to its efficacy.🩺
• There are robust studies supporting BFR's effectiveness across various conditions including ACL reconstruction, tendinopathy, and post-operative recovery.📈
• BFR isn't only for muscle strength—it can enhance vascular function and potentially aid in pain relief through endogenous opioid release.🌿
• Safety is paramount; clinicians should ensure they're properly trained and aware of contraindications before applying BFR.🚫

Overview

Chapters

• 00:00 - 00:30: Introduction and Welcome The chapter titled 'Introduction and Welcome' is an opening segment of the Rehab and Performance Lab podcast, produced by MedBridge. It sets the stage by highlighting the focus on Orthopedics and Sports, promising to explore significant topics within these fields and providing practical insights and tips from renowned professionals. Listeners are encouraged to visit MedBridge for continuing education credits and to access additional resources. The podcast is hosted by Phil Plisky.
• 00:30 - 01:00: Host Introduction: Phil Plisky The chapter introduces Phil Plisky, a professor, founder of the Coaches Club, author at Phil.com, and a performance systems consultant in professional sports. Phil is also a physical therapist, athletic trainer, and certified strength and conditioning specialist. The focus is to approach topics from multiple angles, presenting the latest evidence while ensuring practicality for immediate application in practice. The aim is to dive into experts' areas to understand how to implement knowledge effectively in practice.
• 01:00 - 01:30: Topic Introduction: Blood Flow Restriction & Guest Introduction The chapter introduces the topic of Blood Flow Restriction (BFR) and its potential impact as a revolutionary tool for rehabilitation professionals. Host Phil welcomes guest Johnny Owens, an expert in BFR, to the podcast. Johnny begins by sharing his background, mentioning his 20-plus years of experience as a physical therapist, during which he has witnessed various trends in the field.
• 01:30 - 03:00: Johnny Owens' Background and Initial Involvement with BFR The chapter begins by introducing Johnny Owens and his journey into Blood Flow Restriction (BFR) therapy. It outlines his educational background in orthopedics and sports medicine, which laid the foundation for his future work. After graduation, Johnny started working for the Department of Defense (DoD) at the onset of the Global War on Terror (Operations Enduring Freedom and Iraqi Freedom). During his 13-year tenure with the DoD, he developed a strong interest in combat casualty care and focused on rehabilitating injured service members to return them to active duty.
• 03:00 - 06:00: Development of BFR in Military Context This chapter explores the development of Blood Flow Restriction (BFR) techniques within a military context. The narrator recalls their earliest encounters and experiences with BFR at the Center for the Intrepid, noting its application and growth over time. The exchange of expertise and insights with Dr. Tahan and others highlights the pioneering stages of BFR's integration into military rehabilitation efforts. The chapter captures reminiscences on the initial adoption and experimentation with BFR methods, celebrating its potential and the collaborative spirit that drove its early success.
• 06:00 - 09:00: Importance of BFR for Rehab Professionals The chapter focuses on the importance of Blood Flow Restriction (BFR) therapy for rehabilitation professionals, particularly in the context of limb salvage cases. One of the main groups receiving attention were individuals who had experienced severe lower extremity trauma, often due to Improvised Explosive Devices (IEDs). The preference was to salvage the limb rather than opt for amputation immediately, as was common in past conflicts. By bringing service members back home, they had the opportunity to make more informed decisions about their treatment with family and peer support.
• 09:00 - 12:00: Research and Physiological Basis of BFR The chapter 'Research and Physiological Basis of BFR' highlights the challenges and frustrations experienced in limb salvage efforts, specifically in military settings. It discusses the lengthy and difficult process of rehabilitating limbs, often taking 1 to 3 years, and the high rate of amputations even after successful salvage attempts. The emotional toll on service members and the medical team is evident as they navigate the complex journey of tissue and bone recovery.
• 12:00 - 15:00: Clinical Application and Safety Considerations The chapter discusses the challenges faced by veterans, particularly those who became addicted to drugs or faced mental health crises like suicide and divorce. It highlights the difficult decisions related to achieving a high level of function, such as considering amputation, as veterans strive for physical capability to run, jump, and redeploy. Despite advancements, it also acknowledges that older veterans' quality of life might not always match the expectations of younger service members.
• 15:00 - 18:00: Specific Use Cases in Orthopedics and Beyond The chapter discusses the use of an exoskeleton device called the Ideo which acts like a prosthesis. This device is used to help individuals, particularly in orthopedics, allowing them to run, jump, and perform other activities. It has significantly reduced amputation rates by 50% and increased redeployment rates by almost 50%. However, there are challenges in using this device, as it is quite stiff and may feel uncomfortable, posing a risk of knee dislocation.
• 18:00 - 21:00: Recovery and Remote Ischemic Preconditioning The chapter discusses alternative approaches to recovery and rehabilitation for individuals who are load intolerant due to injuries, lack of muscle or nervous tissue, or pain. The traditional method following the ACSM guidelines focuses on using heavy loads, which isn't always feasible for everyone. The author explores other avenues with physiologists, including remote ischemic preconditioning, as potential solutions.
• 21:00 - 25:00: Case Studies and Clinical Trials The chapter explores the concept of Blood Flow Restriction (BFR) and its roots in old literature. The excitement around BFR grows, especially with the proximity of tourniquet experts from the Department of Defense (DoD) who shared their expertise. The focus lies on vetting the safety measures, particularly when using BFR in severe trauma cases, including situations involving large, open residual limbs.
• 25:00 - 27:00: Clinical Trials and Conditions for Future Research This chapter discusses the development and implementation of a particular medical technique or tool, starting from a practical need. The story highlights how an initial joke about medical necessity led to the creation and adoption of this tool or technique. The chapter further elaborates on the success and widespread acceptance of the procedure once it was implemented, meeting all expectations and expanding beyond the original scope.
• 27:00 - 34:00: Cautions and Contraindications The chapter titled 'Cautions and Contraindications' discusses the surprising expansion of certain practices into the world of rehab professionals. The author reflects on the high rate of redeployment among individuals wanting to strengthen themselves to handle specific tasks. This phenomenon underlines the importance of discussions around the need for rehab providers to understand the cautions and contraindications of certain rehabilitative practices, highlighting the broader implications for average rehab providers.
• 34:00 - 37:00: Analgesic Effects and Pain Management The chapter discusses the process and challenges involved in integrating new analgesic practices into clinical settings, particularly outside of the Department of Defense (DOD). Initially, positive clinical results from trials encouraged collaboration with the American Psychological Association (APA) to explore the viability of these methods within standard clinical practice. A significant hurdle identified was the disparity between DOD practices and civilian Practice Acts, which regulate what medical professionals can do, such as ordering imaging or medications. The work included conducting a Practice Act review to ensure compliance and feasibility for broader clinical use.
• 37:00 - 43:00: Tendon Adaptation and Rehab Strategies The chapter discusses the adaptation and rehabilitation strategies for tendons, highlighting the potential interest and application within professional spaces, such as conferences. It points out that certain techniques, though potentially beneficial, are not typically taught during traditional education or training programs. Professionals interested in applying these methods must ensure their personal and professional liability coverage is adequate. Additionally, there's a mention of the lack of instruction on the use of tourniquets, indicating a gap in standard medical training. This implies a need for extra training for those who wish to incorporate these methods into their practice.
• 43:00 - 48:00: Concluding Thoughts and Future Directions for BFR The chapter discusses the importance of being prepared for worst-case scenarios, particularly in professional settings like rehabilitation. It emphasizes the necessity of formal education and training, as relying solely on self-taught methods can lead to complications, especially in legal situations. The author predicts that certain skills, like applying a tourniquet, will become standard in university curricula and professional exams, highlighting the ongoing development and future directions in the field of Blood Flow Restriction (BFR) therapy.
• 48:00 - 54:00: Closing Remarks and Resources The 'Closing Remarks and Resources' chapter discusses the importance of understanding and embracing emerging practices, especially in fields like physical therapy. It highlights how emerging practices are often a sign of long-term changes in the field. The chapter encourages readers to look at published literature and clinical results to better understand these new methods. This chapter serves as a call to action for individuals to take a deeper dive into emerging practices for their own growth and understanding.

Rehab & Performance Lab Ep 11: Blood Flow Restriction: Is it a Game Changer for Rehab Professionals? Transcription

• 00:00 - 00:30 [Music] welcome to the rehab and performance lab the medbridge podcast where we dive into the world of Orthopedics and Sports we're here to unpack the big topics offering you practical insights and valuable tips from some of the most inspiring Professionals in our field don't forget to visit medbridge decom to get your continuing education credit for this episode plus access bonus resources hey everyone welcome to the podcast I'm your host Phil plisky I'm a
• 00:30 - 01:00 professor and founder of coaches club and an author at phil.com and a performance systems consultant in professional sports being a physical therapist and athletic trainer and certified strength and conditioning specialist we like to come at this from multiple angles we want to present the latest evidence but most importantly we want this to be practical for you we want to go into the areas of our experts to really dive in and say how do we use this in our practice the next day I'm
• 01:00 - 01:30 looking forward to this topic today we're talking about Blood Flow Restriction is it a game Cher for Rehab professionals I'm joined by Johnny Owens who's an expert in Blood Flow Restriction welcome to the podcast Johnny hey Phil thanks for having me it's great to see you again man fantastic well could you get us started uh tell us a little bit about your background yeah sure so um I'm a physical therapist I've been at it over 20 plus years now so um I've seen kind of a lot of things come and go during
• 01:30 - 02:00 that time all the way from dimy up now to this crazy thing called Blood Flow Restriction um and so I'm excited to day to talk about this my my initial background coming out of school was um orthos sporks and that was kind of my focus and then I began working for the dod at the start of the of the conflicts of O and oif and I I was there for about 133 years and became passionate with combat casualty care and um how we can return our service Fighters back to Duty
• 02:00 - 02:30 or back to the highest level function and that's kind of where we stumbled into Blood Flow Restriction and in the dod I I think that's actually where we first met was uh I came down with uh uh uh Dr tahan and the group and at the center for Intrepid and and saw that probably in its pretty early days yeah I was wondering did did you come down when we were doing it I didn't know if it would made it into yeah you just I think you had basically just started it yeah yeah that's awesome you know the story
• 02:30 - 03:00 was that one of the main groups that I was working with at the center for the Intrepid was what we call limb Salvage and so typically um when you have an IED go off or severe lower extremity trauma most of the service members would choose to salvage their limb back in earlier conflicts you know you might see an amputation at the mash units or or while they were still down range um we felt it was better to get them back home when they're a little bit more Lucid they can make a decision with their family or or talk to peer groups and so most would
• 03:00 - 03:30 elect to salvage uh unfortunately that's a very long and laborious process it can be from 1 to 3 years to to actually salvage some of these limbs just from the soft tissue and bone loss and the frustrating thing was we had about 30% that would come back after we'd had what we thought was a successful Salvage and they would amputate um and so you know we it was a lot of frustration our end for the service members because of of what they've gone through and you know we had multiple um of of our guys you
• 03:30 - 04:00 know commit suicide during this period lots of they became addicted to drugs divorce we're like we're putting them through the ringer trying to get back to higher level function should we just amputate but then when we would look at our veterans who were you know older MPS um their life wasn't always as as great as you know what some of our young service members would see and it was it was mostly they just wanted to get the high level function now to run jump and hopefully redeploy because that's that was kind of what a lot of them were asking us for so we developed this
• 04:00 - 04:30 exoskeleton device called the Ideo um which acted like a prosthesis so we would put this um exoskeleton on their lower leg and it would allow a lot of them to be able to run to jump and you know we publish some papers we we reduced amputation rates by 50% we were able to increase redeployment rates by almost 50% but the rub was this device is is really stiff and really make it work and and not feel like your knee was going to maybe dislocate when you're
• 04:30 - 05:00 trying to use it you had to be super strong in your quad uh to control the knee moment and a lot of these individuals were load intolerant either from their injury they didn't have muscle tissue um nervous tissue or they had pain so we we just really we're looking at is there any other Avenue other than ACSM guideline type heavy load that we could look at and working with a bunch of our physiologists that we had across the street in our in our kind of science lab um I started asking them about this thing I was reading in
• 05:00 - 05:30 in some of the literature old literature decades old about Blood Flow Restriction um so we got super excited as as we dug into it luckily across the street at that same facility was the tourniquet experts for the dod and and they learned me up on tourniquets really quickly we vetted for right for quite a while this safety and would this be okay to put this on you know these severe trauma especially a residual limb right you know when you have a a large large open
• 05:30 - 06:00 wound you know and at what point and all that well the running joke was they were going to cut their leg off anyway so if we made the leg fall off with this tourniquet it was it it would save us some time yeah yeah so we got blessed and we implemented it in the do and and um it just it just kind of it it met all of our expectations um it just kind of proliferated from there that's fantastic so so I mean that origin story is pretty amazing like it came from a need right you know we need
• 06:00 - 06:30 to to get these you know folks stronger so that they can handle what they want to do and that redeployment rate always blows my mind that that you know so many want to redeploy and and so it came out of this need but why is it important to discuss this for the average rehab provider what where does how does this fit into that yeah well I I think what we weren't expecting was the proliferation um into the the rehab professionals world out there you know
• 06:30 - 07:00 so when we were first vetting it and then we were seeing some positive clinical results and then publishing some trials um we we started working with the APA um asking them would this be something that if we presented at conferences and we get asked you know can I do this or how do I do this in my clinic outside of the dod that that meets The Practice Act because there was a lot of things that we do you know we order Imaging we can order meds we can do all sorts of things in DOD that don't meet the practice acts and so you know did a Practice Act review for us and um
• 07:00 - 07:30 came back and said this looks like it fits within our space um this would be something that you know if if you're at conferences speaking you could say they would most likely be able to do it but but the caveats were um were were not taught it in school and so people would probably it would be on them to make sure their you know their personal liability is is up to par along with their professional liability of of I'm going to do this new technique and we're also not taught how to do tourniquets
• 07:30 - 08:00 um in school and so um always work from a worst case scenario if something goes really bad if the lawyer the first thing he asked you was who taught you how to put on a tourniquet rehab professional and you say I read about it um that that's not going to up in court so I I think talking about it is getting awareness because I think you should hear about it the the if you read the tea leaves this is going to be taught in in universities and part of Capa it sounds like I I I wrote a book chapter for the board exams of you know pre- preparing for to be there so I think it
• 08:00 - 08:30 it behooves us to know about it and I think it's such a powerful tool for us and obviously I'm very biased but um I I I just think the writings on the wall from the publish literature and the clinical results that that folks should know about it and take a deeper dive absolutely absolutely that and you know it is it is certainly you know you can always see that that emerging practice it first shows up uh when it's showing up in physical therapy school you know it's probably here to stay
• 08:30 - 09:00 so what question should we be asking as clinicians like you know what does this what does this look like yeah well I I think you again you got to ask yourself am I appropriate doing this and so as a clinician how did you learn Blood Flow Restriction how you know did you get trained on using a tourniquet so once you check that box then you start asking yourself when do I apply it and to whom should I apply it um how long should I apply it and we could go on for three days now with with with those questions but um you know we
• 09:00 - 09:30 get to ask this question all the time like what exercises do I do with Blood Flow Restriction and and I don't know if we need to go in kind of deeper what Blood Flow Restriction is but but basically when you let's talk about that I mean so so pretend I just I just dropped in here and I don't know what our goals or why we're why we're doing it yeah so um basically the the elevator pitch is ACSM guidelines say that to make muscle strength and hypertrophy
• 09:30 - 10:00 occur in individuals you should lift a a heavy load or do an intense type of activity and so the load is typically you know 60 to 70% of a 1 RM to to make any adaptive changes and then you need to do that over weeks um and and that's a rub because in rehab most of us don't hit those targets we might in later phases you know you go to most rehab facilities that only you only have the weights um available to to hit those kind of targets and right so then Blood Flow Restriction is the application of a
• 10:00 - 10:30 tourniquet to the proximal thigh or the proximal arm that that's an important statement right there because tourniquets are made to go High um you know if you go have a surgery for nil repair they don't put the tourniquet down below your knee they put it up because it's all Plumbing if you're using good equipment it can shut it off so one of the biggest complications with a tourniquet is nerve damage so we don't want it around a superficial nerve so we keep that high but you put that tourniquet high on the limb and then you
• 10:30 - 11:00 reduce blood flow going into the limb and so um we typically will reduce it um by around 60 to 80% in the lower extremity and by about 50% in the upper extremity and what that does is it creates a real hypoxic environment and so when you start lifting a lightweight under that much hypoxia you basically choke out the KB cycle and it it can no longer use what its preferred muscle fiber would be for that which is a slow twitch fiber it physiologically can't do
• 11:00 - 11:30 it so you switch to a fast twitch fiber to lift that light load and if we in rehab can say I can make a posttop patient in the days or weeks posttop start using fast twitch fibers and sufficiently use them to fatigue which we can do with Buffalo restriction we've won the anabolic jackpot we've won the mle the muscle jackpot that's yeah that's and that's and I think that's an important
• 11:30 - 12:00 consideration there is that what we're we're basically trying to bypass the system when we can't get when the tissue healing will not allow us to load the tissue that it it to the extent that it needs to get hypertrophy right is that is that a kind of a bottom line there yeah that is 100% you know it's people I hate this term they say it's almost like a biohack but it's pretty straight forward you know it's just physiologically we know how these these Pathways work one uses oxygen one doesn't do so let's just take the oxygen
• 12:00 - 12:30 away and and we starve that pathway so your body always wants to use slow twitch fibers because you don't get a reward for slow twitch you know you and I are using slow twitch just hanging around here talking and and moving a little bit we won't get muscle from that but if we cause a significant amount of muscle stress we'll get muscle and then you know I I just want to cave on one thing you said and it's when the tissues don't allow because they're healing because I get this so much when I when I speak of conferences and things is so this is only for post-operative patients
• 12:30 - 13:00 and and it's not there other conditions you know there's there's injuries there's people who are are have pain um or just generally load intolerant and especially the elderly individuals or other comorbidities where you know lifting a high load might be hemodynamically wrong for them or their joints can't handle it um or they they're just not accustomed to that Grandma Smith might not want to just start throwing some weights around in the gym and this is maybe a little better Avenue even From hemodynamic perspective for them oh that's fantastic yeah that's that's great yeah the the
• 13:00 - 13:30 applications of this are so are so Broad and I hope we get into some of those the the so let's start us off with the research like what you know from what I have looked into I mean there's pretty well like a comprehensive body of literature in this this is this is not a new this is not a new you know phenomena that we're just talking about but can you give us the highlights of that give us the takeaways of that yeah well I think what you said is important there is a lot of literature out there you know I'll get some some people come up and said this new novel thing if once
• 13:30 - 14:00 they get some research behind it I think it'll be interesting now I say there's a thing called the internet has a thing called PubMed you want might want to try it um because you know if you if you do go to PubMed there there is a lot and lot of literature I mean we're talking into the thousands now of papers on Blood Flow Restriction D you know the first actual use of tourniquet for some conditions but besides surgical um was in 1927 in the Journal of jamama so it's an old thing Beer's hyperemia technique
• 14:00 - 14:30 yeah um but what what we have is we're kind of standing on a really great foundation with this because what what started in the publish literature with Blood Flow Restriction came mostly out of the physiological Labs a lot of benchwork and so they went through all the mechanistic work for us and and were able to to say look this thing does increase muscle strength and hypertrophy and if you're ever around muscle physiologists always one thing they'll ask you is why and so you know we have
• 14:30 - 15:00 these really high-powered Labs that went into the Y looking at biopsies and muscle protein synthesis and satellite cell proliferation and basically has said yes this thing works in a study I'd like to highlight um when people said well what's the difference between Blood Flow Restriction and lifting heavy is um it's I think it's from 2015 they they did 12 weeks of bfr light or lifting heavy in the same individual so a crossover design um and they did biopsies at Baseline biopsies halfway through and biopsies at the end end and at the end they found the muscle
• 15:00 - 15:30 strength and size were similar between the groups they both significantly increased but on those biopsies there's 29 genes that are really responsible for muscle adaptation some need to go up some need to go down for us to make the muscle make positive changes and all of those genes had changed the same way between bfr and lifting heavy so when you say you know how does it get the muscle to respond like lifting heavy it does the exact same gene expression just it uses hypoxia and low load instead of a heavy load to to make that fast twitch
• 15:30 - 16:00 metabolism happen so well that's interesting because that that's the thing that's different maybe than any other rehab intervention that we have is this really does lend itself to both what I would call you know the the like you say the lab research the bench research and clinical research like it allows both and that that rarely actually intersects in in Rehabilitation and it's all it makes things undeniable you know when you have this giant science-based foundation and it's like these aren't rehab people that were
• 16:00 - 16:30 doing this these were you know you know physiologists and other groups who were looking just trying to understand is this that thing you know when we first were implementing this center for the Intrepid we we called around to some of the the researchers in in the US that were putting out some work and and two of the three we called they said you know this has been around for years we were wondering when you clinicians were going to finally start looking at this you know and so what we don't have a lot and I love what you said with in rehab
• 16:30 - 17:00 is a strong science-based foundation and now this massive clinical trial Foundation if you go to clinical charles. goov I think there's over a hundred bfr studies going on um I have quite a few going on as well and so that's where I hope we can take this and go to the Medicare of the world and the insurance payers and say this is undeniable from a science aspect here's what the clinical trials showed we would this needs a code and we're looking at codes not just for muscle we we'd like a code for its improvements the vascular system potentially for controlling
• 17:00 - 17:30 glucose levels in in diabetics so I think there's a lot of potential for our profession so you mentioned that the that we we can really measure this physiological response what is that physiological response that is actually happening what what are those factors that occur yeah so whenever you work a muscle where it has to move in to that fast switch metabolism you get a several things that happen so one of them is you you'll get a lot of muscle metabolis light that start to cleave off and so um
• 17:30 - 18:00 as you're a byproduct of fast switch metabolism using that using that glycolytic pathway is that you will get um lactate and hydrogen ions that are created in the muscle so you create this real acidity while you're doing it and that's this muscle stress that I talked about and so that muscle stress becomes a signal for things like a pituitary gland which will increase growth hormone when it starts to see acid in the muscle and and we also see and I think we'll talk about a little bit later an endogenous opioid release um but we also will start to see a
• 18:00 - 18:30 proliferation of the muscle stem cells um and then on Down the Line hours later we'll see this drive of muscle protein synthesis so if people want to say how does muscle get bigger over time it would be that you increase its myosite content which is a proliferation of those muscle stem cells you increase muscle protein synthesis is what makes the muscle hypertrophy and and so some people say well I don't really care about this muscle hypertrophy I care strength I get it and the bfr studies
• 18:30 - 19:00 show that we increase strength as well but what's different with the way we are looking at it compared to a lot of my muscle physiology friends is we're watching people lose muscle daily it happens you know within a three days you're already seeing changes on MRI with muscle and so by just keeping that muscle on it puts us so far ahead of the game and and now we're looking at reducing um you know return to play Return to duty return to work Times by
• 19:00 - 19:30 keeping that muscle on um and it and it helps with things like bone as well so that that's kind of some of the physiological Pathways that I I think are kind of impressive that yeah that's incredible I mean the idea that you can do that and we've got to keep coming back to the fact that it's under a safe low load like that's a very big deal like that's that's that is really the difference between you know traditional heavy weight lifting like you said and and what we're doing with bfr all right so how do we trans translate this into the clinic though I mean I I think the
• 19:30 - 20:00 physiology I love the Science Background I think it's important for all of us to know but bottom line I have to get this into the clinic you know what's the research say when I should be using it you know who's who's it appropriate for and what does it what does it do like what are the outcomes how does it how does it uh translate into what we're looking for yeah and well I would say first getting it into the clinic no one is as big of an expert on low load exercise as rehab professionals unfortunately you know and so if you're
• 20:00 - 20:30 G look out there wait wait Johnny you do have to put a little bit of a clarification on there it is uh under and I'm not GNA say low load I'm gonna say underloaded exercise I'll even take it a step I'll take it a step farther not not appropriately loaded exercise I we brought some of our scientists in the early days from across the street to kind of look through our exercises see where we were maybe missing things they are watching some of our guys on the mat doing their mat exercises and things and they they ask if those were the further
• 20:30 - 21:00 range of motion for their hip like doing their hip abduction because they could we were calling these things strength exercises now if you throw a tourni it on that it changes the game and you know I know Phil you're familiar with Blood Flow Restriction and it it I'm gonna say this it is low load but it is highly intense to do it um so you know I don't know if you remember coming in our place and we have tough dudes in there who were moaning and groaning lifting very light weights with a tourniquet on with
• 21:00 - 21:30 with with five PBS on their on yeah they yeah they there look sounds like a Max a max squat right in there yeah so that's what people need to understand is it is it is hard if you're doing it right you have a right system where it's really including blood flow and you get this hypoxic state you're having to recruit fast switch fibers and some people haven't done that maybe ever or years and so it's a new feeling to them and you're you're kind of tapping out the energy systems as well so like the
• 21:30 - 22:00 phosphagen system is a is a is a like the rocket fuel it's the it's the one that you use to get those first few reps up or if you heard the mom lifted the car off the kid that's that real high power system it it really relies on oxygen um and it really um gets buffered down with the lactate so that system goes away so people are having to pull from Energy Systems they haven't used before so it it's very hard and intense but it's very safe on their injury so I I think you just
• 22:00 - 22:30 need to make sure you you know the patient would be able to handle you know what's going to feel like a heavy lifting session to them even though it's very light um and then you can ease them into it so I I hear people you know like I did on my patient and they said it was terrible and I talked to them and they're like yeah well we did four exercises the first day um so you know I would I would always start with one Blood Flow Restriction exercise and then build the person up to it we we control pressures um of how much artery arterial occlusion we take out so the more
• 22:30 - 23:00 occlusion lots of times the harder it is and so you can start at a lower pressure and and build them up to get used to the tourniquet you know you remember your patient has probably never felt a tourniquet while they have have been anesthesia right yeah so it is a very uncomfortable and weird feeling at the start but some Studies have shown over a week or two that R and perceive exertion attenuates down they start to get used
• 23:00 - 23:30 to it and accustomed to it and then you can really start to go they've even measured cortisol levels when you start bfr they're really high um but then over time they attenuate down so the stress of it starts attenuate down so you can ease these people into it as well as far as you know where do you use it or or when would you use it we had a sand at a center for the Intrepid ACSM says you should lift around 70% of a one rep max to make positive muscle quantity and quality changes if you're doing an
• 23:30 - 24:00 exercise and you're saying I'm doing this for strength and hypertrophy then ask yourself every time am I following ACSM guideline loads if you say no then we say put a tourniquet on it because it's undeniable in the literature I think we have 79 system revie of meta analysis that lied Blood Flow Restriction it always beats so pause there for a second so so don't don't gloss over that so you said 79 not studies you said systematic reviews and meta anal icies right so that's that's a
• 24:00 - 24:30 lot that's that's robust yeah I have a one of my favorite slides when I speak is showing that you know I had to update it like almost every couple weeks because a new one comes out and we know some of these are always garbage you you you and I have been world but um there there is a robust amount of studies that they can get that many systematic reviews and many with meta analysis so let's take if those if we were to kind of just even dive into those what are the conditions that you know so we we we go from General and say boy if if you can't achieve that load
• 24:30 - 25:00 that you should be for whatever reason fill in the blank you should be using it but what are those conditions what are the conditions that have been studied that we can pretty well hang our hat on and say these are things you should seriously consider yeah clinically the knee has been most looked at especially for ACL and if you look at the clinical trials that are that are ongoing um we we have a new almost $2 million Grant to study acl's and look at long-term changes right now down at down at our base um so ACL probably has the most
• 25:00 - 25:30 data and and and has positive data in in most of these trials one of the problems with Blood Flow Restriction I'll throw out is you know it's if you look at a drug trial um it's you know it's it's everyone takes the same dose gets the the same drug or they get a placebo when you look at some of these Blood Flow Restriction trials where people are like oh did you see this and it's like they use like a blood pressure cuff which isn't going to hold pressure they didn't measure like how much you know arterial occlusion to do because everyone's
• 25:30 - 26:00 different on how much pressure they should take and so I would say it be like a drug trial where you said well this drug didn't work it's like well some people got 20 milligrams some people got 50 some people got you know and so I from a pure load perspective right you know so you haven't so you you you need dosing in two different areas the inclusion as well as the load on the limb right because it doesn't take away the need it doesn't take away the need to to use our you know ACSM guidelines um to of of what it looks
• 26:00 - 26:30 like that that doesn't go away so you still have to dose appropriately exactly oh that's that's the biggest it's one of the biggest flaws I see as well is people blood flow restrictions hard on a on an easy day with no weight and they'll just kind of stay in this you know maybe they dial in their occlusion right but they keep the load too low and and it it it has to follow the same kind of loading parameters which you would with any resistance program so you know I would probably has the same same accommodation too meaning you know as just as if you started with lifting 100
• 26:30 - 27:00 lb if you kept lifting 100 lb for 6 months you would not see much even though you were appropriate loaded loaded at the beginning you know you're you're probably needing to increase that you know as you get stronger and as you get more hypertrophy right yeah and people there people even do it in studies there there was a a tendon study done years ago where they lifted heavy or they did light with Blood Flow Restriction every two weeks they reassessed one RMS in the heavy group and increased their Lo and the bfr group they never changed it the whole time so
• 27:00 - 27:30 you know it's almost like people are like well I'm doing bfr so I don't need to worry about the load you no no no no if they if they complete all the volume that you've prescribed and typically it's four sets if they do that next time you got to increase the load just like you would with any resistance program getting getting back to your so we have ACL ACL reconstructions a no-brainer uh how soon posttop on that well I mean it depends on your comfort level your doctor's Comfort level your your patients Comfort level when we started it at our Center um it was it was really
• 27:30 - 28:00 interesting because we had these destroyed mingled limbs with muscle flaps and X fixes on and our guys were you know our our trauma surgeons are like yes get this bfr on them as soon as they get in your clinic Johnny and then our our Ortho Sports STS when they started getting involved in this they're like I want to wait at least a month you know they we're like well we're kind of missing the window here but they're nervous you know they went into this repair and it's hypoxia and and so now you know I I myself and the people that I work with we're starting it within
• 28:00 - 28:30 that first week um you know you want the knee to be calmed down no one's going to want a tourniquet and and a lot of you know pain and suffering that goes along with bfr if they got a pissed off hot knee so you get that thing calmed down right and then the quicker you can get it on the better because what we know it's called anabolic resistance and that's basically the the muscle physiology term for atropy is anabolic resistance happens quick that's first few weeks the muscle is just dumping like crazy I mean at two weeks you're
• 28:30 - 29:00 already down 30% strength and you've lost more than the size of your heart in muscle tissue um on these anabolic resistance trials in your thigh muscle um and so if you can slow that train down so I'm I'm a real big advocate of getting it on early um I I think you're GNA see a lot of bang for your buck there we we haven't seen ad you e do you do East with that we do yeah and and we're starting to to see more Trials come out using eem and it's fantastic so if you look at of the the phases of of
• 29:00 - 29:30 how you would do Blood Flow Restriction clinically when they can't really do any load at all just getting the tourniquet on them and inflating it and deflating it you know typically it's around three rounds can slow atrophy and and that's been shown in in several trials now that you can you can have this slowing of atrophy and even a biopsy trial that did that compared to no exercise and people that were um immobilized when they biopsied it the the muscle fiber was is much atrophy than the the group that
• 29:30 - 30:00 did do bfr so it slowed it by about 50% those first two weeks so you can just slow it down with a tourniquet but as soon as you add a contraction that's when you start to get these you know the fast twitch metabolism that's where you can maybe drive some of that muscle protein synthesis and so eem is a great way to go at it um the couple studies that have have done it with Blood Flow Restriction have shown that it's done better than just um eem Alone um because I I think that hypoxic State and if you're cranking your stem up high enough
• 30:00 - 30:30 we always call it University of Delaware levels um because they taught us you got to really crank it there um that you um you know you can probably start switching into more of that fast switch metabolism so I do love eastem early on and then as soon as I can get them loading light I get them loading light with it to really Drive where bfr shines and then as soon as they can handle load I get them off bfr and start pushing load and that might not be with me I might get to the get to the gym or if my pro athletes you know let's get you to
• 30:30 - 31:00 the stream coaches now that's that's fantastic run down the other list of of let's start with the The Heavy Hitters in the research that other I conditions that this would this is great for yeah so you know like I said knee pathologies are one of them now we're starting to see more total joint um studies come out one of the the guys that's part of our group he's an orthopedic surgeon in Germany Alex fron um he starts Blood Flow Restriction within a day or two he came on our
• 31:00 - 31:30 podcast and discussed his his protocol for that a day or two after his joint surgeries um he has published trials that are one's out now he has multiple going on with total joints and and really seeing it looks like some fantastic results with them as well um the lower limb conditions I I think are the Fantastic ones because normally they're immobilized in a camb boot um and so you think something like Achilles repairs HSS has done aill repair study Houston Methodist has a an achill repair
• 31:30 - 32:00 study that they just tease the interim analysis at osm and and it looks like it's going the right direction so those where they can't do anything at all where they're mobilized even if you're doing bfr on the thigh just that Tourette hypoxia might preserve the muscle in the lower leg and what we can talk about maybe a little bit later what that Methodist ailles trial showed which validated a previous ACL trial it preserved the bone stock as well so we might be also looking at as this something we can do for
• 32:00 - 32:30 bone that's that's incredible so you know if we talk about it we've talked about okay here's some here's some uses in that are very clear in the literature where when shouldn't we be doing this like what are the things that you're saying gosh I I don't because I I think a lot of times people think you know okay well they have a postsurgical you know they're post-surgical so I want to wait you know like we said three four weeks afterwards you're saying that's really not the case trials don't indicate that but what are the things that I'm like man I'm not going there
• 32:30 - 33:00 with this yeah yeah well for one it's not even from a safety concern but if they can lift heavy they don't need it um you know and adding bfr to lift and heavy you there's no additive benefit that we've seen so far so if they can lift heavy have them lift heavy save your tourniquet for your other patients um but you know some things like if they if they have an active VTE um or or you know a clot then those patients should not be doing Blood Flow Restriction until cleared by their medical team if
• 33:00 - 33:30 you know people ask me when should they start it we don't know you know the ap's new cpgs for um VTE came out and then they're pretty aggressive on how we should be mobilizing people that have these these things now and once their INR is up they're at a therapeutic level we can probably do more aggressive exercise with them so if if you clear with a medical team their inrs there that would be that would be where you can do it but don't touch them until you discuss it with the medical team people that um have you know kind of a really
• 33:30 - 34:00 out of control hemodynamic so severe hypertension when you do Blood Flow Restriction you you re reduce the arterial flow and then you block Venus return and so that does a couple things one it kicks off the exercise pressure reflex which means blood pressure will go up and blocking Venus return you're reducing stroke volume which means the cardiac output is heart rate times stroke volume so heart rate goes up so the hemodynamic load is higher than lifting light so it's going to be a little bit more from a heart rate and blood pressure workout even though they
• 34:00 - 34:30 might just be doing some light you know lung art quads or something like that so those individuals with with heart conditions cardiovascular disease you you know we we don't know yet that we have some studies going on down at University of Miami and the VA down there that look promising even for heart failure uh but but right now those are ones we don't know yeah um yeah and that you know the initial results on the people the people with the worst injection fraction seem to be doing the best with with it um which is which is
• 34:30 - 35:00 pretty cool um and but the hemodynamic load is less than lifting heavy so just being aware that this could also be an Avenue if you want to introduce resistance exercise into some of those individuals you get cleared by the medical team this could be a way to get at that muscle without a really high hamic load which you get from an ACSM guideline lift um so you know it could be a way to ease into them we don't know with cancer yet um not enough clinical
• 35:00 - 35:30 trials um so those those patients you know we don't know and of course pregnant women no one ever looks at yeah that's that's the standard standard standard rehab poor pregnant women no one ever is like oh yeah they you can't you can't do anything no one will now you're gonna get me in trouble with every person who does rehab with pre pregnant women that's gonna you know now send an email that says there is so much you can do and we do know that so uh there are a lot of cont I believe them it's just when I look at the the studies
• 35:30 - 36:00 I just can't it's it's on every list I think I think it's just on every list absolutely yeah they make us they make us urine tests in our trials you know to make sure they're not pregnant even though that's not an outright Contra yeah but those are some of the ones in the top of my head who would probably um not be not be a candidate but you know we've even you know we we have a trial in the dod with femur fractures and so we're putting it over a a Frank femur fracture with a with an incision um and we've had no dropouts from not being
• 36:00 - 36:30 able to tolerate the tourniquet so oh wow yeah that's fantastic yeah so so now we talked about a lot of different mechanisms from the heavy strength perspective we even talked about uh you know just inflating the tourniquet helping reduce uh you know that that atrophy and and things like that but it seems like you're you're talking about also some pain control uh potential talk about that yeah you know it was it was very interesting when we firsted Ed doing this at our Center that we were seeing an analgesic benefit so our
• 36:30 - 37:00 service M would say man after you did that my knee felt really good for for hours after sometimes even the next day and so one of the problems with tourniquets is they are known to be a pain producer um one one of the main reasons your patients have post-operative pain is not just the incision it's actually from the tourniquet so our first study we did at the center is I I looked at does bfr in postoperative patients increase or decrease pain and it actually decreased pain four weeks and so we we had
• 37:00 - 37:30 multiple other groups tell us they were seeing the same thing some work came out of aspar um over in in Cutter that that showed with anterior knee pain patients they were were getting this analgesic benefit and so we had we had a postdoc at the time Dr Luke Hughes who we tested to kind of look at mechanisms and so he he looked at some of the mechanisms of why people are getting this analgesic benefit and what he found is compared to lifting heavy lifting light or um doing bfr two different pressures bfr at a at
• 37:30 - 38:00 a higher pressure the pressure we recommend in lower extremity um elicited the biggest pain response and and when they looked at the factors that might contribute to that um they saw a really nice increase in what's called beta endorphin in these people's bodies and beta endorphin is an endogenous opioid that's that's in your body and and beta endorphin you know what it does is it kind of follows the lactate pathway so if lactate starts to go up your body starts to release this endorphin and you can think about it almost like a Runner's High um it's an evolutionary
• 38:00 - 38:30 kind of protective mechanism because if you are a caveman and you're building up a lot of lactate you were probably doing something really rough you were fighting a dinosaur or you were like in a war like that and the last thing you want to feel is your little Achilles Tenon opathy so as the muscle was building that lactate your body starts purging out this beta endorphin and and you build up lactate when you lift heavy um but but what's probably different with Blood Flow Restriction is is we don't release the Cuffs during the rest
• 38:30 - 39:00 periods so all that lactate stays in that limb you keep building it up that's why bfr is so hard because you just have this massive pulling of lactate but it just what it does is keep driving that endogenous opioid in the analgesic benefit and so makes sense so you mentioned you mentioned tendonopathy sorry yeah you mentioned tendonopathy in there what what's the research on on uh does it have tendon effects what what load do we you know what is it what do the protocol look like for that yeah so
• 39:00 - 39:30 you know the there's a six mview met analysis that looked at it and said yes bfr works for the tenden and we were you know blah blah blah positive changes and getting back to our system meta analysis when I read it they put all these papers in there and I was like this is a joke because only two of those papers were good um out of the six so that's one of those you can throw out the window but the two that were in there were really good and it's from Chris Center's group in Germany and so they've looked at the telet tendon and the Achilles tendon over 12 weeks of lifting heavy or
• 39:30 - 40:00 lifting light with Blood Flow Restriction using sheer wave elastography and what they have seen is that the adaptation not only the muscle but the tendon for for cross-sectional area and stiffness was equal and significant um between the two groups so there is an effect not only on the muscle but there's an effect on changes in the tendon which for me I think is fantastic because you know I can count on maybe one hand how many people stick to my Ecentric loading program for
• 40:00 - 40:30 tendonopathy it's it's just a pain in the butt to do but if you can say well come to my clinic you know over a short amount of time hopefully I can increase not only your muscle strength I can increase tendons um stiffness and crosssectional area and I'll get you an analgesic benefit while you do it which is reverse of the tendonopathy you know heavy loading programs it's like well let's make it hurt let's make it hurt which is hard byy in um I've I've seen really good results and a lot of the the teams I work with as well for titinopathy I think it's very positive I
• 40:30 - 41:00 have a slide where you know I just listed you know this year the clinical trials that are looking at tendonopathy and tendon problems with Blood Flow Restriction I think it's like 22 right now so there's there's a lot of interest out there people are seeing something with it that's fantastic so so you talked about you know the teams you work with and things like that Blood Flow Restriction uh what do you what are you seeing on the recovery side of things how do you does it work for recovery and how do you use it for recovery yeah I um I might speak more on this at
• 41:00 - 41:30 conferences and with teams than I do about Blood Flow Restriction for clinical rehab now because um it's kind of the the hot thing and and so basically there's this thing called remote schic preconditioning um and RPC is putting a tourniquet on a person inflating it to 100% leaving it on for about five minutes deflating it and repeating that a couple times and that start to see if you could cause enough stress
• 41:30 - 42:00 in the body that you could protect organ tissue and so it started in dogs at University of Washington in the 90s and they showed if they would do that and then clamp the artery off in it in their heart for about 40 minutes the dogs that they preconditioned it actually spared the Heart by like almost 70% and so now if you if you Google Scholar or Pub Med remote es scheme preconditioning you're going to get a ton of papers that are looking at for everything from stroke to liver transplants to heart surgeries I mean
• 42:00 - 42:30 it's just a huge thing in medicine right now it also is protective for muscle it appears and so there's there's been some studies where if you really break someone off so have them do you know soccer or do you know a 100 box jumps for Plyometrics and destroy their muscle and you were most schic precondition them before or after the event there's this protective effect that seems to happen and when they do blood draws and they look at creatine kise those levels
• 42:30 - 43:00 are significantly blunted so we're not seeing you know Frank signs of muscle damage when you look at Dom scores or um yeah Doms or just looking at pain scores days after that's significantly blunted and when you look at return to strength it's days faster than if you didn't do anything after the event or before the event so from a recovery standpoint um that is something we're we're doing quite a bit with the teams where postgame especially with these
• 43:00 - 43:30 high Travelers you know like I have you know I'm an NBA guy I got a game on Wednesday I got a game on Friday I'm gonna be kind of broke off okay let's get the RPC on you after the game and you know within about 48 72 hours we hope your NBC's back you know it's even so the Houston well it's interesting that you say pregame you not that we would probably ever do it pregame I would imagine but you're saying pre-competition pre-stress kind of almost probably applying the literature from the organ Sal uh kind of concept that it you know you're it it's so probably the post game
• 43:30 - 44:00 helps for the post game but also is doing a little bit of that conditioning to that response to for the long-term benefit of it as well yeah that's what to say like the Houston Texans now I mean we we've worked with them they've built out a whole bfr RC room in their new facility where their players are doing it throughout the week just to precondition them and get ready um for you know for the games and they're doing pretty good this year so I'm saying it's all our we won't we won't get in we
• 44:00 - 44:30 won't get into into football that that I would love to but that's that we're not going there all right let's take this to some some uh case examples do you have the specific cases that we can kind of talk through to kind of make sure we understand exactly how to apply this yeah so um I think just building on what we talked about I'll talk about an orthopedia case and then maybe go a different way um you know there there's a new technique with Achilles repairs now is speedbridge so it used to
• 44:30 - 45:00 be you would get into Achilles repair you're in a Cambo and the doctor would kill you if you plan to flex that foot um for for the first six weeks now um with this new technique you can be a lot more aggressive at least in the ability to do range of motion so some light range and so uh you know a couple of cases now in the NFL with Achilles repairs um and we work closely with the doctors that that work on these patients we get the turn to get on right after the repair and so they're just doing
• 45:00 - 45:30 that remote es schic preconditioning and they're they're even though they can't do any calf exercises the first few weeks we're using that to slow that atrophy you know I said that the muscle fiber loss was less than 50% compared to without so they're slowing the atrophy they're also doing some things to keep their thigh strong but then they're allowed to start doing some light planter flexion even with a little bit of theban that's just made for Blood Flow Restriction right there you know it that would be like my scientist said glorified range of motion back in the day but if you put a tourniquet on that
• 45:30 - 46:00 light exercise now a sudden fast switch fibers and then as you can put them maybe on a leg press and load it a little bit more then you know you're really getting for bfr shines here's the deal we know the Achilles Will Repair in about six to eight weeks right especially with this new technique the tendon we know tendon healing it heals the problem is it heals and then when they get out of that can boot they got a tibia for a muscle right
• 46:00 - 46:30 right so all you're doing is waiting months to try and get that calf muscle back if you can but if we could keep that calf muscle on and the repair is solid then what what's holding us back from running at eight weeks or practicing 10 weeks and in this case you know the most recent one this guy was already running at at you know around eight weeks and was cleared to practice and was maybe going to play with his team they didn't make the playoffs you know at that 12we Mark and he's playing
• 46:30 - 47:00 now and doing just fine so that's where I say we can really maybe speed up timelines because we keep if we keep the muscle on once the bone heals we know it heals if they got a muscle what's holding them back let's go man it's eight weeks we don't need to wait another three or four months right absolutely oh that makes sense so that that's I mean that's just a very clear application of multiple principles that you just discussed throughout this episode uh do what what other what other cases you know does it to come to mind well I I think another
• 47:00 - 47:30 one that's different is it's it's a study that just finished and published this year out of Baylor um but I think it's a case example that's fantastic and people might not think about with blood flow restrictions so was with Parkinson's patients and Parkinson's patients have really bad vascular systems and it's primarily from their drug they have to take levodopa and as they get further along in their progression of Parkinson's they have to take more and more and more levadopa and their cardio vascular systems just go kaput they call it the purple hand syndromes because their toes and fingers
• 47:30 - 48:00 become real purple and so what what was done by the researcher and colleague of mine we kind of helped her build this protocol was twice a week for four weeks I'm sorry three times a week for four weeks they did Blood Flow Restriction they did upper body exercises they did lower body exercises and the primary aim of the study was not increasing muscle strength and hypertrophy although that happened um the the control group was lifting heavy they both increased that significantly but the bfr group after this period had significantly improved
• 48:00 - 48:30 vascular systems so their reactive hyperemia index which is how well basically blood peruses into your limbs increased by almost 50% it didn't in the lifting heavy group they indal compliance so the the pliability of their vessels their large vessels improved um their homocysteine levels which is a marker of severe cardiac events dropped below that that threshold of of severe cardiac event risk which
• 48:30 - 49:00 they were all above before so applying bfr for this very short four-week window and in these kind of severely compromised individuals completely remanufactured their vascular system and she has these fantastic which it hearkens back to what you said about uh you know our cardiovascular those with cardiovascular disease you know maybe it's a risk factor or maybe it's you know it's a bridge to actually returning that you know that the hemodynamics of the entire system that's incredible and
• 49:00 - 49:30 really speaks to the whole pervasive physiology that occurs with blood slow restriction yeah and what's beautiful I I can't I don't have to say It's Magic because I I can cite you the mechanistic studies that have looked at why this would happen to the vascular system from from hypoxia to the sheer stress of the touret being released um you know there's the Nobel Prize was giving for these gentlemen that figured out hypoxia can release this thing thing called hiff 1A which increases capillarization which
• 49:30 - 50:00 is VF so we're standing on the shoulders of giants I can explain it mechanistically I never really feel like I have to shrug my shoulders and then we just have these trials that are backing up what we see and I feel like that study if we can get a larger trial is a Medicare ready code because how amazing would it be if we said as physical therapists I'm not only going to increase your muscle strength and size but this four it's four weeks I can give you a complete V ular tuneup potentially that is we're we're really doing
• 50:00 - 50:30 something medically now there was a drug if there was a drug that said could say it could do that right I can increase your strength I can increase your muscle size and I can improve your cardiovascular system it would be a multi-billion dollar drug and we potentially have that in our hands that's that's incredible that's a huge impact and and so I mean let's talk about that impact if like if we were to kind of like summarize this show a little bit what would be your three top actionable takeaways that people should
• 50:30 - 51:00 take away from this and and know about about Blood Flow Restriction yeah I would say don't be afraid to do it the the science behind it is very strong we can back you up with a lot of published trials and and a lot of um not only published just research but clinical trials so um the science backs you up to do this you're not doing some crazy Voodoo type thing um I I would say it's not only for muscle that there's a lot
• 51:00 - 51:30 of potential that we're seeing for things like potential bone healing um for for tendon for the vascular system so you know if you have some of these patients that that have these conditions um if everything if everyone's good with you doing it they might be worth um trying this on as well and then I would say just just it's easy to get excited from this and I'm I'm easily excitable I'm probably you know everyone's like what does it not sure and I'm like there's a lot you know I just get excited talking about it so I can get
• 51:30 - 52:00 carried away but um you know make sure that you are you know competent in doing this um yeah you know there's there's all sorts of courses out there we have a course U but there there's ways to make sure you're competent and and also I think um we need to really think about how we're applying it on on on these FS that's awesome well you know I certainly think you and I could sit down and talk for hours but but unfortunately uh we we're kind of limited on time here so so to wrap things up what have you
• 52:00 - 52:30 recently read or learned that you would like to share with people yeah thank you for sending me this question ahead of time because I hate these questions because I typically right I just sit there and stare like like the Zoom it keeps the uh from yeah happening yeah you know but I I was reading a book finishing up a book at the time I'd read it earlier and I I reread it um called 4,000 weeks I don't know if you've heard of it um I have yeah it's really cool man and so 4,000 weeks is basically the
• 52:30 - 53:00 amount of time we most of us will have on this Earth and so if you look at it in days um or or months it's or years it doesn't hit you but for some reason that 4,000 weeks hit you and I'm probably over halfway there I'm in my 50s now so I've got less of that time yeah so um and and it's not a book about like live your best life or do anything it's it's like accepting your finitude like you know you have a finite time you can only do so much when you need to make decisions you know some of us him and ha once you make a decision you close a
• 53:00 - 53:30 door you know when you marry your wife you close the door on all those other women out there but you you only have a fin out amount of time so make these decisions and move on so I I thought it was super empowering and I've even got a a a mortality countdown timer on my computer just so I think about what oh that's that's that's great I I I love that I'm gonna have to reread that that was a good read but it's been it's been a minute since i' I've read got a book coming out next month as well so it's worth it oh okay so maybe it's perfect time for for a reread so that's that's
• 53:30 - 54:00 great good deal well how can people connect with you yeah um so I I have a a company that focuses on Blood Flow Restriction it's Owens recovery science.com um we have all sorts of blogs on there we have our own podcast so if you love hearing my voice um or you uh you want to hear from bfr experts or teams or Healthcare Systems doing it check out our podcast but you can get in touch with me through through there I'm the worst social media person in the world so if you go there I probably will
• 54:00 - 54:30 never know that you do it um you actually did it right yeah yeah I'll let you guys if y'all want in the show notes put my social feeds on there I don't even know what they are that's fantastic yeah but yeah lots of good ways to connect with you uh if you'd like to connect with me you can find out what I'm doing what you know what I what I'm learning about at phil.com but that's all the time that we have uh be sure to check out uh Johnny's course on Blood Flow Restriction with ACL reconstruction it was part of our Summit that we had
• 54:30 - 55:00 put together and I think it really was a great compliment a lot of a lot of insight from that course so be sure to check that out uh thanks Johnny for being with us today awesome thanks for having me Phil fantastic well until next time let's keep building the future of Rehabilitation and performance [Music] together thank you for tuning in to this episode of rehabit and performance lab by med Bridge please be sure to subscribe and listen to more of our episodes on Spotify or your favorite
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