 In this episode of the BFR Better for Results podcast, we sat down and talked with Durga Prathap, or Dr. GD as he's like to be known, India's first blood flow restriction training instructor. He's a physical therapist that spearheading the adoption of blood flow restriction training in India. And our conversation focused on his journey as well as the important barriers that still exist preventing the long-term adoption of blood flow restriction training in India. I hope you enjoy the episode. What's up, what's up, what's up, what's up, everyone? Welcome back to another episode of the BFR Better for Results podcast with me, the human performance mechanic, or my real name, Nicholas Rolnick. I'm here today with Dr. GD or Durga Prathap, as is, I'm hopefully pronouncing it right. His quest in being the first BFR instructor in India. And I'm really looking forward to today's conversation because there are certainly similar barriers that exist for the implementation of blood flow restriction that we probably share as educators, but also different barriers between India and the United States. So I'm really looking forward to digging in and having a conversation about all things BFR. So today we are gonna be talking about blood flow restriction. So Dr. GD, welcome to the podcast. Thank you so much for your time. I know it's a little late where you are and really just appreciate your time. Why don't you just tell the listeners and the people that are watching this podcast on their devices, who you are, how you got into BFR and your journey towards becoming India's first BFR instructor. Thanks, Nikolas. Thanks for inviting for such a wonderful event. And it's my first podcast as well. So I'm not sure how good I'm going to talk, but I'll be talking like talking to my friends. So hi, hello everyone, and once made a Christmas. So I'm Dr. GD Prathap, I'm a physiotherapist and also I worked as an assistant professor for three years. So during my bachelor degree, it was like 2010, nine, this kind of this period. So no one knows what is BFR. In fact, I was working as a gym trainer. So we had a guys who used to prepare for bodybuilding competitions. So these guys were tying the different materials. I don't know where they got to know about these things. So to do the pumping of the things, when they are near to the stage performance days, they do not have the enough energy to pull the heavy weights. They are in carbohydrate depletion. So apparently they use the high reputations with low load, but that was not mentally satisfying, giving them that kind of metabolic stimulate. So they were reducing the blood flow to enhance the pump and they were enjoying it. So that's how I got this kind of exposure to the BFR. So I started using the straps or whatever available in the gym. So we felt really good pump, even with the straps, but we didn't know what it is, what is the actual signs behind these kind of changes. But of course, one thing was obvious. The pump was insane and we are able to get the very good, the failure even with the less load. So afterwards, then after website was updated, I hope it was in 2016. And when I was doing my master degree, we were able to receive some research papers from the US, Joe's PT, I hope. So I would see the BFR, then I was trying to make the kind of similarities I could make, okay, BFR actually, the things which we were doing without knowing what it is. So then I got exposure to the BFR and in India, it's like whatever the Western world in a way, it comes at least 10 years to 15 years, then only we got to know about things and then we started practicing. And by that time, US started doing the things differently. So to be honest, we follow the things from the US, less likely the things from the UK. My all kind of exposure, everything from the US based curriculum. So the BFR something is which I was so much fascinated as being a gym trainer, being a physio. So we were not having any idea where to go and learn this stuff. So being a ground zero person, I tried to learn the articles, research papers, especially your paper I have gone through a lot though. So I used to follow you and the guys who were doing the BFR, the muscle PhD guys, okay. Then I got to know more so much exposure with that. Then I started doing the, it was a pandemic. We were able to do the lot of presentation on webinars to make the awareness about the BFR. Then later on we access to get the manual variations of Cuff probably generation one Cuff's, which is very simple and economically soundful. Then I started giving the lot of pre-courses. It's very difficult in India to adapt new changes. People here are transforming their profession into chiropractors, a lot of passive therapy, therapeutic approaches are in peak. So introducing the exercise medicine with the BFR, it is really out of the box. So I know that, but the future is really bright towards the exercise medicine. So I kept doing the seminars, talking to the people to make the awareness about BFR. You don't believe many people are doing research on BFR without knowing what is BFR. Yeah. So sometime I may think like, I want to do a lot of research in BFR, but the biggest issue being a clinician is quite hard in India. Probably some of my friends, they are working in Canada and the US. They say we treat six to seven patients a day. That is a big day for us. But in India, we have 80 OPDs, OPD, I mean 80 clients. We are just eight people to manage, six to eight people to manage the kind of cases. We have at least 15 to 20 cases to take care of daily. So as a director of my clinic, so I have to do the consultation everything. So it's quite hard for me to do writing the paper and also, but in future, my aim is to do the research on BFR. So now being a clinician, I'm teaching BFR. I know that my target is to teach the, the enthusiasts who just completed their bachelor program. They wanted to try something new because it was really hard for me to teach the physios who are already having the experience of 10 to 15 years. They already adapted different kind of model. It's very, for them also, it's very, very difficult to adapt the new changes. So this is how it's going. And yes, we have the gym. We have the personal training gym. And also we do strength and conditioning for athletes. So myself, we are actually, we have the Olympic weight lifters we have. We are giving the warmup protocol using the BFR. We are doing the metabolic conditioning using BFR. We have the marathons as we try to do the intermittent occlusion training, this kind of new things we are trying so for. And one thing for, I would like to share here, the recent thing which we have tried is BFR for seatic pain, acute seatic pain. It looks like little kind of caution or contraindication in these area, but having the analogistic effect, the pain reduction effect, or you can say, it changes the pain perception during the BFR. BFR having the strong anti-inflammatory effect, I could say. So, you know, I'm a neurophysiobasically. So we study about the neural inflammation in radiculopathy. So when nerve buds are having the inflammation, so something you need to try to do to reduce the inflammation. So this kind of pressure with the training kind of is like a crossing the nose in between the muscle structure. It has the really good effect. We had very good results within a three days patient, pain and the range of motion, and the SLR test become negative with the BFR. So since it's a single case model, so we are trying to explore it further. But I would say telenoid is where you might be having the pain during this training. With the BFR, we're able to give them training without pain. So there is a strong pain, I mean, changing the pain modulation effect is definitely there. And this kind of new things we are added up apart from the regular hypertrophy and rehabilitation after ACM. Cool, yeah. I mean, it's interesting to hear about your experience and some of the similarities for me getting into the space like me first coming into BFR with the bodybuilding lens. As you kind of mentioned it, the bodybuilders love this technique because we're able to maximize the pump. And part of the reason why the BFR pros is tagline is hashtag chase the pump is because we can really get a nasty, nasty pump with very low loads and mimic that higher intensity training environment. So me being a bodybuilder, a competitive bodybuilder at that time, anything to increase the chance of putting on muscle size was always something that was very intriguing. I just had no idea about the BFR. The underlying physiology more so than, hey, I'm going to include blood flow and exercise and it's gonna give me that sick pump. So that was kind of how our journeys are very similar. And then in terms of your experience in educating other clinicians, like what you mentioned like the healthcare system, it seems is set up a little bit differently than it is in the United States. I definitely will say there are physios or physical therapists depending on how you want to use the abbreviation that do see 15 to 20 plus people a day. So that's definitely a similarity. I'm fortunate enough to be able to see one person in an hour but I'm very, I'm on the rare side just because of the way that my business is structured. But what are the biggest barriers or blood flow restriction implementation in India? So like you can have like the education but there's so many other factors that go into it even if BFR is very sound and safe from an implementation perspective. So I'd love to hear what those barriers that you're encountering are. Yeah, in my opinion, if you say like in India, the orthopedist like the physiotherapist who works with the orthopedic patients, they do get the referral from orthopedic surgeon and in fact, most of the orthopedic surgeons they write the protocols like you give ultrasound you give the SWD, you give the LWD, this kind of protocols they give. They also say go for isometrics, go for the eccentric exercises, okay? And off of the two zeal, they do follow them because they work with the hospital setup, they work closely with the orthopedician so they don't try something new. And so in such a situation, if they wanted to try BFR of course the surgeon supposed to know about the BFR that's the biggest thing. So far, I know only one surgeon in India, he prescribed especially, he's from Mumbai. Probably he's from, he did his fellowship from USA probably. So he already knew about the BFR and he especially wrote that particular athlete you should go undergo BFR, you do not have time for your game preparation. So you need to quick up the muscle game you already lost. He was having the irreversible changes in his VMO after the surgery. That was giving him trouble during the runny. So that guy especially contacted me when I went to Mumbai, I given the personal session about the BFR. So this kind of barrier like, the healthcare system doesn't have the good communication about the recent updates. So the the Uqmsoor I'm educating, I always tell them strongly, it's our responsibility to bring the signs to the another community, especially the orthopaedic surgeons. You know, one thing most of the students, they are fried even after completing the course. What if we do restriction of blood flow anything mis-happening or something? I always say surgeon always they restrict the blood flow to the maximum before doing the surgery. So far for hours. So we are having the strict strictly following the protocols and with the very good calculation of LOP and all definitely it don't cause any damage. So I tell this to them to make them more comfortable to do work on the patients. And it's like a positive wave of BFR, just a positive wave. So to reaching to the people to the maximum, I hope India is the very big country. And so far I'm the only one guy is keep promoting the exercise and BFR. So there are guys who actually works on the SNC strength and conditioning and true gap. So kind of guys, they should also come forward to promote the BFR. So reachability is the biggest factor here. And next thing is the affordability. The availability of the car for everything. We do not have any, I mean made in India product about the BFR. We have the straps, you know, many of my students, they are still using the straps to do the BFR. So I teach them a seven out of 10, you need to tie, you need to keep working on the occlusion cell swelling. This is the only parameter you can watch out for the straps. So they're still using that. And perhaps using that, they're still getting the good results, patient satisfaction. And that they could see the acute cell swelling and in the psychology also they are getting kind of, they're doing something good, you know. So in a rehab setup, it's, you know, if someone having the, the private clinic, they do not have the bigger setup for rehabilitation. They may have, they may invest more amount of money for the electro therapy or manual therapy. They don't invest much money on the exercise setup. That's the biggest issue in India. Why is that? Ah, that's, that's why, you know, now, you know, exercise is just getting popular. Exercise prescription is getting popular. Before what they do is they just give the hands out of the exercise, ask the patient to do at home. If the shoulder pain patient helps, I do dry kneeling. I'll be mobilizing the shoulder. I release the muscle. I send the patient home, do this kind of exercise. So definitely patient don't do exercise. So believe over the exercise also not so strong. But this thing's changing. People are started believing on the exercise. Why? Because we are in a high competition with the gym trainers. You don't believe, gym trainers are treating the ACL surgery. They're training the, you know, they do always the extra, extra things. So these are like, you know, I don't want him to train my client. So better I'll update. I'll try to do something. So this is how now people are having this small, small exercise setup inside their clinic before it was not five, 10 years back. I'd never seen some good gym with the clinic. And India is not spacious though. So there are a lot of things to be considered. Yeah, I mean, I guess for me, it seems that there definitely is a similar barrier for education, particularly with the surgeons. My experience in the United States is, and it's changing now. Like I think the biggest, the biggest issue has been with a lack of awareness of the importance of maintaining muscle mass following an injury or following surgery. And the strategies that are currently being implemented are just not sufficient in being able to create this anabolic response in a very catabolic state. So the, so what ends up happening is we're just resigned to having that atrophy and promoting in essence that anabolic resistance, which sets us up for a challenging long-term recovery. And so that awareness now is starting to change and the change is being brought about in the United States at least because physicians now are seeing the benefit of using blood flow restriction, not only in their patients, but they're also reading in physician journals like arthroscopy, like OJSM, like all of these other physician-cargeting journals that, oh man, BFR, taking with what the podcast name is is really better for results. Like we're getting better outcomes with our patients. And with that awareness has now triggered, at least again in the United States, the physicians being more open to implementing blood flow restriction because now they're seeing, okay, the technology is there in the United States with regards to we have more access to automatic technology. And I think that this mirrors the growth, the growth of BFR is mirroring what normally happens where we have this interest that slowly accumulates. Remember, if anybody listening and familiar with BFR, the legend goes that Yoshiyaki Sato back in the mid-1966, 1967 type discovered Katsu training and over a decade plus was experimenting with it and then it really only reached the United States in 2012 through Johnny Owens who was seeing some efficacy in helping the amputees get an increase in muscle mass when traditional means weren't able to. So now it was initially starting out with high barriers which were the technology. This technology in the United States was using a retrofitted surgical tourniquet device, the Delphi, and then that was prescribed as being the safest way to perform blood flow restriction. And then now we're getting manual cuffs which we pump up manually that were like the lower portion of the affordability curve which again, I'm interested in hearing how that kind of process goes in India. And now in the last two years, the automatic sector of blood flow restriction in the United States has really taken off. So now we're coming across cuffs like smart tools that you're able to connect the device via your phone and bypass the manual determination of personalized pressure that now it's becoming more affordable and it's validated technology. So BFR now is even in the span of five years the cost that these devices are coming down and down and down. So now clinicians are able to implement this piece of technology because before it was, oh, you need to spend thousands upon thousands of dollars which even in the United States, even in hospital based systems that have the money to be able to do that, it's very challenging to be able to do so. So I think that now the physicians are becoming more aware of the benefits of BFR and they're becoming more comfortable with using it. And so my assumption or observation is adoption of any sort of new technology spreads fast, slowly. So like it's now just picking up steam. So a part of what we do in our course is talk about the science of how ideas spread. And you're basically kind of talking about that in a microcosm of India because you're saying, hey, I'm actually the first Indian physio to be able to go about and spread the idea of BFR. And it's happening, but it's happening very slowly. And you've been doing this for a couple of years now, right? Yeah, 2019, I was, I was. Yeah, so it's been like three to four years and how many physios can you recall that you've trained over those three to four years? 400, 400 to 500. How many physios are there in the whole, the whole country of India, you would say? Must be three, four lakhs. So is that 1,000, three, four? I think in like 100,000 is the 1,000. Okay, so 300 to 400,000 physios. And your four years of education, you've educated about 400. So you're in, you know, you're what I would call or what we kind of teach as the actual science of how ideas spread, you're an early adopter. And so you're trying to, you're teaching all of those physios that are looking for the next best thing than the innovative technologies before everyone else. So you're in essence shepherding that growth in India, but it's gonna be interesting because as we're kind of seeing in the United States, once there's a critical mass of people that are aware of the technology and are benefiting from its use, you're gonna start to see it's all of a sudden now gonna cross this critical threshold that will then be considered mainstream. And it takes time and it takes consistency. So especially if you being the only one that's really going out there and spreading the word, kudos to you. Cause that's a big endeavor that you got in your hands. Yeah, she does. So yeah, so that's kind of at least to summarize, we've kind of have similar barriers but a little bit different. You mentioned the economics of BFR and how a lot of the clinicians you're teaching are still only able to implement straps. What, so let's I guess talk a little bit about that cost barrier. Do you think that it's ever gonna get to a point where the majority of people that you educate are gonna be able to afford pneumatic based products? Like what is the, I guess help contextualize for the people outside of India that are listening, like a typical, let's just say a typical cuff that you would buy in the United States would be between 400 and 600 US dollars, okay? That would be like a mid-range cuff. Yes, you can get cheaper, but typically that's where some of the clinicians are spending their money on. So how does that, how does the economics of that differ in Indian culture and society where I don't know too much about the economics but I definitely know that there's a difference in currency relative to the US dollar. So yeah, I'd love to hear about that. Cause that's a, you can't do BFR without, you know, cups of some sort. So the problem is we get the cups from the abroad outside of the India. So the cups are not so costly to be honest, people can afford, but the tax is like 28 percentage, we have to pay the tax and the courier charge, everything makes it little worse. Like you have to pay 50 percentage over the actual price. So for an example, for Indian, like back, I mean, the physio, the pressure, they approximately makes a, I mean, 30,000 rupees per month, 20 to 30,000 per month, the fresh graduate. So cups are somewhere around 15,000 in hand, like if you're able to get. Wow, that's almost a month's salary. Yeah, for most of them, it's a month's salary. Like if you are in the urban setup, like if you're in the cities, then your salary will be a little higher. So 50 to 60% of your, at least your money, you have to spend for your cuff. Wow, that is significant. I can no wonder why people are going and using straps. How much does straps cost relative to? It is just like 400 rupees, 400 rupees. Okay, so yeah, significantly different. Yeah, so I mean, I guess that's probably the biggest barrier overall is even if physicians are aware of the benefits of BFR to be able to implement it in a way that I personally feel we should, which is via pneumatic devices, but I kind of understand that there is limitations in order to implement this. So what do you tell your clinicians that you're educating when we personally, the research has shown that we have a very difficult time of relativizing any sort of pressure with a perceived pressure scale. So the research out of Jeremy Leneke's lab was basically saying that, and they use pneumatic devices for this, but it's still kind of apples to apples, where I don't know if you're familiar with this paper, but they basically had individuals come into the lab over three days and they blindfolded them and they had them pump up cuffs in the arms and the legs, and they basically said, all right, well, I want you to replicate this pressure at a seven out of 10 magnitude, and their results basically said that they, the participant on any given day over or underestimated their applied pressure as much as 25%. So for us working with individuals that, for me at least, this is my bias and I'd love to hear yours, or your approach, I tend to want the clinicians that I am teaching to implement objective and reliable based applications for BFR, and the most reliable and objective is using a relativized pressure. So I wanna know kind of what you teach the Indian physios given that the majority of them are probably gonna be using straps, safety precautions that you take, are you having them take, what screening precautions and what are you having them look for when they're exercising or doing something with the straps, given we know that you're pretty, that seven out of 10 perceived tightness is gonna vary on an application application basis. Yeah, so it's quite challenging to give the individualized pressure and teaching the clinician and these clinicians gonna teach the patients. That is the clinicians should have some knowledge about the pressure, but of course, the patient might not get the things what actually we need to do. So we usually teach like if you are tying too tight, you're probably having the ischemic kind of pain immediately after you're tying and also you may probably getting into numbness or kind of temperature changes in your arm and all immediately. And we don't need that kind of pressure and the pressure if it is too low and you don't feel like you're getting the pump even with the 10, 15 reps. So we need to keep the things in between where probably 15 to 20 reps of light load would give you the kind of pump. Your veins are getting bulged up with the after some reps rather bulging up immediately after tying this kind of small, small practical examination to give them. And also, of course chasing the pump is one of the next things to do. Sometimes you may not have the exact pressure or these kind of things, but if you are able to get the failure, especially metabolic pain failure with the good sales swelling and personal experience when you do over and over, you get the kind of momentum, okay, this is how we'll be doing this kind of experience we have to give them. That's kind of things I do when the workouts are not available. How important do you think it is to actually get a personalized pressure? Okay, for an example, like we have the patients like we have the season whenever the football season is on, we get quite a lot of injuries. So most of the partial tier patients, we start BFR within a week, you can say. And some of them go for the surgery. They come for the pre-react, especially when they have inflammation and they want inflammation to settle down. The surgeon tells the patient to go for physio, get ultrasound or do some exercise. So here we usually check the LOP. We'll be having the progression of LOP. We don't start with the 80% to be honest. So in acute cases, we'll be somewhere around keeping it 60 to 70. And slowly, like within a week, we'll be able to progress 10 mmhp, a little higher side, and up until reaching the 80 mmhp. And of course, in some cases, in acute cases, we'll be using the no exercise, multi-ligament especially, when you have the MCL tier along with the ACL, the knee is really worst condition. And surgeon asked them not to mobilize. So we'll be going for the passive BFR, where we straight away, we go for 70 to 80% of LOP, because there is no exercise that's going to take place. So this kind of things we'll be starting. And we always believe in our practical experience. I don't know about the rest of the world. Progression of the LOP can be done in many patients. So we personally feel like when we give the 80% of the LOP, to be honest, many people, they can't adjust with that pressure, especially they can't do the squat with 80% of LOP in first go. So to adapt the LOP also taking time in our experience. That's why we keep the, even we keep 50% of LOP in some cases. If the movement is larger, like a squat kind of lunches, this kind of movement, then we'll be trying to keep the LOP a little lesser side so he can perform the body weight exercise in a right way. So when we progress the 80% age, the movement is larger. It makes a little complicated. It takes time to adjust with that high pressure. Yeah, I mean, I agree. I haven't done 80% on a major movement in a long time, years. I think that when it first, when BFR first came out and 80% was kind of the pressure that was adopted and shepherded as the pressure that we need to ultimately get all of our patients to, I think that there was a lot of oversight on why that might be or why that might not be the case. And I think, you know, for me, there's a lot of ways in which I've arrived to a lesser applied pressure in almost all circumstances. I will say that there's really only two applications that I can think of off the top of my head where I would use 80% pressure or more. And the first one is if we're getting a very low, like amplitude movement, kind of like what you said before, where if all I'm trying to do is isometrics or I'm doing a short arc quad or I'm doing a bridge, something where there's only a small amount of muscle mass that's actually recruited and we want to maximize that fatigue stimulus, then sure, 80%. The second would be analgesic response. We have evidence that already shows that 40% does not provide the same benefit in terms of analgesic effect as 80%. So if we're looking at trying to get an analgesic response in our patients, then I want to induce as much discomfort as they possibly can because regardless of the mechanism, whether it's endogenous opioid release, whether it's condition pain modulation, we tend to see better results and we have a paper that's currently undergoing review where we compared in a leg press task, moderate strength training. So I think we used 60% of OneRetMax and we compared that to 30% OneRetMax with BFR and we had individuals do 30, 15, 15 failure, I believe. And so they were all effort-matched and we found a greater increase in pain pressure threshold. So that just means that when we apply a pressure point to the muscle, at some point, that pressure point becomes painful. And when we have an increase in that amount of pressure that we can apply to that person before it registers its pain, well, then that magnitude of difference is the delta of the analgesic response pre- and post-exercise. And so when we're able to get a stimulus that can induce that response, well, then that can be a potent tool for clinical practice. So really, those are the only two methods or ways in which I would want a higher pressure. Just for the listeners, we also know that there is not necessarily this beautiful pristine relationship between the amount of applied pressure and the blood flow. And what that just means is that as we apply, let's just say 50% of arterial-occlusive pressure, that's not 50% of the total blood flow that's getting occluded. It doesn't work that way. In fact, 80% of LOP or arterial-occlusive pressure, they're interchangeable, is only restricts something like 65% to 70% of the blood flow to the limb. But yet we start to end up kind of seeing that there's this trade-off, because I don't know if you've encountered this, you kind of said this before, but a big interest of mine is trying to maximize the adherence to blood flow-restricted exercise and maximize the results that we're getting. And if we use too high of a pressure, we might have people that are just like, I don't want to do this. This is way too uncomfortable, right? I mean, we have to find ourselves in some middle ground that is going to get us the results but also have them do the exercise. What are the more common things that you, you're implementing blood flow restriction that you see in the clients or the patients that you work with and how do you work around some of those apprehensions to BFR or the experiences that they're having in BFR? Pardon? Could you please repeat the question? So what are the kind of things that you encounter in blood flow restriction with your clients in terms of the experiences that they have during it, their concerns, and how do you address those? So we have the two different kind of population. One is the athletic population where sports injuries are done. These are easy population. We no need to talk more about the BFR. They already have a good experience about the exercise. They know that what is pumped, metabolic kind of stimuli they get, the kind of things they know, what is the discomfort they should be able to get through the exercise. But when we use the osteoarthritis in the post-THR, TKR, elderly population, we try to do. And we definitely will be, they were so much concerned about, they do not know what it is. And they already given the hands out by the doctor saying, do this all the exercise. We are going to do our own rehabilitation protocols. So we'll be giving them very good explanation. Sometime I use my mobile to show them the video, what it is like schematically giving them idea of what we are trying to do. What video? You say you show them a video? Yeah. What video? So we have the plenty of BFR video, even in your YouTube, I have seen some videos. Oh, okay. Yeah. Just genuinely curious. Because yeah, we do have a what is BFR video, but I think that's a nice way to show new clients what is BFR by showing them doing, other people doing BFR. Okay. So then what about like implementation? Do you talk to them about the experience of what they're going to be feeling before they do the exercise? What do you kind of tell the client or patient? We'll be having some checklists like identifying the risk factors. We'll be discussing with them. And my most of the concern is the like any bleeding disorders or pre-existing cardiac conditions. And we'll be going for the vital screening. And even some clients will be going for the cardiac recovery test. Like we asked them to do exercise, pre and post, how quickly their heart rate is recovering. You know, we even seen a strong hypotensive effect of BFR, even in athletes. So even with the right pressure, he was like yesterday towards my wife, he's a cardiopulmonary physiotherapist. So I was very much concerned about the EPR exercise, pressure, reflex and post-exercise hypotension. Like she encountered a patient, like he was having normal blood pressure 120, about 70. And after the exercise, his blood pressure went 80. The systolic blood pressure went 80 to 90 somewhere. So we start with him and we given the salt and hydration waters. So then he was able to do better. You know, that was the first encounter for him. So we definitely, when we are working with the elderly population, we'll be very, very cautious about the vitals. And since we are first, you know, if the BFR is already known to the people, it's safe, very effective. The mild side effects are okay to have. But in India, nobody knows BFR. So any kind of the negative side would not be acceptable. Even you do dry kneeling, you pierce the nerve, hardly matters, okay? But the post-exercise disease, all the things may put the bad impact on the patient's mind that I don't want to get the BFR. So that's why to ensure the safety, we do small, like their medical history is the very vital one. Even some areas are cautions, large contraindications, still we go for the very least pressure as possible to give them introduction, give them a feel that how actually things are working. And in this way, believe me, last one year, we trained many elderly population, many elderly population, they especially asked for BFR. They are ready to pay extra money to get the BFR. Now, without BFR, exercise don't feel like engaging for them. The BFR, the palm, the kind of things it gives, is psychologically also a huge role for them to stick back to the protocol. One thing we have to always keep in mind is we also ensure least pressure as possible without discomfort initially. Slowly when they adapt, the more you go, they don't feel much difficulty. So, do you think that we need to prescribe a personalized pressure for everyone when we're exercising with BFR? I'm very much interested in this for myself because I think that, well, I'm not going to tell you kind of my thoughts. I'd love to hear yours regarding do we absolutely have to take arterial or limb occlusion pressure every single time with every single person? And if we do, why? And if we don't, why? Okay. Six months back, we had a different scenario. In the clinic, I put up one big board where I wrote when the patient comes, 100 to 120 first a few weeks. Then you go for the 120 to 140. Then you can progress. If the leg is really larger, you can go additional 10 mmhp. This kind of information I've given them. Okay. Because we use the BFR for many cases. So it was very difficult for us to assess the LOP and all. So, me and my wife are having the cell trial. In some athletes, we check the LOP within a month, three times we checked, three to four times we checked. LOP is changing. LOP is really changing. When we checked the first week, I mean the first week of training after these surgery, LOP was different. The muscle is responding, growing, and the vessels are opening up and getting the little bit of muscle thickness. And after four weeks, the LOP is different. So then my personal opinion, especially post-operative cases, every few weeks, once testing the LOP is a really good deal. Because I don't know how much it impact the results of the, I mean, training. You know, sometimes if you have the 10 to 20 mmhp is lower side. If you do five reps extra, you feel still you're getting the failure. Okay. This kind of things also there. But whenever it is possible, it's okay to test especially post-operative cases, elderly population to have the safer side and effective. After this also you'll be ensuring, also safer side also. So a few weeks once getting the personalized LOP is good. That is how we adapted recently. Before six months we were not doing that because limitation of number of Doppler we had, only we had a two Dopplers. So it was very difficult for us. Now we have the access to many Doppler also. So cuffs also we have, we imported recently 50 cuffs from UK. So we have... What cuffs? We imported the occlusion cuff from UK. Okay. We have two variations of occlusion cuff. One is the light one, which is a little smaller. The beauty of the occlusion cuff is, some may think it's really discomfort of the width. It is typically somewhere around 7 to 8 centimeter width. So it is like for Indian population, you can use it for the upper limb as well as the lower limb. It is like in between. So you don't need to have different cuffs for the different size. It's like one fits all kind of things. So this is one of the things which is easy for us to use it in the clinicals. Also our clients like our clinicians who are completing our course, I will to buy this. I will to purchase this. So we already sold 20 plus cuffs in our last course. So hope demand is getting better. Hope for the best. Yeah. I mean, a couple of things. I think you, where I, I have very conflicting thoughts because on LOP assessment, because let's just go, let's just play double edge sword, right? So here's the pros in my mind of assessment of LOP, right? Number one, I totally agree with you. I understand and appreciate that limb occlusion pressure will likely change in post-operative clients. I highly recommend every session people, if they have the capability to assess LOP, right? Because the likelihood is the exercise prescription that you're going to be using with these patient populations are going to be on the lower end of the intensity, and the intensity paradigm. So you're not going to, you want to, in that case, you're likely going to be operating on higher pressures. As much as you possibly can, and the patient can tolerate, you should be creating 80% or so in the lower body. That's predominantly what is used in the early post-operative phase anyways because load is kind of a limiter, right? So I totally agree with that because if we're just shooting in the dark and we're doing something like even a perceptual scale, I just, I want to be as objective and reliable as possible. And that kind of goes into the technology of making sure that whatever you're using, if you're using an automatic device, that it is validated for the amount of applied pressure that it actually gives to be able to determine LOP. So I totally am on board, and that's what I do when I teach other clinicians as well. And again, this is almost like, kind of like, doesn't matter because a lot of the technologies in the United States, we can just determine a personalized pressure like this. The issue becomes when you're using a lot of manual cuffs where you have to use a Doppler and you're in a busy clinic and it's like, you're not going to be able to do that. Like I think that the data pretty much suggests, and I've done work on this, right? I was involved in a publication that we basically looked at and said, all right, if you have between a nine and a 14 centimeter cuff, right? Where we took, I think it was like 74 people and we basically looked at the relativized pressure in all of those individuals. So we looked at 60, 80 and 100 and then we used, we said, all right, well, let's overlay that with a commonly used arbitrary pressures. So things like 100 millimeters of mercury, one times brachial systolic blood pressure, 1.3 times brachial systolic blood pressure, 200 millimeters of mercury. And we wanted to say, okay, well, if you don't have access to a Doppler, but you want to kind of put yourself in the ballpark for what a relativized pressure should be, given you have a cuff that's between the nine and 14 centimeters or something along those lines. Well, we found that about 100 millimeters of mercury is around 60% of the limb occlusion pressure in the lower body. And we also found that 1.3 times the brachial systolic blood pressure tends to be a good estimate for that person's limb occlusion pressure. And then we found that 80% of limb occlusion pressure can be a good surrogate to that, could be about their brachial systolic blood pressure. So that to me, at least if you're not using a Doppler for assessment and you have a cuff that's within that cuff width, that you could be able to put yourself in the ballpark to at least ensure that you're sub-occlusive or you're giving a relativized pressure within that range. And of course, if you're not using a Doppler, the most important things that I think you should be doing is monitoring for numbness. I agree, you kind of said that as well. Monitoring for numbness, tingling, things that yeah, like when you apply BFR, you're going to be compressing blood. So it is going to feel tight, right? There is going to be discomfort, but there should never be numbness that's occurring. If that's the case, then you got to lower the pressure. But also monitoring pulse. So you're going to the distal arterial tree. So looking at the posterior tibial artery that's behind the medial malleolus. So you go to the inside bone and you come hook your finger around, make sure you're feeling a pulse. If you're not feeling a pulse with whatever pressure that you're applying it and that person's at rest, the cuff is too tight, right? So then you have to deflate. These are all simple guidelines that if you don't have access to a Doppler, right? At least you're using research to frame your implementation of blood flow restriction. And that's why it, for me, circling back to the question that I asked about the importance of assessment of limb arterial or occlusion, arterial or limb occlusion pressure or arterial occlusion pressure is that I want to be as objective as possible but I'm fully aware that particularly in other less economically fortunate countries that getting a Doppler or getting other pieces of technology that are available that are pneumatic, even like in Brazil, some of my colleagues, we just finished an aerobic training study that we're using blood pressure costs, right? So these are all not made to restrict blood flow during exercise, but it's the best that they can possibly have given the economic circumstances. So my goal as somebody who's very passionate about blood flow restriction is making sure that we're able to grow BFR safely within the economical realities that exist in various parts of the world. So for you, for example, I would not have any issue whatsoever if somebody's going to come to you and basically be like, hey, Dr. GD, I want to do BFR, but I have a blood pressure cuff and it's 12 centimeters in diameter. What can I do? I don't have access to a Doppler. I can't buy one. So at least you can point to a body of research that says, hey, well, you know, at least let's try to be as objective as possible with our application of blood flow restriction so we can at least put ourselves in the ballpark because like you said, we can start off somebody at 100 millimeters of mercury and we can say, okay, well, that's probably putting us in the ballpark of about 60% of the limb occlusion pressure and then over time, you know, we measure we're taking blood pressure so we understand what their blood pressure is. So then we say, all right, well, let's do our brachial systolic blood pressure for 80%. And we kind of can adjust our pressure prescription without absolutely being tethered to a Doppler. And that's really why I like having conversations like this is to find out where BFR is in, you know, it is expensive, right? People go to a course and they're like, well, all right, it's not like, you know, dry needling has a little bit, you know, more that you're buying needles, but like a manual therapy course or something where, you know, you're just using your hands, then you can implement that on Monday. But with BFR, there's an added expense. So I totally understand and I just think that, you know, to at least go to the flip side and of this, right? We know that if you apply too little pressure that it actually doesn't accelerate the fatigue process, right? So you need to hit somewhere between 50% and 60% of the limb occlusion pressure, according to a recent review by one of my colleagues, Mikhail Sequera, that was published in the Journal of Strength and Additioning Research, that says, hey, we need that amount of pressure to meaningfully accelerate the fatigue process. But to your point, right, it might not even matter if we're getting our patients to exercise to volitional fatigue, right? They're getting to, they're getting the stimulus of BFR, but then they're exercising so much that we're getting that, we're unlocking that access for them. I think for me, where AOP or LOP may matter more is if we're doing things like four sets of 15 or the traditionally recommended 30, 15, 15, 15, where they're not going to failure, but we want to get them as close as possible to failure. So we want to make sure that we're applying an objective stimulus to be able to get them close proximity to that, right? Does that kind of make sense and resonate? Yeah, yeah, definitely. So yeah, I mean, it's, it's very interesting because we also know, right, that if you apply more pressure, it's going to increase the perceptual and cardiovascular responses. And like you said with your wife, where she's working in the cardiopulmonary arena, that we may not necessarily want to stress them at least significantly if they're not ready for it. So having a relativized pressure and understanding, are we hitting the minimum value there? And if we are great, we may not need to proceed any higher from the difference in pressure will increase the exercise pressure response and thus will potentially expose these patients to higher than needed blood pressure for whatever reason. Would you agree? Yeah, definitely. So then my question is, right, is and I would love to hear your thoughts about this, right? My statement that I'm going to ask you is or say and agree or disagree, right? If you're safe to exercise in moderate to high intensity exercise, right, domains, you're safe to do BFR, agree or disagree? And why? I agree. I agree. So it isn't one of the biggest questions I come across when I teach the students. Okay. They ask me like how to say our client BFR is safe. Okay. So I say, if you're able to your doctor saying okay to do exercise, okay, you know, the elderly people, they do have their own intensity of perception and athletes they do have and the normal population, they do have their own. So moderate, many people, they do high density interval training, moderate cycling, this all the things, right? So how we are ensuring safety, we are not doing the BFR with high intensity exercise. We are doing the BFR with moderate to light exercise. In most of the condition we do light, low intensity of exercise. That's how we are ensuring the safer. I won't say like, you know, do BFR with the plyometrics. Okay. Definitely. I don't think so. It is, it's going to be easy or high intensity interval training with the BFR, you know, most of the population, maybe pro at least they may can try, but normal population, even I tried to be honest, I was having like, you know, painting. I was blackout this kind of symptoms. I could be able to experience with the moderate to high intensity of BFR exercises. So making sure that we are giving the exercise that where the patient can do moderate to high intensity, at least moderate intensity, but we are still doing the low intensity with BFR. It's a super safer and also the additional screening we are doing. So to ensure more safer and effective. So, so the reason why I ask that is because I think that they're, you know, everybody is, I think, how do I say this? I, I've become more convinced. Right. So, so follow me along with this. So if exercise in general is prescribed as a non pharmacological intervention for almost every single condition that we're going to encounter as physios. Right. And we want to get our patients the highest stress that they can tolerate and recover from that safe. Okay. So if you have an athlete that comes in, they're clear to exercise regardless, moderate to high intensity, no problem. Right. But I guess for me, it then goes, okay, well, what are, and you touched on this earlier, when you say the differences, what are we doing with blood flow restriction? Right. We are taking what's in essence a tourniquet and we're applying it to a limb and we're having people exercise with it. But we're using some sort of pressure scheme that's hopefully sub occlusive. Right. And we can better ensure that for at risk patients by using a personalized pressure. Right. If I'm working with a body builder that's, that's highly trained. I personally don't think we need to really worry that much about relativized pressure because these people are going to be lifting with heavier weights. These people are going to be more hopefully physically conditioned. And at the end of the day, we're exercising for five to 10 minutes with a low intensity, albeit physiologically stressful bout of exercise. So my question is, are we being overly cautious with our screening procedures or blood flow restriction? Because if we're really applying it in a five to 10 minute scheme for low intensity exercise, and we currently know that even in high intent, relative to high intensity strength training, blood flow restriction in hypertensive patients approaches or maybe slightly exceeds high intensity exercise, but is well within physiological limits. Right. Because if we, if, if, if we say, all right, well, a body builder or somebody that's lifting 85% of their one rep max instantaneous systolic blood pressure is about 480 over 350 for diastolic. That's peak. Right. That's not sustained, but, but whatever. So if our, if our blood flow restriction exercise with single leg extensions or whatever, it gets a little bit more higher with multi-joint. But again, I don't really do much multi-joint exercise with people outside of machines, but that's my own bias. But my question is, right, if, if we know that there's going to be a heightened blood pressure response, but it's not going to be to the same degree as, as what we would do if we were lifting super heavy weights, what, what is the safety concern with exercising with people, with anybody with BFR? Right. Obviously there are certain things like open wounds or, you know, common sense contraindications, but diabetes, hypertension, obesity, exercise is listed as a frontline intervention for all of them. So why would blood flow restriction be any different? Okay. This kind of, this is a good question actually, like, you know, sometimes we think too much about the safety, safety, we undervalued the things where we are not so much confident in progressing the BFR protocols. So as an instructor, what I say I would like to share, like I used to say to my students, I, like, when you are a beginner in a BFR, so you'll be having the learning curve. So you'll be so much into the, checking the screening, contraindications, these all the things. So as you are getting little maturity over the years or over the months, slowly you'll be cut off, like, you know, initially I even, I'll do LOPSS when other screening for bodybuilders. So later on I know that, okay, bodybuilders, okay, not gonna, I get, I get the some kind of experience perception about the how BFR is impacting their blood pressure and how they are cooperating with that changes. So I don't worry, maybe after a few sessions I say, okay, it's okay. Next bodybuilder when he comes, I'm not going to check the assessment. That's how I get mature. So now, honestly, we are, we are, we are too much bothered about the elderly populations. Not much about the middle age or people like athletic population, we don't bother much. We'll be having the little kind of interview kind of things to ask the brief about the medical history and especially kind of bleeding this RS we always ask for, look for because, you know, in India, some people even they don't get it tested or worry about the bleeding this RS. And also, like, I would like to ask you also some, like, would you ask the questions like people are in the anabolic steroids or birth control pills likely to increases the thickness of the blood. We, we, we in certain scenario we used to ask, like, are you on any pill, any medication for a long time? So for the safety and ensuring the things. And also, you know, most of the cases, they do have the blood report where we can check their clock, clocking time and other stuffs, especially post op reduce cases. So that's how we ensure, okay, we are in a right path. Yeah, so I guess I'll answer. I I don't necessarily think that anabolic steroids or birth control pills are contraindications to BFR. I, I really have grown fond of and I teach now with the Australian Institute of Sport screener. Have you ever seen that? Not not. Okay, so I, I would definitely recommend checking that out. I think that it is probably the best. I keep on returning to this. So like, I, I initially was like, hey, I'm going to go through this. I'm going to go through this. I'm going to go through this. And then I might proceed barriers, paper, the funnel algorithm of like going through and checking. I was like, oh, that's good. But that was also just theoretical like thought processes that you should be going through. Like screening for blood disorders. Like I do think that that's important. But the more and more I learn about BFR and physiology, the less and less concerned I am that it's that it's it's safety issue in the past. The, the evidence that we have suggests that BFR does nothing or is slightly beneficial to the clotting, you know, the anti clotting mechanisms. So there's at worst, there's no effect. And so like, especially with the five minutes, 10 minutes duration, I'm not really that worried. So the Australian Institute of Sport screener has really four absolute contraindications. And all of them have to do with arterial related issues. So I think if I'm recalling correctly in arterial, like an arterial vascular surgery, so you have vascular graphs, arterial insufficiencies, which that's the one that we're actually learning can actually BFR could be a therapeutic way to create additional micro vasculature to reduce the hypoxic state, which is super cool. And other a couple other like arterial related stuff like venous insufficiency as well, like that's something that seems like I probably wouldn't want to do a lot of blood flow restriction on somebody who has venous insufficiency because of the difference between the arterial architecture and the venous system architecture and the architecture of the arterial system being more being more muscular and the venous system being more collapsible. And so when we have sort of insufficiency or the valves tend to be stressed more or we have a system where the valves are already stressed probably not going to do as much BFR, but the Australian Institute of Sport basically goes through and it's a handout that you can give a client and they can fill it out and basically will give you talking points for your assessment as you screen them. So it goes through all the major ones and I initially was like eh, but then the more I learned about BFR the more I'm like wow actually I really like this to the point that I actually teach it in the courses that I give because it provides it's not overly aggressive. The screeners that have been published in the past like even the ones that I was on the paper with Dahan Nassimento in Frontiers and Physiology the risk stratification for blood flow restriction exercise and rehabilitation paper that was a little bit conservative but at least it was a starting point. This kind of screener is a much more conclusive way to screen so if you're watching this, listening to this you can go to the Australian Institute of Sport website and type in blood flow restriction and it'll have that screener and it's definitely a good way to get to the nitty gritty of things that may matter for potentially increasing risk of BFR exercise but with that being said what so I don't necessarily believe to answer your question that anabolic steroids or use of contraceptives are absolute contraindications because we do know that BFR has negligible impact on the anticotting mechanisms and if that is kind of the main concern about those individuals I'm not really as concerned about that but again you have to take the picture of the client as a whole into into consideration so if it's a person that has obesity, diabetes is borderline hypertensive and is taking oral contraceptives well then maybe I'm probably going to be less likely to implement BFR in that person just because of a common sense approach to okay maybe I probably won't want to do that but if I'm dealing with a crossfitter who's on oral contraceptives who's super healthy that's not going to even matter to me and I just think that a lot of the issues that come with BFR are due to a lack of understanding of physiology and what's going on when we're temporarily restricting the blood flow and you mentioned it earlier we're not doing this massive restriction of blood flow like they're getting they go into surgery for 45 minutes to 50 minutes right so it's a completely different stimulus and if you're not able to tolerate five minutes of restriction then you are extremely extremely unhealthy I mean it's up to us to say alright well if that's not something that we can implement with this patient maybe we can return back after that person improves their health profile or whatever I think there's a lot of clinical judgment and you touched upon that too that learning curve and being okay with people that have comorbidities it just so happens in the United States 70% of individuals are overweight or obese I think the prevalence of diabetes is like 10% or maybe even more in the United States the last time I checked so people are going to come to you as a clinician with these comorbidities so you just have to be comfortable with implementing it and that's where adhering to guidelines like the assessment of limb occlusion pressure particularly in clinical populations is really important and then obviously the use of that technology right so the question I'm going to have to ask you is what are your biggest safety concerns with the use of blood flow restriction and how do you you know other clinicians to minimize those so you kind of mention blood clotting but what else what are the other safety issues that are on your radar for when you're planning BFR with your clients or teaching others about BFR I can't hear you you're a mute son still there we go now we're good now it's back now we can't hear you still still can't I don't know what's going on now we're good good no well that's crazy I don't know what's happening I can now there we go wait maybe yeah now now it's still out should I come again yeah there we go okay my editor will edit this out so it's all good okay so the biggest concern is for me is the varicose vein you know varicose veins are the more common among the late I mean older adult people and you know I like to I always feel like you know few one or two small varicose vein I don't worry but I often see it's getting bulging badly when we are in the occlusion what's your opinion on that like how you see varicose vein as the caution or a contraindication what's your I mean I think it's a clinical judgment for sporadic varicose veins I'm not that concerned that's just a sign that there are some sort of Venus you know issue going on I I just you know and I'll take photos every two weeks and kind of adjust adjust the plan from there if I notice that the veins are getting worse then we'll stop but yeah it's really just a a way to kind of check the it's a risk it's a risk benefit right so like what's the risk progression the varicosity what's the benefit well improvement in muscle mass strength function etc so so yeah let's finish up with the last question that I want to have from you which it or ask of you what are a couple of things that you want to learn about BFR in the next couple of years so my first thing I wanted to get a good exposure in different variety of the instrumentation especially the different modes and sophisticated instruments which is available in the United States I hope I will if I get a chance I definitely get exposed to it and I also wanted to develop the instrument for Indian scenario like more affordable as well as the easy to use so you know so much benefit how many people can get benefit this is my next goal to do the things and the third one is the want to explore improving the view to max and performance you know we are so many papers are with the strength training I want to see like it impact in the running performance long distance running performance using the intermittent mode like intermittent occlusion mode so for that we need a special device definitely like for example if you are occluding the four limbs one by one the cover maybe on the four limbs but it will be activated with the sync like one two three four like that so kind of different what kind of things it may impact in the running performance this kind of things area I want to do explore and also of course and inflammatory effects of the BFR especially in sciatica and what we can do to reduce the pain among like ten nineties acute cases is all the area I need to explore cool so my question my question my last one now is is BFR better for results what are you finding fantastic you know we are like you know if you go and see my Google reviews last one year we are having the really good results we are so much proud with the BFR I openly agree to it like we were practicing the exercise it's like you know enhancing the exercise experience with the results BFR is really good you know you know in patients who are coming to us we will be using the 1kg 1.5kg we see the results that is not so quick and we are not so much into giving the kind of strong leg but now we really feel that you know acute and chronic changes are really better we were able to send the athletes back to the track quite early before it was not like within 3-4 months they are fit enough to do the trials now they are within 3-4 months after ECL they are able to play well so preserving the muscle mass enhancing the I mean we are also having the anti-inflammatory effect I wanted to say again and again we unfortunately we do not have the data but whenever we use the BFR the post-operative inflammation is settling down quite faster the scar maturation also quite faster than the when we do not use the BFR you see the surgical incision scar it forms the very dark and thick kind of layers when we use the BFR BFR itself cell swelling this all the things I do not like what kind of mechanism behind it they have the better scar healing maybe probably post-exercise high premia improved blood flow and all giving better collagen type position so we have this kind of results so definitely BFR for better results love it well before you wrap wrap up is where can people find you best way to contact you and plug anything you want go for it yeah yeah so I use Instagram for all the purpose so people can reach me through Instagram my ID is I am fit doc I am fit doc that's my ID I'm reachable all the time so definitely I would like to thank you for inviting me and I learned so much from you definitely through this forecast and behind the scene also definitely I'm following you for years now so it's really good to see you doing the things around the world I just wanted to follow your path to do the things in India I hope for the best years to come well again thank you so much for the kind words I am seeing from afar what you're doing you are shepherding this technology in your country and doing it the best way you can so props to you and thank you again for coming on and talking about how BFR is better for results as well as the challenges that you had during your during your time as instructing in BFR so thank you very much and that's the end of the episode everyone thanks for listening and watching thank you thank you so much and that was today's episode of the BFR better for results podcast if you enjoyed the episode I would love if you subscribe to the podcast on whatever platform you're watching or listening on I really appreciate the support