 In this episode of the BFR Better for Results podcast, we talk with Susie Lachowski, PhD, assistant professor of exercise science and core faculty in the physical therapy program at American International College. She's the owner of Glass Training and Education, a blood flow restriction training company that teaches individuals to perform blood flow restriction with a number of different devices, much like the BFR pros. This episode, we really dive deep into device characteristics and features such as auto regulation and cuff bladder type and discuss the ins and outs of BFR. I hope you enjoy the episode. What's up? What's up? What's up? What's up, everyone? Welcome to the BFR Better for Results podcast with me, the Human Performance Mechanic. And my guest today is Dr. Susie Lachowski of Glass Training and Education. Hopefully I said that right. Who does BFR courses? She herself is a PhD and assistant professor of exercise science at American International College and faculty in the physical therapy department. Yep. And our department chair for exercise science. Yep. Perf. Awesome. Yeah. So today, in keeping with the name BFR Better for Results, we are going to talk about BFR, get a little nerdy into BFR, what we think might be going on, because Dr. Lachowski also has a BFR education program. We want to talk about some of the similarities between what I do in the space and what she does and find common ground and maybe discuss things that we may share divergent views on. But at the end of the day, this is all good about increasing the exposure to BFR and really just having a good time getting nerdtastic and discussing exercise, which is at the end of the day, the best non-pharmacological intervention that we can do for ourselves and the society at large. So welcome to the podcast, Dr. Suzy. Please, just for those that in that brief intro, any other things that I left out, favorite dogs, things like that, just fill in our viewers and listeners. Yeah. No, thanks. I appreciate the intro. That's probably my least favorite part is just talking about myself in a bio form. So I think you did great. It works for me. Just general about me. I guess I have a great support system, great husband, son who just turned two years old and I am pregnant with my six months pregnant. So if I squirm in my chair on this video, it's most likely because I have some sort of elbow or foot into my rib at the moment. But other than that, everything's pretty good. Yep. I work at AIC. I started glass training and education. I provide educational courses as well as I do training. So I'm a practitioner in the sense to I train athletes, GenPop, you name it, all those kind of things. And yeah, I'm looking forward to having our conversation today. Yeah. So I guess for me, the thing that why I wanted to have this discussion with you is more so we both have education companies centered on blood flow restrictions. So I kind of want to know what got you interested in the space itself and ultimately how that ended up creating this education program that you deliver to other clinicians and practitioners. Cool. Yeah, absolutely. Starting way back, I've been an athlete. I was a tri-sport athlete my whole life, played sports in college, played soccer in college as well. I've had a decent amount of injuries in college. I would have loved to have this therapy modality be introduced back then, back when I was an injured athlete and having some people know about it. But when I was in graduate school, I was finishing up my master's degree and I was heading into my PhD area, looking at things to do for my dissertation, things like that. Very long story short, I came across an article. Now this had to be, oh my gosh, we're going on almost 12 years ago now. It was a katsu article on which we know is the originator of BFR and I came across it and it was just peer physiology and obviously that's what my degree is in, is physiology and I had to read it like three times. I said, there is no way someone is getting this sort of or this group or these groups of people are getting this type of results with this. It's just I was just so used to the traditional training, the overload, the progressive overload, the microtering, you name it. And so I read it multiple times, brought it to my chair and I said, listen, I want to do a blood flow restriction dissertation. This is what I want to do. I grabbed as many articles as I could find. I did interlibrary loan with the katsu articles from Japan because again, not many articles were available to us, even as of 10, 15 years ago. People think this is novel now. Try to think 10, 12 years ago, getting this started. It was much more novel over here in the United States and so forth. So very long story short, I had come across that article and I was seeing all these physiological responses, this musculoskeletal adaptations, this hormonal adaptations, metabolic adaptations, things like that. And I said, wow, this is pretty, pretty amazing modality that I want to look into. And then lo and behold, I did my dissertation from it from there. I continued my education after defending my dissertation going on. I have worked with multiple devices as a practitioner educating, getting educated on it. I've taken multiple mini courses. I can't even tell you how many. But I started getting a lot of requests to guest speak on this topic because I presented at some national conferences and so forth. So with that being said, using it in a practitioner sense as well as a research sense, I have a number of clinical case studies, things like that. I was like, you know what, there's a lot of gaps out there that I think need to be filled. And I'm trying to do that with my education with BFR, my course as well as that course will always be ever evolving as more information comes out. We have these conversations, more research comes out. But I wanted to fill in a lot of gaps and also teach practitioners not just surface level information of, hey, here's how you use it. And here's some basic benefits to it and so forth, but really dive into the science, the physiology, the why, as well as the practical aspects so that they can be a better practitioner with it as well as get more clients and repeat customers and so forth. That's kind of my goal with all of this. So what was your dissertation on? Like what specifically did you look at? Yeah, so I actually measured growth hormone in IGF1. So I didn't measure blood markers that they had to get drawn six times. It was repeated measures. I was kind of very interested in the micro-gravitational space at that time. So I put my subjects in a head-down tilt position. And then they also trained with and without BFR in that position. And I measured the growth hormone response and IGF1 response hours later, comparatively to the condition when they weren't using BFR. Cool. And did anybody have a comment on that dissertation? Did you end up getting it published? I believe it is published. Yep, I get things that are recorded. I get notifications all the time. I believe my chair and I got that out there. We have a couple clinical case studies. I am sitting on a ton of data. I just need to find the time to publish something. So if someone wants to take it and write it up for me, they're more than welcome to do that out there. But yeah, it was pretty neat. Got some great results from it and got to present it. It was awesome. Yeah, well, that's kind of how I've gotten pretty extensively published in the space is because I have the flexibility to write and do that, which again, for me, writing is cathartic. So it's been awesome because I'm able to collaborate with different groups and understand different aspects of BFR that I don't know, like the best, the best example is like when you're, when you're in school and you have a topic where you're just like, yeah, I'm interested in it, but then like it goes off into this other area and you're like, yeah, but like I'm not that interested in it. And then it, you're like then forced to like look at something because you have a homework or something like in, in that area where it's like forces you to actually examine it. And then you kind of come back. That's how I feel about some of the areas that I've, I've kind of been involved in, um, in helping with manuscript preparation and things like some of these stuff, like I'm not the most interested in, but at the end of the day, as you mentioned, there's so, there's so much we still have yet to learn about BFR in a number of different areas. And so that kind of segues into my next question where, you know, you, you, you do kind of similar to my, my, uh, my education program is we teach with a number of different devices. So how did, how did you kind of land on that? And what is the benefit to, to you, but also your, um, your clinicians that get, you know, that take your course and get certified? Yeah, no, absolutely. So dialing back a little bit, as I was starting this whole journey and then taking like almost every little mini course that like devices had and it, of course is very device driven. Um, so, and me being a physiologist, I'm like, well, I care more about the science, the safety, the application, what's going on for us to make our patients, our clients better, healthier, faster, all those kind of things. So I was like, you know what, um, there's seems to be multiple devices out on the market now, and there's more and more popping up everywhere. So I'm actually in talks with one right now, might be getting, you know, sending me some to get showcased in my, in my course. I said, I have no problem doing that as long as, you know, I feel like it's a safer, more reputable device. I'll definitely try it out and things like that. Um, but with so much research out there, you know, what would be nice for us, which, you know, Nick, what we don't have is okay, it's other than Katsu, which has the majority of the original kind of research with that, their specific system, you know, there's, there's all these different systems coming out and there's multiple systems that are and research that's showing great results like, wow, look at this increase in strength, you know, these cardiovascular adaptations, these adaptations. So, you know, what I thought was important is to really break down the devices into categories based off of materials, pressures, and what is happening physiologically. And once you know how to break those down, doesn't matter what device comes at you, as long as you kind of understand, Oh, this is an LOP based device, or this is an elastic pneumatic system based device. I really kind of hammer away at the differences, but also how you can still get really good results as long as you're properly trained in the device you're using. So, you know, I've had clients or to come to me and say, Hey, someone got me these. I really like them. I like the LOP feature, all these kinds of things. And if I feel like it's a decent device, I train based off of, you know, off of the knowledge and the science behind that specific device to them. You know, I've definitely never trained someone who's just going to turn to get themselves off, you know, I'm, you know, things like that are just going to take an ace bandage or something like that, you know, it still has to be something I believe that has to be somewhat measurable and understanding level of restriction, hemodynamic patterns. But again, I think that it's important to kind of showcase clinicians, strength coaches, trainers, whoever you want out there. Hey, these are the type of the devices that are out there. And I want to give you the tools in the toolbox to make your own educated decision. Yes, do we all as practitioners probably have a few devices that are our preference that we like to use, maybe based off of ease of use, safety of use, time constraints, things like that. Absolutely. But at the end of the day, I want to give you guys or the practitioners like the tools to be educated on various devices so that they can ultimately make their most educated decision on what they want to apply to their clients or patients, because everyone might have a different subset of population that they train. Some people might be extremely niche, some might be specifically only clinical, some might be a mix of all. So I think by providing that education, it gives everyone then that freedom to say, hey, you know what, this actually might be good for our clinic or our facility. Or actually, you know what, getting this one for this type of population might be good. But then I really kind of like this type of device for this population. So you could actually maybe have a multitude of VFR devices depending on your client or your patient that you're going to be using. So that's kind of the meaning behind it, is to kind of give everyone the education and the tools to make that decision what's best for them. Well, you opened up my Pandora's box because I have a lot to say about this area. I'm actually presenting at Combined Sections meeting on this. And so I think that from one practitioner to another who's teaching other people, I guess, listening to what you said, I'm curious as to a couple of things. I'm curious as to what in your mind separates a device that you feel would be comfortable showcasing in your coursework and how, I guess, my biggest thing in general, because again, I don't get paid by any of these cuff companies, they supply their cuffs to my workshops and I just showcase. I guess there's so many different ways in which there are companies that are marketing something. And I feel like there is a dearth of research that currently exists to really separate the marketing from the science. I think that is such a huge thing. And I guess for me, going back to the first part of the question is what separates a cuff where you're like, yeah, I can showcase this no problem to what's not given that you are likely educating people with patient populations where they may have hypertension, diabetes, obesity, they might have a combination of all three. Yeah, absolutely. So when I look at a device, I look at the kind of the capabilities of specifically the risk of occlusion and occlusion for a long period of time. So if a device has the risk of occluding someone's blood flow instead of safely restricting someone's blood flow, then I most likely will steer away from it because obviously discussing based off of katsu literature and most things so far that are out there, we're not saying that if you are occluded that you can't get some sort of results you could, but now we're starting to really increase risks of other things, other physiological consequences for long term specific occlusion. And you mentioned something like hypertension, cardiovascular issues, all that we could definitely dive into. So if a device can safely restrict, then I will most likely showcase it or show it and say this is how this one works or at least just showcasing it. I do get a people who ask me all the time and same with my colleague, we kind of we team up to do the courses together. He's big in the orthopedic space, you know, so and he's been practicing for for a long time now over 30 years or so. We want to make sure that they are safely restricting and based off of population as well. So, you know, we get asked all the time, okay, which ones do you do use completely? I have no problem giving my opinion on the ones I use because I do have systems that I use almost every single day at home with my athletes with certain things like you know, especially when you know, parents come to me or athletes specifically come to me and say, you know, what's the most comfortable, the safest, you know, all these certain kind of things. We kind of look at that and I look at the safety kind of of safely restricting without occluding for long periods of time is the quickest answer I can give you that there's a much more long-winded answer with that. But yeah, I will give you that. I guess it's really important to have these conversations because it for me, my bias, everyone has biases fully, you know, disclose that and you know, do my best to separate the biases but highlight holes in that is I think that a lot of the the caution that's given with blood flow restriction is all based on tourniquet literature, a lot of it, particularly the precautions and contraindications. If you look at kind of the first proposed safety screening tools back, I mean, I think to my knowledge, Casey and Streiser in 2015, they published something and I can't, some sort of journal starts with an A, I can't remember it, but they basically went through a very conservative screener associated with all the different types of conditions and whatever. But when you talk about education, I think a lot of the early aspects of VFR education was using the tourniquet precautions and contraindications. And so that there's a lot of fundamental differences between what goes on in the with the application of a tourniquet and what goes on with arterial and or venous restriction in blood and BFR exercise. And I think that this is one of those things where for me, I'm interested in are we putting the car before the horse in terms of the over cautious screening. And so I bring this back to what you said before, which is if something has the ability to occlude but not restrict. So I guess I want to elaborate on that on your definition of what that particularly means to you. And then ultimately talk about, you know, what are some of the cuffs and you can name brands here. Again, it doesn't really matter to me of cuffs that you use in your practice that you found to be beneficial. Yep. No, absolutely. So what I mean with occlusion is if someone took a tourniquet and tied it off my upper body, upper arm like they were about to take my blood, right? So that's occluding. It's extremely uncomfortable. We can get into that too. Because when we want to talk about afterwards, I love the nerdy sciency piece of this. This is my favorite aspect. But when, let's face it, when we talk to athletes, parents, practitioners, they want to, they care about what's going to be safe and uncomfortable or excuse me, safe, comfortable comfort being number one. I believe out there have working with umpteen people in BFR. As soon as it causes extreme discomfort, it's the modalities turned away from and then the benefits from BFR all go out the window because you can't even get them to adhere to the program. So truthfully, comfort as well as safety is at my forefront for device use. I'll get that out there. So another thing would be is like a blood pressure cuff. So the point of a specific blood pressure cuff is to just do that, cut off your brachial blood flow or for more blood flow if you're doing lower limb. And in order and then measure the blood pressure, you know, you speak back, you know, turn back the dial, you know, you hear the blood was in and all that. So when you find your limb occlusion pressure, that's where we're shutting off that brachial inflow at that point. So you're occluding to the limb at that point. So with that being said, like a blood pressure cuff, you know, and this is we do the blood pressure cuff demonstration specifically to showcase what you're asking right now is we find everyone's with um, I have dopplers, but we also use our palpation skills, you know, with radial pulse and things like that, you know, you can easily do it as a practitioner. You don't always have to have a fancy doppler out to do it. Is we occlude and then we back off a certain percentage. So we find someone's estimated LOP or their LOP and then we back off. And then I actually have them exercise with a blood pressure cuff. You can assume it's pretty uncomfortable because it's not meant to it's meant to be a blood pressure cuff where you cut off blood supply so you can measure someone's blood pressure. Um, every time you flex or you come, you have a concentric exercise at that point, that dial generates X amount of pressure in addition to the pressure that is being pumped up into into the blood pressure cuff. So half the time you are going to be occluding, even if no, even if you are backing off a certain percentage. So that's kind of important to know. So for back to the whole device thing is kind of seeing how how the mechanism is set up. Typically there's other, I like to call rigid pneumatic devices, meaning there's no give to the material. So like a blood pressure cuff type of ring around the limb, meaning you would pretty much find someone's limb occlusion pressure and then you back off a certain percentage and you and you exercise from there. I know there's a lot of literature out there on that. There's been a lot of positive things about that. But then also I've had as a practitioner a lot of individuals depending on the device. Again, some are more comfortable than others saying that was extremely uncomfortable. Um, and because half of the time there's no give to that material and most likely half the time they potentially we were doing the wrong pressure. It was too much too soon or they were occluding half of the time. So I hope that somewhat answers your question. Yeah, I think so when we are contracting against an external load, our micro vasculature, so the vasculature that's supporting the the the muscle fibers giving, you know, offloading oxygen or onboarding oxygen, offloading the metabolites is already fully occluded at 20 to 25%. We know I think it's around 25% in the triceps 20 to 25% in the quads. So I do, I do think that a lot of this in terms of the occlusion, right, for when I think about BFR, I think are we, is this really a micro vasculature thing that we're looking at? Because if we're, if we're creating, if we're having somebody exercise with low loads with or without BFR and we have them exercise the failure, we're going to get equivocal results. And I think this circles back to kind of the topic that you were talking about in the beginning where people were mind blown that you actually that that the hypertrophic response is more is less mediated by the magnitude of load and more mediated by the proximity to, you know, volitional fatigue, however you're going to define that. And I think that that was probably one of the biggest barriers initially when I started out back in 2014, you know, almost a decade ago of posting on Instagram and seeing there's the information just wasn't out there. And I think now BFR has really kind of picked up steam because we're noticing that, hey, like you can actually get equivocal gains as heavy loads, as heavy lifting with at least from the hypertrophy perspective by just adding BFR or training with light loads and whether that light loads without BFR is practical, who knows. But I think the what's always interesting for me is the just just understanding where people are coming from in terms of their in terms of how they're prescribing things and whatnot. And I definitely agree with you that occluding like completely exercising at LLP is probably not something that I would do. Although, again, if you look at the read there, it has, it has been done. Matthias, warm bombs, research, very high pressures, it does show some efficacy, whatever, I would not do that. I guess where I end up and where I kind of am very interested in hearing thoughts, besides just my own and my echo chamber is the importance of applied pressure. And I'm going to preface this, because you never mentioned the cuffs that you use, but I have listened to other podcasts that you're on and you talk about, you know, use of multi, what I call multi chambered BFR system, so to be strong, or B3 bands or something like that. Yep. So I have trouble with this thing here, which is if, and this is again, part of my presentation and part of like my thought process is listen, I am all for the growth of BFR, 100%. I don't care about what cuff companies end up making it out on top, who care less. But when you market the safety of a device, number one, you look at the overall body of literature using single chambered systems and it dramatically outnumbers anything associated with multi chambered systems. Oh yeah, absolutely. And I did a review on this earlier last year and I could only find, I think it was like, it was three longitudinal studies of which none answer the question, does the multi chambered system actually provide a superior benefit to a single chambered system like a blood pressure cuff in the rudimentary of senses. And then there was acute studies where you cited one of them already where you're talking about the uncomfortableness of rigid cuffs, which again, I agree rigid cuffs tend to be more uncomfortable. But some of the research that's been done, and I'm having actually Stan on to discuss some of his work as well, just because I'm interested. I've heard him talk and he's very well spoken. And I think we agree on a lot of different things, which, prefaceing this. But the design that he used and he even admitted this was a exaggerated design whereby, you know, you're walking, this is the treadmill study walking, you know, two minute intervals or three minute intervals a couple of times with wide rigid cuffs versus a narrow elastic up and they basically used a pressure that would not be utilized in practice. It was way high, it was 300 or something like that, like very, very, very high pressure where even if they were exercising at 80% LOPs, it was not going to happen. So minus, you know, study designs like that where they're comparing rigid to narrow elastic cuffs. Fine. We know that there's a difference. But getting back to the pressure situation is if we can't occlude or we can't restrict arterial inflow to some degree. And we already know that the majority of the research has been conducted on single bladder systems. So systems that have been designed to occlude, even katsu, even though it's a narrow elastic, there are research that you can, especially in the upper body, standardize it according to LOP if you so choose. Not many people do, but Jeremy Lenneke's lab in the beginning was doing that. But I guess for me, I have a hard time rectifying this. If the goal of BFR is to accelerate fatigue, irrespective of the mechanisms. You know, whatever. And we know that at least according to a recent systematic review of meta analysis published in the Journal of Strength and Edition Research by one of my colleagues, Mikhail Serquera. I don't know if you've got to come across that paper. But basically what he showed was, is that when you actually standardize the pressure according to a percentage of arterial or limb occlusion pressure, and he stratified his results for greater than or equal to 50% AOP and less than 50% AOP. He found that when you have lesser pressure, less than 50% AOP, it actually doesn't accelerate the fatigue process. In fact, there's no difference like it. And, and, but if you have, if you have a pressure that is greater than or equal to 50%, there is a significant reduction in the amount of repetitions performed relative to low load. So I guess for me, my whole qualm is I understand the safety angle, right? If we're not restricting, we're not restricting a blood flow or at least we're not occluding blood flow. I totally get that. But I guess for me, it's very difficult to understand the narrative or the marketing, because there's a lot of marketing associated with this saying how you can, you can basically take all of the good where you're citing research that is on single chambered systems. Yep. But then you're saying, I'm not going to use the safety profile there and I'm going to create a less intense stimulus because I'm not going to be restricting blood flow. And we kind of know that, that there was a paper published last year in Frontiers and Physiology that looked at the Hockinson versus the B Strong and basically showed that B Strong doesn't alter arterial inflow unless pressure is about 350 millimeters of mercury. So, and that's not millimeters mercury applied to the skin, right? That's a separate conversation. But I guess getting back to, and the reason why there's such a long winded explanation is because I want to give context is I guess as somebody who educates and teaches with a multi chambered system, how can we be sure that we're able to maximize the therapeutic benefit if we're not using a cuff that's capable of generating that same stimulus as another cuff that's standardized to a percentage of arterial occlusion pressure when we know that there is a, there is likely a minimum pressure, probably 40 to 50 percent of arterial occlusion pressure that we can be sure that we're actually getting a therapeutic benefit. Okay. Do you mind rewordy? That was a really long question. Yeah. So basically, like, and this is where, again, I'm going to be just, just where my mind goes where it's like, okay, you can take the good and we know BFR works. Yeah, you know it. And, and to be honest, clinically, as a researcher, I don't even care anymore because I'm that certain that BFR works. I guess I am just trying to poke holes in some of the narratives that are given with the, you know, different cuff companies. And so one of them is the multi chambered versus single chamber debate where we talked, which I just talked about where the multi chambered system is designed not to occlude. Fine. Totally get it. In fact, if you're going to go and exercise with BFR and you're a healthy person and you're going to be able to lift 40 to 50 percent of your one rep max and you want to, for whatever reason, implement a very cost effective issue, I have no problem with the multi chambered system at all. I guess it's, it's just interesting how when we discuss about the benefits of BFR, they're very easy. That company is very easy to highlight all the benefits that are, that exist within the, that, you know, the BFR literature, but then distance themselves from the BFR literature in saying that what they're doing is actually not safe when we, if we really take that totality of evidence, okay, okay. BFR is very safe with a single chambered system. And yes, there is a degree of discomfort. And I will be the first person to say, I started talking about this discomfort and barriers to long term adherence five, five years ago, when everybody was recommending 80% LOP. And I was like, that's not going to, that's not going to be able to, to, to be adhered to. So I guess it's just, I want to dissect and have a discussion about how you can take the good, but then disregard the potential bad, but then the good is using a, what is in actuality a different system. Correct. So no, I got what you're saying. I totally got it. And no, that's, that's why these, we have to keep having these conversations. Honestly, I now I completely understand where you're connecting it. And I completely agree with you. And I think what you and I as sounds like you're a researcher, scientist as well, like as a physiologist and so forth, we have to keep looking at these things because we have to give the most honest and updated answers to people if we are going to be educating individuals on that. So I think this would be a segue to a totally different conversation. If we just want to talk about like how companies market their device, because I'm agreeing with everything you're saying, because how can one company say, I'm going to use all of this literature, but that's not safe. This is safe. Unless there's another big body of literature proving that get what I'm saying. Yeah. And that's, and so, so exactly. So exactly that. I have, I have three main buckets where my research is focused on the one bucket is safety. So I published a couple of papers on safety screening, etc. And honestly, I think those papers, well, the second paper in that the risk stratification is way too conservative, but whatever. Yeah. My second is perceived discomfort. And so we've had papers on, we did a meta analysis on RP, RPD with low load and low load BFR and basically showing kind of what we're talking about. And then the third is device characteristics and features. Yep. So in line with our conversation and me being somebody who's interested in the science behind all the marketing, there was never and looking at the paper or looking at the totality of evidence. And this, by the way, you're going to appreciate this because you teach, you're, you're aware and you teach BFR. But this is another wrinkle after this comment. But yep, I was looking and I was like, well, we actually don't have a lot of evidence associated with the potential relative efficacy because we know that if you apply BFR in some capacity, it's going to work. Right. And I will be the first to say that, that a multi chamber device system is probably going to do something. How much I don't necessarily know, but I do know that practitioners have used BFR successfully with those devices. So it's some, there is a practical relevancy for sure. But for me, I'm, I'm then saying, okay, I've taught with all these devices now for four plus years. And, and I don't know, do you have any auto regulated devices that are in your, that they're in your BFR cuffs? Yep. So what, which are the auto regulated devices do you have? The Delphi. The Delphi. Yeah. So Delphi was the big one, then smart tools came out with Yep. And I also have that one with their, with their generation three cough. And now fit cuffs has another auto regulated cough, which I, you know, have been trialing pretty extensively in the last month. Those three I all have in my course, just letting you know. So yeah. So, so I've been in, okay. So then stick, take a step back and then say, okay, well, people were saying, oh, you, you even made this comment, which is totally normal, totally, you know, anybody is like, Oh, the auto regulation feature must make it safer because it adjusts for the pressure that is exerted on the cuff on the limb. And, and again, I, I, I agree. I think that there is some variation of pressure that's associated with the, the non auto regulated cough. So for me, I'm like, okay, I hear all the time about the potential benefits of auto regulation. We know that there are very prominent researchers that only use, you know, an auto regulated for one reason or another. So it's like, all right, well, let me look at the literature and let me see what's going on here. And can we actually make the determination that we need auto regulation to help with our prescription? Right. And I think when we, we want to dive in nitty nitty gritty, auto regulation, you know, it's, I'll give it, it's definitely better than if I just slapped a blood pressure cuff on an occluded you and you had no idea, you know, XYZ, you know, all those kinds of things. Well, my concern with the sum of that is to is think about just the mechanics of a, of a muscle contraction of how fast things happen. There is no device out there that is going to beat the speed of speed of human physiology, where you're increasing and decreasing pressure with every concentric, eccentric action, isometric action at the same time for you to be perfectly within that window. Now, do are there different devices that probably keep you in that window a little bit better than others? I would like to say yes. I'm not going to go ahead and just give it an astounding yes, but like, let's talk, you want to talk like real physiology of how quick things happen. Oh, very quick. There is, there is nothing you can't, I mean, the, you can't even appreciate it. I told this to my students all the time when I'm teaching advanced ex-phys, they're like, we just talk a basic action potential muscle contraction. The fractions and millions of seconds that things happen and you're generating tension and all of this, no man made device out there is going to be able to keep up with that speed. So, you know, we could kind of chat about that all day, you know, so it's kind of like, oh, we're ever with every contraction, this, it's pulling pressure off and then putting pressure on and then pulling pressure off. I will give it that that's great. I think those are really, it's a big step forward with, I'm going to go back to comfort again, because at the end of the day, you want people to use VFR and those type of automated devices are doing, I feel like a good job at automating those pressures, you know, backing off, putting on, backing off, putting on. And I think it's more of, more so than anything is more of a comfort and an adherence thing than anything. But if you want to talk pure speed of physiology, no man made device out there is going to be able to automate pressures as fast as you are contracting or, you know, you're completely teeing me up here. So I, I agree. But at the same time, you know, teaching, now you have the Delphi and you have the smart toll. So you're familiar. I knew for a while that the speed of auto regulation between the devices differ. So for me, I said, okay, looked at, looked at the literature found that there was only one paper at that time, which is the Luke Hughes paper who's, I think it was his first or first study that was published in his PhD track that basically compared Hockinson, the occlusion cough Delphi to each other. And basically was like, okay, does that impact adherence or does it impact the perceptual experience, cardiovascular responses? And is the set interface pressure, which is the third kind of bucket that, that within this whole device features, which for those that are, are, are listening or watching, just because we apply a pressure, so say we set a device to 100 millimeters of mercury, that doesn't mean that at the limb cuff interface, which is the interface pressure that that pressure is actually being applied to the underlying limb. And so you can have a discrepancy associated with the set pressure versus the interface pressure. And basically Luke's, Luke's first paper showed that compared, compared to certainly the occlusion cuff, which is a manual cuff, that the, the ability of that cuff to regulate the interface pressure within 15 millimeters of mercury was significantly greater than the occlusion cuff where they were getting above 30 by the end of the, by the end of the last set. And the Hockinson kind of fell in between, in between the two. So that was the only paper. But other than that, there really hasn't been anything else that's been looking at auto regulation. So I was like, all right, well, I live and breathe this stuff. Let's, let's create a design where we can look at the differences in auto regulation. And so we've now completed three different studies, two of which are published, one in the British Journal of Sports Medicine, where we looked at the smart tools cuff, and we said, all right, based, we use the, because that cup can auto regulate and not auto regulate based on whether you, you pull it, pull it out. So we had individuals, I think it was 56 of them exercise with auto and without auto in a fixed versus failure repetition scheme. And we found that there was really no meaningful difference between the, you know, cardiovascular perceptual responses for the most part in, in the fixed routine. But we found that in the failure routine that the BFR auto regulated group was able to perform like 23.6% more repetitions than the non auto regulated group. And, and so the reason why I bring that up is because then you would automatically assume, and this is where the Pandora's box in my little niche area or niche area comes in. It's like, well, then you would automatically assume from that, that this auto regulation feature is a great way to get more volume, because maybe for whatever reason they're stopping because of discomfort or whatever. We also found by the way that your three, we have a three times relative risk reduction in experiencing an adverse event. We had 16 adverse events, 13 were dizziness. So we're as really minor adverse events, but using auto regulation versus not. So then, so then we, you would then say, Oh, okay, well, auto regulations, the, you know, we have to use auto regulation. It's much, you know, it's a great feature. But you and I both know that the responsiveness of the auto regulation devices are greatly different. And the motor is very different between the, the, the one cut versus the other. And so that got me thinking. And I was like, well, auto regulation, that's great, right? We can enhance safety, whatever, using this device. But if the responsiveness is not strong enough, then what do you think happens in between the adjustments of the pressure? Well, I would imagine that if we don't have the cuff that's able to tighten up in the eccentric phase to a, you know, in a quick capacity, what are we going to get? We're going to get metabolites escaping in the off the muscle fiber. We're going to get blood coming in to the blood coming into the exercising muscle. And thus we're able to perform more repetitions. Then we're like, okay, well, if you're just reading one paper, then you're like, okay, auto regulation, we have to have auto regulation. And so I was like, all right, well, let's use a device that's been well studied in clinical and normal, you know, and healthy populations of Delphi. And so I collaborated with a researcher in Salisbury, Maryland, and we did now two studies, one of which was published and one that's undergoing review right now, where we then just said, all right, well, Delphi actually created a feature that abolishes the auto regulation. So we're able to directly compare now auto regulation or non auto regulation in acute outcomes. And for me, I'm interested in really interested in, is there a difference in performance? So the amount of ability to do work. And is there a difference in the perceptual factors? Like you mentioned before, right? Like, if it's more comfortable, then of course, we're going to want to do auto regular or at least have auto regulation for clients that may be, you know, for one reason or another, we be, you know, I call them the quitter types, the people that haven't really exercised and now we're putting them on BFR. And now it's like, we really got to be cautious about how we're going to progress them. But so what we found was, and then so Tim's interest is in measuring central cardiovascular responses, including arterial stiffness. So he's very interested in what happens at the level of the aorta and the peripheral stiffness that results from BFR. And what we found was very, very, very interesting, which I kind of had an idea. So we did individuals had them do, I think it was 20 that we're finishing finished in this study in the lower body, but we had them do wall squat exercises to fatigue. And basically what we found was that auto regulation had no impact on the perceptual response, as well as the performance response, compared to the same exercise performed without auto regulation, and the individuals are blinded to the condition. But both of them had higher levels of discomfort than low load exercise. We kind of know that just in general. And they also had, I think it was like 30 or 40% less volume, which aligns with the body of research. What's interesting is that we found that auto regulation blunted acute increases in central stiffness, which basically, we have no idea how to explain that, you know, why that happened, but not auto regulated and acute, you know, and low load didn't. So again, interesting results. So then we were like, okay, well, let's repeat it in the upper body. And what we, and we did bicep curls and we have more subjects at this point 32. But what we did was we said, all right, we did the same thing. And we use 60% of supine LOP so we could, you know, compare. We found no difference in performance. So again, a good or a more responsive auto regulation function has no impact on exercise performance, when done for sets to fatigue, which is something that I kind of suspected helps support the hypothesis that there is a device specific potential, which opens up Pandora's box, right? Because if you're now doing a study that is, you know, exercising two conditions, but then you have the auto regulation feature on a study that doesn't have a high responsiveness to auto regulation. Well, now you could have a a non significant result, but that might be due to the inability of that cuff to regulate the pressure. So that for me is a really big alarm point. That's that's the big alarm point for me in the auto regulation kind of arena. We also found though that in the upper body, auto regulation actually in is induced more discomfort than not auto regulated, which is a unique finding in terms of what we would expect. So and also no impact on stiffness, nothing, no no impact on on any sort of variable that we were monitoring of significance, practical significance. Yep. Again, it's kind of is it's so interesting because as BFR continues to grow, you feel strongly that our role is, you know, very agnostic in nature to kind of say, hey, if you have different people that that obviously a lot of people can't afford a $5,000 device, right? That that that in of itself is is a is a barrier. But for those that can, you know, I tell them three things and I'd be interested to hear kind of your your thoughts and how you tell people how they decide on their BFR cup of choice. Number one, I say what is your patient population? Yep. Right. So like you're using very high, high risk patient populations, very acute setting, like or or even like I saw at CSM last year, which completely blew my mind and changed my thoughts on the safety of BFR. They're having individuals exercise in the intensive care unit, mechanically ventilated and doing recumbent cycling on. So insane. And so the sickest of the sick are being able to do BFR. Again, like we have to assume we have to assess relative risk, which is the second factor, right? Like what is your tolerance for risk? Because if your tolerance for risk is is is high, well, then yeah, then whatever you want to use is is fine. But if your tolerance for risk is low, well, then maybe you want to go with a more, you know, higher, you know, a device with more features or a device that may not occlude. But understanding that, and this is kind of where it circles back to the next kind of area that we kind of talked about the multi chamber system, where it's like, okay, if it can occlude, well, then maybe you might need a little bit more volume to accommodate for that. And that's kind of the recommendations that I've seen on the website. Now, caveat before I move on, I then put my money where my mouth is. And I had a study that I collaborated on in the Mayo Clinic with a group of orthopedic surgeon residents, and we compared the Delphi, the smart tools and the B strong. And we found that no differences in repetitions to fatigue, which blows my mind like absolutely blows my mind. But the difference is we only use two sets to failure. And Delphi was trending to higher RPE and a reduced amount of repetitions. So I think we may have missed the treatment effect. So we're actually in this regard, we're actually doing this study again in the lower body with with my collaborator. So I really just try to get evidence out there to help us understand how we can teach BFR to the, you know, to our clients and be able to say, hey, like this is, you know, this is something based on your risk profile and your, your patient population, but then third, which is cost, right? Like, what do you open to spending on a BFR device? Because we both know that BFR doesn't reimburse greater than, yeah, it doesn't reimburse. We just use it as codes to Therax or RIA depending on what you're doing, or even their activity, to be honest, like, if they're doing squat task, task, I'm building Therax their activity. But, but yeah, so like, those are kind of like the things that I kind of tell my clients for, and I would just be here curious to hear your thoughts based on what I said about auto regulations, but also, you know, the, the, how do you choose a device, which is the question I get asked all the time. And it's a great question. And it's, it's funny because you have different, I guarantee you have the same responses I'm going to have is you have different conversations with different people, different clinic clinics with different populations, the hospital acute care, comparatively to a performance center, strength and condition, you know, there's, there's so many factors to consider when choosing a device, correct. You hit the, you kind of go over very similar, I'm not going to just repeat everything you said, but we go over very similar aspects to that choice is, you know, the risk, the level of comfort, we can discuss automation, all those other kind of things, but it comes back to efficiency and cost for most people. So I don't know how many you've done, I have done a ton, a ton of courses, a ton of one-on-ones, a ton of training, and the thing that keeps coming back, and it depends on because you and I are in such a niche, and the, also the guests that are enjoying this are probably very niche and just enjoying everything you and I are talking about, same with pressures, capillary refill, this, I mean, we could keep going on and on about all of that. And I think that's extremely important because we do need to advance the field of BFR in a truthful sense, you know, going back to what you said way earlier about, we go off of these contraindications and risk stratifications based off of pretty much studies way back using tourniquets. And I don't really think that's truthfully, I'm not saying there's no validity to it anymore, but we have gotten so much more evidence of, like you were just talking about ICU, all these, you know, because someone will come up to me and say, hey, I wouldn't use it on this patient. I'm like, well, why not tell me the physiological reasons? Well, this one paper said, don't use it on this. I'm like, yeah, well, did you read the methods? Did you read what they were using? They used a tourniquet, you know, we're not in the same field. So that's part of our education within them. Once you have those conversations like, oh, well, that makes sense. But you know, you and I know people just zoom in on the discussion. Yeah, I think the the the the issue is and and I think it's getting less and less. But when I go out three years ago, like, well, now for right before COVID, and I would go and talk to physicians, and I would I would basically get laughed out of the room for a lot of them. And now I am getting people that are reaching out to me trying to learn more because they're seeing that BFR is better for results, they are getting better outcomes, their patients are experiencing less pain, less swelling, all of these things a lot earlier. And the research is just going to lag behind a couple of years. I think that the current body of evidence does suggest that BFR works, it's going to outperform low intensity exercise, whether you're doing it resistance, which is my bias. But certainly, from a personal perspective, like teaching it resistance exercise is my bias. But I use BFR four times four times a week. And I do a modified protocol for moderate to high intensity aerobic exercise, but I use one cough on at a time. So I'm able to push higher levels of of cardiovascular response, but also maximize the the physiologic response and the periphery. So I'm very much, you know, live and breathe this stuff. But at the same time, there's this, there's this absence of knowledge. And I think that that or ignorance, and I don't ignorance is not a not really the right word or lack of awareness, regarding the differences between a tourniquet, which is which is 100 plus percent, it's not 100%. It's 100 plus for 20 plus minutes. And they're at rest. And they're undergoing surgery. So they're static. So there's no movement versus something with BFR, whether or not we're exercising with occlusion. Now, I think we already kind of know that there's very diminishing returns as you get higher and higher pressure, especially with exercise. So it's not, it doesn't make sense to exercise with occlusion. But even if we did, we're doing it at five to 10 minutes max. And so it's like, okay, well, we know that, and this is like apples to oranges, but we do know that like there are very, very, very, very, very, very sick people where they're doing remote ischemic conditioning. So they're basically contracting, they're creating a high amounts of pressure on their bilateral upper or bilateral lower limbs. And then they're going to get organ transplants and they're going. So it's like, we know that that at least acute ischemic stimulus without exercise is something that is tolerated and even the sickest of patients. So I guess it goes back to, for me, I'm always just trying to poke holes in apprehension. And I think that. So yeah, go ahead. Yeah, I just think that there's something. That's where I hit home, Nick, is truthfully because like I said, we're so, so niche on the interest of divide, like the pressure is automated versus not versus like I was kind of saying before, we are such a small faction of people, right? I do think it's important that we exist because it's our job to educate the others, right? I for sure think so. But what becomes at the forefront for me is when we talk about clinicians, there's, because there's so much information, we have to go over with regards to BFR, right? And of course, or something like that. One, it's extremely overwhelming. But two, we do know, I mean, from a practitioner standpoint, like you already mentioned, we're probably lagging a little bit behind on research. So we, we're probably using it on patients on populations, getting amazing results just from a practical standpoint, where it's like, they're muscular endurance, their skills, their agility, their everything is drastically increased, but you didn't publish it. So like, you know, so we're, I have, I can't even tell you how many patients and clients or people have gotten kicked to me that I've used that I'm like, this would be a great right, this would be a great right. I mean, we can't keep up with that. So I think the biggest piece of education is, as long as you feel comfortable, as well as I feel comfortable as an educator with their device choice, then I think that as long as they know how to apply it, I would say, again, safely and correctly based off of that specific device, then they can get some really good results with BFR. You know, there's so many people that, you know, between PTs and ATs and string coaches that come up in my courses, that not saying that they won't understand the level of you and I discussing right now, but they don't care about it. At the end of the day, they do not care. They're a practitioner. What, and what I've come to realize is going too far, I'm not saying I don't go too far into the education piece of the device education, they can always set a one on one with me afterwards to do what you and I are doing and say, so you have some of those PTs or the clinicians or the owner saying, hey, let's meet one on one for an hour so you and I can dive into this so we can make the correct decision. But at the end of the day, practitioners who are going to use BFR, they're not going to be you and I. They're not the educators that are teaching the courses or doing things like that. They want to know, will my patient get good results from this or my client get good results? Will they come back to me because is it, you know, how many, I'm sure you've worked with people, if you put BFR on someone and someone said, I hated that, I'm never coming back to you for BFR. So you just lost a client, you just lost a patient. And now some people are like, I don't care, you know, I got so many, many people care about that. You care about repeat customers, referrals, that's how your business works. So if you're applying BFR, again, correctly, I would like to just say kind of correctly in that sense. And you're seeing good results, that's really what I kind of care about for clinicians, not saying I don't care, I do care about everything you and I have talked about. But when I'm out there, I educated hundreds of clinicians, they don't care about what you and I are talking about. They care about getting patients good results, maybe even faster in their rehab regimen, as well as, you know, again, coming back to them referrals, this and that, are they doing it correctly? And so if I'm not saying that they don't care about safety or device or any of that, because many of them do, but do you get what I'm kind of saying with this? They care about the practical aspects. Okay, so if, you know, based off of like volume, level of restriction, comfort, things like that, what is going to get a patient to come back to me or a client or, you know, personal training client? And at the same time, you're going to have patients, which I'm sure you've had to go get their own set, go do their own stuff. I'm going to go buy it myself, you know, so that's where you and I chatted a little bit about cost. So then you do have to, I feel like as an educator, give good suggestions on cost effective ones that are effective, because not everyone is going to get a Delphi at $5,000. Not everyone is going to go get the Katsu machines at a couple grand or whatever they are now. You know what I'm saying? Like, you know, I'm losing track of all the price point changes at the moment, but most people can't afford that. Most or most people don't want to pay for that, you know, unless you're like a clinic with deep, deep pockets, you know, I went to one of the courses I gave, I went to, or I gave someone had attended and said, you know, my previous employer bought four of the $5,000 machines. And I said, that's awesome. Great. I said, that's great. You guys have a budget. That's like that. But it's also you and I limb. It's, you are tethered. You are, you have all these other things that might limit you that sometimes maybe a strength ignition coach is like, well, I want to actually see you do a little bit of agility with this or kind of focus more on your biomechanical movement of your squat or your hinge or something, you know, certain things that may, that might hinder. So again, it comes back to what's your population, who are you serving and what's your goal? Because then I can kind of steer them into these one or two or three might be, might be good for you versus if someone's like, I can choose whatever I want. Then I'm like, you know what, maybe get a couple of different ones because if you're working with this population, this might be a better idea for you because if you want to do a little bit of research XYZ. And then you also have clients or patients over here that maybe this one is better for you. So it's not a black or white answer. Does that make sense? Yeah, I think the only thing that I just want to elaborate on slightly is while they don't care about this stuff for the most part, it has the potential to really shape the trajectory of blood flow restriction research in the future. And let me give you, let me give you a, let me preface this. So we know, right, that, that by and large, my guess, and we'll know more again is that the fatiguing stimulus from a multi chamber system is going to be less than the fatiguing stimulus from a single chamber system that can restrict blood flow, right? Practical experience kind of is very obvious in that regard. We have one study, of course, that says not cool. That's why we continue to do research. That's why we continue to learn. But what's happening, and I'm observing this firsthand, which is wild, is you're getting, because BFR is so hot and it's, and people are getting funded and they want BFR research, you're getting researchers that are entering the field of blood flow restriction that don't take the necessary steps to familiarize themselves with device characteristics and features. And, and this is why it's important. Because if you have a, for example, we have Jeremy Lenneke's group has been basically they were the first people in reality to spearhead the discussion of device characteristics and features. They did work on cuff width and they did work on cuff material. And when we kind of standardize it according to a relativized pressure, they don't really matter. That's their research in terms of outcomes as well longitudinally. But where I'm getting at is I've already read three papers this year that have, that have used a B strong cuff and have applied the, the limb circumference algorithm from Dr. Lenneke's group that was done on a single chambered system. And what we know is with a single chambered system, we're of course going to get greater amounts of restriction relative to the amount of pressure that we're applying. So for example, if we apply 100 millimeters of mercury with a single chambered system, we're going to expect that we're going to get a significantly greater restrictive stimulus than if we're applying it with 100 on a multi chamber. So what researchers have now done is they're skipping a step. And we know that all at some point, all of these researchers that are now applying the, that are applying incorrectly an algorithm that was meant for a cuff, you know, cuff design feature that was different, they're now going to get meta analyzed in the future. And now we're going to get this even more heterogeneous hodgepodge of BFR research. So while I totally agree with you that they don't really care. And to be frank, like we spend, you know, 20 minutes in, in lab and I go through my spiel about different device stuff. Because at the end of the day, I really, you know, if we're applying it according to principle based and not diagnosis based, which is my next plug, where we're never going to have enough research to support every single diagnosis. But we already know that BFR hits on relevant impairments, loss of muscle strength, loss of muscle mass, loss of cardiovascular endurance, there's pain, there's decrease in functional capacity, ADLs, all of these things BFR can impact. And if therefore, you use your clinical judgment, along with their medical history to be able to make an appropriate risk determination whether not that person is safe for BFR. But for me, as somebody who's very interested in the growth, the safe growth of BFR, I am, I am concerned that they're putting the car before the horse with not appreciating the different device features and how that could impact the acute and potentially longitudinal benefits or longitudinal effects of that intervention. And that's kind of where I'm coming from with, with this is more from the research side, but ultimately, right? We are as practitioners looking to the research. Yep, no, exactly. So it all kind of feeds into this circle. And so like, while I do agree that, listen, they don't, a lot of care about it, they do care about it, because when it's in a journal and they see, Oh, BFR doesn't work. Okay, well, I get what you mean. I think I guess I was meeting the nuances of a couple. Oh, yeah, no, no, I completely understood what you said. And I, and I agree. It's more like, I just want to bring to light that even though this might not be relevant on a person to person basis, because of clinicians that are selecting, you know, at the end of the day, and I've taught, you know, 60 plus of these courses, like Europe, United States, whatever, at the end of the day, the most, the biggest concern for practitioners across the board is cost is, and then it's safety, and then it's safety after that, but it's really cost. Do I want to spend this amount of money? Can I spend this amount of money? And then secondarily is, okay, if I spend this amount of money, what am I getting? For sure, it's always cost time. I'm going to give you a head and time is another one for me because some machines take forever to set up. And does ever do everyone have the leisure to have hour and a half sessions one on one with patients and clients? The answer is no. Absolutely not. So you have to, so the thing is cost and time to set up is, is my, I mean, listen, these are all variables, right? So, and I agree with what you're saying in that sense. So I'm with you because the practitioners are using the research. If there's flaws in the research, we're going to have flaws out here. So I get what you're saying. So that's why it's really important for us to care about all of these other things. Absolutely. And I'm going to come back to, wouldn't it be great if we just had one fantastic device? That's it? And then we could just compare. Yeah, but it's democracy, it's capitalism, you know, everything. That's why I'm saying, you know, in a perfect world, we could have one beautiful BFR device. And we can compare every piece of literature to that based off of every physiological response, volume, effects, whatever it is, I mean, that would be lovely in a perfect world. But the truth is, Nick, what's going to happen is more and more devices are going to come out. So you know, your job is going to get harder and harder. So it's, but it's going to be, it's going to get harder and harder, but easier and easier in the sense of as there's more research coming out, we'll be able to make other conclusions, maybe other stratification guides, things like that. So I think mine again, definitely still comes down to that's why I do put device education in there because it is extremely important to me as well as to, I believe others to understand what is out there. And then if they want to do a deeper dive after the course, like you said, I could spend eight hours on device, like that's not what the point of the BFR course is. It is to understand the modality and to understand what is happening physiologically to the individual and, you know, other risks, benefits and all of these other kinds of things. Because at the end of the day, like, let's just look at my next phase physiologist. So look at trends in general. How sedentary are we globally? Extremely. How are we in the United States? It's through the roof. To get anyone to even exercise or move now is a feat in itself. So then now when we want to say, hey, we're going to strap some cuffs on you and alter blood flow patterns and do all these other kinds of things, you know, I think the bigger issue is getting them to buy in because you want to have them have the benefits physiologically from a cardiovascular perspective. We know musculoskeletal perspective, you know, there's a ton out there. So we want individuals to safely use BFR so that we can enhance their quality of life. At the end of the day, we're here to enhance quality of life and maybe performance or whatever your goal is as a trainer or clinician or so forth. So I think that's where I've kind of shifted into the mindset of that is kind of seeing is being super educative as much as I can be on the devices but also really discuss the buy in for them, for their clients, for their patients to get the benefits of this whole modality. I mean that at the end of the day is the biggest thing and I always said, maybe I'll trademark this or copyright it at some point. I don't even know. If I could have called blood flow restriction something different, I wouldn't have called it blood flow restriction. Oh yeah. Because I can't tell you how many people I've talked to and parents and they're like, oh no. So I guess you talked about some orthopedic surgeons. I went to Brigham and Women's Hospital a couple years ago to guest speak to their orthopedic surgeon. I got invited there and they're Harvard sports med students on it. And the lead surgeon there said when he had heard of it, six, seven, 10 years ago, he blocked it out. He goes, nope, can't be good because of the wording, right? He got out there and then he called me up and was like, listen, I need you to come educate on this because I was totally wrong. So we're completely there. We fight that. So if I always said, you know, because I'm a scientist, a physiologist, and I feel like it's easier to explain this way. I'm like, I would have called it hat training or hat therapy or something where it's like hemodynamic alteration training is what I would have called it because one, it sounds more scientific. Two, people would be like, hey, oh, what's that? And I'd be like, oh, you know, we're really, we're altering some blood flow patterns to activate different muscle fiber types to get this really big response. Now I'm talking about like a soccer player I'm talking to or a parent or something like that. This is what we're doing here. But they would probably be more so like, that sounds pretty cool. Let's do it. But as soon as you put blood and restrict in someone's head, it's just the psychology of human beings. They're going to say, that doesn't sound right. It sounds like you want to ultimately do a venal puncture on me and draw my blood. And I hate that. So that's just my kind of side note on all of that and education, so to speak. So I would have totally called it something different. Yeah, no, I mean, I think I agree. I think that BFR blood flow restriction is an inflammatory type name. The buzzword. It is what it is. So two points. Number one, what we spend time on in our course is patient communication, because a lot of physical therapy in general, you know, unfortunately, for better or worse, there's a lot of jargon that's associated with patients don't know what we're talking about, even if we think we're not. So it's troubleshooting, communication, and obviously getting informed consent and things like that and asking for permission to you know, educate or whatever to allow them to be more open to, you know, experiencing the, you know, the blood flow restriction. And then the second, the second bit is it is funny because again, I'm, I follow the industry seeing how Katsu now is talking about their blood flow modulation. So now they're using the BFR literature, but now they're saying, instead of restricting, they're modulating blood flow. So it's almost like a similar thing where it's like, well, you want to be associated with the benefits of blood flow restriction or even Katsu training if you're talking about that, but then you don't want to publicize the same. So it's just pointing out some of the, the hypocrisy that I see when I'm listening to podcasts or, or coming in where it's like, we have to, there's a ready and my mission in general is helping people get back to the activities that they love as quickly as possible. BFR is one of those modalities that I've just found to be better, but also on a larger role, we do have an obesity crisis in the United States. So people don't exercise in general. Right. And so like it's, it's really important that we as educators continue to break down those barriers and have people understand even clinicians, like sometimes clinicians don't exercise themselves. I don't get it, but that's just, that's just the reality of the world we're living in. So trying to break down all of the multimodal impacts that strength training and exercise in general, cardiovascular, whatever can have on the individual, but also systemically reducing the healthcare burden is so, so, so important. It's just, yeah, we have conversations like this where we're nerdy and like, we're talking about things that, you know, have a very small impact in the grand scheme of things, but could, you know, have a larger impact depending on how focused people are on talking about these topics. And that's part of the reason why, again, had you, had you on today to just go over some of these things, have a nice discussion. Yeah. And Nick, elaborating on what you said, like that, that's for sure are my emphasis too. And our emphasis is that, is, is, is that educational piece is the, is the, how do you talk to your patient or client about it? Because I mean, some people don't even know what the term scapula is. I have to use, or if I say clavicle, it, and then there's, there's not a big, that's not a bad deal. I'm not saying that that's wrong. So to your point of the jargon we use, we do have to, that is a big part of the course is breaking down these extreme complex topics that will dive in, be some, be nerdy in the, in the class, but then break it down to the most basic practical level of how they can communicate it then with their patient or client, because they don't have to have someone's like, I'm like, oh no, you know, someone broke their collarbone. Oh, okay. No, I did that skiing once. Yeah, I got what you're saying. Like, you know, it's all the generic stuff. So when you and I are talking so, so intricate, which I love, I mean, it's our fields, right? So, you know, it's the big part of the educational course is, is teaching clinicians that, but like I also have clinicians who haven't been in an ex-viz class for 20 plus years. So they're like, when I bring up how important energy systems are to this, and we review a little bit about energy systems, you know, I can see some heads explode a little bit. But I, what I feel like I do very well is break down very complex physiological concepts to easy basic understanding concepts. And I think I do that well for clinicians and then clinicians go, you know, and then we teach them one step further to how to break it down even further, further patients or their clients. I emphasize so much, especially when I get strength, the conditioning people in there, I'm a strength coach as well, is even with PTs, anyone I'm teaching that this is a tool in your toolbox, this isn't to erase any other sort of training or any sort of other, you know, protocols or programming that works. It's just another really good tool, like you were saying, to have to be able to maybe get someone to that next level. We've had, I've had a colleague who's had a patient who he threw everything at her, you know, she had, I can't remember what happened with her knee. She had some pretty intense knee surgery and I can't remember specific condition at the moment, but he threw absolutely everything at her. She just wasn't progressing, wasn't progressing. Once we got together, I started him on VFR. She just like literally took off to the absolute next level. Like it was that's what was needed to activate her musculoskeletal cardiovascular, everything that's happened in physiologically. And those are the things that we really hit home with clinicians on and obviously among safety and risks and all these other, other kinds of things. But it's really the why is VFR so, you know, so good and why should you add this into your toolbox into your practice, you know, and those are kind of at the forefront. And then afterwards, if they want one on ones or more of an intricate setting on this type of education you and I are doing, then we totally do that because it's, I think it's important and some people do care about it, but back to the, it's cost time to set up and ultimately the benefits, right? So am I using a device that's going to be beneficial to my patients? Has it been, is there a proven track record that this has been, that this is, this is successful, if that makes sense? Yeah, no, completely, completely on board. Well, in the interest of, of keeping this podcast at a reasonable time, we'll wrap up now. Is there any, any last things that, you know, you wanted to mention briefly hit upon before we stop? When are you teaching your next course? You're scheduling for 2024. Like now is the opportunity to kind of pitch your, your stuff. Well, well, first and foremost, thank you for having me on. I enjoyed our conversation. I think it's important for us to, us educators to have these conversations and continuously, continuously do so. So I just want to thank you for having me on first and foremost. But yeah, so heading into 2024, there's going to be some, some big moves, bigger changes. I do have the offer that we do for the courses are, you know, purely in person. There's a lot of in person courses, live stream, and then I will be launching an online version, which will obviously be different than the in person version. But that would be coming up. I'm actually might be looking for 15 to 20 people who want to be ground floor founding on the beta testing of it coming up in a few weeks. So there's that my whole website's getting switched over. So there's a lot of changes occurring right now. But yeah, there'll be an online offering. You mentioned CSM. I will actually be at CSM. I will actually have a whole booth there. So if anyone is interested in chatting with me on courses, education, devices, application, patients, clients, this and that you for free can for sure stop by the glass training booth. And I would love to chat with you about BFR. And that's that. So we're, yeah, we're definitely making some moves, some, some hopefully bigger outreach in the in 2024, we have a, I've been talks with India, they want me to go over for a couple of weeks, as well as we are doing a full online slash live stream with the with the country of Jordan. So we're excited about that as well as the only thing that is my, and we're starting to hopefully schedule out for later spring, but in about 12 weeks, I'll be on maternity leave for a little bit. So we got to bake that in there. So I'm trying to get a lot of things done ahead of time with the online portion of the course and live stream, but I'll definitely still be consulting and doing all that, you know, while I take a break from my normal day to day job, which is being, you know, professor, director and all that kind of stuff. So I again, thank you for having me on and I appreciate it. Yeah, no, listen is, as I said, I just, I always love these opportunities to discuss, get a little nerdy, because I guarantee you there's not a podcast on the planet that covered some of the stuff that we talked about in depth. And that's, you know, kind of the conversations as a shameless plug for my podcast that we that we kind of do is just talk about things BFR in particular, but anything that's better for results. And yeah, so BFR is definitely one of them. And so yeah, no, it looks like 2024 is going to be really, really, really exciting for you. I will of course stop by so we'll be able to meet in person and chat a little bit more. And as I said, thank you so much for your time. And I'll put more information in the podcast, little info section for, for all the relevant contact info and more information. Perfect. All right. Thanks. And yeah. And lastly, for listeners, if you feel like, I mean, I got to be a little bit better with my social media. But Dr. Cecilia Chowsky is my social media. Hopefully we'll be spending that a little bit soon with everything else coming into 24. So before I took connecting to anyone or answering questions as we move forward. All right. Thanks again. Thanks Nick. And that was today's episode of the BFR Better for Results podcast. If you enjoyed the episode, I would love if you subscribed to the podcast on whatever platform you're watching or listening on. I really appreciate the support.