- QLI’s clinical team is using blood flow restriction therapy to help people with spinal cord injuries build strength without heavy loads.
- Research documents strength gains compared to traditional methods, with clients progressing toward independent transfers faster than conventional therapy alone would allow.
- QLI is bringing these findings to a national audience at ASCIP this September, intending to make BFR standard practice in neurological rehabilitation facilities across the country.
Imagine you just sustained a spinal cord injury. You can’t lift more than 10 pounds. Your window for acute rehabilitation is closing, insurance is counting days, and the clock on your recovery is running whether therapy is happening or not.
Now imagine a clinician walks in with what looks like an oversized blood pressure cuff, wraps it around your upper arm or lower leg, and tells you that within a few weeks, you’re going to feel like you just did a max bench press session using a resistance band.
That is not a sales pitch. At QLI in Omaha, Nebraska, it is a typical day of the week.
QLI has been using blood flow restriction therapy, a technique long embraced in outpatient orthopedics but largely absent from neurological rehabilitation, with its spinal cord injury population for more than two years.
Physical therapist Connor Davis, PT, DPT, fitness coach Tyler Von Rentzell, occupational therapist Sara Waid, OT, and researcher Karen Hux, Ph.D., have spent that time not just using the method but studying it, documenting it, and preparing to present their findings to some of the most prominent spinal cord injury rehabilitation clinicians in the country.
The Idea That Started at a Conference
Connor heard blood flow restriction therapy mentioned at an American Spinal Cord Injury Association (ASCIP) conference about two and a half years ago.
A student he was training had also seen the technique used extensively in outpatient orthopedic settings and pushed for QLI to move in the same direction.
Connor was not alone in wanting to bring BFR to QLI. Sara, QLI’s coordinator of physical and occupational therapy services, was equally motivated to bring the therapy to campus.
When Connor returned from the conference, he approached QLI clinical leadership with a proposal: invest in a pair of Smart Cuffs, pneumatic devices chosen specifically because they allow clinicians to set precise, objective occlusion pressures, which matters for research.
It was not a cheap ask. The cuffs run about $800 a pair.
QLI leadership agreed, with one condition: the team would study the outcomes alongside implementation.
As the research took shape, Connor ended up working with the greatest number of residents who met the study criteria, particularly those targeting triceps strength for transfer independence. That naturally drew Tyler into the work as well, given his role running fitness sessions with clients. But the research had always been a team effort from the start, with Sara and Karen, providing the structure and rigor that would carry it toward publication.
That instinct to do more than just adopt a technique — to understand it, document it, and contribute to the field — is exactly what has carried QLI’s work to the national stage.
The team earned QLI a presentation slot at the very ASCIP conference where Connor first encountered the therapy.
The paper the team co-authored documents triceps strength gains and improvements in functional independence among adults with incomplete cervical spinal cord injuries, and the results are difficult to dismiss.
What Blood Flow Restriction Therapy Actually Does
At its core, BFR is straightforward: a pneumatic cuff is placed high on the limb and inflated to partially reduce arterial blood flow while blocking venous return.
More blood is pumped in, but it cannot get back out. The muscle beneath the cuff works in a low-oxygen, metabolite-rich environment that signals the body to respond as if it is working far harder than it actually is.
That matters because of how traditional strength training works. To build true muscle, Connor says a person generally needs to lift at roughly 80% of their one-repetition maximum, the most weight they can move in a single effort.
For people with spinal cord injuries or post-surgical weight restrictions, that threshold is simply out of reach.
“You need that heavy stimulus to make a change in your muscles,” Connor explains. “You’d have to go heavier, but that’s dangerous, especially with people who already have a compromised upper extremity.”
Although the resistance is light, the body responds as though the muscles are working under heavy load.
“What we can do is create the feeling that it’s 80% of the one rep max, and our body responds to that as if we are maxing out,” Connor said. “That’s why you get that soreness from blood flow restriction.”
At QLI, the cuff is inflated to 50% of a person’s limb occlusion pressure, a threshold precise enough to be applied consistently across research sessions.
Participants perform four sets of 20 repetitions with 30 seconds of rest between sets, with the cuff placed as proximal to the joint as possible, so the entire muscle belly sits underneath it and receives the full effect.
“I’ve equated it to when you work out, and you’re almost done with your set, and you have that muscle burning,” Tyler said, “but then it just never goes away, even on your rest breaks.”
Who Benefits and Who Doesn’t
Blood flow restriction therapy is not appropriate for everyone. At QLI, clinicians screen all candidates carefully before adding BFR to a treatment plan.
“You want to rule out any red flags,” Connor said. “Clotting factor disorders, unregulated blood pressure, blood clots — we just want to make sure they’re appropriate medically.”
Many people with brain injury also cannot tolerate the intensity of the intervention from a sensory-stimulation standpoint, Tyler notes, which is why BFR at QLI has been used most heavily with the spinal cord injury population.
That said, both clinicians are actively exploring applications for stroke and brain injury populations, particularly in combination with functional electrical stimulation and gait training.
For clients who do qualify, the cuff offers a unique workaround for one of the most common constraints in acute and post-acute rehabilitation: weight restrictions.
“Think about all our people who come in with spinal precautions who can’t lift more than 10 pounds, but they may be stronger than that,” Tyler said.
What the Research Shows
The study QLI is preparing for publication tracked six clients with incomplete cervical spinal cord injuries classified at levels C4 through C6. All were medically stable and enrolled in QLI’s inpatient post-acute rehabilitation program.
Each participant performed BFR targeting the triceps, with sessions supplemented by electrical stimulation when needed, and progressive resistance training as strength improved.
Clinicians measured outcomes using two validated tools: the Functional Independence Measure (FIM), a seven-point scale ranging from total assistance to complete independence, and the Borg Category Ratio 10 Rating of Perceived Exertion scale, which captures a person’s subjective sense of effort from no exertion to maximal.
Across seven to 26 sessions, participants achieved substantial triceps strength gains and measurable improvements in functional independence.
One participant progressed from total assistance, meaning they contributed less than 25% of the effort needed for a slide-board transfer, to supervision-only status.
Another reached modified independence for pop-over transfers. Perceived exertion ratings declined as strength and independence improved, meaning functional tasks became easier over time.
“Based on what we found, these people had 600% improvement in strength,” Connor said, comparing the gains to what research shows for traditional strength training methods. “That doesn’t happen that quickly.”
The individual-level findings are just as telling. One participant with a C6-C7 injury needs to extend his elbows to perform transfers, and Connor tracked a steady decline in the amount of assistance required.
A separate client working toward independent slide-board and pop-over transfers noticed changes that did not always show up on a chart. He told Tyler that his shoulders were less fatigued at the end of the day because his triceps were doing more of the work.
“As a clinician, I may not even see as much change,” Tyler said, “but they’re reporting that their triceps are getting stronger.”
One client named Gary offered perhaps the most striking endorsement. After working with equipment that costs as much as a new car, he told Connor that the much less expensive blood flow restriction cuffs were the single biggest factor in improving his function.
Redefining What’s Possible Between Therapy Sessions
BFR can be layered with other modalities. Tyler has incorporated it into group PT weight sessions and is now walking clients with the cuffs inflated, adding a strength stimulus to gait training that previously could not be easily combined with resistance work.
Connor has paired BFR with electrical stimulation, progressing clients from assisted contractions to independent movement and eventually weighted resistance training.
Tyler has been exploring something similar, working compound movements first while the cuffs are inflated, then moving directly to isolated exercises while the muscle is still fatigued.
“Before BFR, if I got someone with not a lot of muscle activation, it was easier to say, OK, we’re going to do four sets of 15 with very light resistance and call that our strength training time,” Tyler said. “Now it’s given me the ability to still push our people just as hard as anyone else.”
Why This Work Matters Beyond QLI
What the QLI team are doing with BFR is relatively rare in neurological rehabilitation. Blood flow restriction has been used in outpatient orthopedics for years, covering ACL recovery, post-surgical atrophy prevention, and general reconditioning, but its adoption in spinal cord injury and neurorehabilitation settings has lagged far behind.
Part of the reason is a lack of published research specific to neurological populations. Without peer-reviewed data, clinicians at major rehabilitation centers are reluctant to adopt new protocols, regardless of what their clinical instincts tell them. That is exactly what QLI’s study is designed to address.
The ASCIP presentation this September places QLI’s work in front of therapists from some of the most prominent acute spinal cord injury rehabilitation centers in the country, including Craig Hospital, Shirley Ryan AbilityLab, and Shepherd Center.
Connor and Tyler both believe even one or two of those institutions picking up the protocol could meaningfully accelerate adoption nationwide.
“There’s been some really cool research out there of people putting it on directly after a traumatic event and pairing it with TENS units to prevent atrophy,” Tyler said. “Because muscle atrophy causes so many issues for our people when they get here. If you can prevent that atrophy, can that lead to a greater increase in potential return after a spinal cord injury?”
Connor frames it in terms of what each additional hour of recovery could mean for the people he serves.
“If someone already started doing BFR in their traditional inpatient rehab facility before getting to us,” he said, “that would be a way for them to get some strength gains before they arrive so that we can hit the ground running with what we want to do functionally. So ultimately they can go back and participate in life somehow.”
That’s the drive underneath all of it. The conference attendance, the research, the cuffs, and the conversations about combining modalities that have never been tested together before.
For the clinicians at QLI, the question is no longer whether blood flow restriction belongs in neurological rehabilitation. It is how many more people could benefit if the field embraced it.
