## 4 Practical Guidelines to Enhance Safety and Optimize Training Effectiveness  
To prevent potential adverse events from occurring and make this type of training accessible for a diverse (patient) population, the use of personalized limb occlusion pressures (LOP)--which is the minimal pressure necessary to fully occlude both the arterial and venous systems--is recommended to limit excessive stress on the vascular system [27]. The calculation of this personalized LOP allows practitioners to select a pressure at a certain percentage of this LOP to standardize the level of occlusion across patients with different body characteristics. However, it should be noted that individualized LOPs are determined at rest and do not consider muscle contractions, thereby producing a higher-than-anticipated pressure compared to resting conditions [88]. Therefore, in addition to using individualized LOPs, devices capable of autoregulation are recommended, as they consider the contraction-related pressure and thus further enhance the safety of BFRT [88]. Although it is a device-specific feature, these devices aim to ensure a constant LOP during resistance training sessions as they adjust limb occlusion level in function of muscle contraction and relaxation phase throughout BFRT [73]. Despite the fact that blood flow restriction training has been shown to be effective and well-tolerated in clinical settings, the current literature often lacks an individualized prescription of BFRT, especially regarding occlusive pressures, which should be tailored to ensure safe and effective application. For example, in the study of [PERSON] et al. in patients with KOA risk factors [89], a low load BFRT protocol was administered in a cohort of women, which was replicated in a cohort of men using similar modalities. While the women demonstrated an increase in muscle strength, no significant improvement in strength was observed in the male cohort, despite the same BFR protocol being applied [90]. As men tend to have greater thigh circumference than women, it is conceivable that the same BFR pressure induced an insufficient BFR stimulus to enhance muscle strength. Indeed, besides blood pressure and cuff width, previous studies used thigh circumference to determine limb occlusion pressure, with larger limbs requiring higher pressures to reach a similar degree of occlusion compared to smaller limbs [27]. These arbitrary pressures will have highly variable effects within heterogenous (patient or athletic) populations, possibly increasing the risk for adverse events [91] or reducing their effectiveness, depending on the level of occlusion, which cannot be estimated on the basis of thigh circumference. Although more research is necessary, individualized pressures between 40 and 80% LOP are generally recommended, with some studies showing the pressure to be inversely proportional to the load applied (i.e., when exercising at the low end of the load spectrum (~20% 1 RM), higher pressures around 80% LOP should be applied) [92]. However, from a perceptual perspective, greater degrees of (muscle) discomfort have been linked to higher pressures, especially during the initial application period [93]. Therefore, while higher pressure might be advantageous for a given goal (e.g., pain reduction), it is important for practitioners to consider the associated perceptual demands. Employing lower, perhaps physiologically suboptimal pressures around 40% LOP at the outset of care may serve as a valuable approach to gradually acclimating KOA patients to the perceptual demands required for exercise adaptation. Furthermore, individual assessment of (relative)-contra indications using questionnaires, medical history, Virchow's Triad, and physical examination remains important, especially in post-surgical patients or patients with comorbidities such as hypertension, obesity, or diabetes [74; 75]. Comparable to the heterogeneity in terms of LOP pressures applied, a lot of variety exists in terms of volume necessary to enhance muscular adaptations. However, according to [PERSON] et al.