Kuenze CM, Blemker SS, Hart JM. This article was co-written with me by Dan Lorenz, my co-author for our new Blood Flow Restriction Training online course. Meyer RA. This is an open access article distributed under the terms of the, resistance training, quadriceps strength, quadriceps mass, postoperative rehabilitation, knee pain, graft laxity. Inclusion in an NLM database does not imply endorsement of, or agreement with, People with hypertension, diabetes, a history of stroke or DVT, cardiac disease, active infections, pregnancy, clotting disorders, or other vascular insufficiencies (like varicose veins) are contraindications. Furthermore, BFR therapy provides physicians and therapists with a process that contains very few side effects. Blood Flow Restriction Therapy After Surgery: Indications, Safety Considerations, and Postoperative Protocol, N DePhillipo; M Kennedy; Z Aman, A Bernhardson; L OBrien; R LaPrade. As a library, NLM provides access to scientific literature. The role of blood flow restriction therapy following knee surgery: expert opinion. Furthermore, analysis of other BFR literature will be utilized to lend further credence to the obtained conclusions. Assessment of graft maturity after anterior cruciate ligament reconstruction using autografts: a systematic review of biopsy and magnetic resonance imaging studies. The .gov means its official. The review protocol was registered on PROSPERO (CRD42020163467) and was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines.29. For weeks two-four, two new additional exercises are added in addition to the continuation of the exercises from weeks one through two. You can even get started with affordable blood flow restriction cuffs. Low-load resistance training with blood flow restriction improves clinical outcomes in musculoskeletal rehabilitation: a single-blind randomized controlled Trial. BFR therapy is not hindered by traditional limitations. Progression models in resistance training for healthy adults. Careers. The intervention protocols are shown in Table 3. National Library of Medicine Jessee MB, Buckner SL, Dankel SJ, Counts BR, Abe T, Loenneke JP. Again, new BFR exercises are implemented. DePhillipo NN, Kennedy MI, Aman ZS, Bernhardson AS, O'Brien LT, LaPrade RF. Bethesda, MD 20894, Web Policies Session: 2x/day, Isometric quadriceps contraction progressing to leg extension over a knee-roll and straight leg raise, 12 days 2022 Apr 1;17(3):334-346. doi: 10.26603/001c.33151. The initial 2 weeks after surgery, or prior to initiation of BFR, will consist of the physical therapy following the surgeon's postoperative protocol. Well, that would be correct! FOIA Thus, pain relief may be the result of low external loads and hypoalgesia effects of LL-BFR training compared to HLR training.47,48,57,58. Go to: Introduction Blood flow restriction therapy (BFR) has become an increasingly popular method of post-operative rehabilitation. Clinical reasoning and decision-making are just as important with BFR as with any other treatment approach you use. Continue this exercise for two to three days to help blood circulation and to prevent blood clots from forming in your legs. The present systematic review has several limitations. You guessed it BFR can help even in cases of immobilization. 2023 Mar 13;38:47-52. doi: 10.1016/j.jor.2023.03.007. However, caution should be noted with patients with cardiac conditions or clotting concerns. Higgins JPT, Altman DG, Gotzsche PC, et al. The results of this systematic review indicate that LL-BFR training after ACL reconstruction may be beneficial on quadriceps strength, quadriceps mass, and knee joint pain compared to non-BFR training with non-detrimental effects on ACL graft laxity. Tenderness. Ohta H, Kurosawa H, Ikeda H, Iwase Y, Satou N, Nakamura S. Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Essentially, with training loads of 20-30% 1RM with 15-30 repetitions per set. observed no difference in quadriceps CSA between LL-BFR and non-BFR training.39 The authors acknowledged that subtherapeutic training (e.g. The https:// ensures that you are connecting to the We really believe that BFR is a technique we should all be using, the science is there. However, due to the limited evidence available, as well as a lack of established protocols, BFR has not been widely adapted. Koc BB, Truyens A, Heymans MJLF, Jansen EJP, Schotanus MGM. The lowered pH from the hypoxic environment is a hypertrophic stimulus. Garcia SA, Curran MT, Palmieri-Smith RM. The results of this systematic review indicate that LL-BFR training after ACL reconstruction may be beneficial on quadriceps strength, quadriceps mass, and knee joint pain compared to non-BFR training with non-detrimental effects on ACL graft laxity. Ankle Mobility Drills to Improve Dorsiflexion. no personalized BFR pressures) were possible reasons for this difference.39 Current evidence recommends training durations of 6-12 weeks and the use of personalized LL-BFR pressures (80% of limb occlusion pressure [LOP]) to achieve muscle strength and hypertrophy.2325 In contrast to the previous studies, the non-BFR group of Hughes et al. PMC Postoperatively, heavy load resistance training can have detrimental effects on knee joint pain and ACL graft laxity. 1-3 sets day. Luckily, learning about BFR doesnt need to be complicated or expensive! Comparing the Effectiveness of BloodFlow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial. 1,3 Quadriceps mass deficits can be as high as 30% and can persist for many years after ACL reconstruction. ACL, lood flow restriction, econstruction, herapy. End: 238 mmHg Muscle atrophy contributes to quadriceps weakness after anterior cruciate ligament reconstruction. Youve seen it in patients (and maybe yourself if youve had surgery!). HHS Vulnerability Disclosure, Help That all sounds great, but what about diagnosis-specific evidence? official website and that any information you provide is encrypted The third exercise performed is bent knee ankle plantar flexion with a light elastic band that is increased for more resistance as the patient progresses. How Does Blood Flow Restriction Training Work? Low-load Resistance Muscular Training with Moderate Restriction of Blood Flow After Anterior Cruciate Ligament Reconstruction, H Ohta; H Kurosawa; H Ikeda; Y Iwase; N Satou; S Nakamura. LL-BFR: low-load blood flow restriction; LOP: limb occlusion pressure; 1RM: one repetition maximum; Postop: postoperatively; Reps: repetitions. Postoperative bracing does not offer any advantages or improve limb asymmetry. So we want to help you quickly and easily learn everything you need to know to get started with BFR training. As fast as you can, can you think about something we do in the rehabilitation or fitness professions that does NOT have a strong scientific rationale or clinical research to support its use? Clipboard, Search History, and several other advanced features are temporarily unavailable. Two studies observed significant greater quadriceps mass after LL-BFR compared to non-BFR training, while two studies observed no significant difference in quadriceps mass. By exercising at these resistances, individuals obtain type II muscle recruitment leading to increased muscle hypertrophy (6). Humes C, Aguero S, Chahla J, Foad A. Over the years, Ive seen a lot of fads come and go in our professions. eCollection 2020 Mar. An overview of the quality assessment of the included studies is reported in Figure 2. Heres everything we currently know about the science of blood flow restriction training, including some of the science we know about the safety and effectiveness of BFR training. Many of the exercises are performed with weights approximately 30% of the one repetition maximum. Furthermore, different LL-BFR and non-BFR protocols with heterogeneous outcome measurements were used. Fukunaga T, Johnson CD, Nicholas SJ, McHugh MP. FOIA However, squatting is implemented into the exercise regimen. used ultrasound to assess changes in vastus lateralis muscle thickness and demonstrated no significant difference in quadriceps increase between LL-BFR and non-BFR training (p=0.230).35, Knee joint pain was assessed using a numerical rating scale in two studies, while one study used the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score.18,35,36 Knee joint pain was evaluated following each session, 24h post-exercise or 10 weeks postoperatively.18,35,36 Two studies observed significant lower knee joint pain scores in LL-BFR compared to non-BFR training.18,36 Furthermore, one study showed significant greater increase in KOOS pain score after LL-BFR compared to non-BFR training.35, Two studies used a knee ligament arthrometer to measure changes in ACL graft laxity.35,37 ACL graft laxity was measured pre-operatively and at 10 up to 16 weeks postoperatively. DePhillipo NN, Kennedy MI, Aman ZS, Bernhardson AS, OBrien LT, LaPrade RF. In the absence of type II muscle recruitment, atrophy can result, causing stark limitations in the post-operative recovery. Postoperatively, heavy load resistance training can have detrimental effects on knee joint pain and ACL graft laxity. The remaining 11 articles were fully read and six articles met the inclusion criteria. Loss of range of motion in your knee. The included studies involved a total of 152 patients who had been randomized into LL-BFR (n=76) or non-BFR (n=76) group.18,3539 Sample sizes ranged between 16 and 44 patients.18,3539 Five studies used hamstring graft for ACL reconstruction, whereas one study did not report type of graft.18,3539 Patient characteristics were not statistically significant different between the LL-BFR and non-BFR group. These studies assert that BFR therapy represents a suitable and positive alternative to traditional methods. High-volume, moderate-intensity increases growth hormone, but low-volume, high-intensity does not. Swelling that starts immediately (but can start four to six hours after the injury) and lasts for two to four weeks. 2018 Aug;34(8):2506-2510. doi: 10.1016/j.arthro.2018.05.038. Fujimoto E, Sumen Y, Urabe Y, et al. However, DePhillipo et al observed in their investigation of BFR a lack of potential side effects such as thromboembolism and ischemic changes in the extremities (14). An increasingly popular method for post-operative rehabilitation of an ACL reconstruction, as a substitute for traditional therapy, is blood flow restriction therapy (BFR). BFR research has been going on for over 20 years now, and were here to tell you its solid. In case SD was not available, this was estimated in accordance with recommendations provided by Cochrane Handbook for Systematic Reviews.33 Data were pooled for a meta-analysis if the included studies were clinically, methodologically and statistically homogenous. Bookshelf ACL recovery. Hospital for Special Surgery (HSS) in New York City is currently studying the effect of blood flow restriction (BFR) therapy following Achilles tendon rupture and repair. Notably, this therapeutic method is growing more prolific particularly following anterior cruciate ligament (ACL) reconstruction. Medicine and science in sports and exercise. External load: 30% 1RM Piussi R, Broman D, Musslinder E, Beischer S, Thome R, Hamrin Senorski E. Recovery of preoperative absolute knee extension and flexion strength after ACL reconstruction. 2020 BY THE ARCHIVES OF BONE AND JOINT SURGERY. Many of these mechanisms involve multi-step pathways that will likely put you to sleep if we go into too much detail on them in this post but they are nevertheless important to understand. 8600 Rockville Pike How amazing is that? Blood flow restriction rehabilitation for extremity weakness: a case series. After anterior cruciate ligament (ACL) surgery, move your ankles up and down an average of 10 times every 10 minutes. Nielsen JL, Aagaard P, Bech RD, Nygaard T, Hvid LG, Wernbom M, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. The Role of Blood Flow Restriction Therapy Following Knee Surgery: Expert Opinion. Exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial. Other symptoms include: Pain. Phase three rehabilitation begins three months and beyond status post ACL reconstruction. did not consist of LLR but HLR training.35 In their study, ultrasound was used to examine vastus lateralis muscle thickness and no difference in muscle thickness was observed between LL-BFR and non-BFR training groups.35 Thus, the results of the present review are consistent with literature showing that LL-BFR training may be beneficial on quadriceps mass compared to LLR training and equally effective when compared to HLR training in healthy and postoperative patients.4046, The application of LL-BFR has generally been indicated for the elderly or injured/postoperative patients who cannot tolerate high external loads.43,4750 This review adds evidence on the application of LL-BFR as three studies assessing pain observed improved pain relief with LL-BFR compared to non-BFR training in patients following ACL surgery.18,35,36 This is in contrast with a recent systematic review that observed no significant difference in pain relief between LL-BFR and non-BFR training in individuals with knee joint pain.51 The study participants were heterogeneous and included individuals with patellofemoral pain, risk of symptomatic knee osteoarthritis, anterior knee pain and post knee arthroscopy.51 Furthermore, the heterogeneity in LL-BFR pressures and cuff width could explain the lack of effect on knee joint pain.51 Current evidence suggests that therapeutic restriction (defined as 80% of LOP) is achieved at lower LL-BFR pressures with wide compared to narrow cuffs.5256 Furthermore, lower LL-BFR pressures are associated with less discomfort and greater safety.5256 Thus, the use of non-personalized pressures without calculating the LOP may cause pain.5256 In the present systematic review, all studies on knee joint pain used wide cuffs with an automatic personalized tourniquet system to calculate the LOP.18,35,36 Furthermore, all studies used HLR training as non-BFR training. 6 times per week. Random sequence generation and allocation concealment was defined as high risk for bias in two of the six studies. FOIA So, if we know that getting strong requires a combination of load and volume, what do we do in cases where people are not appropriate for high loads or cant tolerate them? Iversen E, Rstad V, Larmo A. Ithurburn MP, Altenburger AR, Thomas S, Hewett TE, Paterno MV, Schmitt LC. Effect of Blood Flow Restriction Training on Quadriceps Muscle Strength, Morphology, Physiology, and Knee Biomechanics Before and After Anterior Cruciate Ligament Reconstruction: Protocol for a Randomized Clinical Trial, LN Erickson; KCH Lucas; KA Davis; CA Jacobs; KL Thompson; PA Hardy; AH Anderson; CS Fry; BW Noehren. Accessed February 2021. https://training.cochrane.org/. Im not one to jump on a bandwagon, but as more and more evidence continues to be published, its starting to become clear that BFR is something we should be considering. Federal government websites often end in .gov or .mil. A SYSTEMATIC REVIEW OF THE EFFECTS OF BLOOD FLOW RESTRICTION TRAINING ON QUADRICEPS MUSCLE ATROPHY AND CIRCUMFERENCE POST ACL RECONSTRUCTION. As a library, NLM provides access to scientific literature. Luckily, a recent review showed that the risk of clots, or DVTs, is extremely low. Accessibility Blood flow restriction training is a great technique to be able to help people gain strength in a low load environment. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. This is much more applicable to training with healing tissue that is not yet ready to accept more intense loading. This article will seek to examine and reassert the value and validity of BFR therapy in patients recovering from ACL reconstructions. Effects of cuff width on arterial occlusion: implications for blood flow restricted exercise. Table 1 shows an overview of the study characteristics. A number of studies have shown the benefit of BFR on pain reduction in patellofemoral pain, knee osteoarthritis, and function after ACL reconstruction and knee osteoarthritis. official website and that any information you provide is encrypted How to choose the best BFR bands, cuffs, and equipment to get started using blood flow restriction training. An official website of the United States government. As previously mentioned, the American College of Sports Medicine recommends, that in order to strengthen muscle and maintain muscular strength, resistance exercises should be performed at 60 to 100 percent of the one repetition maximum (1). ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. Factors to consider when weighing the risks versus benefits of BFR training related to the surgery should include: The type of surgery performed - Common sense would suggest the more invasive the surgery, the greater the risk. Effect of Low-Load Blood Flow Restriction Training After Anterior Cruciate Ligament Reconstruction: A Systematic Review. The included studies used different LL-BFR and non-BFR protocols with heterogeneous outcome measurements. Notice above that the key term is high load. We need high loads to get strong. At this point, the patient has regained enough muscle to move onto phase three. Hughes L, Paton B, Haddad F, Rosenblatt B, Gissane C, Patterson SD. Unauthorized use of these marks is strictly prohibited. Interset rest periods: unknown Cuyul-Vsquez I, Leiva-Seplveda A, Cataln-Medalla O, Araya-Quintanilla F, Gutirrez-Espinoza H. The addition of blood flow restriction to resistance exercise in individuals with knee pain: a systematic review and meta-analysis. Skeletal muscle hypertrophy in response to isometric, lengthening, and shortening training bouts of equivalent duration. Also known as occlusion, hypoxic or KAATSU training, BFR is the process of restricting blood flow out of the working muscle by wrapping a tourniquet-like strap to the top of your arms or legs. Atrophy results from a low load bearing state in which the down regulation of hypertrophic signaling cascade occurs as well as the activation of cascades that cause muscle protein degradation (2). Is there a minimum intensity threshold for resistance training-induced hypertrophic adaptations? Loenneke JP, Fahs CA, Rossow LM, et al. Based on the literature, BFR therapy mitigates atrophy through type II muscle recruitment while also stimulating hypertrophy in patients, supporting its use post-operatively. These exercises mitigate atrophy while beginning the hypertrophic phase. One additional exercise added is prone hip extension. At this time, we recommended that BFR training commence about 2 weeks after surgery to help reduce the risk of adverse events. Kouzaki M, Yoshihisa T, Fukunaga T. 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Rosenblatt B, Gissane C, Aguero S, Chahla J, Foad.! Become an increasingly popular method of post-operative rehabilitation when to start bfr after acl surgery used high-intensity does not commence 2.