Clinical Applications of Blood Flow Restriction Training (BFR)JOSHUA T. WILLIAMS

Muscular Response to Injury

Injury/surgery and disuse can lead to sequelae of neurologic inhibition, atrophy, weakness, & sarcopenia in addition to predisposition of aging

Selective inhibition of fast-twitch early

Imbalance of protein synthesis & protein degradation

Rehabilitation Conundrum

Rehab following injury may require protection from heavy loads &/or weight-bearing that accentuates this process

Loss of muscle mass and strength deficits can persist for years following injury/surgery

Traditional Management Options

Wait & See

Neuromuscular Stimulation

High intensity resistance training (70% 1RM)

High volume low load resistance training

Possible Solution?

Low Load Resistance Training with BFR

Is it safe?

Theoretical Safety Issues

Impaired Hemodynamics

Ischemic/Muscle Injury

Cardiac Issues

Nerve Injury

Thrombus Formation

No increase in clotting factors with BFR

DVT < 0.06%

PE < 0.01%

Case Report (2017)

29 year old female KAATSU instructor

Diagnosed with Subclavian vein thrombosis/Thoracic Outlet

Intermittent and progressive symptoms over 2 years

unknown protocol

• 30 min – 1 hr in duration; 3 times per week

Ischemic/Muscle Injury

Rhabdomyolysis

<0.01%

Case Report (2016)

• 30 year old Japanese Obese Male

• 1 session of BFR on LE with 3 sets of 20 squats

• Unknown Protocol

• ER next day

• Also diagnosed with an acute bacterial tonsillitis

Cardiac

Abnormal excessive pressure reflex

No current reports

At risk = heart failure, hypertension, PAD (precaution)

Reduce % BFR pressure

Nerve Injury

Transient

No permanent injury reported

<0.2%

Safety in BFR Studies

Lack of reporting in studies (either presence or absence)

Study exclusions

Clinical vs Healthy population?

Current Consensus/Recommendations

Most common issue is bruising &/or discomfort

No greater risk than other exercise modes

Assuming correct application

Short duration of application

Use caution in clinical populations

Possible use of lower occlusion pressures

Avoid in potential high risk populations

prone to clot, Sickle cell, previous compartment syndrome, previous rhabdomyolysis, lymphedema, infection, diabetes, etc.

Continued Questions

Acute vs Chronic use?

Clinical populations at risk?

Has in been studied in typical clinical rehabilitation populations?

2016 Systematic Review of BFR in Musculoskeletal Rehabilitation

20 studies

13 were focused on elderly (no apparent clinical diagnosis)

Only 7 represented use in clinical populations with pathologic conditions

• 3 ACL

• 3 knee OA/risk of OA

• 1 myositis

Clinical populations studied…

ACL

Phases of BFR within rehab progression Early – passive

Gait with BFR

• No evidence specifically in ACLR

Low load resistance BFR

Heavy loading

No evidence pre-ACLR

No evidence re: functional improvements, return to sport

Early Phase

Takarada, et al (2000)

8 patients used a 90mm width cuff to create a progressive pressure between 180 and 260 mmHg for 5 sets of 5 minutes with 3 minutes between sets twice a day on days 3-14 post-op

NO exercise- passive process

Decreased quad mm atrophy in BFR group compared to 8 person control group

Early Phase

Iversen, et al (2016)

24 patients (12 BFR, 12 control)

18-40 years old post-ACLR with HS graft

14cm wide cuff provided progressive pressure between 130 and 180 mmHg for 5 sets of 5 minutes with 3 minutes between sets twice a day on days 2-14 post-op

20 reps of quad isometrics, SAQ, or SLR during each 5 minute set

No difference in post-op mm atrophy between BFR & control

BFR group had more variability

BFR group avg. 2.5 mo since injury while control group avg. 5.4 mo since injury

Low Load Resistance with BFR

Ohta (2003)

44 patients (22 BFR, 22 control)

18-52 years old post-ACLR with HS graft

180mmHg of pressure (unknown cuff width) during a standardized exercise program from week 2-16 post-op

BFR group demonstrated greater strength improvements and less mm atrophy compared to control group (same exercises, no BFR)

Knee OA

Risk of OA (Segal 2015) - Men

Community dwelling, ambulatory, 45-90 y.o., volunteers (n=42)

Radiographic knee OA without symptoms OR at least 1 risk factor

previous knee injury

previous knee surgery

pain/aching/stiffness >30days

overweight/obese

Risk of OA (Segal 2015) - Men

BFR with 65mm width cuff

Pressure progressively increased over 5 minute period

Standard final pressures of 160 mmHg at week 1 progressing to 220 mmHg at week 4

4 sets of leg press (30, 15, 15, 15) with 30 sec rest periods between sets at 30% of 1RM No adjustments made during training period

Control group = same as intervention group, but without BFR

3 sessions per week for 4 weeks

Risk of OA (Segal 2015) - Men

Outcome Measures = bilateral leg press 1RM, isokinetic knee extensor strength, KOOS

1 person dropped out due to “intolerance to the cuff”

No significant differences between the 2 groups for any of outcomes

Risk of OA (Segal 2015) - women

Same population as study in men except age was 45-65 years old (n=45)

Same BFR protocol & exercise program as in men

Same outcome measures with addition of quad volume & stair climb muscle power

1 person dropped out due to “inability to tolerate the intervention”

Leg press 1RM & isokinetic strength improved in BFR > control

No differences between groups in quad volume, stair climb, or KOOS scores

Why Gender Differences?

Thigh girth NOT considered

Pressure NOT individualized

Age differences of groups

Differences within included sub-groups

OA (Byrk 2016)

Women with clinical & radiographic diagnosis of knee OA (n=34)

Standard program of stretching, general strengthening of other LE mm, balance

OKC knee extension at 30% 1RM 3 sets of 30 reps

BFR group used 200 mmHg pressure (unknown cuff)

Control group = exercise without BFR

1RM updated weekly

3 sessions per week for 6 weeks

OA (Byrk 2016)

Outcomes

11-point NPRS (max pain in last week & during BFR ex)

Lequesne questionnaire

Timed Up-and-Go (TUG)

isometric dynamometer strength of quadriceps

Results

Improved quad strength in BFR group compared to control

Decreased pain during exercise for BFR group vs control

No between group differences for Lequesne, TUG, or max pain

Anterior Knee Pain

Anterior Knee Pain (Giles 2017)

18-40 years old (n=79)

Atraumatic anterior knee pain >8wks

Pain with at least 2 activities

running, jumping, squatting, kneeling, stair ascent/descent, prolonged sitting

Pain with 2 tests

patellar compression, peripatellar palpation, seated resisted isometric knee extension

Anterior Knee Pain (Giles 2017)

BFR using 60% of arterial occlusion pressure (measured with Doppler)

Leg press & Leg extension exercises

30% of estimated 1RM

4 sets (30, 15, 15, 15) with 30 sec between sets

Control group = 70% of estimated 1RM 3 sets of 7-10 reps with sham BFR

3 sessions per week for 8 weeks

Anterior Knee Pain (Giles 2017)

Both groups improved

BFR group decreased pain with ADLs compared to controls at 8 weeks (BFR group had higher pain with ADLs at baseline)

No difference between groups with function, pain at worst, muscle size, or muscle strength

No differences between groups for any measure at 6 months

Subgroup of patients who had pain with resisted isometric extension improved strength more with BFR than controls at 8 weeks

Anterior Knee Pain (Korakakis 2018)

Non-experimental Design

30 male patients with anterior knee pain (post-op ACLR, PFJS, post-op meniscus, OCD, patellar tendinopathy)

Measured pain with shallow single limb squat (SLS), deep SLS, and double limb squat (DLS)

Measurements pre- and post- BFR exercise and again following 45 minute PT session

Anterior Knee Pain (Korakakis 2018)

10 cm cuff induced pressure to 80% of vascular occlusion (measured with Doppler)

Performed OKC knee extension with BFR at a pain determined load 4 sets (max, 15, 15, 15) with 30 sec between sets

Statistically significant decrease in pain following BFR for all tests and maintained at 45 minutes

BFR early in session may help reduce pain with subsequent exercise or activity

Other Conditions…

Following Knee Scope (Tennet 2017)

17 patients 18-65 y.o.

Non-reconstructive knee scope

12 visits of PT with BFR vs 12 visits of PT without BFR

initiated at 3 weeks post-op

Standard post-op exercise protocol for both groups

Following Knee Scope (Tennet 2017)

“Additional” exercises for BFR group

Leg press, Leg extension, “Reverse press” (standing bent knee hip ext)

30% of 1 RM; 4 sets (30, 15, 15, 15) with 30 sec rest between sets

Pressure = 80% limb occlusion pressure (using Doppler)

Following Knee Scope (Tennet 2017)

Increase thigh girth in BFR group compared to control (tape measure)

Improved mental component score (not physical) of Veterans RAND-12 Health Survey in BFR compared to control

Improved timed stair assent in BFR group compared to control

Knee extension & flexion strength improved in BFR group compared to control

Cast Immobilization (Kubota 2011)

healthy, male patients (n=11)

Immobilized lower leg in cast & used crutches with NWB for 2 weeks

BFR group vs No treatment group

50 mmHg pressure

5 sets twice a day for 14 days (5 minutes BFR, 3 minutes rest)

Less loss of calf muscle strength (at 60 deg/sec) compared to non BFR group

No difference between groups for other isokinetic tests

Athletes & Performance

Not a detriment

No improvements in strength, size, or functional performance compared to high intensity exercise

Benefits for in-season strength training?

Case Studies

Osteochondral Fracture (Loenneke, et al 2013)

22 y.o. male, bodybuilder

Injured knee & began self management/compensation with BFR (elastic wrap)

Ortho visit (3 days post injury) = joint effusion, decreased knee flexion, mild limp

MRI (5 days post injury) = significant osteochondral defect; surgery recommended

Continued BFR training & postponed surgery due to upcoming competition

Returned for pre-op visit (17 days post injury) – normal gait, pain free, no effusion

• osteochondral fracture was healing and patient was continued to be managed conservatively

Case Studies

Parkinson’s (Douris, et al 2018)

65 y.o. male, recreational boxer

Walking program with BFR (120 – 160 mmHg)

Improved Timed Up-and-Go, 6-minute walk test, 30-second chair stand test, and decreased restless leg symptoms

Improvements every 2 weeks over the course of 6 week intervention

Case Studies

Achilles Rupture (Yow, et al 2018)

2 patients

• 29 y.o. active-duty military; 38 y.o. male service member

Both had experience complications/unusual circumstances

Both increased strength at 5-6 weeks

Both returned to running program

Theoretical Proposals

Low Back Pain

TKA Prehab

Chronic Ankle Instability

In-patient Rehab

End-stage Renal Disease with dialysis

Other thoughts…

Cancer

Obesity

Fractures

Neurologic

Cardiovascular

Concussion?

Factors to Consider

Cuff Width

Thigh or Arm Girth

Time to achieve maximal pressure

Maximal pressure

Risk vs Benefit in clinical populations & individual patients

Intensity & Volume of resistance

Length of program

Timing of program during course of recovery

Timing of program within a session

Outcome measures

What we know…

Current studies in clinical populations are generally low quality with methodological issues

No worse than low intensity training alone

No better than high intensity training

Likely a reduction in pain compared to high intensity training

Individualized determination of pressure

Short duration of application

Continued progression of resistance with gains

30% 1RM (30, 15, 15, 15)

Questions we still have…

Do strength and muscle size translate to functional improvements?

How long of a program is needed to be effective?

Does BFR early in session facilitate other exercises/interventions?

How does BFR interact with other interventions?

Proximal effects?

Improved bone healing?

Clinical populations?

Upper Extremity?

Children/Adolescents?

Current Recommendations

Individualized approach

40% - 80% occlusion pressure

Resistance progression

20% - 30% 1RM

4 sets (30,15,15,15)

NOT to point of complete exhaustion/maximal volume

Consider rehab progression

BFR alone during early stages of rest

BFR with low workload walking/cycling

BFR with low load resistance training

BFR with low level functional training

Approximately 30 on-going clinical trials

ACL

OA

Chronic Heart Failure

TKA

Meniscus

Articular Cartilage

Urinary Stress Incontinence

Coronary Heart Disease

Multiple Sclerosis

Achilles Tendinopathy

Fracture

Low Back Pain

Biceps Tenodesis

Chronic Kidney Disease

Questions?

References Amano, S., Ludin, A. F. M., Clift, R., Nakazawa, M., Law, T. D., Rush, L. J., . . . Clark, B. C. (2016). Effectiveness of blood flow

restricted exercise compared with standard exercise in patients with recurrent low back pain: study protocol for a randomized controlled trial. Trials, 17, 81-81. doi:10.1186/s13063-016-1214-7

Bryk, F. F., Dos Reis, A. C., Fingerhut, D., Araujo, T., Schutzer, M., Cury, R. d. P. L., . . . Fukuda, T. Y. (2016). Exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA, 24(5), 1580-1586. doi:10.1007/s00167-016-4064-7

Clarkson, M. J., Fraser, S. F., Bennett, P. N., McMahon, L. P., Brumby, C., & Warmington, S. A. (2017). Efficacy of blood flow restriction exercise during dialysis for end stage kidney disease patients: protocol of a randomised controlled trial. BMC Nephrology, 18(1), 294-294. doi:10.1186/s12882-017-0713-4

Cook, S. B., LaRoche, D. P., Villa, M. R., Barile, H., & Manini, T. M. (2017). Blood flow restricted resistance training in older adults at risk of mobility limitations. Experimental Gerontology, 99, 138-145. doi:10.1016/j.exger.2017.10.004

Douris, P. C., Cogen, Z. S., Fields, H. T., Greco, L. C., Hasley, M. R., Machado, C. M., . . . DiFrancisco-Donoghue, J. (2018). THE EFFECTS OF BLOOD FLOW RESTRICTION TRAINING ON FUNCTIONAL IMPROVEMENTS IN AN ACTIVE SINGLE SUBJECT WITH PARKINSON DISEASE. International Journal of Sports Physical Therapy, 13(2), 247-254.

Faltus, J., Owens, J., & Hedt, C. (2018). THEORETICAL APPLICATIONS OF BLOOD FLOW RESTRICTION TRAINING IN MANAGING CHRONIC ANKLE INSTABILITY IN THE BASKETBALL ATHLETE. International Journal of Sports Physical Therapy, 13(3), 552-560.

Franz, A., Queitsch, F. P., Behringer, M., Mayer, C., Krauspe, R., & Zilkens, C. (2018). Blood flow restriction training as a prehabilitation concept in total knee arthroplasty: A narrative review about current preoperative interventions and the potential impact of BFR. Medical Hypotheses, 110, 53-59. doi:10.1016/j.mehy.2017.10.029

Giles, L. (2016). BLOOD-FLOW RESTRICTION TRAINING: A LOW-LOAD ALTERNATIVE TO HEAVY STRENGTH TRAINING. Sport Health, 34(4), 38-41.

References Giles, L., Webster, K. E., McClelland, J., & Cook, J. L. (2017). Quadriceps strengthening with and without blood flow

restriction in the treatment of patellofemoral pain: a double-blind randomised trial. British Journal Of Sports Medicine, 51(23), 1688-1694. doi:10.1136/bjsports-2016-096329

Gorgey, A. S., Timmons, M. K., Dolbow, D. R., Bengel, J., Fugate-Laus, K. C., Michener, L. A., & Gater, D. R. (2016). Electrical stimulation and blood flow restriction increase wrist extensor cross-sectional area and flow meditated dilatation following spinal cord injury. European Journal Of Applied Physiology, 116(6), 1231-1244. doi:10.1007/s00421-016-3385-z

Hackney, K. J., Brown, W. J., Stone, K. A., & Tennent, D. J. (2018). The Role of Blood Flow Restriction Training to Mitigate Sarcopenia, Dynapenia, and Enhance Clinical Recovery. Techniques in Orthopaedics, 33(2), 98-105.

Hughes, L., Paton, B., Rosenblatt, B., Gissane, C., & Patterson, S. D. (2017). Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. British Journal Of Sports Medicine, 51(13), 1003-1011. doi:10.1136/bjsports-2016-097071

Hughes, L., Rosenblatt, B., Paton, B., & Patterson, S. D. (2018). Blood Flow Restriction Training in Rehabilitation Following Anterior Cruciate Ligament Reconstructive Surgery: A Review. Techniques in Orthopaedics, 33(2), 106-113.

Iversen, E., Røstad, V., & Larmo, A. (2016). Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction. Journal of Sport and Health Science, 5(1), 115-118. doi:https://doi.org/10.1016/j.jshs.2014.12.005

Korakakis, V., Whiteley, R., & Epameinontidis, K. (2018). Blood Flow Restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading. Physical Therapy In Sport: Official Journal Of The Association Of Chartered Physiotherapists In Sports Medicine, 32, 235-243. doi:10.1016/j.ptsp.2018.05.021

References

Kubota, A., Sakuraba, K., Koh, S., Ogura, Y., & Tamura, Y. (2011). Blood flow restriction by low compressive force prevents disuse muscular weakness. Journal Of Science And Medicine In Sport, 14(2), 95-99. doi:10.1016/j.jsams.2010.08.007

Ladlow, P., Coppack, R. J., Dharm-Datta, S., Conway, D., Sellon, E., Patterson, S. D., & Bennett, A. N. (2017). The effects of low-intensity blood flow restricted exercise compared with conventional resistance training on the clinical outcomes of active UK military personnel following a 3-week in-patient rehabilitation programme: protocol for a randomized controlled feasibility study. Pilot And Feasibility Studies, 3, 71-71. doi:10.1186/s40814-017-0216-x

Loenneke, J. P., Young, K. C., Wilson, J. M., & Andersen, J. C. (2013). Rehabilitation of an osteochondral fracture using blood flow restricted exercise: a case review. Journal Of Bodywork And Movement Therapies, 17(1), 42-45. doi:10.1016/j.jbmt.2012.04.006

Noto, T., Hashimoto, G., Takagi, T., Awaya, T., Araki, T., Shiba, M., . . . Sugi, K. (2017). Paget-Schroetter Syndrome Resulting from Thoracic Outlet Syndrome and KAATSU Training. Internal Medicine (Tokyo, Japan), 56(19), 2595-2601. doi:10.2169/internalmedicine.7937-16

Ohta, H., Kurosawa, H., Ikeda, H., Iwase, Y., Satou, N., & Nakamura, S. (2003). Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthopaedica Scandinavica, 74(1), 62-68.

Patterson, S. D., Hughes, L., Head, P., Warmington, S., & Brandner, C. (2017). Blood flow restriction training: a novel approach to augment clinical rehabilitation: how to do it. British Journal Of Sports Medicine, 51(23), 1648-1649. doi:10.1136/bjsports-2017-097738

Scott, B. R., Loenneke, J. P., Slattery, K. M., & Dascombe, B. J. (2016). Blood flow restricted exercise for athletes: A review of available evidence. Journal Of Science And Medicine In Sport, 19(5), 360-367. doi:10.1016/j.jsams.2015.04.014

References

Scott, B. R., Peiffer, J. J., & Goods, P. S. R. (2017). The Effects of Supplementary Low-Load Blood Flow Restriction Training on Morphological and Performance-Based Adaptations in Team Sport Athletes. Journal Of Strength And Conditioning Research, 31(8), 2147-2154. doi:10.1519/JSC.0000000000001671

Segal, N., Davis, M. D., & Mikesky, A. E. (2015). Efficacy of Blood Flow-Restricted Low-Load Resistance Training For Quadriceps Strengthening in Men at Risk of Symptomatic Knee Osteoarthritis. Geriatric Orthopaedic Surgery & Rehabilitation, 6(3), 160-167. doi:10.1177/2151458515583088

Segal, N. A., Williams, G. N., Davis, M. C., Wallace, R. B., & Mikesky, A. E. (2015). Efficacy of blood flow-restricted, low-load resistance training in women with risk factors for symptomatic knee osteoarthritis. PM & R: The Journal Of Injury, Function, And Rehabilitation, 7(4), 376-384. doi:10.1016/j.pmrj.2014.09.014

Slysz, J., Stultz, J., & Burr, J. F. (2016). The efficacy of blood flow restricted exercise: A systematic review & meta-analysis. Journal Of Science And Medicine In Sport, 19(8), 669-675. doi:10.1016/j.jsams.2015.09.005

Tabata, S., Suzuki, Y., Azuma, K., & Matsumoto, H. (2016). Rhabdomyolysis After Performing Blood Flow Restriction Training: A Case Report. Journal Of Strength And Conditioning Research, 30(7), 2064-2068. doi:10.1519/JSC.0000000000001295

Takarada, Y., Takazawa, H., & Ishii, N. (2000). Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles. Medicine And Science In Sports And Exercise, 32(12), 2035-2039.

References

Tennent, D. J., Hylden, C. M., Johnson, A. E., Burns, T. C., Wilken, J. M., & Owens, J. G. (2017). Blood Flow Restriction Training After Knee Arthroscopy: A Randomized Controlled Pilot Study. Clinical Journal Of Sport Medicine: Official Journal Of The Canadian Academy Of Sport Medicine, 27(3), 245-252. doi:10.1097/JSM.0000000000000377

Vanwye, W. R., Weatherholt, A. M., & Mikesky, A. E. (2017). Blood Flow Restriction Training: Implementation into Clinical Practice. International Journal Of Exercise Science, 10(5), 649-654.

Warmington, S. A., Staunton, C. A., May, A. K., & Brandner, C. R. (2016). Blood flow restriction exercise: acute versus chronic safety. European Journal Of Applied Physiology, 116(4), 861-862. doi:10.1007/s00421-015-3319-1

Yasuda, T., Fukumura, K., Fukuda, T., Iida, H., Imuta, H., Sato, Y., . . . Nakajima, T. (2014). Effects of low-intensity, elastic band resistance exercise combined with blood flow restriction on muscle activation. Scandinavian Journal of Medicine & Science in Sports, 24(1), 55-61. doi:10.1111/j.1600-0838.2012.01489.x

Yow, B. G., Tennent, D. J., Dowd, T. C., Loenneke, J. P., & Owens, J. G. (2018). Blood Flow Restriction Training After Achilles Tendon Rupture. The Journal Of Foot And Ankle Surgery: Official Publication Of The American College Of Foot And Ankle Surgeons, 57(3), 635-638. doi:10.1053/j.jfas.2017.11.008

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