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Blood Flow Restriction Training Can Improve Peak Torque Strength in Chronic Atrophic Postoperative Quadriceps and Hamstrings Muscles

      Purpose

      To report a prospective study of patients who underwent blood flow restriction training (BFRT) for marked quadriceps or hamstring muscle deficits after failure to respond to traditional rehabilitation after knee surgery.

      Methods

      The BFRT protocol consisted of 4 low resistance exercises (30% of 1 repetition maximum): leg press, knee extension, mini-squats, and hamstring curls with 60% to 80% limb arterial occlusion pressure. Knee peak isometric muscle torque (60° flexion) was measured on an isokinetic dynamometer.

      Results

      Twenty-seven patients (18 females, 9 males; mean age, 40.1 years) with severe quadriceps and/or hamstrings deficits were enrolled from April 2017 to January 2020. They had undergone a mean of 5.3 ± 3.5 months of outpatient therapy and 22 ± 10 supervised therapy visits and did not respond to traditional rehabilitation. Prior surgery included anterior cruciate ligament reconstruction, partial or total knee replacements, meniscus repairs, and others. All patients completed 9 BFRT sessions, and 14 patients completed 18 sessions. The mean quadriceps and hamstrings torque deficits before BFRT were 43% ± 16% and 38% ± 14%, respectively. After 9 BFRT sessions, statistically significant improvements were found in muscle peak torque deficits for the quadriceps (P = .003) and hamstring (P = .02), with continued improvements after 18 sessions (P = .004 and P = .002, respectively). After 18 BFRT sessions, the peak quadriceps and hamstring peak torques increased > 20% in 86% and 76% of the patients, respectively. The failure rate of achieving this improvement in peak quadriceps and hamstring torque after 18 BFRT sessions was 14% and 24%, respectively.

      Conclusions

      BFRT produced statistically significant improvements in peak quadriceps and hamstring torque measurements after 9 and 18 sessions in a majority of patients with severe quadriceps and hamstring strength deficits that had failed to respond to many months of standard and monitored postoperative rehabilitation.

      Level of Evidence

      Level IV therapeutic case series.
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      References

        • Huber R.
        • Viecelli C.
        • Bizzini M.
        • et al.
        Knee extensor and flexor strength before and after anterior cruciate ligament reconstruction in a large sample of patients: Influence of graft type.
        Phys Sportsmed. 2019; 47: 85-90
        • Chung K.S.
        • Ha J.K.
        • Yeom C.H.
        • et al.
        Are muscle strength and function of the uninjured lower limb weakened after anterior cruciate ligament injury? Two-year follow-up after reconstruction.
        Am J Sports Med. 2015; 43: 3013-3021
        • Larsen J.B.
        • Farup J.
        • Lind M.
        • Dalgas U.
        Muscle strength and functional performance is markedly impaired at the recommended time point for sport return after anterior cruciate ligament reconstruction in recreational athletes.
        Hum Mov Sci. 2015; 39: 73-87
        • Hsiao S.F.
        • Chou P.H.
        • Hsu H.C.
        • Lue Y.J.
        Changes of muscle mechanics associated with anterior cruciate ligament deficiency and reconstruction.
        J Strength Cond Res. 2014; 28: 390-400
        • Schache M.B.
        • McClelland J.A.
        • Webster K.E.
        Lower limb strength following total knee arthroplasty: A systematic review.
        Knee. 2014; 21: 12-20
        • Moon Y.W.
        • Kim H.J.
        • Ahn H.S.
        • Lee D.H.
        Serial Changes of quadriceps and hamstring muscle strength following total knee arthroplasty: A meta-analysis.
        PLoS One. 2016; 11e0148193
        • Tourville T.W.
        • Jarrell K.M.
        • Naud S.
        • Slauterbeck J.R.
        • Johnson R.J.
        • Beynnon B.D.
        Relationship between isokinetic strength and tibiofemoral joint space width changes after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2014; 42: 302-311
        • Risberg M.A.
        • Oiestad B.E.
        • Gunderson R.
        • et al.
        Changes in knee osteoarthritis, symptoms, and function after anterior cruciate ligament reconstruction: A 20-year prospective follow-up study.
        Am J Sports Med. 2016; 44: 1215-1224
        • de Jong S.N.
        • van Caspel D.R.
        • van Haeff M.J.
        • Saris D.B.
        Functional assessment and muscle strength before and after reconstruction of chronic anterior cruciate ligament lesions.
        Arthroscopy. 2007; 23 (28 e21-23)
        • Oiestad B.E.
        • Holm I.
        • Engebretsen L.
        • Aune A.K.
        • Gunderson R.
        • Risberg M.A.
        The prevalence of patellofemoral osteoarthritis 12 years after anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 942-949
        • Karanikas K.
        • Arampatzis A.
        • Bruggemann G.P.
        Motor task and muscle strength followed different adaptation patterns after anterior cruciate ligament reconstruction.
        Eur J Phys Rehabil Med. 2009; 45: 37-45
        • Konishi Y.
        • Oda T.
        • Tsukazaki S.
        • Kinugasa R.
        • Hirose N.
        • Fukubayashi T.
        Relationship between quadriceps femoris muscle volume and muscle torque after anterior cruciate ligament rupture.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 641-645
        • Konishi Y.
        • Oda T.
        • Tsukazaki S.
        • Kinugasa R.
        • Fukubayashi T.
        Relationship between quadriceps femoris muscle volume and muscle torque at least 18 months after anterior cruciate ligament reconstruction.
        Scand J Med Sci Sports. 2012; 22: 791-796
        • Pietrosimone B.G.
        • Lepley A.S.
        • Ericksen H.M.
        • Gribble P.A.
        • Levine J.
        Quadriceps strength and corticospinal excitability as predictors of disability after anterior cruciate ligament reconstruction.
        J Sport Rehabil. 2013; 22: 1-6
        • American College of Sports M
        American College of Sports Medicine position stand. Progression models in resistance training for healthy adults.
        Med Sci Sports Exerc. 2009; 41: 687-708
        • Barber-Westin S.
        • Noyes F.R.
        Blood flow-restricted training for lower extremity muscle weakness due to knee pathology: A systematic review.
        Sports Health. 2019; 11: 69-83
        • Hughes L.
        • Paton B.
        • Rosenblatt B.
        • Gissane C.
        • Patterson S.D.
        Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis.
        Br J Sports Med. 2017; 51: 1003-1011
        • Loenneke J.P.
        • Thiebaud R.S.
        • Abe T.
        Does blood flow restriction result in skeletal muscle damage? A critical review of available evidence.
        Scand J Med Sci Sports. 2014; 24: e415-e422
        • Mattocks K.T.
        • Jessee M.B.
        • Mouser J.G.
        • et al.
        The application of blood flow restriction: Lessons from the laboratory.
        Curr Sports Med Rep. 2018; 17: 129-134
        • Minniti M.C.
        • Statkevich A.P.
        • Kelly R.L.
        • et al.
        The safety of blood flow restriction training as a therapeutic intervention for patients with musculoskeletal disorders: A systematic review.
        Am J Sports Med. 2020; 48: 1773-1785
        • Kilgas M.A.
        • Lytle L.L.M.
        • Drum S.N.
        • Elmer S.J.
        Exercise with blood flow restriction to improve quadriceps function long after ACL reconstruction.
        Int J Sports Med. 2019; 40: 650-656
        • 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.
        Acta Orthop Scand. 2003; 74: 62-68
        • Takarada Y.
        • Takazawa H.
        • Sato Y.
        • Takebayashi S.
        • Tanaka Y.
        • Ishii N.
        Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans.
        J Appl Physiol (1985). 2000; 88: 2097-2106
        • Tennent D.J.
        • Hylden C.M.
        • Johnson A.E.
        • Burns T.C.
        • Wilken J.M.
        • Owens J.G.
        Blood flow restriction training after knee arthroscopy: A randomized controlled pilot study.
        Clin J Sport Med. 2017; 27: 245-252
        • Gaunder C.L.
        • Hawkinson M.P.
        • Tennent D.J.
        • Tubb C.C.
        Occlusion training: Pilot study for postoperative lower extremity rehabilitation following primary total knee arthroplasty.
        US Army Med Dep J. 2017; : 39-43
        • Hughes L.
        • Rosenblatt B.
        • Haddad F.
        • et al.
        Comparing the effectiveness of blood flow 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.
        Sports Med. 2019; 49: 1787-1805
        • Iversen E.
        • Rostad V.
        • Larmo A.
        Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction.
        J Sport Health Sci. 2016; 5: 115-118
        • Giles L.
        • Webster K.E.
        • McClelland J.
        • Cook J.L.
        Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: A double-blind randomised trial.
        Br J Sports Med. 2017; 51: 1688-1694
        • DePhillipo N.N.
        • Kennedy M.I.
        • Aman Z.S.
        • Bernhardson A.S.
        • O'Brien L.T.
        • LaPrade R.F.
        The role of blood flow restriction therapy following knee surgery: Expert opinion.
        Arthroscopy. 2018; 34: 2506-2510
        • Franz A.
        • Behringer M.
        • Nosaka K.
        • et al.
        Mechanisms underpinning protection against eccentric exercise-induced muscle damage by ischemic preconditioning.
        Med Hypotheses. 2017; 98: 21-27
        • Wilkinson B.G.
        • Donnenwerth J.J.
        • Peterson A.R.
        Use of blood flow restriction training for postoperative rehabilitation.
        Curr Sports Med Rep. 2019; 18: 224-228
        • DePhillipo N.N.
        • Kennedy M.I.
        • Aman Z.S.
        • Bernhardson A.S.
        • O'Brien L.
        • LaPrade R.F.
        Blood flow restriction therapy after knee surgery: indications, safety considerations, and postoperative protocol.
        Arthrosc Tech. 2018; 7: e1037-e1043
        • Kraemer W.J.
        • Patton J.F.
        • Gordon S.E.
        • et al.
        Compatibility of high-intensity strength and endurance training on hormonal and skeletal muscle adaptations.
        J Appl Physiol. 1995; 78: 976-989
        • Reiman M.P.
        • Manske R.C.
        Functional Testing in Human Performance.
        Human Kinetics, Champaign, IL2009
        • Patterson S.D.
        • Hughes L.
        • Warmington S.
        • et al.
        Blood flow restriction exercise position stand: Considerations of methodology, application and safety.
        Front Physiol. 2019; 10: 533
        • Cohen J.
        Statistical Power Analysis for the Behavioral Sciences.
        Academic Press, New York1977
        • Batterham A.M.
        • Hopkins W.G.
        Making meaningful inferences about magnitudes.
        Sportscience. 2005; 9: 6-13
        • Lixandrao M.E.
        • Ugrinowitsch C.
        • Berton R.
        • et al.
        Magnitude of Muscle Strength and Mass Adaptations Between High-Load Resistance Training Versus Low-Load Resistance Training Associated with Blood-Flow Restriction: A Systematic Review and Meta-Analysis.
        Sports medicine (Auckland, N.Z.). 2018; 48: 361-378
        • Curran M.T.
        • Lepley L.K.
        • Palmieri-Smith R.M.
        Continued improvements in quadriceps strength and biomechanical symmetry of the knee after postoperative anterior cruciate ligament reconstruction rehabilitation: Is it time to reconsider the 6-month return-to-activity criteria?.
        J Athl Train. 2018; 53: 535-544
        • Hylden C.
        • Burns T.
        • Stinner D.
        • Owens J.
        Blood flow restriction rehabilitation for extremity weakness: A case series.
        J Spec Oper Med. 2015; 15: 50-56
        • Vopat B.G.
        • Vopat L.M.
        • Bechtold M.M.
        • Hodge K.A.
        Blood flow restriction therapy: Where we are and where we are going.
        J Am Acad Orthop Surg. 2020; 28: e493-e500
        • Kilgas M.A.
        • McDaniel J.
        • Stavres J.
        • Pollock B.S.
        • Singer T.J.
        • Elmer S.J.
        Limb blood flow and tissue perfusion during exercise with blood flow restriction.
        Eur J Appl Physiol. 2019; 119: 377-387
        • Singer T.J.
        • Stavres J.
        • Elmer S.J.
        • et al.
        Knee extension with blood flow restriction: Impact of cuff pressure on hemodynamics.
        Eur J Appl Physiol. 2020; 120: 79-90
        • Aebi M.R.
        • Willis S.J.
        • Girard O.
        • Borrani F.
        • Millet G.P.
        Active preconditioning with blood flow restriction or/and systemic hypoxic exposure does not improve repeated sprint cycling performance.
        Front Physiol. 2019; 10: 1393
        • Willis S.J.
        • Alvarez L.
        • Borrani F.
        • Millet G.P.
        Oxygenation time course and neuromuscular fatigue during repeated cycling sprints with bilateral blood flow restriction.
        Physiol Rep. 2018; 6e13872
        • Scott B.R.
        • Loenneke J.P.
        • Slattery K.M.
        • Dascombe B.J.
        Blood flow restricted exercise for athletes: A review of available evidence.
        J Sci Med Sport. 2016; 19: 360-367
        • Hughes L.
        • Patterson S.D.
        • Haddad F.
        • et al.
        Examination of the comfort and pain experienced with blood flow restriction training during post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: A UK National Health Service trial.
        Phys Ther Sport. 2019; 39: 90-98
        • Cristina-Oliveira M.
        • Meireles K.
        • Spranger M.D.
        • O'Leary D.S.
        • Roschel H.
        • Pecanha T.
        Clinical safety of blood flow-restricted training? A comprehensive review of altered muscle metaboreflex in cardiovascular disease during ischemic exercise.
        Am J Physiol Heart Circ Physiol. 2020; 318: H90-H109
        • Spranger M.D.
        • Krishnan A.C.
        • Levy P.D.
        • O'Leary D.S.
        • Smith S.A.
        Blood flow restriction training and the exercise pressor reflex: a call for concern.
        Am J Physiol Heart Circ Physiol. 2015; 309: H1440-H1452
        • Loenneke J.P.
        • Wilson J.M.
        • Wilson G.J.
        • Pujol T.J.
        • Bemben M.G.
        Potential safety issues with blood flow restriction training.
        Scand J Med Sci Sports. 2011; 21: 510-518