Does blood flow restriction training improve quadriceps measures after arthroscopic knee surgery? A critically appraised topic

Introduction: Knee injuries are one of the most prevalent pathologies in sport. It is estimated that 100,000 - 250,000 ACL injuries occur per year3. It is common for patients to struggle with quadriceps strength impairment as high as 18% at two years post ACL repair11. Quadriceps strength is strongly associated with athletic performance and likelihood of re-injury after ACL repair4,5,10,12,13,19. Quadriceps strength deficits are also documented after other arthroscopic procedures and the presence of knee effusion 2,8,14,18. Blood flow restriction (BFR) training is an intervention gaining popularity in rehabilitation. BFR can improve strength and hypertrophy measures with loads as low as 20% of 1RM1. This makes BFR an ideal intervention when heavier loads are contraindicated.Research Question: To determine if BFR improves relevant measures of the quadriceps after arthroscopic knee surgery.Study Design: Critically Appraised TopicMethods: An online search was performed using the following terms; "blood flow restriction," "knee surgery," "knee arthroscopy," "anterior cruciate ligament," "kaatsu training," and "occlusion training."Results: Five of six articles included in this review support the utilization of BFR to improve post-op quadriceps measures. All five articles demonstrated a significant improvement in at least one quadriceps outcome. All studies consisted of small sample sizes, there was inconsistent initiation of BFR, and little consistency in protocols. There was variability among outcomes measured across the studies.Conclusion: There is low level evidence that BFR should be included to improve quadriceps following arthroscopic knee surgery. More high quality studies are needed to make stronger recommendations

Influence of ischemia on the discharge rate in motor units during a sustained submaximal contraction

Motor unit discharge patterns were observed under ischemic and non-ischemic conditions in the tibialis anterior during two sessions approximately 48 hours apart. Ten subjects completed three 5-second maximum voluntary contractions [MVCs) followed by a prolonged, submaximal, isometric contraction to induce fatigue, and three additional MVCs. This fatigue trial was completed under both ischemic and non-ischemic conditions. For the ischemic condition, a pressure cuff was placed above the knee, inflated to 180 mmHg, and arterial occlusion verified via Doppler ultrasound. During the fatigue task, a constant force of 20% MVC was maintained until endurance time. Single motor unit activity was recorded with intramuscular fine wire electrodes. Endurance time during the ischemic fatigue task (3.71 ± 0.58 min) was significantly less than the non-ischemic fatigue task (9.11 ± 0.56 min). Both tasks showed a significant decline in motor unit discharge rate. There was greater variability in the discharge rate during ischemic compared to non-ischemic conditions. Time to minimum discharge rate was greater during ischemic conditions. Overall, ischemic conditions resulted in decreased endurance time, greater rate of decline in discharge rate, and greater variability in discharge rate of motor units.Kinesiology and Health Educatio

Outpatient Physical Therapy Management of Patient with Torn Right Anterior Collateral Ligament Prior to Surgical Repair: A Case Study

Background and Purpose: Anterior cruciate ligament injuries are one of the most common in sports medicine. This structure provides stability to the knee joint. Depending on the level of ligament injury, this injury can be treated conservatively or surgically. The purpose of this case study is to explore a preoperative treatment plan for a patient looking to have a future ACL surgical repair. Case Description: This case study describes the 13-week treatment plan for a 21-year-old patient that had plans for a future surgical repair. This was the second time this patient tore the ACL in that extremity within 3 years. He also presented 2 weeks post knee arthroscopy, bone grafting of femoral tunnel, debridement and medial meniscus repair and deflexion of the proximal tibial osteotomy to prepare the knee joint for ACL repair. Intervention: The physical therapy interventions for the patient included blood flow restriction, neuromuscular re-education, lower extremity strengthening, gait training and mobility activities. Outcomes: The patient following the therapy episode discharged himself. He no longer had pain at rest, was functional and independent with all activities of daily living, no longer needed an assistive device, was able to tolerate full workdays while standing and felt comfortable continuing on with the home exercise program independently leading up to the ACL reconstruction. This case study demonstrated that physical therapy treatment can be sufficient for returning a younger patient to be functional and independent without repai

Low-Load Resistance Training With Blood Flow Restriction Improves Clinical Outcomes in Musculoskeletal Rehabilitation: A Single-Blind Randomized Controlled Trial.

Background: There is growing evidence to support the use of low-load blood flow restriction (LL-BFR) exercise in musculoskeletal rehabilitation. Purpose: The purpose of this study was to evaluate the efficacy and feasibility of low-load blood flow restricted (LL-BFR) training versus conventional high mechanical load resistance training (RT) on the clinical outcomes of patient's undergoing inpatient multidisciplinary team (MDT) rehabilitation. Study design: A single-blind randomized controlled study. Methods: Twenty-eight lower-limb injured adults completed a 3-week intensive MDT rehabilitation program. Participants were randomly allocated into a conventional RT (3-days/week) or twice-daily LL-BFR training group. Outcome measurements were taken at baseline and 3-weeks and included quadriceps and total thigh muscle cross-sectional area (CSA) and volume, muscle strength [five repetition maximum (RM) leg press and knee extension test, isometric hip extension], pain and physical function measures (Y-balance test, multistage locomotion test-MSLT). Results: A two-way repeated measures analysis of variance revealed no significant differences between groups for any outcome measure post-intervention (p > 0.05). Both groups showed significant improvements in mean scores for muscle CSA/volume, 5-RM leg press, and 5-RM knee extension (p < 0.01) after treatment. LL-BFR group participants also demonstrated significant improvements in MSLT and Y-balance scores (p < 0.01). The Pain scores during training reduced significantly over time in the LL-BFR group (p = 0.024), with no adverse events reported during the study. Conclusion: Comparable improvements in muscle strength and hypertrophy were shown in LL-BFR and conventional training groups following in-patient rehabilitation. The LL-BFR group also achieved significant improvements in functional capacity. LL-BFR training is a rehabilitation tool that has the potential to induce positive adaptations in the absence of high mechanical loads and therefore could be considered a treatment option for patients suffering significant functional deficits for whom conventional loaded RT is contraindicated. Trial Registration: ISRCTN Reference: ISRCTN63585315, dated 25 April 2017

Low-Load Resistance Training With Blood Flow Restriction Improves Clinical Outcomes in Musculoskeletal Rehabilitation: A Single-Blind Randomized Controlled Trial.

Background: There is growing evidence to support the use of low-load blood flow restriction (LL-BFR) exercise in musculoskeletal rehabilitation. Purpose: The purpose of this study was to evaluate the efficacy and feasibility of low-load blood flow restricted (LL-BFR) training versus conventional high mechanical load resistance training (RT) on the clinical outcomes of patient's undergoing inpatient multidisciplinary team (MDT) rehabilitation. Study design: A single-blind randomized controlled study. Methods: Twenty-eight lower-limb injured adults completed a 3-week intensive MDT rehabilitation program. Participants were randomly allocated into a conventional RT (3-days/week) or twice-daily LL-BFR training group. Outcome measurements were taken at baseline and 3-weeks and included quadriceps and total thigh muscle cross-sectional area (CSA) and volume, muscle strength [five repetition maximum (RM) leg press and knee extension test, isometric hip extension], pain and physical function measures (Y-balance test, multistage locomotion test-MSLT). Results: A two-way repeated measures analysis of variance revealed no significant differences between groups for any outcome measure post-intervention (p > 0.05). Both groups showed significant improvements in mean scores for muscle CSA/volume, 5-RM leg press, and 5-RM knee extension (p < 0.01) after treatment. LL-BFR group participants also demonstrated significant improvements in MSLT and Y-balance scores (p < 0.01). The Pain scores during training reduced significantly over time in the LL-BFR group (p = 0.024), with no adverse events reported during the study. Conclusion: Comparable improvements in muscle strength and hypertrophy were shown in LL-BFR and conventional training groups following in-patient rehabilitation. The LL-BFR group also achieved significant improvements in functional capacity. LL-BFR training is a rehabilitation tool that has the potential to induce positive adaptations in the absence of high mechanical loads and therefore could be considered a treatment option for patients suffering significant functional deficits for whom conventional loaded RT is contraindicated. Trial Registration: ISRCTN Reference: ISRCTN63585315, dated 25 April 2017

Blood Flow Restriction Training for Chronic Quadriceps Weakness and Atrophy: A Case Report

Background and purpose The high load and intensity of traditional strength training may not always be appropriate or beneficial for certain patient populations such as the elderly or those with orthopedic injuries. In these cases blood flow restriction training with light resistance has been shown to be effective method of increasing strength and hypertrophy. However, what if traditional strength training is tolerated but not effective for an individual? The purpose of this case report is to describe the use of blood flow restriction training in a recreationally active male who was fully functional but continued with chronic unilateral quadriceps weakness and atrophy. Case Description A 37 year old male who participated in frequent physical activity and was functional for daily activities and hobbies presented with decreased quadriceps strength and atrophy 25 years post a well healed femur fracture. A 15% deficit was noted on initial evaluation during isokinetic testing along with a two centimeter difference in quadriceps girth. Light resistance, isotonic, single leg quadriceps strengthening was performed on the involved lower extremity with blood flow restriction. These exercises included straight leg raises, long arc knee extension and single leg press on the shuttle. A blood flow restriction device was used with the settings applied according to the instructions from the manufacturer. The cuff was placed as proximal as possible on the patient’s thigh. The unit continuously adjusted the pressure to maintain 80% occlusion throughout the exercise program. The exercises were performed two times a week for 6 weeks in addition to the patient’s normal exercise routine of high intensity interval training and weight lifting 2 times weekly. Outcomes Isokinetic testing was performed at initial evaluation, 3 weeks into the training program and upon completion at 6 weeks. Results indicated that at the end of the 6 week program the 15% deficit had improved to an 8% advantage over the uninvolved leg for a total percentage change of 27%. Girth measurement also increased by 1.5 centimeters. Discussion Blood flow restriction training has been used to improve quadriceps strength and muscle size. It has been used for increasing strength post injury or surgery, during immobilization and in the elderly. It has been used to augment traditional strength training in athletes. The patient in this case had been active with sports and normal exercise routines that included traditional strength training, college football and high intensity interval training since the time of injury. Despite remaining active and fully recovering range of motion and normal strength, as graded with a manual muscle test, atrophy remained 25 years later. Upon completion of 6 weeks of blood flow restricted training, hypertrophy and improved strength were noted; these changes were not able to be achieved in the past with traditional strength training at higher intensities and resistances

Graft-Specific Surgical and Rehabilitation Considerations for Anterior Cruciate Ligament Reconstruction with the Quadriceps Tendon Autograft

Anterior cruciate ligament reconstruction (ACLR) with a bone-patellar tendon-bone (BPTB) or hamstring tendon (HT) autograft has traditionally been the preferred surgical treatment for patients returning to Level 1 sports. More recently, international utilization of the quadriceps tendon (QT) autograft for primary and revision ACLR has increased in popularity. Recent literature suggests that ACLR with the QT may yield less donor site morbidity than the BPTB and better patient-reported outcomes than the HT. Additionally, anatomic and biomechanical studies have highlighted the robust properties of the QT itself, with superior levels of collagen density, length, size, and load-to-failure strength compared to the BPTB. Although previous literature has described rehabilitation considerations for the BPTB and HT autografts, there is less published with respect to the QT. Given the known impact of the various ACLR surgical techniques on postoperative rehabilitation, the purpose of this clinical commentary is to present the procedure-specific surgical and rehabilitation considerations for ACLR with the QT, as well as further highlight the need for procedure-specific rehabilitation strategies after ACLR by comparing the QT to the BPTB and HT autografts. # Level of Evidence Level

Effectiveness of Blood Flow Restriction on Functionality, Quality of Life and Pain in Patients with Neuromusculoskeletal Pathologies: A Systematic Review

Background: Blood flow restriction is characterized as a method used during exercise at low loads of around 20–40% of a repetition maximum, or at a low-moderate intensity of aerobic exercise, in which cuffs that occlude the proximal part of the extremities can partially reduce arterial flow and fully restrict the venous flow of the musculature in order to achieve the same benefits as high-load exercise. Objective: The main objective of this systematic literature review was to analyze the effects of BFR intervention on pain, functionality, and quality of life in subjects with neuromusculoskeletal pathologies. Methods: The search to carry out was performed in PubMed, Cochrane, EMBASE, PEDro, CINHAL, SPORTDiscus, Trip Medical Database, and Scopus: “kaatsu” OR “ischemic training” OR “blood flow restriction” OR “occlusion resistance training” OR “vascular occlusion” OR “vascular restriction”. Results: After identifying 486 papers and eliminating 175 of them due to duplication and 261 after reading the title and abstract, 50 papers were selected. Of all the selected articles, 28 were excluded for not presenting a score equal to or higher than 6 points on the PEDro scale and 8 for not analyzing the target outcome variables. Finally, 14 papers were selected for this systematic review. Conclusions: The data collected indicate that the blood flow restriction tool is a therapeutic alternative due to its effectiveness under different exercise modalities. The benefits found include decreases in pain thresholds and improvement in the functionality and quality of life of the neuro-musculoskeletal patient during the first six weeks. However, the results provided by this tool are still not clear for medium- and long-term interventions.Partial funding for open access charge: Universidad de Málag

Patellar Tendinopathy: “Jumper’s Knee”

“Patellar tendinopathy” is also known as “Jumper’s knee” and is a common cause of impaired function in athletes who participate in sports that require jumping and running activities. The exact etiology of disease is still unknown and several theories have been postulated for its pathogenesis. It usually presents as anterior knee pain that is related to the sports activity and might lead to decreased sports participation. USG and MRI are the main modality of investigation that aids in the diagnosis. Non-operative therapy forms the main stay of treatment in form of rest, brace, physical therapy and anti-inflammatory medications. Other adjuncts such as cryotherapy, corticosteroids injection, platelet -rich plasma injections and electrical therapy like TENS or ESWT have been used with some success. Operative intervention in form of open or arthroscopic procedures are reserved for chronic and refractory cases

Is it possible to establish reference values for ankle muscle isokinetic strength? A meta-analytical study

BACKGROUND: The importance of measuring ankle muscle strength (AMS) has been demonstrated in a variety of clinical areas. Much data has been accumulated using the Cybex Norm isokinetic dynamometer but a uniform framework does not exist. OBJECTIVE: To identify pertinent studies which have used the Cybex Norm to measure AMS in order to establish reference values. METHODS: A narrative review of the literature was used to identify papers that have used the Cybex Norm to measure isokinetic concentric and eccentric AMS. RESULTS: Fifty five research papers were identified but each study used a different isokinetic protocol. CONCLUSIONS: It is not possible to produce AMS reference values due to the wide variation in data collection methods. This is therefore an area of research that needs further exploration