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Fraca-Fernández E, Ceballos-Laita L, Hernández-Lázaro H, Jiménez-del-Barrio S, Mingo-Gómez MT, Medrano-de-la-Fuente R, Hernando-Garijo I. Effects of Blood Flow Restriction Training in Patients before and after Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2024; 12:1231. [PMID: 38921345 PMCID: PMC11203215 DOI: 10.3390/healthcare12121231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/04/2024] [Accepted: 06/17/2024] [Indexed: 06/27/2024] Open
Abstract
(1) Objective: To examine the effects of blood flow restriction (BFR) training on muscle strength, cross-sectional area and knee-related function in patients selected for anterior cruciate ligament reconstruction (ACLR). (2) Methods: A literature search was conducted in PubMed, PEDro, Cochrane Library, Web of Science, SCOPUS, and ProQuest databases until 20 May 2024. Controlled clinical trials comparing the effects of BFR training with unrestricted training in patients before or after ACLR were selected. The GRADE approach was used to assess the degree of certainty for each meta-analysis. (3) Results: Ten studies were included (n = 287 participants). Standardized mean differences in favor of BFR training applied postoperatively were observed in knee extensor (SMD = 0.79; 95% CI = 0.06 to 1.52; I2: 68%) and flexor isokinetic strength (SMD = 0.53; 95% CI = 0.04 to 1.01; I2: 0%), and quadriceps cross-sectional area (SMD = 0.76; 95% CI = 0.27 to 1.26; I2: 0%). No changes were found in knee extensor isometric strength and knee-related function. The degree of certainty according to the GRADE was very low. (4) Conclusions: Very low degree of certainty suggests that BFR training provides additional benefits to unrestricted training on isokinetic strength and quadriceps cross-sectional area in patients undergoing ACLR.
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Affiliation(s)
- Eduardo Fraca-Fernández
- Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain; (E.F.-F.); (L.C.-L.); (H.H.-L.); (S.J.-d.-B.); (M.T.M.-G.); (I.H.-G.)
| | - Luis Ceballos-Laita
- Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain; (E.F.-F.); (L.C.-L.); (H.H.-L.); (S.J.-d.-B.); (M.T.M.-G.); (I.H.-G.)
- Clinical Research in Health Sciences Group, University of Valladolid, 42004 Soria, Spain
| | - Héctor Hernández-Lázaro
- Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain; (E.F.-F.); (L.C.-L.); (H.H.-L.); (S.J.-d.-B.); (M.T.M.-G.); (I.H.-G.)
| | - Sandra Jiménez-del-Barrio
- Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain; (E.F.-F.); (L.C.-L.); (H.H.-L.); (S.J.-d.-B.); (M.T.M.-G.); (I.H.-G.)
- Clinical Research in Health Sciences Group, University of Valladolid, 42004 Soria, Spain
| | - María Teresa Mingo-Gómez
- Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain; (E.F.-F.); (L.C.-L.); (H.H.-L.); (S.J.-d.-B.); (M.T.M.-G.); (I.H.-G.)
- Clinical Research in Health Sciences Group, University of Valladolid, 42004 Soria, Spain
| | - Ricardo Medrano-de-la-Fuente
- Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain; (E.F.-F.); (L.C.-L.); (H.H.-L.); (S.J.-d.-B.); (M.T.M.-G.); (I.H.-G.)
- Clinical Research in Health Sciences Group, University of Valladolid, 42004 Soria, Spain
| | - Ignacio Hernando-Garijo
- Faculty of Health Sciences, University of Valladolid, 42004 Soria, Spain; (E.F.-F.); (L.C.-L.); (H.H.-L.); (S.J.-d.-B.); (M.T.M.-G.); (I.H.-G.)
- Clinical Research in Health Sciences Group, University of Valladolid, 42004 Soria, Spain
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Johns WL, Vadhera AS, Hammoud S. Blood Flow Restriction Therapy After Anterior Cruciate Ligament Reconstruction. Arthroscopy 2024; 40:1724-1726. [PMID: 38811111 DOI: 10.1016/j.arthro.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 03/05/2024] [Indexed: 05/31/2024]
Abstract
Anterior cruciate ligament reconstruction (ACLR) rehabilitation necessitates restoration of quadriceps strength to minimize reinjury and optimize return to sport (RTS). Patients recovering from ACLR are limited by pain and activity restrictions, resulting in quadriceps muscle atrophy. Blood flow restriction (BFR) therapy involves performing exercises while a specialized blood pressure cuff is applied to the proximal aspect of the operative extremity and inflated to 40% to 90% of the arterial occlusion pressure, as determined using Doppler ultrasonography. BFR is theorized to induce an anaerobic environment and metabolic stress during exercise, promoting muscle hypertrophy and strength gains. Although the physiological mechanism has not been fully elucidated, it is theorized that BFR combined with low-load resistance training could yield muscle adaptations comparable to those of high-load resistance training. For ACLR patients with pain and restrictions precluding high-intensity strength training, incorporation of BFR into postoperative rehabilitation protocols could help mitigate quadriceps weakness and promote RTS. Randomized controlled trials report a prolonged, dose-dependent relation between BFR use and quadriceps and hamstring strength gains, improved bone and muscle mass, and earlier RTS, whereas other studies report no significant difference in quadriceps size, strength, or patient satisfaction compared with controls. Furthermore, although generally considered safe, there are rare reports of associated adverse events such as rhabdomyolysis, and BFR should be avoided in patients with a history of thromboembolic disease or peripheral vasculopathy. The literature examining BFR after ACLR is heterogeneous; lacks standardization; and contains broad variation in reported cuff pressures, as well as timing and duration of BFR use, among protocols. Although the use of BFR after ACLR shows promise, further study is necessary to elucidate the efficacy, safety, and optimal protocols.
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Affiliation(s)
- William L Johns
- Thomas Jefferson University Hospital and Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A..
| | - Amar S Vadhera
- Thomas Jefferson University Hospital and Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Sommer Hammoud
- Thomas Jefferson University Hospital and Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
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Devana SK, Solorzano CA, Vail J, Jackson N, Pham D, Jones KJ. Outcomes of Blood Flow Restriction Training After ACL Reconstruction in NCAA Division I Athletes. Orthop J Sports Med 2024; 12:23259671241248589. [PMID: 38745915 PMCID: PMC11092532 DOI: 10.1177/23259671241248589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/13/2023] [Indexed: 05/16/2024] Open
Abstract
Background Blood flow restriction training (BFRT) is a safe and potentially effective adjunctive therapeutic modality for postoperative rehabilitation related to various knee pathologies. However, there is a paucity of literature surrounding BFRT in high-performance athletes after anterior cruciate ligament reconstruction (ACLR). Purpose To (1) compare the overall time to return to sports (RTS) in a cohort of National Collegiate Athletic Association (NCAA) Division I athletes who underwent a standardized rehabilitation program either with or without BFRT after ACLR and (2) identify a postoperative time interval for which BFRT has the maximum therapeutic benefit. Study Design Cohort study; Level of evidence, 3. Methods A total of 55 student-athletes who underwent ACLR between 2000 and 2023 while participating in NCAA Division I sports at a single institution were included in this study. Athletes were allocated to 1 of 2 groups based on whether they participated in a standardized postoperative rehabilitation program augmented with BFRT (BFRT group; n = 22) or completed the standardized protocol alone (non-BFRT group [control]; n = 33). Our primary outcome measure was time to RTS. The secondary outcome measure was handheld dynamometry quadriceps strength testing at various postoperative time points, converted to a limb symmetry index (LSI). Quadriceps strength was not tested between the BFRT and non-BFRT groups because of the limited amount of data on the control group. Results The mean age at the date of surgery was 18.59 ± 1.10 years for the BFRT group and 19.45 ± 1.30 years for the non-BFRT group (P = .011), and the mean RTS time was 409 ± 134 days from surgery for the BFRT group and 332 ± 100 days for the non-BFRT cohort (P = .047). For the BFRT group, the mean quadriceps strength LSI increased by 0.67% (95% CI, 0.53%-0.81%) for every week of rehabilitation, and there was a significantly positive rate of change in quadriceps strength in weeks 13-16 compared with weeks 9-12 (ΔLSI, 8.22%; P < .001). Conclusion In elite NCAA Division I athletes, a statistically significant delay was observed in RTS with BFRT compared with standardized physical therapy alone after undergoing ACLR. There also appeared to be an early window during the rehabilitation period where BFRT had a beneficial impact on quadriceps strength.
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Affiliation(s)
- Sai K. Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Carlos A. Solorzano
- Department of Orthopaedic Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Jeremy Vail
- Department of Athletics, University of California at Los Angeles, Los Angeles, California, USA
| | - Nicholas Jackson
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA, USA
| | - Derek Pham
- Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA, USA
| | - Kristofer J. Jones
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
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Hasegawa ME, Delos Reyes CD, Rimm JB, Radi JK, Singh DS, Obana KK, Weldon EJ, Thorne TJ, Tamate TM, Alferos SR, Min KS. Update on Current Concepts of Blood Flow Restriction in the Perioperative Period of Anterior Cruciate Ligament Reconstruction. Orthopedics 2023; 46:e333-e340. [PMID: 37561100 DOI: 10.3928/01477447-20230804-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Anterior cruciate ligament tears or ruptures are common orthopedic injuries. Anterior cruciate ligament reconstruction (ACLR) is an orthopedic procedure allowing for earlier return to sports, improved maintenance of lifestyle demands, and restored knee stability and kinematics. A perioperative rehabilitative adjunct recently gaining interest is blood flow restriction (BFR), a method in which temporary restriction of blood flow to a chosen extremity is introduced and can be used as early as a few days postoperative. There has been increasing investigation and recent literature regarding BFR. This review synthesizes current concepts of BFR use in the ACLR perioperative period. [Orthopedics. 2023;46(6):e333-e340.].
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Solie BS, Eggleston GG, Schwery NA, Doney CP, Kiely MT, Larson CM. Clinic and Home-Based Exercise with Blood Flow Restriction Resolves Thigh Muscle Atrophy after Anterior Cruciate Ligament Reconstruction with the Bone-Patellar Tendon-Bone Autograft: A Case Report. Healthcare (Basel) 2023; 11:1885. [PMID: 37444719 DOI: 10.3390/healthcare11131885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/19/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
Anterior cruciate ligament reconstruction (ACLR) results in thigh muscle atrophy. Of the various interventions proposed to mitigate thigh muscle atrophy, exercise with blood flow restriction (BFR) appears safe and effective. Some literature suggests daily exposure to exercise with BFR may be indicated during the early phase of ACLR rehabilitation; this case report outlines the methodology utilized to prescribe clinic- and home-based BFR within an outpatient rehabilitation program. A 15-year-old male soccer player suffered a left knee injury involving the anterior cruciate ligament and both menisci. He underwent ACLR and completed exercise with BFR as part of his clinic- and home-based rehabilitation program, which included practical blood flow restriction during home-based rehabilitation. After 16 weeks of rehabilitation, surgical limb thigh girth values were objectively larger than the non-surgical limb (surgical, 52.25 cm; non-surgical 50 cm), as well as the multi-frequency bioelectrical impedance analysis of his lower-extremity lean body mass (surgical limb, 10.37 kg; non-surgical limb, 10.02 kg). The findings of this case report suggest that the inclusion of clinic- and home-based BFR within an outpatient rehabilitation program may be indicated to resolve thigh muscle atrophy early after ACLR.
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Affiliation(s)
- Braidy S Solie
- Training HAUS, 2645 Viking Circle, Suite #200, Eagan, MN 55121, USA
| | | | - Nicole A Schwery
- Training HAUS, 2645 Viking Circle, Suite #200, Eagan, MN 55121, USA
| | | | - Michael T Kiely
- Training HAUS, 2645 Viking Circle, Suite #200, Eagan, MN 55121, USA
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Cote MP, Nolan D, Hazzard S, Waugh S, Asnis P. Editorial Commentary: Blood Flow Restriction Therapy Prior to Anterior Cruciate Ligament Reconstruction: Small Effects Require Accurate Measurements. Arthroscopy 2023; 39:382-383. [PMID: 36604004 DOI: 10.1016/j.arthro.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 01/04/2023]
Abstract
A recent research study showed that blood flow restriction (BFR) therapy was safe and well tolerated but failed to demonstrate efficacy as a modality that provides greater gains in quadriceps strength when added to a standard home program in patients awaiting anterior cruciate ligament (ACL) reconstruction. Despite employing a validated method of measurement, the results were highly variable, indicating the need for measurements with sufficient accuracy to detect the small, but potentially meaningful, gains in quadriceps strength that's been attributed to BFR. The results inform future investigations of BFR prior to ACL surgery by demonstrating the need for accurate methods of measurements when the anticipated effects are small.
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