Blood Flow Restriction Therapy after Closed Treatment of Distal Radius Fractures

Effect of Low-Intensity Bloodflow Restriction Training on Nontraumatic Knee Joint Conditions: A Systematic Review and Meta-analysis

CONTEXT

Nontraumatic knee conditions are common in clinical practice. Existing pharmaceutical and immobilization approaches provide limited pain relief and functional enhancement. Low-intensity bloodflow restriction training (LI-BFRT) is being investigated as a nonpharmacological alternative; however, its efficacy is uncertain.

OBJECTIVE

To assess the effectiveness of LI-BFRT for nontraumatic knee conditions and compare it with high-intensity resistance training (HI-RT) and low-intensity resistance training (LI-RT).

DATA SOURCES

PubMed, EBSCO, Science Direct, Cochrane Library, China Knowledge Infrastructure, Wanfang Data, and VIP databases were searched until May 30, 2023.

STUDY SELECTION

Original randomized controlled trials involving nontraumatic knee joint conditions with interventions consisting mainly of LI-BFRT, HI-RT, or LI-RT. The results assessed mainly pain and muscle performance.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

Sample characteristics, study design, country, disease, groups, evaluation time, duration, and outcomes were extracted.

RESULTS

A total of 13 randomized controlled trials were included in the systematic review. Compared with pretreatment, LI-BFRT significantly alleviated pain (weighted standardized mean difference [SMD], -1.33; 95% CI, -1.62 to -1.05), with better additional effects on hip muscle training (SMD, -3.14; 95% CI, -4.07 to -2.75). Compared with LI-RT, LI-BFRT significantly relieved pain in male patients (SMD, -1.47; 95% CI, -1.92 to -1.01). LI-BFRT significantly increased quadriceps cross-sectional area (SMD, 0.53; 95% CI, 0.27-0.78), knee extension strength (SMD, 0.84; 95% CI, 0.48-1.2), and leg press strength (SMD, 0.64; 95% CI, 0.34-0.94) compared with pretreatment. Its effects were superior to those of LI-RT and similar to those of HI-RT. However, sex differences in muscle strength improvement were observed.

CONCLUSION

In patients with nontraumatic knee joint conditions, LI-BFRT effectively alleviated pain, increased muscle cross-sectional area, and enhanced muscle strength. LI-BFRT showed pain relief comparable with that of LI-RT while surpassing LI-RT in muscle growth and strength improvement.

BFR Training Improves Patients' Reported Outcomes, Strength, and Range of Motion After Casting for Colles' Fracture

PURPOSE

This study compared traditional rehabilitation as a treatment modality after plaster cast treatment of Colles' fracture with a combination of individualized blood flow restriction (BFR) and traditional rehabilitation.

METHODS

Twenty-eight participants were randomized into a BFR group and a non-BFR group after plaster cast treatment of Colles' fracture. The BFR group completed traditional rehabilitation with a medical grade tourniquet applied to the upper arm, and the non-BFR group underwent traditional rehabilitation only. Patients were followed up with radiographic outcomes (palmar tilt and radial inclination) to ensure the stability of the fracture. Clinical assessment of patient-rated wrist evaluation (PRWE) score, grip strength, pinch strength, wrist range of motion (ROM), and muscle stiffness was conducted at cast removal and 6 wk after cast removal. Two-way repeated-measures ANOVA determined significant interactions between time and group in the aforementioned variables. An independent-sample t -test assessed the differences in baseline variables and radiographic outcomes.

RESULTS

Significant interactions between time and group were noted for PRWE score ( F = 11.796, P = 0.002, η2p = 0.339), grip strength ( F = 5.445, P = 0.029, η2p = 0.191), and wrist ROM (ulnar deviation; F = 7.856, P = 0.010, η2p = 0.255). No significant interactions between time and group were found in measurements of pinch strength or wrist ROM (flexion, extension, radial deviation, pronation, supination). An independent-sample t -test showed no significant difference in baseline variables and radiographic outcomes between the groups before or after intervention.

CONCLUSIONS

This study found that combining individualized BFR with traditional rehabilitation resulted in greater increases in PRWE score, grip strength, and wrist ROM (ulnar deviation) than traditional rehabilitation alone. Therefore, adding individualized BFR to traditional rehabilitation might be a better option for treatment for similar patients.

[Blood flow restriction training as a treatment option for lateral elbow tendinopathy-a study presentation]

Blood flow restriction training, developed in 1966 in Japan, is a training modality that utilizes partial arterial and complete venous blood flow occlusion. Combined with low load resistance training, it aims to induce hypertrophy and strength gains. This makes it particularly suitable for people recovering from injury or surgery, for whom the use of high training loads is unfeasible. In this article, the mechanism behind blood flow restriction training and its applicability for the treatment of lateral elbow tendinopathy is explained. An ongoing prospective, randomized, controlled trial on the treatment of lateral elbow tendinopathy is presented.

Blood Flow Restriction Therapy for Use After Extremity Fracture: A Critically Appraised Topic

CLINICAL SCENARIO

Blood flow restriction (BFR) therapy has emerged as a viable treatment option to enhance clinical recovery in patients with primarily muscular injuries. However, BFR therapy has been rarely investigated in patients with osseous injuries to include extremity fracture.

FOCUSED CLINICAL QUESTION

Does BFR-enhanced therapy improve clinical outcomes in patients during the acute to subacute rehabilitation period after extremity fracture?

SUMMARY OF KEY FINDINGS

(1) In cases of 2 high-performing athletes with talus and osteochondral fracture of the knee, BFR was well tolerated and an effective rehabilitation regimen. (2) In 2 randomized controlled trials evaluating BFR use in patients after operative and nonoperative management of distal radius fractures, pain with activity and self-perceived function were improved in BFR-enhanced therapy as compared with a standard rehabilitation regimen. (3) Objective clinical outcomes including radiographic healing, extremity range of motion, and grip strength evaluated by the randomized controlled trials did not differ significantly between the BFR-enhanced and standard rehabilitation groups.

CLINICAL BOTTOM LINE

BFR-enhanced therapy may improve pain and self-perceived function of the injured extremity during the acute to subacute rehabilitation period after fracture. However, there is not yet a demonstrated benefit of BFR on hastening objective measures of clinical recovery. Large-scale clinical trials comparing BFR-enhanced rehabilitation with standard rehabilitation regimens are needed to better characterize BFR use in patients with osseous injuries.

STRENGTH OF RECOMMENDATION

Two case reports and 2 randomized controlled trials provide level IIB evidence suggesting that BFR may improve pain in the acute rehabilitative stage and improve the patient's perceived function of the injured extremity, without greater improvement in objectively measured clinical parameters as compared with a standard rehabilitation regimen.

The effects of upper body blood flow restriction training on muscles located proximal to the applied occlusive pressure: A systematic review with meta-analysis

BACKGROUND

Blood flow restriction combined with low load resistance training (LL-BFRT) is associated with increases in upper limb muscle strength and size. The effect of LL-BFRT on upper limb muscles located proximal to the BFR cuff application is unclear.

OBJECTIVE

The aim of this systematic review was to evaluate the effect of LL-BFRT compared to low load, or high load resistance training (LL-RT, HL-RT) on musculature located proximal to cuff placement.

METHODS

Six electronic databases were searched for randomized controlled trials (RCTs). Two reviewers independently evaluated the risk of bias using the PEDro scale. We performed a meta-analysis using a random effects model, or calculated mean differences (fixed-effect) where appropriate. We judged the certainty of evidence using the GRADE approach.

RESULTS

The systematic literature searched yielded 346 articles, of which 9 studies were eligible. The evidence for all outcomes was of very low to low certainty. Across all comparisons, a significant increase in bench press and shoulder flexion strength was found in favor of LL-BFRT compared to LL-RT, and in shoulder lean mass and pectoralis major thickness in favor of the LL-BFRT compared to LL-RT and HL-RT, respectively. No significant differences were found between LL-BFRT and HL-RT in muscle strength.

CONCLUSION

With low certainty LL-BFRT appears to be equally effective to HL-RT for improving muscle strength in upper body muscles located proximal to the BFR stimulus in healthy adults. Furthermore, LL-BFRT may induce muscle size increase, but these adaptations are not superior to LL-RT or HL-RT.

Low-Load Resistance Training With Blood Flow Restriction Is Effective for Managing Lateral Elbow Tendinopathy: A Randomized, Sham-Controlled Trial

OBJECTIVE: To evaluate the effect of low-load resistance training with blood flow restriction (LLRT-BFR) when compared to LLRT with sham-BFR in patients with lateral elbow tendinopathy (LET). DESIGN: Randomized controlled trial. METHODS: Forty-six patients with LET were randomly assigned to a LLRT-BFR or a LLRT with sham-BFR treatment group. All patients received soft tissue massage, supervised exercises with BFR or sham intervention (twice a week for 6 weeks), advice, and a home exercise program. The primary outcome measures were pain intensity, patient-rated tennis elbow evaluation (PRTEE) score, pain-free grip strength, and global rating of change, measured at baseline, 6 weeks, and 12 weeks. Between-group differences were evaluated using mixed-effects models with participant-specific random effects for continuous data. Global rating of change was analyzed using logistic regression. RESULTS: Statistically significant between-group differences were found in favor of LLRT-BFR compared to LLRT with sham-BFR in pain intensity at 12-week follow-up (-1.54, 95% CI: -2.89 to -0.18; P = .026), pain-free grip strength ratio at 6-week follow-up (0.20, 95% CI: 0.06 to 0.34; P = .005), and PRTEE at 6- and 12-week follow-up (-11.92, 95% CI: -20.26 to -3.59; P = .006, and -15.23, 95% CI: -23.57 to -6.9; P<.001, respectively). At 6- and 12-weeks, patients in the LLRT-BFR group had greater odds of reporting complete recovery or significant improvement (OR = 6.0, OR = 4.09, respectively). CONCLUSION: Low-load resistance training with blood flow restriction produced significantly better results compared to the LLRT with sham-BFR for all primary outcomes. Considering the clinically significant between-group improvement in function (>11 points in PRTEE) and the better success rates in the LLRT-BFR group, this intervention may improve recovery in LET. J Orthop Sports Phys Ther 2022;52(12):803-825. Epub: 14 September 2022. doi:10.2519/jospt.2022.11211.

The Effect of Blood Flow Restriction Therapy on Shoulder Function Following Shoulder Stabilization Surgery: A Case Series

Background

Traumatic shoulder instability is a common injury in athletes and military personnel. Surgical stabilization reduces recurrence, but athletes often return to sport before recovering upper extremity rotational strength and sport-specific abilities. Blood flow restriction (BFR) may stimulate muscle growth without the need for heavy resistance training post-surgically.

Hypothesis/Purpose

To observe changes in shoulder strength, self-reported function, upper extremity performance, and range of motion (ROM) in military cadets recovering from shoulder stabilization surgery who completed a standard rehabilitation program with six weeks of BFR training.

Study Design

Prospective case series.

Methods

Military cadets who underwent shoulder stabilization surgery completed six weeks of upper extremity BFR training, beginning post-op week six. Primary outcomes were shoulder isometric strength and patient-reported function assessed at 6-weeks, 12-weeks, and 6-months postoperatively. Secondary outcomes included shoulder ROM assessed at each timepoint and the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), the Upper Extremity Y-Balance Test (UQYBT), and the Unilateral Seated Shotput Test (USPT) assessed at the six-month follow-up.

Results

Twenty cadets performed an average 10.9 BFR training sessions over six weeks. Statistically significant and clinically meaningful increases in surgical extremity external rotation strength (p < 0.001; mean difference, .049; 95% CI: .021, .077), abduction strength (p < 0.001; mean difference, .079; 95% CI: .050, .108), and internal rotation strength (p < 0.001; mean difference, .060; CI: .028, .093) occurred from six to 12 weeks postoperatively. Statistically significant and clinically meaningful improvements were reported on the Single Assessment Numeric Evaluation (p < 0.001; mean difference, 17.7; CI: 9.4, 25.9) and Shoulder Pain and Disability Index (p < 0.001; mean difference, -31.1; CI: -44.2, -18.0) from six to 12 weeks postoperatively. Additionally, over 70 percent of participants met reference values on two to three performance tests at 6-months.

Conclusion

While the degree of improvement attributable to the addition of BFR is unknown, the clinically meaningful improvements in shoulder strength, self-reported function, and upper extremity performance warrant further exploration of BFR during upper extremity rehabilitation.

Level of Evidence

4, Case Series.

Blood-flow restricted exercise following ankle fractures - A feasibility study

BACKGROUND

The objective was to investigate the feasibility of blood flow restricted exercise (BFRE) as a rehabilitation modality in patients with a unilateral ankle fracture.

METHODS

Feasibility study with a prospective cohort design. Inclusion criteria were above 18 years of age and unilateral ankle fractures.

EXCLUSION CRITERIA

history of cardiac or embolic diseases, cancer, diabetes, hypertension and family history of cardio or vascular diseases. The predefined feasibility outcome was based on three criteria regarding patients experience with participating in the BFRE protocol and the absence of any serious adverse events.

RESULTS

Eight patients were included. Median age was 33 years (range: 23-60). All eight patients reported maximum satisfaction on the two questions regarding patient's perception of the overall experience with BFRE training and the feasibility to introduce BFRE as an intervention.

CONCLUSION

Early use of BFRE in patients with unilateral ankle fractures seems feasible in patients without comorbidity.

Overall Safety and Risks Associated with Blood Flow Restriction Therapy: A Literature Review

INTRODUCTION

Blood flow restriction therapy (BFRT) is used in scenarios ranging from muscle building in athletic performance to decreasing recovery time in postoperative orthopedic rehabilitation. The efficacy of BFRT for treating diseases has been increasingly researched; however, there has been less literature focused on establishing the safety of this therapy.

MATERIALS AND METHODS

An extensive literature review pertaining to BFRT and any deleterious events related to its usage was completed by searching multiple databases, including PubMed, EMBASE, and Cochrane Library using the terms "blood flow restriction therapy" or "KAATSU."

RESULTS

Ten case reports, five case series, two national surveys, two questionnaires, six randomized controlled studies, and one systematic review were included. A total of 1,672 individuals reported an adverse event following BFRT use out of 25,813 individuals. Commonly reported adverse events were numbness, dizziness, subcutaneous hemorrhage, and rhabdomyolysis. There were unique adverse effects of this therapy reported in individuals with comorbid conditions, such as hypertension and thoracic outlet syndrome, which included isolated cases of central retinal vein occlusion and Paget-Schroeder syndrome.

CONCLUSION

Blood flow restriction provides tremendous opportunity with a potential for accelerated exercise rehabilitation and injury prevention. This modality could be used in the military setting to help injured active duty personnel expeditiously return to deployable status. Further prospective randomized controlled trials are warranted to further support BFRT safety; however, from this literature review, it can be concluded that BFRT can be utilized safely in the proper patient population when administered by qualified professionals who have undergone the appropriate training.

Perceived Barriers to Blood Flow Restriction Training

Blood flow restriction (BFR) training is increasing in popularity in the fitness and rehabilitation settings due to its role in optimizing muscle mass and strength as well as cardiovascular capacity, function, and a host of other benefits. However, despite the interest in this area of research, there are likely some perceived barriers that practitioners must overcome to effectively implement this modality into practice. These barriers include determining BFR training pressures, access to appropriate BFR training technologies for relevant demographics based on the current evidence, a comprehensive and systematic approach to medical screening for safe practice and strategies to mitigate excessive perceptual demands of BFR training to foster long-term compliance. This manuscript attempts to discuss each of these barriers and provides evidence-based strategies and direction to guide clinical practice and future research.

Current Clinical Concepts: Blood Flow Restriction Training

Muscle weakness and atrophy are common impairments following musculoskeletal injury. The use of blood flow restriction (BFR) training offers the ability to mitigate weakness and atrophy without overloading healing tissues. This approach requires consideration of a wide range of parameters and the purpose of this manuscript is to provide insights into proposed mechanisms of effectiveness, safety considerations, application guidelines, and clinical guidelines for BFR training following musculoskeletal injury. BFR training appears to be a safe and effective approach to therapeutic exercise in sports medicine environments. While training with higher loads produces the most substantial increases in strength and hypertrophy, BFR training appears to be a reasonable option to bridge between earlier phases of rehabilitation when higher loads may not be tolerated by the patient and later stages that are consistent with return to sport performance.

Safety and Efficacy of Blood Flow Restriction Therapy after Operative Management of Distal Radius Fractures: A Randomized Controlled Study

Background  Blood flow restriction (BFR) therapy is an emerging addition to rehabilitative programs that allows patients to increase strength at lower loads over shorter time periods. Therefore, we conducted a study to evaluate the safety and efficacy of a rehabilitation program using BFR to a traditional rehabilitation protocol following operative fixation of distal radius fractures. Methods  A randomized controlled study was conducted comparing a standardized rehabilitation protocol alone to a combined protocol with the use of BFR therapy in patients treated with volar plate fixation following a displaced distal radius fracture. The same exercises done in the control group were performed by the BFR group with a restrictive tourniquet in place. Patients were followed with serial radiographs to ensure fracture stability. Outcome measures included wrist range of motion, grip strength, pinch strength, visual analog scale (VAS) pain scores at rest and during activity, patient rated wrist evaluation scores (PRWE), and disabilities of the arm, shoulder, and hand scores. Results  Nine patients were randomized and enrolled within the BFR group ( n  = 5) and control ( n  = 4) groups. Patients within the BFR group had a significantly greater reduction in pain with activity over the course of the rehabilitation program. Additionally, the BFR group had a significant improvement in PRWE scores during the 8-week rehabilitation program. There was no difference in radiographic measures after initiation of BFR, and all patients tolerated therapy without noted complications. Conclusion  BFR therapy is safe and well tolerated after operatively treated distal radius fractures. The addition of BFR therapy can result in quicker reduction in pain with activity and improvement in patient disability when used early following operative management of a distal radius fracture. Level of Evidence  This is a Level 1, prognostic study.

The Evidence for Common Nonsurgical Modalities in Sports Medicine, Part 2: Cupping and Blood Flow Restriction

There are a number of nonsurgical modalities used by athletes in attempts to improve performance or prevent, treat, and rehabilitate musculoskeletal injuries. A concise review of available evidence on common nonsurgical modalities used today is necessary, so that practitioners may appropriately counsel patients.