Blood Flow Restriction therapy in the post-

surgery rehabilitation of ACL reconstruction

patients

Department: CHCSJ-MFR
Presenter: IEONG SAM U
Instructor: CHU MAN FONG
Date:2023/05/22

1
OUTLINE
› 01 Background
› 02 Methods
› 03 Outcome Measurement
› 04 Results
› 05 Discussion
› 06 Conclusion & Clinical relevance

2
 Background

01
Blood Flow Restriction therapy (BFR)
› KAATSU training (1960s in Japan)
› Reduce arterial inflow and occlude venous outflow
› Resistance exercises : 20-30% of 1 repetition max (1RM), high repetitions
per set (15-30) , short rest intervals between sets (30 seconds)

Deltoid

Ing
uin
al
Biceps

Low intensity exercise = High intensity training Pope et al., 2013 3

Cognetti et al., 2022
 Background

01
Equipment
› BFR Cuff
› BFR Cuff Width
› BFR Cuff Material

Fujita, S et al., 2007 4

 Background

01
Equipment
• BFR Cuff Pressure
› Automatic personalised tourniquet system : Automatically calculate limb occlusion
pressure (LOP)
Defned : Minimum pressure required for full arterial occlusion

DePhillipo et al., 2018

5
 Background

01
Equipment

6
 Background

01 Blood Flow Restriction therapy

Type Mode Function

Prevent muscle loss and muscle

P-BFR Passive
atrophy

Improve muscle strength and muscle

BFR-RE Resistance exercise
hypertrophy

Improve muscle strength and muscle

BFR-AE Aerobic exercise
hypertrophy
Neuromuscular Early postoperative ,
BFR-NS
stimulation. maintenance/preventative therapy

Cognetti et al., 2022 7

 Background

01 Blood Flow Restriction therapy

Resistance exercise Aerobic exercise

Passive Neuromuscular stimulation

Cognetti et al., 2022 8
 Background

01 Blood Flow Restriction therapy-RE

Mechanical Tension and Metabolic
Stress

Activation of satellite cells (SC)

LL- HL-
BFR RT
Hypoxia

Greater motor unit recruitment

Low load blood flow restriction training (LL-BFR group) 9

Heavy load resistance training (HL-RT)
 Background

01
Physiology of Muscle Hypertrophy
› Muscle hypertrophy :
•  Diameter of the muscle
• Protein content within the fibres
•  Cross-sectional area of the muscle

Muscle tension and metabolic stress

Bonnieu, et al., 2007 10

 Background

01
Physiology/Mechanism of Action
› Mechanical Tension ---Muscle activation
① Metabolic changes
② External compression: changes in venous blood oxygen saturation and
partial pressure of oxygen and carbon dioxide and accumulation of lactate
and hydrogen ions.

Yasuda, T et al., 2009 11

 Background

01
Physiology/Mechanism of Action
› Mechanical Tension  Satellite cells (SC)
• SC (high-resistance training ): Multipotent cells within muscle connective
tissue responsible for muscle growth a regeneration
› LL-BFR: SC Muscle protein synthesis, myofiber size, and muscle
strength

Cognetti et al., 2022 12

 Background

01
Physiology/Mechanism of Action
• BFR’s relative ischemic and hypoxic conditions
• Metabolic changes Metabolites (amplified) : Mediators of muscular
hypertrophy

• Greater motor unit recruitment

› Type II fast-twitch muscle fibers(greater intensity)
 BFR : Activated at lower loads intensity

Cognetti et al., 2022 13

 Background

01
Effects of BFR on Muscle Strength
› The aim of BFR training : Mimic the effects of high intensity exercise  Hypoxic
environment
› Outflow of blood is limited: Capillary blood that has a low oxygen content collects and there
is an  lactic acid

Same physiological adaptations to the muscle

Wilson et al., 2013 14

 Background

01
Contraindications Potential contraindications
› Poor circulatory system › Venous thromboembolism
› Obesity › Peripheral vascular compromise
› Diabetes › Extremity infection
› Arterial calcification › Lymphadenectomy
› Sickle cell trait › Cancer
› Severe hypertension › Tumor
› Renal compromise

DePhillipo et al., 2018 15

 Background

01
Applications
› Blood flow restriction (BFR-RE)
Blood flow restriction (BFR-RE)
Frequency 2-4 times a week/1-2 times per day
Load 20% to 40% of 1 RM
Restriction time 5-10 min per exercise (reperfusion
between exercise)
Type Small and large muscle groups(arms
and legs/uni or bilateral)
Sets 2-4
Restriction pressure (75reps)30-15-15-15, 40% and 80%
of limb occlusion pressure (LOP)
Rest between sets 30-60s

Patterson et al., 2019

16
Cognetti et al., 2022
 Background

01
Applications
› Blood flow restriction (BFR-AE)

Blood flow restriction (BFR-AE)

Frequency 2-3 times a week/1-2 times per day
2-6wks
Intensity 40% VO2 max/HRR
Restriction time 15-20 min per exercise
Type Small and large muscle groups(arms
and legs/uni or bilateral)
Restriction pressure 40-80% of LOP
Exercise mode Cycling or walking

Patterson et al., 2019

17
Cognetti et al., 2022
 Background

01
Applications
› Blood flow restriction (P-BFR)

Blood flow restriction (P-BFR)

Frequency 1-2times per day(duration of bed
rest/immobilization) 3-4wks
Restriction time 5min intervals
Type Small and large muscle groups(arms
and legs/uni or bilateral)
Restriction pressure 70-100% of LOP
Rest between sets 3 min

Patterson et al., 2019 18

Cognetti et al., 2022
 Background

01
Postoperative Rehabilitation

Muscle atrophy
Nonsurgical patients-immobilization 7%  in quadriceps muscle at 7 days
After knee surgery Atrophy up to 33% at 3 weeks

› Post-surgery rehabilitation of ACL reconstruction(ACLR)

DePhillipo et al., 2018

19
Cognetti et al., 2022
 Background

01
Postoperative Rehabilitation

20
Roula Kotsifaki et al., 2023
 Methods

02
Post-surgery rehabilitation of ACL reconstruction(ACLR) patients
Author Study design Total number of Study arms (No.) Outcome
patients
Won et al., 2022 Randomized controlled 26 LL-BFR group (n=12) Quadriceps strength
trial Non-BFR group (n=12) Hamstring strength
Muscle activity
(VMO/RF)
Knee functional ability
De Melo et al., 2022 Randomized controlled 28 LL-BFR group (n=14) Quadriceps strength
trial Non-BFR group (n=14) Hamstring strength
Knee joint pain
Knee functional ability
Hughes, L et al., 2019 Randomized controlled 28 LL-BFR group (n=12) Quadriceps strength
trial Non-BFR group (n=12) Knee joint pain
Quadriceps mass
ACL graft laxity
Knee functional ability
Iversen et al., 2014 Randomized controlled 24 LL-BFR group (n=12) Quadriceps mass
trial Non-BFR group (n=12)

Low load blood flow restriction training (LL-BFR group)

21
 Methods

02
Post-surgery rehabilitation of ACL reconstruction(ACLR) patients
Author Graft for ACL Male in LL-BFR Age (years) in LL-BFR Weight (kg) in LL-BFR
reconstruction & non-BFR group & non-BFR group & non-BFR group

Won et al., 2022 - 9 (75%) & 9 (75%) 28 (8) & 31 (8) 79 (19) & 72 (10)

De Melo, et al., 2022 - 8 (66.6%) & 9 (75%) 4`1 (10) & 40 (11) 73 (14) & 69 (10)

Hughes, L et al., 2019 Hamstring 7 (58%) & 10 (83%) 29 (7) & 29 (7) 76 (15) & 79 (15)

Iversen et al., 2014 Hamstring 7 (58%) & 7 (58%) 25 (7) & 30 (9) 77 (12) & 78 (10)

22
 Methods

02
Post-surgery rehabilitation of ACL reconstruction(ACLR) patients
Author BFR device Cuff BFR LL-BFR training Non-BFR Exercises Duration Total training
width pressure training sessions
Won et Smart Cuffs - 40% of 4 sets (30-15-15-15 reps) 4 sets (30-15 ROM 12weeks 36
al., device LOP 15-15 reps) exercise
2022 Interset rest periods: 30 Weight- Start: 3 days
seconds Interset rest bearing postop
periods: 30 exercise
External load: 30% 1RM seconds CKC End: 12 weeks
OKC postop
Session: 3x/60min Session:3x/
/week 60min /week
De Cuff 10cm 80% of 4 sets (30-15-15-15 reps) 4 sets (30-15- Flexor 12weeks 24
Melo, Scientific LOP 15-15 reps) chair
et al., Leg® – Interset rest periods: 30 Leg press Start: 2 weeks
2022 WCS seconds Interset rest postop
periods: 30
vascular External load: 30% 1RM seconds End: 12 weeks
Doppler postop
device Session: 2x/ week External load:
70% 1RM
Session: 2x/ 23
week
 Methods

02
Post-surgery rehabilitation of ACL reconstruction(ACLR) patients
Author BFR device Cuff BFR LL-BFR Non-BFR training Exercises Duration Total training
width pressure training sessions
Hughes, Automatic 11.5 Mean 150 4 sets (30-15-15-15 reps) 3 sets (10-10-10 Unilateral leg 8 weeks 16
L et al., personalized cm mmHg reps) press
2019 tourniquet Interset rest periods: 30 Start 2
system Based on seconds Interset rest periods: weeks
80% of 30 seconds postop
LOP External load: 30% 1RM
External load: 70% End: 10
Session: 2x/ week 1RM Session: 2x/ weeks
Week postop
Iversen Contoured 14 cm Start:130 5 sets of 20 reps 5 sets of 20 reps Isometric 12 days 24
et al., pneumatic mmHg quadriceps
2014 occlusion Interset rest periods: 3 Interset rest periods: contraction Start: 2
cuff End: 180 minutes 3 minutes progressing to days
mmHg leg extension postop
External load: low External load: low over a knee-
Based on roll and End: 14
previous Session: 2x/day Session: 2x/day straight leg days
research raise postop
24
 OUTCOME MEASUREMENTS

03
OUTCOME MEASUREMENTS

Measures Assessment tools

Quadriceps strength Isometric dynamometer/isokinetic
dynamometer (Biodex system IV)
Hamstring strength Isometric dynamometer/isokinetic
dynamometer (Biodex system IV)
Quadriceps mass USD
Knee joint pain KOOS
Knee functional ability Lysholm and IKDC questionnaire

Knee Injury and Osteoarthritis Outcome Score (KOOS)

International Knee Documentation Committee, (IKDC)
Lysholm Knee Scoring Scale

25
 RESULTS

04
RESULTS
› Quadriceps strength

Injured limb VS uninjured

Week : 4 8 12

(De Melo, et al., 2022)

Isokinetic function (e.g., peak torque and total

work) quadriceps with an muscle strength LL-BFR : Significantly less strength
(p<0.01) after 12 weeks (Won et al., 2022) deficits in isokinetic knee extension at 26
150° and 300°/seconds (Hughes et al.,2019)
 RESULTS

04
RESULTS
› Hamstring strength
› Muscle strength hamstrings (p<0.01) after 8 and 12 weeks
(De Melo et al., 2022)

Muscle strength hamstrings (p<0.001) after12weeks (Won et al., 2022)

27
(De Melo et al., 2022)
 RESULTS

04
RESULTS
› Quadriceps mass
• Between LL-BFR and non-BFR training
› No significant difference in quadriceps cross-sectional area(CSA)(p=0.626) (Iversen et al.,2

› No significant difference in quadriceps increase (p=0.230)(Hughes et al.,2019)

28
(Hughes et
 RESULTS

04
RESULTS
› Knee joint pain— KOOS
› KOOS pain score  After 4 weeks (p<0.01) (De Melo et al., 2022)
› Over 8 weeks of training : Signifcantly greater  in KOOS pain score with
BFR-RT Hughes et al.2019

(De Melo et al., 2022)

(As 0 represents extreme pain and 100 represents no pain)
29
 RESULTS

04
RESULTS
• Knee functional ability
Group Lysholm p IKDC P
Significant Significant
Hughes et LL-BFR  P<0.001  P<0.05
al.,2019 group
Non-BFR  P<0.05  P<0.05
group
Won et al., LL-BFR  p<0.001  p<0.001
2022 group
Non-BFR  P<0.01  P<0.05
group
De Melo, et LL-BFR  p<0.01  p<0.01
al., 2022 group
Non-BFR  P<0.05  p<0.05
group

30
 DISCUSSION

05
DISCUSSION
Post-surgery rehabilitation of ACL reconstruction(ACLR) patients
12wks

8wks Quadriceps 8wks 8wks 4wks

strength
Knee Knee
Hamstring Quadriceps
functional functional
strength mass
ability ability

4wks 4wks Non-

Knee joint LL-BFR Quadriceps BFR
pain group mass group

31
Weeks(wks) : significant difference
 DISCUSSION

05
Post-surgery rehabilitation of ACLR patients

Non-BFR group LL-BFR group

Heavy load resistance training Low load blood flow restriction training

65–70% 1RM
= 20‒30% 1RM


Quadriceps
strength
Knee  Hamstring
joint pain strength
 Knee
functional ability

32
 Conclusions
BFR therapy stimulates muscle hypertrophy via a synergistic response to metabolic stress and mechanical tension. Low
load blood flow restriction training might be used in addition to standard care in the early phase of rehabilitation to
improve quadriceps and hamstring strength, particularly when patients have increased knee pain or cannot tolerate high
knee joint loads.

New forms of BFR and expanding applications in postoperative patients and athletes hold promise for expedited recovery.

33
 Reference
Fujita, S., Abe, T., Drummond, M. J., Cadenas, J. G., Dreyer, H. C., Sato, Y., ... & Rasmussen, B. B. (2007). Blood flow
restriction during low-intensity resistance exercise increases S6K1 phosphorylation and muscle protein synthesis. Journal
of applied physiology, 103(3), 903-910.

Yasuda, T., Brechue, W. F., Fujita, T., Shirakawa, J., Sato, Y., & Abe, T. (2009). Muscle activation during low-intensity
muscle contractions with restricted blood flow. Journal of sports sciences, 27(5), 479-489.

Hughes, L., Rosenblatt, B., Haddad, F., Gissane, C., McCarthy, D., Clarke, T., ... & Patterson, S. D. (2019). 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
Medicine, 49, 1787-1805.

Cognetti, D. J., Sheean, A. J., & Owens, J. G. (2022). Blood flow restriction therapy and its use for rehabilitation and
return to sport: physiology, application, and guidelines for implementation. Arthroscopy, Sports Medicine, and
Rehabilitation, 4(1), e71-e76.

Pope, Z. K., Willardson, J. M., & Schoenfeld, B. J. (2013). Exercise and blood flow restriction. The Journal of Strength &
Conditioning Research, 27(10), 2914-2926.

Bonnieu, A., Carnac, G., & Vernus, B. (2007). Myostatin in the pathophysiology of skeletal muscle. Current
genomics, 8(7), 415-422.

34
 Reference
Wilson, J. M., Lowery, R. P., Joy, J. M., Loenneke, J. P., & Naimo, M. A. (2013). Practical blood flow restriction training
increases acute determinants of hypertrophy without increasing indices of muscle damage. The Journal of Strength &
Conditioning Research, 27(11), 3068-3075.

DePhillipo, N. N., Kennedy, M. I., Aman, Z. S., Bernhardson, A. S., O'Brien, L., & LaPrade, R. F. (2018). Blood flow
restriction therapy after knee surgery: indications, safety considerations, and postoperative protocol. Arthroscopy
techniques, 7(10), e1037-e1043.

Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., Owens, J., ... & Loenneke, J. (2019). Blood flow
restriction exercise: considerations of methodology, application, and safety. Frontiers in physiology, 533.

DePhillipo, N. N., Kennedy, M. I., Aman, Z. S., Bernhardson, A. S., O'Brien, L., & LaPrade, R. F. (2018). Blood flow
restriction therapy after knee surgery: indications, safety considerations, and postoperative protocol. Arthroscopy
techniques, 7(10), e1037-e1043.

35
 Reference
De Melo, R. F. V., Komatsu, W. R., De Freitas, M. S., De Melo, M. E. V., & Cohen, M. (2022). Comparison of Quadriceps
and Hamstring Muscle Strength after Exercises with and without Blood Flow Restriction following Anterior Cruciate
Ligament Surgery: A Randomized Controlled Trial. Journal of Rehabilitation Medicine, 54, jrm00337-jrm00337.

Jung, W. S., Kim, S. H., Nam, S. S., Kim, J. W., & Moon, H. W. (2022). Effects of Rehabilitation Exercise with Blood
Flow Restriction after Anterior Cruciate Ligament Reconstruction. Applied Sciences, 12(23), 12058.

Koc, B. B., Truyens, A., Heymans, M. J., Jansen, E. J., & Schotanus, M. G. (2022). Effect of Low-Load Blood Flow
Restriction Training After Anterior Cruciate Ligament Reconstruction: A Systematic Review. International journal of
sports physical therapy, 17(3), 334.

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THANK YOU

37
 Background

01
補充
Physiology/Mechanism of Action
› Blood flow restriction (BFR)
› Stimulation of protein translation via the mechanistic target of rapamycin
pathway, which is important in muscle protein synthesis and hypertrophy
› whereas myostatin, a negative regulator of muscle growth and promoter of
muscle fibrosis, has been shown to be downregulated after BFR.

Cognetti et al., 2022

38
 Background

01
Activation of satellite cells
› SC : Between the basal lamina and plasma membrane of myofibers
› SC Activate : Muscle injury / muscle tension
• Differentiation  Proliferate  Fusion = Myotube

 Repair of damaged muscle fibres +growth of the fibres themselves

Bonnieu, et al., 2007

39
 Background

01
Physiology/Mechanism of Action
› Blood flow restriction (BFR)
› We have recently shown that both the mammalian target of rapamycin
(mTOR) signaling pathway and muscle protein synthesis (MPS) were
stimulated after an acute bout of high-intensity resistance exercise in
humans.

Fujita, S et al., 2007

40
 Background

01
Applications
› Blood flow restriction (BFR-NS)
›  Unloaded, isometric contractions,
› Early recovery period : knee surgery ---Quadriceps control

Cognetti et al., 2022 41

 RESULTS

04
RESULTS
› Quadriceps strength
• LL-BFR
› Quadriceps with an  muscle strength (p<0.01) after 12 weeks(De Melo, et al., 2022)
› Isokinetic function (e.g., peak torque and total work) quadriceps with an
muscle strength (p<0.01) after 12 weeks. ( Won et al., 2022)
› LL-BFR VS. non-BFR training (p=0.010)
› Significantly less strength deficits in isokinetic knee extension at 150° and
300°/seconds (Hughes et al.,2019)

42
 RESULTS

03
RESULTS
› KOOS

43
 RESULTS

03
RESULTS
› The Lysholm Knee Scale : Highest level of function

44
 RESULTS

03
RESULTS
› IKDC questionnaire: Highest level of function

45
Post-surgery rehabilitation of ACL
reconstruction(ACLR) patients

LL-BFR

Won et al., 2022

46