Blood-Flow Restriction Therapy: - PowerPoint Presentation

1. Blood-Flow Restriction Therapy:Effectiveness and clinical applicationWyatt Kurzejeski, SPT

2. Learning objectives1. The audience should be able to identify proper parameters for BFR use in a clinical setting, and explain the benefits and risks of this intervention2. Based on pertinent research in this presentation, the audience should be able to reasonably decide if BFR is an appropriate intervention for given patient examples3. The audience should be able to accurately identify contraindications to BFR

3. What is BFR?1Application of a tourniquet to a limb, to occlude venous outflow to an area, while maintaining arterial inflow Purpose: To increase strength and hypertrophy using lighter resistance loads than traditional strength training, thereby reducing stress on the surrounding tissues and joints

4. Background1,2Predominantly used in the military - blast injuries and limb salvageExpanded to elite-level athletesNow being used as an adjunct training method, as well as rehabilitative techniqueAccording to the apta – BFR is within the professional scope of practice for physical therapists

5. Cellular mechanism3,4BFR  hypoxia  metabolic stress  anabolic hormone release, immune response, and increased recruitment of fast-twitch muscle fibers cell swelling and skeletal muscle remodelingAka: hypertrophy and strength! Interestingly: studies show decreased amount of inflammatory cytokines produced as a result of bfr – decreased soreness??In theory, strength gains in the absence of muscle damage

6. Appropriate populations3“Although heavier loading seems necessary to maximize muscular strength development (Peterson et al., 2005), high-intensity loads performed in traditional strength training programs may not be a viable option for sarcopenic populations, older individuals with chronic health problems, or individuals with injuries who may be unable to tolerate heavy loading.”3

7. Indications/contraindications4indicationsResist atrophy/Build strength Lifting/post-op restrictions Slow to recoverjoint degeneration Pain? contraindicationsCurrent dvt or peEndothelial injury near cuff siteParalysis/sensation lossPregnancy? HTN?*cardiovascular disease*MAY ACTUALLY PROMOTE FIBRINOLYSIS?

8. Screening pre treatmentSimilar to a normal pt screen before prescribing exercise to a patient Red flagsPotentially more of a concern in the acute care settingIf you wouldn’t feel comfortable prescribing traditional exercise/resistance, then they probably aren’t appropriate for bfr!Patient education – muscle soreness, temporary numbness, irritation around cuff site, bruising

9. Vs monitoring during treatmentMake sure the cuff stays in place! Monitor cuff pressureBPHRRPESkin integrity/coloration

10. Parameters4,5Application of cuff – proximal limb segmentPressure – 40-80% of limb occlusion pressure (via doppler ultrasound)180mmhg standard, 1.5x systolic bp, thigh circumferenceCuff width: 10-12cm (standard BP cuff 12cm), vs 15cm+20-30% 1RM (ACSM recommends 70%+)30x15x3, 15-45s rest between sets with cuff inflatedallow reperfusion (5 min/3 min)

11. Is bfr safe?4,5,6In general, yes!No increased risk of DVT in patients post knee surgeryReviews & meta analysis conclude: safe, no adverse effects, no greater risk associated with bfr than those accompanying traditional exerciseCaveat: scarcity of research, especially long-term

12. how to improve safetyDo’sPersonalized tourniquet system with pneumatic cuffWider cuffs  lower occlusion pressuresTapered cuffs – pressure gradientsLimb-specific cuffsAllow reperfusionDon’tsjust wrap a band around their limb and have them do stuff!Multiple cuffs?

13. Effectiveness7,8Meta analysis: Effect size 0.58 for strength, and 0.39 for hypertrophyCompared to 0.00 and -0.01 respectively, for low-intensity exercise without bfr2-3 days/week vs. 4-5 days/weekAnother study: resistance training  Hypertrophy <4 weeks, strength <10 weeks – opposite of traditional Improved cardiorespiratory endurance (vo2 peak), walking/cycling30% Hr max, 15-20 min, 2-3x/week, for 6 weeks Note: most research has been conducted in healthy individuals

14. Effectiveness cont.9Case series: 7 patients, traumatic leg injuries, chronic quad/hamstring weakness35-75% torque deficit compared to contralateral leg despite prior therapy2 weeks bfr, 110mmhg, 20% 1rmLeg extensions, leg presses, reverse leg pressesTorque: improved 13-37% Power: improved 42-81%Success!!

15. Anecdotal – Jadeveon clowney2,10Underwent microfracture surgery on knee in late 20146 weeks nwbPT johnny owens (owens recovery science)Texans head trainer: "The athletes [undergoing BFR training] are exhibiting better muscle control and making progressions -- like moving from double-leg activities to single-leg -- faster than what we typically see.”10Clowney: full recovery for 2015, pro-bowler 3 years straight

16. LimitationsLimbs only – not applicable for weakness in the thorax.. Yet!Benefits potentially only short term? - speculationLack of research regarding long-term effects/outcomesNo standards for protocol/parameters/screeningLack of pt knowledge/comfort with intervention

17. Clinical application/summaryBfr is a safe and effective alternative to traditional resistance exercise, for improving muscular strength and hypertrophyDoppler ultrasound and Pts cuffs are the gold standard for clinical useIndications/contraindications very similar to those for traditional exerciseCan be recommended post-op and to otherwise healthy peopleGeneral parameters exist; use best clinical judgement

18. General information11You can get certified via ”owens recovery science”One day course, price not specifiedPurchase of official ors equipment requires active medical license and completion of courseHowever, anyone can buy a tourniquet or bfr devices on amazon. be wary, as patients may ask about this intervention!

19. Products12,13,14Signature Series BFR Bands: $297Smart Cuffs – Clinical Setw/ Doppler: $1,500BFR Bands – Amazon: $18

20. Case examples

21. Case #119yo male college fb player, NWB post ACL surgery, is worried he may get cut if he can’t return to plofYES NO

22. Case #285yo woman who walks daily but has difficulty lifting groceries due to arm weakness, otherwise healthyYES NO

23. Case #360yo man post tka, decreased quad activation… leg is hot, swollen, and painfulYES NO

24. Case #475yo man, Advanced hip oa, 7/10 pain at all times, progressively weakening, difficulty getting out of chairsYES NO

25. Case #526yo woman, post mva, r arm lifting restrictions…pain/temp sensation in R arm is impairedYES NO

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27. Activity

28. Survey time

29. Resources1. Blood-Flow Restriction Training (BFRT). Available at: https://www.apta.org/PatientCare/BloodFlowRestrictionTraining/. Accessed June 9, 2019.2. Innovation boosts recovery from battlefield and gridiron injuries - TMC News. Available at: https://www.tmc.edu/news/2018/11/innovation-boosts-recovery-from-battlefield-and-gridiron-injuries/. Accessed June 9, 2019.3. Rossi FE, de Freitas MC, Zanchi NE, Lira FS, Cholewa JM. The role of inflammation and immune cells in blood flow restriction training adaptation: A review. Front. Physiol. 2018;9:1376. doi:10.3389/fphys.2018.01376.4. Bond CW, Hackney KJ, Brown SL, Noonan BC. Blood flow restriction resistance exercise as a rehabilitation modality following orthopaedic surgery: A review of venous thromboembolism risk. J. Orthop. Sports Phys. Ther. 2019;49(1):17-27. doi:10.2519/jospt.2019.8375.5. DePhillipo NN, Kennedy MI, Aman ZS, Bernhardson AS, O’Brien L, LaPrade RF. Blood flow restriction therapy after knee surgery: indications, safety considerations, and postoperative protocol. Arthrosc. Tech. 2018;7(10):e1037-e1043. doi:10.1016/j.eats.2018.06.010.6. Loenneke JP, Wilson JM, Wilson GJ, Pujol TJ, Bemben MG. Potential safety issues with blood flow restriction training. Scand J Med Sci Sports 2011;21(4):510-518. doi:10.1111/j.1600-0838.2010.01290.x.7. Loenneke JP, Wilson JM, Marín PJ, Zourdos MC, Bemben MG. Low intensity blood flow restriction training: a meta-analysis. Eur. J. Appl. Physiol. 2012;112(5):1849-1859. doi:10.1007/s00421-011-2167-x.8. Vanwye WR, Weatherholt AM, Mikesky AE. Blood Flow Restriction Training: Implementation into Clinical Practice. Int J Exerc Sci 2017;10(5):649-654.

30. Resources cont.9. Hylden C, Burns T, Stinner D, Owens J. Blood flow restriction rehabilitation for extremity weakness: a case series. J. Spec. Oper. Med. 2015;15(1):50-56.10. Jadeveon Clowney among Texans using blood flow restriction training - Houston Texans Blog- ESPN. Available at: https://www.espn.com/blog/houston-texans/post/_/id/10132/clowney-fitzpatrick-cushing-undergoing-blood-flow-restriction-training. Accessed June 9, 2019.11. Owens Recovery Science - Blood Flow Restriction Training. Available at: https://www.owensrecoveryscience.com/. Accessed June 9, 2019.12. Signature Series BFR Bands - Hand Pump Blood Flow Restriction Bands to. Available at: https://www.bfrshop.com/products/signature-series-bfr-bands-hand-pump-blood-flow-restriction-bands-to-dial-in-the-pressure?variant=12228173791324&utm_campaign=gs-2018-10-07&utm_source=google&utm_medium=smart_campaign&gclid=EAIaIQobChMIvamn-I-m4gIVx8DICh2G9AvAEAQYAiABEgJVJfD_BwE. Accessed June 9, 2019.13. Smart Cuffs. Available at: https://www.schoolhealth.com/smart-cuff?utm_source=google&utm_medium=cpc&adpos=1o6&scid=scplp1031211&sc_intid=1031211&gclid=CIfK6OSy2uICFTr34wcdE_gLFw. Accessed June 9, 2019.14. Amazon.com : BFR BANDS Occlusion Training Bands, 2 in Rigid Edition, Blood Flow Restriction Bands Give Lean & Fast Muscle Growth Without Lifting Heavy Weights - Strong Adjustable Strap + Comfort Liner (Arms) : Sports & Outdoors. Available at: https://www.amazon.com/Occlusion-Training-BFR-Restriction-without/dp/B06XRZC67R. Accessed June 9, 2019.