Tuesday, July 9, 2019

Blood Flow Restriction Training (BFRT) and Rehabilitation

Blood Flow Restriction Training (BFRT), or occlusion training began in the 1960’s, coined by Dr. Yoshiaki Sato as KAATSU (or “additional pressure,” “ka” + “atsu” in Japanese). This initial process began with Sato rehabilitating himself after a ski injury resulting in a fractured ankle and ligamentous knee injury. While in the plaster cast for his ankle, he experimented applying various tubes and bands to his upper leg and performing isometric exercises resulting in minimal atrophy as well as an improved recovery compared to what he expected to be normal. Fifty years later, the United States military began to adopt Sato’s methods as a means of improving endogenous production of Growth Hormone to assist in healing of skin and tissue grafts. Further experimentation and research protocols were then subsequently developed to aid in the strengthening of residual limbs to prepare for prosthetics. To date, over 800 published articles have been dedicated to this topic since its initial hypothesis, consequently resulting in the clinical application of BFRT in exercise physiology and rehabilitation settings.  The use of BFRT is currently implemented in professional/collegiate sports teams and hospitals all around the world.

BFRT is the brief and intermittent occlusion or restriction of arterial and venous blood flow that is performed by applying a tourniquet to the upper or lower extremity while at rest or exercising. Using this technique, one can exercise using significantly less weight, and still achieve significant gains in muscle strength and size.  With BFRT, restriction of blood flow results in reduction of oxygen supply to a working muscle to result in a change from aerobic to anaerobic metabolism. At the cellular level, the current evidence shows that BFRT increases lactate by-product within the muscle, resulting in Growth Hormone release, stimulated Insulin-like Growth Factor (IGF-1) and cell swelling.  All of these physiologic changes have influence on:

Ø Rehabilitation/prehabilitation of injuries
Ø Increasing strength
Ø Attenuating muscular atrophy
Ø Creating muscle hypertrophy
Ø Aiding in recovery
Ø Improving bone density and function
Ø Improving cardiovascular function

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There are multiple protocols established by the current research:  protocol chosen will be based the clinical goal to be achieved. See below for an example: 
Hypertrophy Protocol:
Volume: 1 cluster set of 4 sets: 30/15/15/15 repetitions (at 2 seconds concentric and 2 seconds eccentric) with 30 second rest breaks between each set.   
Frequency: 2-3x per week (mixed in with normal strength and endurance training)
Load: 15-30% of 1RM
Limb Occlusion Pressure (LOP): 80% of max for lower extremity and 50% of max for upper extremity
*Disclaimer: Do not apply BFR or tourniquets without the supervision of a licensed professional.

Please note the contraindications and risk categories for BFRT

Extremities with dialysis port
Excessive swelling in post-surgical limb, often UE (i.e. lymphedema)
Infection within extremity
Increased intracranial pressure
Impaired circulation
Lymphedema (on limb)
Open fracture/open wound
Previous revascularization of limb

Sickle cell anemia
Severe hypertension
Severe crush injury
Vascular graft
Venous thromboembolism
Women who have had a mastectomy with or without radiation and/or an axillary node dissection- avoid BFRT on the affected arm.
People in hemodialysis who have arterial venous fistulas- avoid BFRT exercise on the affected limb

Known clotting risk

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Personal Experience & Application of BFRT

My first exposure to BFRT was about 5 years ago, where I experimented on myself for personal use at the gym. That later evolved to the clinical setting, using BFRT in a sports setting for both rehabilitation and active recovery.  

I recently attended Smart ToolsBlood Flow Restriction course, instructed by Ed Le Cara, DC, AT,PhD.  This course dove deep into the physiology and demonstrated that the benefits transcend across the entire rehabilitation continuum from bedridden to professional athletes.   Dr. Le Cara’s energetic style in combination with our eager participation in the lab portion created an amazing atmosphere to the very last minute.  Dr. Le Cara did a wonderful job explaining that BFRT is a tool, and when applied to the correct context, can be beneficial to better serve our patients.  After this course, my understanding of the clinical application expanded way beyond my initial narrow vantage point.  In addition, what made this course very special and highly conducive to learning, was nearly everyone already knew each other. Thank you to Movement Links, Dr. Clare Frank, and Dr. Ed Le Cara for putting this course together and providing a great experience to learn and provide the best possible care.

Nicholas Smith is a Physiotherapist with Casa Colina in Azusa California. He is a Movement Links Certified Clinician, a graduate of the Azusa Pacific University Movement & Performance and owner of Smith Forged Strength & Conditioning (@smithforgedsc). Nick has a passion for movement and hopes to help more people participate in the activities they love.

AORN. Recommended Practices for Use of the Pneumatic Tourniquet in the Preoperative Practice Setting. In: Preoperative Standards and Recommended Practices for Inpatient and Ambulatory Settings. 2014 ed. Denver, CO AORN Inc, 2014:183-208.

Abe, T., Fujita, S., Nakajima, T., Sakamaki, M., Ozaki, H., Ogasawara, R., Ishii, N. (2010). Effects of Low-Intensity Cycle Training with Restricted Leg Blood Flow on Thigh Muscle Volume and VO2MAX in Young Men. J Sports Sci Med, 9(3), 452-458.

Abe, T., Sakamaki, M., Fujita, S., Ozaki, H., Sugaya, M., Sato, Y., & Nakajima, T. (2010). Effects of low intensity walk training with restricted leg blood flow on muscle strength and aerobic capacity in older adults. J Geriatr Phys Ther, 33(1), 34-40.

Fry, C. S., Glynn, E. L., Drummond, M. J., Timmerman, K. L., Fujita, S., Abe, T., Rasmussen, B. B. (2010). Blood flow restriction exercise stimulates mTORC1 signaling and muscle protein synthesis in older men. J Appl Physiol(1985), 108(5), 1199-1209.

Fujita S, Abe T, Drummond MJ, et al. Blood flow restriction during low-intensity resistance exercise increases S6K1 phosphorylation and muscle protein synthesis. J Appl Physiol. 2007;103(3):903–10.

Gundermann, DM, Walker DK, Reidy, PT., Borack, MS, Dickinson, JM, Volpi E, & Rasmussen B. (2014).Activation of mTORC1 signaling and protein synthesis in human muscle following blood flow restriction exercise is inhibited by rapamycin. Am J Physiol Endocrinol Metab, 306 (10), E1198-1204

Hameed M, Lange KH, Andersen JL, et al. The effect of recombinant human growth hormone and resistance training on IGF-I mRNA expression in the muscles of elderly men. J Physiol.
2004;555(Pt 1):231–40.
Haussinger D, Roth E, Lang F, Gerok W. Cellular hydration state: an important determinant of protein catabolism in health and disease. Lancet (1993); 341: 1330–1332.

Haussinger D. The role of cellular hydration in the regulation of cell function. Biochem J 1996;313(Pt3):697–7103.

Kostek MC, Delmonico MJ, Reichel JB, et al. Muscle strength response to strength training is influenced by insulin-like growth factor 1 genotype in older adults. J Appl Physiol. 2005;98(6): 2147–54

Kubota, Atsushi, et al. "Blood flow restriction by low compressive force prevents disuse muscular weakness." Journal of Science and Medicine in Sport14.2 (2011): 95-99.

Loenneke, J. P., Wilson, J. M., Wilson, G. J., Pujol, T. J., & Bemben, M. G. (2011). Potential safety issues with blood flow restriction training. Scand J Med Sci Sports, 21(4), 510-518. doi: 10.1111/j.1600-0838.2010.01290.x

Loenneke, J. P., Wilson, J. M., Marin, P. J., Zourdos, M. C., & Bemben, M. G. (2012). Low intensity blood flow restriction training: a meta-analysis. Eur J Appl Physiol, 112(5), 1849-1859. doi: 10.1007/s00421-011-2167-x

Loenneke JP, Fahs CA, Thiebaud RS, et al. The acute muscle swelling effects of blood flow restriction. Acta Physiol Hung 2012;99:400–10

Schliess F, Richter L , Dahl S, & Haussinger D. (2006). Cell hydration and mTOR-dependent signalling. Acta Physiol(Oxf), 187(1-2), 223-229

Takarada Y, Haruo T, Ishii N. "Applications of vascular occlusions diminish disuse atrophy of knee extensor muscles.” Medicine and science in sports and exercise32.12 (2000): 2035-2039