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    Blood flow restriction

    Clinical use to attenuate strength loss, muscle atrophy and pain during immobilization or severely limited mobility
    Dr. Alexander Franzvon Dr. Alexander Franz14 Min. Lesezeit
    Photo: © istockphoto.com / softservegirl

    Authors:

    ROBERT BIELITZKI, TOM BEHRENDT, PROF. LUTZ SCHEGA / DEPARTMENT OF SPORT SCIENCE, OTTO-VON-GUERICKE UNIVERSITY MAGDEBURG

    PROF. MICHAEL BEHRINGER MD / DEPARTMENT OF SPORTS SCIENCES, GOETHE UNIVERSITY FRANKFURT

    ALEXANDER FRANZ MD / DEPARTMENT OF ORTHOPEDICS AND TRAUMA SURGERY, UNIVERSITY HOSPITAL BONN 

    Acute severe injuries and degenerative diseases of the musculoskeletal system as well as surgical interventions are usually characterized by phases of restricted mobility with strongly reduced load-bearing capacity or complete immobility of corresponding areas [1]. This temporary or long-lasting situations are strongly associated with strength loss due to neural impairments (e.g., decline in high threshold motor unit recruitment and arthrogenic inhibition [2, 3]) and muscle atrophy (due to an imbalance in muscle protein synthesis and breakdown [3, 4]). 

    In the recent past, a new conservative therapy approach termed blood flow restriction (BFR) has gained great inte­rest from scientists and therapists. BFR training describes an alternative me­thod based on partial vascular occlusion to induce metabolic changes that allow mitigating functional and morpho­lo­gical degeneration or increasing muscle mass and strength by using no additional activities [5] or low mechanical loads [6], respectively. Considering these be­neficial effects, BFR seems sui­table after acute injuries (e.g., anterior cruciate ligament rupture) as well as for patients with degenerative diseases (e.g., gon­arthrosis) or after a surgical intervention (e.g., total knee arthroplasty). 

    Mechanisms of BFR-induced effects on muscular adaptations and pain management

    BFR is characterized by the application of pneumatic cuffs to the proximal part of a limb to decrease arterial and block venous blood flow [7]. Venous blood pooling is thought to increase metabolic stress due to a change in energy meta­bolism in favor of anaerobic processes and accumulating metabolites [8, 9], which accelerates muscle fatigue deve­lopment [10]. In this regard, invasive catheter studies demonstrated that low-load resistance exercise under venous occlusion causes hypoxemia in the exercising limb [11]. Further occurring mechanisms (e.g., increased type II muscle fiber recruitment and cell swelling) are assumed to trigger signal cascades which increase protein synthesis and thus, induce muscle hypertrophy [8, 9]. In addition, BFR is able to reduce pain due to provoking hypoalgetic effects [12]. Considering the current evidence, BFR-induced hypoalgesia is probably caused by a conditioned pain modulation [13] (i.e., diffuse noxious inhibi­tory control-like effect [14] or “pain inhibits pain” [15]) where a reduction in pain perception is evoked by another hetero­topically applied noxious stimulus [16]. Another possible mecha­nism is the activation of the endo­genous opioid and endocannabinoid systems due to stimu­lation of group III and IV afferents leading to the production of specific neurotransmitters, which modulate the sensitivity of nociceptors [17, 18]. 

    BFR in clinical practice in phases of immobilization or severely restricted mobility

    Preoperative treatment of degenerative diseases and/or elective surgery

    Considering the main benefits of BFR training, inducing significant adap­tations in the muscular system with the associated ability to reduce pain, its application in the medical field is of particular interest. Joint arthrosis is one of the major diseases affecting the ske­letal system, leading to severe reductions in mobility as well as in skeletal muscle mass and strength [19, 20]. Total joint replacement (e.g., total knee arthroplasty, TKA) is often the last option to maintain or restore mobility. However, the surgery itself and early postoperative immobilization usually causes further progression of muscular atrophy and strength loss [21]. Therefore, an improvement in patients’ functional and morphological resources before elective surgeries such as TKA is a strong predictor for a better postoperative outcome [22, 23]. While previous attempts about prehabilitation (i.e., exercise programs prior to a surgery) showed too small and/ or only short-term effects in improving postoperative function and reducing pain after joint replacement surgery [24], BFR could provide a decisive new alternative to create a favo­rable functional and morphological environment before surgery. Prehabi­litative treatment with BFR training has already been shown to have a major impact on pre- and postoperative muscle mass, strength and function in patients receiving elective TKA [25] or abdo­minal surgery [26].

    Postoperative treatment or conservative rehabilitation

    In the early postoperative period, especially during complete immobilization, BFR can be used passively (i.e., without additional exercise) to counteract the injury/ surgery-induced loss of muscle mass [27], strength [28, 29], and to reduce local pain [30]. If possible, resis­tance exercises with very low loads can be performed during phases of limited mobility. It has been shown that low-load BFR training induces similar increases in muscle mass to high-load [6] and low-load training performed until exhaustion [31]. In this regard, especially low-load BFR training might be a convenient option as high mechanical stress of high-load training is avoided and cumulative low mechanical stress of low-load training until exhaustion is reduced (i.e., due to lower total work) [32]. Furthermore, Korakakis et al. have shown that BFR combined with low load knee extension exercise not only reduced anterior knee pain but also allowed the patients tolerate higher mechanical loads in subsequent therapy sessions [14, 33] which, in turn, favors gains in muscle strength. Therefore, Bielitzki et al. proposed that an early integration of BFR potentially accele­rates the recovery process compared to traditional care [32]. 

    Safety information

    Generally, there is no increased risk of adverse health events when performing BFR training [34]. Apart from side effects of traditional exercise/ training (e.g., muscle damage/ soreness), the most common adverse events are tingling sensations in distal extremities (71.2 %), hematomas (4.8 – 13.1 %), and numbness (1.3 – 26.9 %). In few cases, serious side effects such as rhabdomyo­lysis (0.01 – 1.9 %) or venous thrombus formation (0.06 %) may occur [35, 36]. However, BFR exercise may cause an increased response of the metabolic and cardiovascular systems (lactic acidosis, venous hypertension) [37, 38]. To mini­mize the risk of adverse health events, patients should be screened for possible contraindications (Table 1). However, if used appropriately, BFR can also be applied in critically ill patients (e.g., patients with chronic kidney [39] or cardiovascular disease [40]).  

    Tab. 1 Overview of possible contraindications of BFR training (according to Brandner et al. [44])
    Tab. 2 Recommendations for the application of BFR during immobilization and severely limited mobility (modified according to Patterson et al. [34]). 1RM, one repetition maximum; AOP, arterial occlusion pressure; HRR, heart rate reserve; V̇O2max, maximal oxygen uptake recommendations refer to *hypoalgetic effects, #safety considerations

    Recommendations for application during strongly reduced load capacity

    Considering the current recommen­dations, Table 2 provides guidance for the proper application of BFR training during immobilization and strongly limited mobility with very low-load tolerance with the goal of optimizing training efficacy and patient safety [34]. Especially in these phases, it seems nece­ssary to set an adequate high level of cuff pressure in order to induce beneficial effects. For example, Mouser et al. have shown that only high pressures combined with very low-load resistance training induced beneficial vascular adaptations similar to high-load resis­tance training [41]. Furthermore, the studies by Hughes et al. demonstrated that high pressures are more likely to induce hypoalgetic effects than low pressures combined with low-load resistance and aerobic exercise [17, 18].

    Conclusion

    Considering the current evidence on muscle mass and strength in clinical populations [42, 43], BFR provides a promising method for patients especially during immobility or periods of strongly reduced mobility with very low mechanical resilience. While a preoperative treatment can create a protective effect on the surgical limb to reduce post-surgical strength loss and muscle atrophy [3], post-injured / post-surgical therapy can be supported by the application of BFR, either passive or combined with very low-load exercises, to regain pre-traumatic / presurgical strength level faster compared without using BFR [32]. 

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    Autoren

    Dr. Alexander Franz

    Department of Orthopedics and Trauma Surgery, University Hospital Bonn.

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