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Abstract and Figures

Chronic ankle instability (CAI) is a common dysfunctional state in the basketball population accompanied by pain, weakness and proprioceptive deficits which greatly affect performance. Research evidence has supported the use of blood flow restriction (BFR) training as an effective treatment strategy for improving muscle strength, hypertrophy and function following injury in a variety of patient populations. In managing CAI, it is important to address proximal and distal muscle weakness, pain, and altered proprioception to reduce the likelihood of re-occurring ankle injury. The ability to mitigate acute and cumulative strength and muscle volume losses through the integration of BFR after injury has been supported in research literature. In addition, applications of BFR training for modulating pain, improving muscle activation and proximal muscle strength have recently been suggested and may provide potential benefit for athletes with CAI. The purpose of this clinical commentary is to discuss background evidence supporting the implementation of blood flow restriction training and use a theoretical model for managing CAI as well as to suggest novel treatment strategies using this method. Level of evidence: 5.
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Chronic ankle instability (CAI) is a common dysfunctional state in the basketball population accompanied
by pain, weakness and proprioceptive deficits which greatly affect performance. Research evidence has
supported the use of blood flow restriction (BFR) training as an effective treatment strategy for improving
muscle strength, hypertrophy and function following injury in a variety of patient populations. In manag-
ing CAI, it is important to address proximal and distal muscle weakness, pain, and altered proprioception
to reduce the likelihood of re-occurring ankle injury. The ability to mitigate acute and cumulative strength
and muscle volume losses through the integration of BFR after injury has been supported in research lit-
erature. In addition, applications of BFR training for modulating pain, improving muscle activation and
proximal muscle strength have recently been suggested and may provide potential benefit for athletes with
CAI. The purpose of this clinical commentary is to discuss background evidence supporting the implemen-
tation of blood flow restriction training and use a theoretical model for managing CAI as well as to suggest
novel treatment strategies using this method.
Key Words: Ankle instability, blood flow restriction, strength training
Level of Evidence: 5
John Faltus, DPT, SCS, ATC, CSCS1
Johnny Owens, MPT2
Corbin Hedt, PT, DPT, SCS, CSCS3
1 University Physical Therapy and Sports Medicine at Clemson
University, Clemson, SC, USA
2 Owens Recovery Science, San Antonio, TX, USA
3 Houston Methodist, Houston, TX, USA
Confl ict of interest:
Author Johnny Owens is a shareholder of Owens Recovery
Science and is a medical consultant for Delfi Medical
Innovations Inc. Owens Recovery Sciences has a fi nancial
relationship with Delfi Medical Innovations Inc. Johnny
Owens is a medical consultant for the Major Trauma Research
Consortium (METRC). Other authors declare they have no
confl ict of interest in the authorship and publication of this
manuscript or fi nancial interest in the subject matter
discussed in this article.
John Faltus, DPT, SCS, ATC, CSCS
UPTSM, 205 Fike Rec Center,
Clemson University, Clemson SC 29634
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 552
DOI: 10.26603/ijspt20180552
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 553
Chronic ankle instability (CAI) consists of charac-
teristic sequelae including recurrent sprain, pain,
instability and avoidance of activities1 and is typi-
cally defined as mechanical or functional instabil-
ity.2 Mechanical instability is anatomical laxity in
the stabilizing structures around the ankle mortise
where functional instability is a subjective feeling of
giving away despite the lack of displacement beyond
the normal physiological range of talar motion.3 It
can be a particularly debilitating condition in the
athletic population, with an associated high risk for
re-injury.4,5,6 Time loss from sport due to this injury
is typically associated with increased pain and crep-
itus as well as decreased strength, proprioception,
range of motion and balance.7,8 Multiple proprio-
ceptive impairments have been linked to persistent
functional instability including altered muscle spin-
dle activation of the peroneal musculature, abnor-
mal reflex responses to inversion or supination and
proximal kinetic chain deficits as exhibited by pres-
ence of neural inhibition and associated weakness
in the hip abductors.9,10,11 Furthermore, deficits in
postural control and ankle arthro-kinematic motion
quality were identified in athletes with CAI using
accelerometry.12 Repeat episodes of ankle sprains
commonly occur in CAI and appear to further exac-
erbate instability, associated functional deficits and
the ability to maintain a competitive status.5
The multidirectional and repetitive movement
aspects associated with the sport of basketball can
predispose these athletes to ankle injuries. While
jump landing has been identified as the most com-
mon mechanism of injury in this population, change
of direction, cutting and pivoting movements also
contribute to injury occurrence.5 Over half of total
time missed due to injury in this population has
been attributed to ankle injury.13 Both elite and rec-
reational basketball players of both genders with a
previous ankle injury have also been identified as
being at 4.9 times greater risk for subsequent ankle
injury.5 Therefore, it appears that CAI leads to sig-
nificant time lost in sport and previous injury can
result in greater re-injury risk.
Increased pain associated with CAI greatly affects
a basketball athlete’s ability to return to sport and
perform at an elite level. CAI typically presents with
articular changes and chondral lesions within the
ankle joint which can manifest as chronic pain.14
The combination of altered somatosensory afferent
signaling and efferent motor control deficits result-
ing from ankle ligament sprains negatively affects
the ability to produce desired protective motor
responses in the event of an inversion mechanism.15
The resulting injury pathology then can further
exacerbate faulty mechanical patterns and subse-
quent pain presentation associated with repetitive
injury and articular changes.15
Muscle inhibition which occurs following an ankle
sprain has been documented.8 Perron et al. have
found that significant strength deficits exist up to six
months following injury and may contribute to the
high recurrence of lateral ankle sprain.16 Further-
more, increased resting motor thresholds have been
demonstrated in the peroneus longus muscle, bilat-
erally, in subjects with CAI.17 This would indicate
deficits in corticomotor excitability of the peroneus
longus to control subsequent inversion mechanisms
which may result in re-injury.17 Decreased cortico-
motor excitability was also moderately correlated
to self-reported function which would indicate that
subjects’ perceptions of functional limitations likely
manifests in resulting neuromuscular deficits and
poor motor control.17
Altered neuromuscular recruitment and motor con-
trol patterns are not strictly isolated to the ankle joint
in presentations of CAI. Proximal muscle weakness
can contribute to functional deficits which persist
following an ankle sprain.9 In particular, weakness
of the gluteal musculature can contribute to altered
landing mechanics as a result of poor shock absorp-
tion and decreased force attenuation throughout the
lower quarter.18 In the case of basketball athletes,
landing has been identified as a common mecha-
nism of injury for ankle sprains so failing to address
these limitations is problematic.5 Therefore, it is
important to focus on the entire kinetic chain dur-
ing the rehabilitation process with strategies which
effectively address these underlying neuromechani-
cal deficiencies and altered movement patterns.
The purpose of this clinical commentary is to dis-
cuss background evidence supporting the imple-
mentation of blood flow restriction training and
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 554
into the intervention. Giles at al found that, when
compared to standard quadriceps strengthening, low
load exercise with BFR greatly reduced pain in daily
living in subjects with patellofemoral pain (PFP)
following an eight-week program.32 The conceptual
understanding for these changes is that subjects
were able to improve quadriceps muscle strength
with BFR while tolerating loads lower than those
required to make similar gains utilizing traditional
quadriceps strengthening activities.32 Given the
association of quadriceps muscle weakness and PFP
and the increases of knee extensor torque with sig-
nificantly decreased reported pain in this BFR study
group, it has been hypothesized that BFR training
can potentially modulate pain through central and
neural adaptations which influence strength gains.32
Additionally, subjects with anterior knee pain dem-
onstrated an acute reduction in pain immediately
after BFR resisted quad exercises up to 45 minutes
post treatment.33 Although, mechanisms behind
a potential reduction in pain through the applica-
tion of BFR have not been elucidated, intensity of
exercise may play a role in the endogenous opioid
response.34 Despite BFR being performed under low
loads, when performed under continuous occlu-
sion ( deflation cycles during rest periods), the
metabolic stress produced in the working muscle is
similar to exercise at much higher loads.35 This may
allow patients in the early stages of rehabilitation
or with chronic painful injuries to promote cortical
release of opioids to allow for tolerance of rehabilita-
tion programs. Although not directly related to pain
inhibition, increases in corticomotor excitability
have been demonstrated for up to 60-minutes post
continuous BFR exercise possibly due to altered sen-
sory feedback via group III and IV afferents.36 Future
BFR studies are warranted that assess pain in clinical
populations and the peripheral and central mecha-
nisms of pain modulation that may be involved.
Muscle Inhibition
The work by Brandner et al. provides promise as to
the applications of BFR as a potential neuromodu-
lator.36 Following an acute bout of upper extremity
exercise utilizing BFR, corticomotor excitability of
the biceps brachii rapidly increased and remained
elevated for up to 60 minutes post exercise.36 It
is theorized that these adaptations result from
use a theoretical model for managing chronic ankle
instability in the basketball athlete to suggest novel
treatment strategies using this method.
The inability to utilize loads sufficient to induce
strength and hypertrophy responses after ankle
injury due to pain or healing processes may limit
rehabilitation progression. Recently, blood flow
restriction (BFR) training has emerged as a novel
treatment technique due to its ability to create robust
muscle anabolic responses similar to high load train-
ing while utilizing very low loads.19 BFR has shown
to be an effective treatment strategy for diminish-
ing disuse atrophy and weakness during periods of
immobilization as well as increasing strength and
hypertrophy in post-op patient populations.20,21,22
Additionally, BFR has been shown to enhance func-
tion in blast trauma patients and injured military per-
sonnel23 as well as improve performance outcomes
as part of a comprehensive strength and condition-
ing program in the high-performance athlete.24,25
American College of Sports Medicine guidelines rec-
ommend utilization of 60-80% of a one rep max (1
RM) load targeting major muscle groups 2-3 days per
week in order to achieve strength and hypertrophy
gains from resistance training.26 However, similar
gains utilizing BFR have been shown within a two-
week training period at loads of much lower intensity
(20-30% 1 RM).27,28 Although the exact mechanism
is not fully understood, increased muscular fatigue
under hypoxia, cellular swelling and upregulation of
muscle protein synthesis via mammalian target of
rapamycin complex 1 and mitogen-activated protein
kinases (MTORC1/MAPK) which are responsible for
protein synthesis and cell signaling, have been sug-
gested to play a role.29,30,31 While most of these afore-
mentioned studies focused on the lower extremity
in general and post-operative conditions, currently
no studies examining the utilization of BFR with CAI
have been published.
Chronic Pain Management
Chro nic pain which results from CAI can be debili-
tating if not properly managed. Recently published
clinical trials that have assessed pain have reported
significant reductions in pain if BFR is incorporated
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 555
of BFR (Table 1) to attenuate muscle atrophy and
weakness commonly associated with disuse.20,21 For
optimal motor control in these early stages of rehab,
it is important integrate external focus of atten-
tion strategies which have been shown to increase
muscle excitability.43,44 These strategies may include
use of a metronome for repetition pacing or bio-
feedback, especially during exercises which actively
recruit the peroneal and gluteal muscles which have
been identified as commonly inhibited and weak-
ened muscle groups in CAI.9,17,43,44
The proprioceptive, balance and motor control deficits
associated with CAI have been well documented.8,15,17
Exercises which challenge the proprioceptive system
on both stable and unstable surfaces with altered
visual and somatosensory feedback have been effec-
tive for reducing the recurrence of ankle sprains.45
Examples would include single leg static balance on
an unstable surface, multidirectional weight shifting
activities and reactive drills (Figures 2 and 3). These
exercises can target basketball specific demands by
integrating passing (Figure 3), ballhandling and reac-
tive movement drills utilizing verbal or visual cues,
with resources such as a light reactive system (Fig-
ure 2) or a laser pointer, in order to emphasize an
external focus of attention. Exercise progressions
would include band-resisted movements replicating
basketball specific patterns such as jab steps, close
increased excitability of corticospinal circuits which
results in long-lasting adaptations similar to those
which occur following heavy-load resistance train-
ing.36 Further research evidence is needed to suggest
whether utilization of BFR can potentially improve
motor recruitment and neural excitability of inhib-
ited or weak musculature following injury, such as
CAI as addressed conceptually in this commentary.
Kinetic Chain Considerations and Proximal
BFR training would appear to be an effective treat-
ment strategy that can be implemented to improve
proximal muscle strength. Abe et al. found signifi-
cant increases in gluteal muscle strength and hyper-
trophy following a two-week BFR program compared
to a control group, implementing BFR with exer-
cises that included the low load squat and leg curl.37
Despite distal occlusion, proximal gains may result
from fatigue of musculature below the cuff requiring
more recruitment of synergistic proximal muscles,
a backflow effect into musculature above the area
of restriction or a potential systemic effect second-
ary to the anabolic cascade created by BFR.38,39,40,41
Potential benefits of proximal effects from this train-
ing strategy may allow safe implementation during
both early rehabilitation and return to sport specific
exercises which challenge proprioception and bal-
ance to incorporate proximal and distal effects.
With a comprehensive understanding of the research
evidence behind BFR training, one can then attempt
to translate this information into applied clinical
practice. Loenneke et al. proposed a clinical integra-
tion model which advocates for utilization of BFR
throughout various phases of injury rehabilitation.42
The four proposed phases of BFR implementation
include: 1) BFR alone during periods of bed rest, 2)
BFR combined with low-workload walking exercise,
3) BFR combined with low-load resistance exercise,
and 4) low-load BFR training combined with tradi-
tional high-load resistance exercise.42 In cases of pro-
longed immobilization or restricted weightbearing
where BFR walking may not be appropriate, low-load,
resisted, open kinetic chain exercises, such as ankle
ROM, leg lift (Figure 1) and bridge variations may
be used safely and effectively with implementation
Figure 1. Open kinetic chain leg lift variation for hip muscle
strengthening with BFR (Delfi Medical Innovations Inc. Van-
couver, BC Canada).
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 556
Table 1. Integration of BFR with Rehabilitation for Ankle Instability.
Figure 2. BFR static single leg balance on unstable surface
with integration of light system (Dynavision D2 -Dynavi-
sion International, LLC West Chester Township, OH; Delfi
Medical Innovations Inc. Vancouver, BC Canada)
Figure 3. BFR single leg stability with reactive passing com-
ponent (BOSU® Ashland, OH; Delfi Medical Innovations Inc.
Vancouver, BC Canada).
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 557
As the athlete progresses back into sport specific
activities, BFR training can still play an integral role
in developing strength and performance attributes
when combined with a traditional strength and con-
ditioning program. Implementation of BFR would
follow a high load-low load model whereas BFR
exercises would be implemented intra-session in a
low-load strategy following traditional high load resis-
tance exercises to enhance hormonal responses and
strengthening benefits following the session.49 An
example as it applies to the lower extremity would be
completing modified bodyweight squats or leg press
exercise at 20% maximal load utilizing BFR at the end
of a lifting session which consisted of near maximal
(80% max) squat and deadlift exercises. This strategy
would be especially beneficial in transferring BFR
training adaptations which occurred during the rehab
process over to individualized strength and condition-
ing programs that are implemented upon return to
play in athletes with CAI. Lastly, nutritional consid-
erations must be addressed in the rehabilitating an
athlete using BFR as part of a comprehensive perfor-
mance enhancement program. Due to the increased
protein synthesis response following BFR training, it
is important the athlete consume 20-35 grams of pro-
tein post-activity for muscle tissue healing and recov-
ery.50 Whey protein is preferred due to both its rapid
digestion and absorption as well as greater leucine
content which further enhances protein synthesis.50
Safety is of paramount concern when considering
rehabilitation programs for injured individuals. BFR
utilizes non-traditional methods of building strength
and inducing muscle hypertrophy, so reasonable
vigilance is required of rehabilitation professionals
to maintain safety.
In the instance of tourniquet systems, research on
safety and efficacy has consistently been moni-
tored with technological advancements.51,52,53 In
the surgical environment, tourniquets are applied
for upwards of several hours at a time to provide a
bloodless operating field.51 Generally, it is suggested
that tourniquet time is minimized as much as pos-
sible during surgeries such as total knee arthro-
plasty (TKA) to mitigate risks such as deep vein
thrombosis (DVT), wound infection, hematoma, and
out steps, drop step squats and lateral slides (Figure
4). These exercises can be safely integrated with BFR
training to further enhance proximal strengthening
and neuromuscular control (Table 1).
BFR training can both complement and enhance
the conditioning aspects of a return to play rehab
program. A BFR treadmill walking protocol, per-
formed six days per week for two weeks, resulted in
significant improvements in maximal aerobic capac-
ity, maximal ventilation and anaerobic capacity in
male collegiate basketball athletes.46 The protocol
consisted of five periods of three-minute working
sets at 4-6 km/h and 5% grade with 60 second inter-
set rest.46 Similar findings occurred, in addition to
increased size and strength of the leg muscles, fol-
lowing both BFR cycling and low-intensity walking
programs.47,48 This indicates that, when utilized as
part of a non-impact conditioning program, BFR
training can improve overall cardiovascular fitness
when combined with aerobic activity. This is espe-
cially important during rehab phases where limita-
tions in mobility and dynamic loading do not permit
the athlete to run or perform on-court conditioning
activities. Athletes with CAI who sustain recurrent
ankle injuries would likely benefit from such a pro-
gram during periods when dynamic loading activi-
ties are limited in order to promote tissue healing
and recovery from acute injury.
Figure 4. BFR band resisted drop step squat (Delfi Medical
Innovations Inc. Vancouver, BC Canada).
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 558
have demonstrated positive efficacy and good safety
with very few ill effects. Under skilled supervision
and with appropriate equipment, BFR can be used as
a safe alternative to traditional high-intensity exercise
to develop strength and muscular hypertrophy.
BFR training could theoretically be safely and
effectively implemented as part of a rehabilitation
program addressing deficits associated with CAI.
Benefits of BFR training include minimizing mus-
cle weakness and atrophy associated with the acute
phase of injury, potentially modulating pain related
to injury conditions, facilitating tissue healing and
enhancing muscle hypertrophy and strength gains
when combined with low load exercise. Evidence
also suggests that BFR training can enhance both
aerobic and anaerobic properties when integrated as
part of a cycling or walking protocol. These strategies
and suggestions provided in this commentary could
be especially helpful in cases of CAI where recurrent
injury due to both local and proximal weakness, pain,
and both decreased proprioception and function con-
tribute to periods of low loading or limited sports spe-
cific activities during rehab where tissue healing and
recovery is prioritized. Safety of the athlete should be
prioritized through utilization of appropriate medical
devices by trained medical personnel.
1. Guillo S, Bauer T, Lee J et al. Consensus in chronic
ankle instability: aetiology, assessment, surgical
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ecchymosis.53 Similar risks can be expected during
BFR training as with the use of tourniquet devices
including pneumatic cuffs and straps. However, at
lower levels of constriction and reduced tourniquet
time, these risks are likely minimal.
Research on safety during BFR and exercise is cur-
rently limited, however several measures have
been examined with regard to outcomes of exercise
with BFR training versus regular exercise. A recent
review by Loenneke and colleagues examined
peripheral blood flow hemodynamics with BFR and
determined that changes in blood flow appear to
occur in a “similar fashion as regular exercise”.54 Fur-
thermore, Lida et al observed certain central cardio-
vascular responses to BFR and found that subjects
exhibit elevated cardiac markers (blood pressures,
heart rate) in occlusive protocols compared to con-
trol groups.55 However, these values are still far less
than those performing high intensity exercise, and
low-intensity exercise (20% 1RM) with occlusion
may be a safe alternative.55
The potential for thrombosis and clotting can be a
serious risk when considering patients in a rehabilita-
tive state. Complete vascular occlusion can be expe-
rienced with strenuous, high-intensity exercise with
tourniquets and has been shown to increase the for-
mation of thrombus.56 However, reported issues of
thrombosis with BFR are as little as 0.06% in some
studies.57 Others have found that neither prothrombin
time (PT) nor D-dimer levels increased following BFR
training.58 This may be due to the fact that occlusion
levels during most researched BFR protocols do not
promote maximal occlusion, given that the device has
a means of pressure regulation. suggesting cuff pres-
sures be relative to cuff width and limb circumference
to protect the neurovasculature of the extremity.54,59,
60 Nerve conduction velocity (NCV) can be affected
significantly by tourniquet pressure, giving rise to fur-
ther research into electrophysiological changes dur-
ing BFR.61 The use of wide tourniquets significantly
reduces pressures needed for vascular occlusion and
has been recommended in clinical settings.62 Addition-
ally, personalized BFR utilizes Doppler technologies
to individualize tourniquet pressures for each patient,
providing further safety benefit.63
Ultimately, further investigation into BFR protocols
and their safety is warranted. However, most protocols
The International Journal of Sports Physical Therapy | Volume 13, Number 3 | June 2018 | Page 559
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... 121 Using BFR with lower loads and mitigating loss of Type II muscle would be highly beneficial for basketball athletes. Additionally, Faltus et al. 122 provide further theoretical concepts for BFR within the basketball population, inclusive of chronic pain management, increased motor unit recruitment, and kinetic chain/proximal improvements. Further study is needed within these athletes to determine appropriate loading parameters as well as exercise selection and frequency. ...
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The use of blood flow restriction (BFR) within rehabilitation is rapidly increasing as further research is performed elucidating purported benefits such as improved muscular strength and size, neuromuscular control, decreased pain, and increased bone mineral density. Interestingly, these benefits are not isolated to structures distal to the occlusive stimulus. Proximal gains are of high interest to rehabilitation professionals, especially those working with patients who are limited due to pain or postsurgical precautions. The review to follow will focus on current evidence and ongoing hypotheses regarding physiologic responses to BFR, current clinical applications, proximal responses to BFR training, potential practical applications for rehabilitation and injury prevention, and directions for future research. Interestingly, benefits have been found in musculature proximal to the occlusive stimulus, which may lend promise to a greater variety of patient populations and conditions. Furthermore, an increasing demand for BFR use in the sports world warrants further research for performance research and recovery. Level of Evidence Level V, expert opinion.
Of all sports-related injuries treated in the emergency room, basketball accounts for over 34%. Basketball-related injuries are the most common type of sports-related injury in patients under the age of 25 years and second in those aged 25–40 years. The ankle is by far the most common joint injured in the National Basketball Association, with ankle sprains being the most common type of injury to the ankle. Prevention strategies, functional rehabilitation, and judicious use of operative intervention are all important in the management of the injured basketball player for safe and timely return to play.
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Purpose: To determine the influence of different cuff widths on muscle size and strength, and also investigate whether a wider cuff would result in less adaptation compared to a narrow cuff when inflated to the same relative pressure (80% arterial occlusion pressure). Methods: Eleven physically active males had their arms randomly divided into two separate conditions: low-load blood flow restriction exercise with a narrow cuff (BFR+N - 5 cm) and low-load blood flow restriction exercise with a wide cuff (BFR+W - 10 cm). All participants underwent 12-wk of unilateral elbow flexion at 20% of their one repetition maximum (1RM). Elbow flexion strength (1RM), elbow flexor muscle cross sectional area (CSA), arterial blood flow, training volume, ratings of perceived exertion (RPE) and pain (RPP) were assessed before and after training. Results: Elbow flexion 1RM and CSA significantly increased in both conditions (BFR+N = 13.5%, and 9% vs BFR+W = 11.9% and 11.2%, respectively). The arterial blood flow was significantly reduced when 80% of arterial occlusion pressure was applied in both conditions (BFR+N = 61.2% and BFR+W = 63.5%). There were no significant differences in the training volume, RPE or RPP between conditions (p>0.05). Conclusion: We wish to suggest that, regardless of cuff width, both protocols produced similar increases in 1RM and elbow flexor CSA and these responses may be related to the similar training volume and/or similar reductions in arterial blood flow produced when both cuffs were inflated to the same relative pressure.
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We used transcranial magnetic stimulation (TMS) to investigate whether an acute bout of resistance exercise with blood flow restriction (BFR) stimulated changes in corticomotor excitability (motor evoked potential; MEP) and short-interval intracortical inhibition (SICI), and compared the responses to two traditional resistance exercise methods. Ten males completed four unilateral elbow flexion exercise trials in a balanced, randomized crossover design: 1) heavy-load (HL: 80% one-repetition maximum [1-RM]); 2) light-load (LL; 20% 1-RM); and two other light-load trials with BFR applied 3) continuously at 80% resting systolic blood pressure (BFR-C) or 4) intermittently at 130% resting systolic blood pressure (BFR-I). MEP amplitude and SICI were measured using TMS at baseline, and at four time-points over a 60 min post-exercise period. MEP amplitude increased rapidly (within 5 minutes post-exercise) for BFR-C and remained elevated for 60 minutes post-exercise compared with all other trials. MEP amplitudes increased for up to 20 and 40 min for LL and BFR-I, respectively. These findings provide evidence that BFR resistance exercise can modulate corticomotor excitability, possibly due to altered sensory feedback via group III and IV afferents. This response may be an acute indication of neuromuscular adaptations that underpin changes in muscle strength following a BFR resistance training programme.
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Blood flow restriction (BFR) training has been shown to increase muscle size and strength when combined with low-load [20-30 % one-repetition maximum (1RM)] resistance training in the lower body. Fewer studies have examined low-load BFR training in combination with upper body exercise, which may differ as some musculature cannot be directly restricted by the BFR stimulus (chest, shoulders). The objective of this study was to examine muscle adaptations occurring in the upper body in response to low-load BFR training. Google Scholar, PubMed, and SPORTDiscus were searched through July 2015 using the key phrases 'blood flow restriction training', 'occlusion resistance training', and 'KAATSU'. Upper body training studies implementing the BFR stimulus and providing a pre and post measure of muscle size and/or strength were included. A total of 19 articles met the inclusion criteria for this review. The effectiveness of low-load BFR training appears to be minimally impacted by alterations to the intensity and restrictive pressures used; however, the ability to quantitatively analyze our results was limited by unstandardized protocols. Low-load BFR training increased muscle size and strength in limbs located proximal (chest, shoulders) and distal (biceps, triceps) to the restrictive stimulus; while volume-matched exercise in the absence of BFR did not elicit beneficial muscle adaptations. Some of the musculature in the upper body cannot be directly restricted by the application of BFR. Despite this, increases in muscle size and strength were observed in muscles placed under direct and indirect BFR.
Central opioidergic mechanisms may modulate the positive effects of physical exercise such as mood elevation and stress reduction. How exercise intensity and concomitant affective changes affect central opioidergic responses is unknown. We studied the effects of acute physical exercise on the cerebral μ-opioid receptors (MOR) of 22 healthy recreationally active males using positron emission tomography (PET) and the MOR-selective radioligand [¹¹C]carfentanil. MOR binding was measured in three conditions on separate days: after a 60-min aerobic moderate-intensity exercise session, after a high-intensity interval training (HIIT) session, and after rest. Mood was measured repeatedly throughout the experiment. HIIT significantly decreased MOR binding selectively in the frontolimbic regions involved in pain, reward, and emotional processing (thalamus, insula, orbitofrontal cortex, hippocampus, and anterior cingulate cortex). Decreased binding correlated with increased negative emotionality. Moderate-intensity exercise did not change MOR binding, although increased euphoria correlated with decreased receptor binding. These observations, consistent with endogenous opioid release, highlight the role of the μ-opioid system in mediating affective responses to high-intensity training as opposed to recreational moderate physical exercise.
Background: Quadriceps strengthening exercises are part of the treatment of patellofemoral pain (PFP), but the heavy resistance exercises may aggravate knee pain. Blood flow restriction (BFR) training may provide a low-load quadriceps strengthening method to treat PFP. Methods: Seventy-nine participants were randomly allocated to a standardised quadriceps strengthening (standard) or low-load BFR. Both groups performed 8 weeks of leg press and leg extension, the standard group at 70% of 1 repetition maximum (1RM) and the BFR group at 30% of 1RM. Interventions were compared using repeated-measures analysis of variance for Kujala Patellofemoral Score, Visual Analogue Scale for 'worst pain' and 'pain with daily activity', isometric knee extensor torque (Newton metre) and quadriceps muscle thickness (cm). Subgroup analyses were performed on those participants with painful resisted knee extension at 60°. Results: Sixty-nine participants (87%) completed the study (standard, n=34; BFR, n=35). The BFR group had a 93% greater reduction in pain with activities of daily living (p=0.02) than the standard group. Participants with painful resisted knee extension (n=39) had greater increases in knee extensor torque with BFR than standard (p<0.01). No between-group differences were found for change in Kujala Patellofemoral Score (p=0.31), worst pain (p=0.24), knee extensor torque (p=0.07) or quadriceps thickness (p=0.2). No difference was found between interventions at 6 months. Conclusion: Compared with standard quadriceps strengthening, low load with BFR produced greater reduction in pain with daily living at 8 weeks in people with PFP. Improvements were similar between groups in worst pain and Kujala score. The subgroup with painful resisted knee extension had larger improvements in quadriceps strength from BFR. Trial registration number: 12614001164684.
Background and objective Low-load exercise training with blood flow restriction (BFR) can increase muscle strength and may offer an effective clinical musculoskeletal (MSK) rehabilitation tool. The aim of this review was to systematically analyse the evidence regarding the effectiveness of this novel training modality in clinical MSK rehabilitation. Design This is a systematic review and meta-analysis of peer-reviewed literature examining BFR training in clinical MSK rehabilitation (Research Registry; researchregistry91). Data sources A literature search was conducted across SPORTDiscus (EBSCO), PubMed and Science Direct databases, including the reference lists of relevant papers. Two independent reviewers extracted study characteristics and MSK and functional outcome measures. Study quality and reporting was assessed using the Tool for the assEssment of Study qualiTy and reporting in EXercise. Eligibility Search results were limited to exercise training studies investigating BFR training in clinical MSK rehabilitation, published in a scientific peer-reviewed journal in English. Results Twenty studies were eligible, including ACL reconstruction (n=3), knee osteoarthritis (n=3), older adults at risk of sarcopenia (n=13) and patients with sporadic inclusion body myositis (n=1). Analysis of pooled data indicated low-load BFR training had a moderate effect on increasing strength (Hedges’ g=0.523, 95% CI 0.263 to 0.784, p<0.001), but was less effective than heavy-load training (Hedges’ g=0.674, 95% CI 0.296 to 1.052, p<0.001). Conclusion Compared with low-load training, low-load BFR training is more effective, tolerable and therefore a potential clinical rehabilitation tool. There is a need for the development of an individualised approach to training prescription to minimise patient risk and increase effectiveness.
Study Design Controlled laboratory study, cross sectional. Background Lateral ankle sprains are among the most common injuries encountered during athletic participation. Following the initial injury there is an alarmingly high risk of re-injury and development of chronic ankle instability (CAI), which is dependent on a combination of factors, including sensorimotor deficits and changes in the biomechanical environment of the ankle joint. Objective To evaluate CAI-related disturbances in arthrokinematic motion quality and postural control and the relationships between them. Methods Sixty-three male subjects (31 with CAI and 32 healthy controls) were enrolled in the study. For arthrokinematic motion quality analysis, the vibroarthrographic signals were collected during ankle flexion/extension motion using an acceleration sensor and described by variability (VMS), amplitude (R4) and frequency (P1 and P2) parameters. Using the Biodex Balance System, single leg dynamic balance was measured by overall (OSI), anteroposterior (APSI), and mediolateral (MLSI) stability indices. Results In the CAI group values of vibroarthrographic parameters (VMS, R4, P1 and P2) were significantly higher than in the controls (p<0.01). Similar results were obtained for all postural control parameters (OSI, APSI, MLSI; p<0.05). Moreover, correlations between OSI and VMS, P1 and P2, as well as APSI and P1 and P2 were observed in the CAI patient group but not in controls. Conclusions In patients with CAI, deficits in both quality of ankle arthrokinematic motion and postural control was present. Therefore physical therapy interventions focused on improving ankle neuromuscular control and arthrokinematic function are necessary in CAI patient care. J Orthop Sports Phys Ther, Epub 4 Nov 2016. doi:10.2519/jospt.2017.6836.
A single session of skill or strength training can modulate the primary motor cortex (M1), which manifests as increased corticospinal excitability (CSE) and decreased short-latency intra-cortical inhibition (SICI). We tested the hypothesis that both skill and strength training can propagate the neural mechanisms mediating cross-transfer and modulate the ipsilateral M1 (iM1). Transcranial magnetic stimulation (TMS) measured baseline CSE and SICI in the contralateral motor cortex (cM1) and iM1. Participants completed 4 sets of unilateral training with their dominant arm, either visuomotor tracking, metronome-paced strength training (MPST), self-paced strength training (SPST) or control. Immediately post training, TMS was repeated in both M1s. Motor-evoked potentials (MEPs) increased and inhibition was reduced for skill and MPST training from baseline in both M1s. Self-paced strength training and control did not produce changes in CSE and SICI when compared to baseline in both M1s. After training, skill and MPST increased CSE and decreased SICI in cM1 compared to SPST and control. Skill and MPST training decreased SICI in iM1 compared to SPST and control post intervention; however, CSE in iM1 was not different across groups post training. Both skill training and MPST facilitated an increase in CSE and released SICI in iM1 and cM1 compared to baseline. Our results suggest that synchronizing to an auditory or a visual cue promotes neural adaptations within the iM1, which is thought to mediate cross transfer. Copyright © 2015. Published by Elsevier Ltd.