Effect of low-load resistance training with different degrees of blood flow restriction in patients with knee osteoarthritis: study protocol for a randomized trial

Abstract Background Knee osteoarthritis (KOA) is a common degenerative disease that causes pain, functional impairment, and reduced quality of life. Resistance training is considered as an effective approach to reduce the risk of muscle weakness in patients with KOA. Blood flow restriction (BFR) with low-load resistance training has better clinical outcomes than low-load resistance training alone. However, the degree of BFR which works more effectively with low-load resistance training has not been determined. The purpose of this study is to evaluate the effectiveness of different degrees of BFR with low-load resistance training in patients with KOA on pain, self-reported function, physical function performance, muscle strength, muscle thickness, and quality of life. Methods This is a study protocol for a randomized, controlled trial with blinded participants. One hundred individuals will be indiscriminately assigned into the following groups: two training groups with a BFR at 40% and 80% limb occlusion pressure (LOP), a training group without BFR, and a health education group. The three intervention groups will perform strength training for the quadriceps muscles twice a week for 12 weeks, while the health education group will attend sessions once a week for 12 weeks. The primary outcome is pain. The secondary outcomes include self-reported function, physical function performance, muscle strength of the knee extensors, muscle mass of the quadriceps, quality of life, and adverse events. Intention-to-treat analysis will be conducted for individuals who withdraw during the trial. Discussion Previous studies have shown that BFR with low-load resistance training is more effective than low-load resistance training alone; however, a high degree of BFR may cause discomfort during training. If a 40% LOP for BFR could produce similar clinical outcomes as an 80% LOP for BFR, resistance training with a low degree of BFR can be chosen for patients with KOA who are unbearable for a high degree of BFR. Trial registration Chinese Clinical Trial Registry ChiCTR2000037859 (http://www.chictr.org.cn/edit.aspx?pid=59956&htm=4). Registered on 2 September 2020

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Effect of Low-load resistance training with different degrees of blood flow restriction in patients with knee osteoarthritis: study protocol for a randomized trial

10.21203/rs.3.rs-467579/v1 ◽

2021 ◽

Author(s):

Haonan Wang ◽

Lin Cheng ◽

Yan Chen ◽

Shen-Tao Wang ◽

De-Xin Hu ◽

...

Keyword(s):

Quality Of Life ◽

Blood Flow ◽

Resistance Training ◽

Muscle Strength ◽

Load Resistance ◽

Flow Restriction ◽

Education Group ◽

Low Load ◽

High Degree

Abstract Background: Knee osteoarthritis (KOA) is a common degenerative disease that causes pain, functional impairment, and a reduced quality of life. Resistance training is considered an effective approach to reduce the risk factor of muscle weakness in patients with KOA. Blood flow restriction (BFR) with low-load resistance training have better clinical outcomes than low-load resistance training alone. However, the effective degree of BFR with low-load resistance training has not been determined. The purpose of this study will be to evaluate the effectiveness of different degrees of BFR with low-load resistance training in patients with KOA on pain, self-reported function, physical function performance, muscle strength, muscle mass, and quality of life.Methods: This is a study protocol for a single-blind, randomized, controlled trial. One hundred individuals will be indiscriminately assigned into the following groups: two training groups with a BFR at 40% and 80% limb occlusion pressure (LOP), a training group without BFR, and a health education group. The three intervention groups will perform strength training for the quadriceps muscles twice a week for 12 weeks. The health education group will attend sessions once a week for 12 weeks. The primary outcomes will include pain, self-reported function, and adverse events. The secondary outcomes will include physical function performance, muscle strength of the knee extensors, muscle mass of quadriceps, and quality of life. The intention-to-treat analysis will be conducted for individuals who withdraw during the trial.Discussion: Previous studies have shown that BFR with low-load resistance training is more effective than low-load resistance training alone; however, a high degree of BFR may cause discomfort during training. If a 40% LOP for BFR will produce similar clinical outcomes as an 80% LOP for BFR, resistance training with a low degree of BFR can be chosen for those patients with KOA who are intolerant to a high degree of BFR.Trial registration: Chinese Clinical Trial Registry, ChinCTR2000037859. Registered on 2 September 2020.

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Blood Flow Restriction Therapy Impact on Musculoskeletal Strength and Mass

Video Journal of Sports Medicine ◽

10.1177/26350254211032681 ◽

2021 ◽

Vol 1 (5) ◽

pp. 263502542110326

Author(s):

Steven R. Dayton ◽

Simon J. Padanilam ◽

Tyler C. Sylvester ◽

Michael J. Boctor ◽

Vehniah K. Tjong

Keyword(s):

Blood Flow ◽

Resistance Training ◽

Muscle Strength ◽

Load Resistance ◽

High Load ◽

Blood Flow Restriction ◽

Occlusion Pressure ◽

Total Occlusion ◽

Flow Restriction ◽

Low Load

Background: Blood flow restriction (BFR) training restricts arterial inflow and venous outflow from the extremity and can produce gains in muscle strength at low loads. Low-load training reduces joint stress and decreases cardiovascular risk when compared with high-load training, thus making BFR an excellent option for many patients requiring rehabilitation. Indications: Blood flow restriction has shown clinical benefit in a variety of patient populations including healthy patients as well as those with osteoarthritis, anterior cruciate ligament reconstruction, polymyositis/dermatomyositis, and Achilles tendon rupture. Technique Description: This video demonstrates BFR training in 3 clinical areas: upper extremity resistance training, lower extremity resistance training, and low-intensity cycling. All applications of BFR first require determination of total occlusion pressure. Upper extremity training requires inflating the tourniquet to 50% of total occlusion pressure, while lower extremity exercises use 80% of total occlusion pressure. Low-load resistance training exercises follow a specific repetition scheme: 30 reps followed by a 30-second rest and then 3 sets of 15 reps with 30-seconds rest between each. During cycle training, 80% total occlusion pressure is used as the patient cycles for 15 minutes without rest. Results: Augmenting low-load resistance training with BFR increases muscle strength when compared with low-load resistance alone. In addition, low-load BFR has demonstrated an increase in muscle mass greater than low-load training alone and equivalent to high-load training absent BFR. A systematic review determined the safety of low-load training with BFR is comparable to traditional high-intensity resistance training. The most common adverse effects include exercise intolerance, discomfort, and dull pain which are also frequent in patients undergoing traditional resistance training. Severe adverse effects including deep vein thrombosis, pulmonary embolism, and rhabdomyolysis are exceedingly rare, less than 0.006% according to a national survey. Patients undergoing BFR rehabilitation experience less perceived exertion and demonstrate decreased pain scores compared with high-load resistance training. Conclusion: Blood flow restriction training is an effective alternative to high-load resistance training for patients requiring musculoskeletal rehabilitation for multiple disease processes as well as in the perioperative setting. Blood flow restriction has been shown to be a safe training modality when managed by properly trained physical therapists and athletic trainers.

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Magnitude of Muscle Strength and Mass Adaptations Between High-Load Resistance Training Versus Low-Load Resistance Training Associated with Blood-Flow Restriction: A Systematic Review and Meta-Analysis

Sports Medicine ◽

10.1007/s40279-017-0795-y ◽

2017 ◽

Vol 48 (2) ◽

pp. 361-378 ◽

Cited By ~ 74

Author(s):

Manoel E. Lixandrão ◽

Carlos Ugrinowitsch ◽

Ricardo Berton ◽

Felipe C. Vechin ◽

Miguel S. Conceição ◽

...

Keyword(s):

Systematic Review ◽

Blood Flow ◽

Resistance Training ◽

Muscle Strength ◽

Meta Analysis ◽

Load Resistance ◽

High Load ◽

Blood Flow Restriction ◽

Flow Restriction ◽

Low Load

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The effectiveness of blood-flow restricted resistance training in the musculoskeletal rehabilitation of patients with lower limb disorders: A systematic review and meta-analysis

Clinical Rehabilitation ◽

10.1177/02692155211003480 ◽

2021 ◽

pp. 026921552110034

Author(s):

Nico Nitzsche ◽

Alexander Stäuber ◽

Samuel Tiede ◽

Henry Schulz

Keyword(s):

Blood Flow ◽

Resistance Training ◽

Muscle Strength ◽

Lower Limb ◽

Meta Analysis ◽

Load Resistance ◽

Muscle Volume ◽

Low Load ◽

Study Characteristics ◽

Musculoskeletal Rehabilitation

Objective: This meta-analysis aimed to evaluate the effectiveness of low-load Resistance Training (RT) with or without Blood Flow Restriction (BFR) compared with conventional RT on muscle strength in open and closed kinetic chains, muscle volume and pain in individuals with orthopaedic impairments. Data sources: Searches were conducted in the PubMed, Web of Science, Scopus and Cochrane databases, including the reference lists of randomised controlled trials (RCT’s) up to January 2021. Review method: An independent reviewer extracted study characteristics, orthopaedic indications, exercise data and outcome measures. The primary outcome was muscle strength of the lower limb. Secondary outcomes were muscle volume and pain. Study quality and reporting was assessed using the TESTEX scale. Results: A total of 10 RCTs with 386 subjects (39.2 ± 17.1 years) were included in the analysis to compare low-load RT with BFR and high or low-load RT without BFR. The meta-analysis showed no significant superior effects of low-load resistance training with BFR regarding leg muscle strength in open and closed kinetic chains, muscle volume or pain compared with high or low-load RT without BFR in subjects with lower limb impairments. Conclusion: Low-load RT with BFR leads to changes in muscle strength, muscle volume and pain in musculoskeletal rehabilitation that are comparable to conventional RT. This appears to be independent of strength testing in open or closed kinetic chains.

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Low-load resistance training to task failure with and without blood flow restriction: muscular functional and structural adaptations

AJP Regulatory Integrative and Comparative Physiology ◽

10.1152/ajpregu.00243.2019 ◽

2020 ◽

Vol 318 (2) ◽

pp. R284-R295 ◽

Cited By ~ 4

Author(s):

Christopher Pignanelli ◽

Heather L. Petrick ◽

Fatemeh Keyvani ◽

George J. F. Heigenhauser ◽

Joe Quadrilatero ◽

...

Keyword(s):

Skeletal Muscle ◽

Blood Flow ◽

Resistance Training ◽

Resistance Exercise ◽

Load Resistance ◽

Muscle Endurance ◽

Flow Restriction ◽

Muscle Adaptations ◽

Low Load ◽

Skeletal Muscle Adaptations

The application of blood flow restriction (BFR) during resistance exercise is increasingly recognized for its ability to improve rehabilitation and for its effectiveness in increasing muscle hypertrophy and strength among healthy populations. However, direct comparison of the skeletal muscle adaptations to low-load resistance exercise (LL-RE) and low-load BFR resistance exercise (LL-BFR) performed to task failure is lacking. Using a within-subject design, we examined whole muscle group and skeletal muscle adaptations to 6 wk of LL-RE and LL-BFR training to repetition failure. Muscle strength and size outcomes were similar for both types of training, despite ~33% lower total exercise volume (load × repetition) with LL-BFR than LL-RE (28,544 ± 1,771 vs. 18,949 ± 1,541 kg, P = 0.004). After training, only LL-BFR improved the average power output throughout the midportion of a voluntary muscle endurance task. Specifically, LL-BFR training sustained an 18% greater power output from baseline and resulted in a greater change from baseline than LL-RE (19 ± 3 vs. 3 ± 4 W, P = 0.008). This improvement occurred despite histological analysis revealing similar increases in capillary content of type I muscle fibers following LL-RE and LL-BFR training, which was primarily driven by increased capillary contacts (4.53 ± 0.23 before training vs. 5.33 ± 0.27 and 5.17 ± 0.25 after LL-RE and LL-BFR, respectively, both P < 0.05). Moreover, maximally supported mitochondrial respiratory capacity increased only in the LL-RE leg by 30% from baseline ( P = 0.006). Overall, low-load resistance training increased indexes of muscle oxidative capacity and strength, which were not further augmented with the application of BFR. However, performance on a muscle endurance test was improved following BFR training.

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Low-load blood flow restriction training induces similar morphological and mechanical Achilles tendon adaptations compared with high-load resistance training

Journal of Applied Physiology ◽

10.1152/japplphysiol.00602.2019 ◽

2019 ◽

Vol 127 (6) ◽

pp. 1660-1667 ◽

Cited By ~ 6

Author(s):

Christoph Centner ◽

Benedikt Lauber ◽

Olivier R. Seynnes ◽

Simon Jerger ◽

Tim Sohnius ◽

...

Keyword(s):

Blood Flow ◽

Resistance Training ◽

Achilles Tendon ◽

Load Resistance ◽

High Load ◽

Blood Flow Restriction ◽

Resistance Training Program ◽

Flow Restriction ◽

Low Load ◽

Tendon Properties

Low-load blood flow restriction (LL-BFR) training has gained increasing interest in the scientific community by demonstrating that increases in muscle mass and strength are comparable to conventional high-load (HL) resistance training. Although adaptations on the muscular level are well documented, there is little evidence on how LL-BFR training affects human myotendinous properties. Therefore, the aim of the present study was to investigate morphological and mechanical Achilles tendon adaptations after 14 wk of strength training. Fifty-five male volunteers (27.9 ± 5.1 yr) were randomly allocated into the following three groups: LL-BFR [20–35% of one-repetition maximum (1RM)], HL (70–85% 1RM), or a nonexercising control (CON) group. The LL-BFR and HL groups completed a resistance training program for 14 wk, and tendon morphology, mechanical as well as material properties, and muscle cross-sectional area (CSA) and isometric strength were assessed before and after the intervention. Both HL (+40.7%) and LL-BFR (+36.1%) training induced significant increases in tendon stiffness ( P < 0.05) as well as tendon CSA (HL: +4.6%, LL-BFR: +7.8%, P < 0.001). These changes were comparable between groups without significant changes in Young’s modulus. Furthermore, gastrocnemius medialis muscle CSA and plantar flexor strength significantly increased in both training groups ( P < 0.05), whereas the CON group did not show significant changes in any of the evaluated parameters. In conclusion, the adaptive change in Achilles tendon properties following low-load resistance training with partial vascular occlusion appears comparable to that evoked by high-load resistance training. NEW & NOTEWORTHY Low-load blood flow restriction (LL-BFR) training has been shown to induce beneficial adaptations at the muscular level. However, studies examining the effects on human tendon properties are rare. The findings provide first evidence that LL-BFR can increase Achilles tendon mechanical and morphological properties to a similar extent as conventional high-load resistance training. This is of particular importance for individuals who may not tolerate heavy training loads but still aim for improvements in myotendinous function.

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Low load resistance training with blood flow restriction decreases anterior knee pain more than resistance training alone. A pilot randomised controlled trial

Physical Therapy in Sport ◽

10.1016/j.ptsp.2018.09.007 ◽

2018 ◽

Vol 34 ◽

pp. 121-128 ◽

Cited By ~ 13

Author(s):

Vasileios Korakakis ◽

Rodney Whiteley ◽

Giannis Giakas

Keyword(s):

Blood Flow ◽

Randomised Controlled Trial ◽

Resistance Training ◽

Controlled Trial ◽

Load Resistance ◽

Pilot Randomised Controlled Trial ◽

Flow Restriction ◽

Low Load ◽

Randomised Controlled ◽

Anterior Knee

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Perceptual and Neuromuscular Responses Adapt Similarly Between High-Load Resistance Training and Low-Load Resistance Training With Blood Flow Restriction

The Journal of Strength and Conditioning Research ◽

10.1519/jsc.0000000000003879 ◽

2020 ◽

Vol Publish Ahead of Print ◽

Author(s):

Emerson Luiz Teixeira ◽

Vitor de Salles Painelli ◽

Brad Jon Schoenfeld ◽

Carla Silva-Batista ◽

Ariel Roberth Longo ◽

...

Keyword(s):

Blood Flow ◽

Resistance Training ◽

Load Resistance ◽

High Load ◽

Blood Flow Restriction ◽

Flow Restriction ◽

Low Load ◽

Neuromuscular Responses

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Acute cellular and molecular responses and chronic adaptations to low-load blood flow restriction and high-load resistance exercise in trained individuals

Journal of Applied Physiology ◽

10.1152/japplphysiol.00464.2021 ◽

2021 ◽

Author(s):

Charlie J. Davids ◽

Tore C. Næss ◽

Maria Moen ◽

Kristoffer Toldnes Cumming ◽

Oscar Horwath ◽

...

Keyword(s):

Blood Flow ◽

Resistance Training ◽

Resistance Exercise ◽

Muscular Strength ◽

Load Resistance ◽

High Load ◽

Training Groups ◽

Flow Restriction ◽

Low Load ◽

Muscle Biopsies

Blood flow restriction (BFR) with low-load resistance exercise (RE) is often used as a surrogate to traditional high-load RE to stimulate muscular adaptations, such as hypertrophy and strength. However, it is not clear whether such adaptations are achieved through similar cellular and molecular processes. We compared changes in muscle function, morphology and signaling pathways between these differing training protocols. Twenty-one males and females (mean ± SD: 24.3 ± 3.1 years) experienced with resistance training (4.9 ± 2.6 years) performed nine weeks of resistance training (three times per week) with either high-loads (75-80% 1RM; HL-RT), or low-loads with BFR (30-40% 1RM; LL-BFR). Before and after the training intervention, resting muscle biopsies were collected, and quadricep cross-sectional area (CSA), muscular strength and power were measured. Approximately 5 days following the intervention, the same individuals performed an additional 'acute' exercise session under the same conditions, and serial muscle biopsies were collected to assess hypertrophic- and ribosomal-based signaling stimuli. Quadricep CSA increased with both LL-BFR (7.4±4.3%) and HL-RT (4.6±2.9%), with no significant differences between training groups (p=0.37). Muscular strength also increased in both training groups, but with superior gains in squat 1RM occurring with HL-RT (p<0.01). Acute phosphorylation of several key proteins involved in hypertrophy signaling pathways, and expression of ribosomal RNA transcription factors occurred to a similar degree with LL-BFR and HL-RT (all p>0.05 for between-group comparisons). Together, these findings validate low-load resistance training with continuous BFR as an effective alternative to traditional high-load resistance training for increasing muscle hypertrophy in trained individuals.

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