Exercise with Blood Flow Restriction to Improve Quadriceps Function Long After ACL Reconstruction

Abstract

Quadriceps atrophy and weakness can persist for years after anterior cruciate ligament reconstruction (ACLR). We evaluated the effectiveness of a home-based blood flow restriction (BFR) exercise program to increase quadriceps size and strength several years after ACLR. Nine adults with ACLR (5±2 yrs post-surgery, ≤90% symmetry in quadriceps size and strength) and nine uninjured controls volunteered. ACLR participants exercised at home for 25 min, 5×/wk for 4 wks (single-leg knee extension, bodyweight half-squats, walking). Blood flow in only the involved leg was restricted using a thigh cuff inflated to 50% of limb occlusion pressure. Rectus femoris and vastus lateralis thickness and knee extensor strength were measured before and after training. Baseline and post-training symmetry (involved leg/uninvolved leg) indices were compared to uninjured controls. Rectus femoris and vastus lateralis thickness and knee extensor strength in the involved leg increased by 11±5%, 10±6%, and 20±14%, respectively (all P<0.01). Compared to baseline, post-training knee extensor strength symmetry increased from 88±4 to 99±5% (P<0.01) and did not differ from uninjured controls (99±5%, P=0.95). Implementation of BFR exercise at home was feasible, safe and effective. Results extend upon early post-operative application of BFR exercise for ACLR recovery and demonstrate that BFR can improve quadriceps function long after ACLR.

Key words

anterior cruciate ligament injury - quadriceps weakness - limb asymmetry - BFR exercise

• References

• 1 Konishi Y, Ikeda K, Nishino A, Sunaga M, Aihara Y, Fukubayashi T. Relationship between quadriceps femoris muscle volume and muscle torque after anterior cruciate ligament repair. Scand J Med Sci Sports 2007; 17: 656-661
• 2 Marcon M, Ciritsis B, Laux C, Nanz D, Fischer MA, Andreisek G, Ulbrich EJ. Quantitative and qualitative MR-imaging assessment of vastus medialis muscle volume loss in asymptomatic patients after anterior cruciate ligament reconstruction. J Magn Reson Imaging 2015; 42: 515-525
• 3 Thomas AC, Wojtys EM, Brandon C, Palmieri-Smith RM. Muscle atrophy contributes to quadriceps weakness after anterior cruciate ligament reconstruction. J Sci Med Sport 2016; 19: 7-11
• 4 DeJong SN, van Caspel DR, van Haeff MJ, Saris DB. Functional assessment and muscle strength before and after reconstruction of chronic anterior cruciate ligament lesions. Arthroscopy 2007; 23: 21-28, 28.e1-3
• 5 Hughes L, Paton B, Rosenblatt B, Gissane C, Patterson SD. Blood flow restriction training in clinical musculoskeletal rehabilitation: A systematic review and meta-analysis. Br J Sports Med 2017; 51: 1003-1011
• 6 Thomas AC, Villwock M, Wojtys EM, Palmieri-Smith RM. Lower extremity muscle strength after anterior cruciate ligament injury and reconstruction. J Athl Train 2013; 48: 610-620
• 7 DiStasi SL, Logerstedt D, Gardinier ES, Snyder-Mackler L. Gait patterns differ between ACL-reconstructed athletes who pass return-to-sport criteria and those who fail. Am J Sports Med 2013; 41: 1310-1318
• 8 Palmieri-Smith RM, Lepley LK. Quadriceps strength asymmetry after anterior cruciate ligament reconstruction alters knee joint biomechanics and functional performance at time of return to activity. Am J Sports Med 2015; 43: 1662-1669
• 9 Schmitt LC, Paterno MV, Hewett TE. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2012; 42: 750-759
• 10 Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Arna Risberg M. Simple decision rules reduce reinjury risk after anterior cruciate ligament reconstruction. Br J Sports Med 2016; 50: 804-808
• 11 Oiestad BE, Holm I, Gunderson R, Myklebust G, Risberg MA. Quadriceps muscle weakness after anterior cruciate ligament reconstruction: A risk factor for knee osteoarthritis?. Arthritis Care Res (Hoboken) 2010; 62: 1706-1714
• 12 Tourville TW, Jarrell KM, Naud S, Slauterbeck JR, Johnson RJ, Beynnon BD. Relationship between isokinetic strength and tibiofemoral joint space width changes after anterior cruciate ligament reconstruction. Am J Sports Med 2014; 42: 302-311
• 13 Krishnan C, Williams GN. Factors explaining chronic knee extensor strength deficits after ACL reconstruction. J Orthop Res 2011; 29: 633-640
• 14 Kuenze CM, Hertel J, Weltman A, Diduch D, Saliba SA, Hart JM. Persistent neuromuscular and corticomotor quadriceps asymmetry after anterior cruciate ligament reconstruction. J Athl Train 2015; 50: 303-312
• 15 Longo UG, Rizzello G, Frnaceschi F, Campi S, Maffulli N, Denaro V. The architecture of the ipsilateral quadriceps two years after successful anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft. Knee 2014; 21: 721-725
• 16 Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP. American College of Sports M. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc 2011; 43: 1334-1359
• 17 Barber-Westin S, Noyes FY. Blood-flow restriction training for lower extremity muscle weakness due to knee pathology: A systematic review. Sports Health 2019; 11: 69-83
• 18 DePhillipo NN, Kennedy MI, Aman ZA, Bernhardson AS, O’Brien LT, LaPrade RF. The role of blood flow restriction therapy following knee surgery: Expert opinion. Arthroscopy 2018; 34: 2506-2510
• 19 Takarada Y, Takazawa H, Ishii N. Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles. Med Sci Sports Exerc 2000; 32: 2035-2039
• 20 Ohta H, Kurosawa H, Ikeda H, Iwase Y, Satou N, Nakamura S. Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthop Scand 2003; 74: 62-68
• 21 Tennent DJ, Hylden CM, Johnson AE, Burns TC, Wilken JM, Owens JG. Blood flow restriction training after knee arthroscopy: A randomized controlled pilot study. Clin J Sport Med 2017; 27: 245-252
• 22 Curran MT, Lepley LK, Palmieri-Smith RM. Continued improvements in quadriceps strength and biomechanical symmetry of the knee after postoperative anterior cruciate ligament reconstruction rehabilitation: Is it time to reconsider the 6-month return-to-activity criteria?. Athl Train 2018; 53: 535-544
• 23 Lewek M, Rudolph K, Axe M, Snyder-Mackler L. The effect of insufficient quadriceps strength on gait after anterior cruciate ligament reconstruction. Clin Biomech (Bristol, Avon) 2002; 17: 56-63
• 24 Grant JA, Mohtadi NG, Maitland ME, Zernicke RF. Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: A randomized clinical trial. Am J Sports Med 2005; 33: 1288-1297
• 25 Harriss DJ, Macsween A, Atkinson G. Standards in sport and exercise science research: 2018 update. Int J Sports Med 2017; 38: 1126-1131
• 26 Hunt JE, Stodart C, Ferguson RA. The influence of participant characteristics on the relationship between cuff pressure and level of blood flow restriction. Eur J Appl Physiol 2016; 116: 1421-1432
• 27 Kilgas MA, McDaniel J, Stavres J, Pollock BS, Singer TJ, Elmer SJ. Limb blood flow and tissue perfusion during exercise with blood flow restriction. Eur J Appl Physiol 2019; 119: 377-387
• 28 Twist C, Eston R. The effects of exercise-induced muscle damage on maximal intensity intermittent exercise performance. Eur J Appl Physiol 2005; 94: 652-658
• 29 Martin-Hernandez J, Marin PJ, Menendez H, Loenneke JP, Coelho-e-Silva MJ, Garcia-Lopez D, Herrero AJ. Changes in muscle architecture induced by low load blood flow restricted training. Acta Physiol Hung 2013; 100: 411-418
• 30 Brzycki M. Strength testing: Predicting one-rep max from repetitions to fatigue. Journal of Physical Education Recreation & Dance 1993; 64: 88-90
• 31 Meier WA, Marcus RL, Dibble LE, Foreman KB, Peters CL, Mizner RL, LaStayo PC. The long-term contribution of muscle activation and muscle size to quadriceps weakness following total knee arthroplasty. J Geriatr Phys Ther 2009; 32: 35-38 13
• 32 Petterson SC, Barrance P, Marmon AR, Handling T, Buchanan TS, Snyder-Mackler L. Time course of quad strength, area and activation after knee arthroplasty and strength training. Med Sci Sports Exerc 2011; 43: 225-231
• 33 Abe T, Yasuda T, Midorikawa T, Sato Y, Kearns CF, Inoue K, Koizumi K, Ishii N. Skeletal muscle size and circulating IGF-1 are increased after two weeks of twice daily “KAATSU” resistance training. Int J KAATSU Training Res 2005; 1: 6-12
• 34 Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training. J Appl Physiol (1985) 2006; 100: 1460-1466
• 35 Lejkowski PM, Pajaczkowski JA. Utilization of Vascular Restriction Training in post-surgical knee rehabilitation: A case report and introduction to an under-reported training technique. J Can Chiropr Assoc 2011; 55: 280-287
• 36 Loenneke JP, Wilson JM, Marin PJ, Zourdos MC, Bemben MG. Low intensity blood flow restriction training: A meta-analysis. Eur J Appl Physiol 2012; 112: 1849-1859