The purpose of this systematic review with meta-analysis was to compare the effects of low load resistance combined with blood flow restriction (BFR) versus conventional quadriceps strengthening on knee symptoms and function as well as knee extensor strength and muscle thickness in adults with knee conditions.
LITERATURE SURVEY:
Guidelines based on the latest evidence highlight the importance of quadriceps strengthening to reduce pain and improve function in patients with knee conditions. Blood flow restriction is based on brief periods of vascular occlusion which cause muscle hypertrophy and increased strength. Before it can be recommended for individuals with knee conditions, quadriceps strengthening with low load resistance combined with BFR (LL-BFR) must show beneficial effects on clinical outcomes in addition to quadriceps strength and mass.
METHODS:
A systematic review with meta-analysis was conducted to identify relevant studies through PubMed, PEDro, and ScienceDirect up to January 2019. The protocol was registered on PROSPERO (CRD42019121306). Differences in pre- and post-intervention means and standard deviations were extracted to calculate the standardized mean difference for each intervention in each included study.
SYNTHESIS:
Eight studies were included. Limited evidence suggests that LL-BFR is more beneficial on quadriceps strength and thickness in patients with knee conditions than LL training alone or in addition to a rehabilitation program. Limited evidence indicates that LL-BFR training is equally effective in improving function and muscle thickness compared with a HL quadriceps strengthening program but elicits less knee pain, corresponding to additional benefits of 22 (95% confidence interval 1 to 43) mm on a 0–100 mm visual analogue scale.
CONCLUSIONS:
BFR could be a useful option for patients with knee conditions where conventional quadriceps strengthening program exacerbate knee symptoms. Future investigations should compare different BFR protocols to help establish better guidelines for clinicians.
KostogiannisIAgebergENeumanPDahlbergLFridenTRoosH. Activity Level and Subjective Knee Function 15 Years after Anterior Cruciate Ligament Injury: A Prospective, Longitudinal Study of Nonreconstructed Patients. Am J Sports Med. 2007; 35: 1135-43.
2.
SwirtunLRRenströmP. Factors affecting outcome after anterior cruciate ligament injury: a prospective study with a six-year follow-up. Scand J Med Sci Sports. 2008; 18: 318-24.
3.
AminSBakerKNiuJClancyMGogginsJGuermaziA, et al. Quadriceps strength and the risk of cartilage loss and symptom progression in knee osteoarthritis. Arthritis Rheum. 2009; 60: 189-98.
4.
CollinsNJBartonCJvan MiddelkoopMCallaghanMJRathleffMSVicenzinoBT, et al. 2018 Consensus statement on exercise therapy and physical interventions (orthoses, taping and manual therapy) to treat patellofemoral pain: recommendations from the 5th International Patellofemoral Pain Research Retreat, Gold Coast, Australia, 2017. Br J Sports Med. 2018; 52: 1170-8.
5.
FernandesLHagenKBBijlsmaJWJAndreassenOChristensenPConaghanPG, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013; 72: 1125-35.
6.
MurakiSAkuneTTeraguchiMKagotaniRAsaiYYoshidaM, et al. Quadriceps muscle strength, radiographic knee osteoarthritis and knee pain: the ROAD study. BMC Musculoskelet Disord. 2015; 16: 305.
7.
LoennekeJPPujolTJ. The Use of Occlusion Training to Produce Muscle Hypertrophy. Strength Cond J. 2009; 31: 77-84.
8.
LoennekeJPKimDFahsCAThiebaudRSAbeTLarsonRD, et al. Effects of exercise with and without different degrees of blood flow restriction on torque and muscle activation: Effects of Pressure and Load on Muscle. Muscle Nerve. 2015; 51: 713-21.
ScottBRLoennekeJPSlatteryKMDascombeBJ. Blood flow restricted exercise for athletes: A review of available evidence. J Sci Med Sport. 2016; 19: 360-7.
11.
Barber-WestinSNoyesFR. Blood Flow-Restricted Training for Lower Extremity Muscle Weakness due to Knee Pathology: A Systematic Review. Sports Health Multidiscip Approach. 2019; 11: 69-83.
12.
HughesLPatonBRosenblattBGissaneCPattersonSD. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med. 2017; 51: 1003-11.
13.
LixandrãoMEUgrinowitschCBertonRVechinFCConcei玢oMSDamasF, et al. 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 Med. 2018; 48: 361-78.
14.
CentnerCWiegelPGollhoferAKönigD. Effects of Blood Flow Restriction Training on Muscular Strength and Hypertrophy in Older Individuals: A Systematic Review and Meta-Analysis. Sports Med. 2019; 49: 95-108.
15.
HigginsJPTThompsonSGDeeksJJAltmanDG. Measuring inconsistency in meta-analyses. BMJ. 2003; 327: 557-60.
16.
de MortonNA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009; 55: 129-33.
17.
MaherCGSherringtonCHerbertRDMoseleyAMElkinsM. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003; 83: 713-21.
18.
van TulderMFurlanABombardierCBouterL, Editorial Board of the Cochrane Collaboration Back Review Group. Updated method guidelines for systematic reviews in the cochrane collaboration back review group. Spine. 2003; 28: 1290-9.
19.
BrykFFdos ReisACFingerhutDAraujoTSchutzerMde Paula Leite CuryR et al. Exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1580-6.
20.
FerrazRBGualanoBRodriguesRKurimoriCOFullerRLimaFR, et al. Benefits of Resistance Training with Blood Flow Restriction in Knee Osteoarthritis. Med Sci Sports Exerc. 2018; 50: 897-905.
21.
GilesLWebsterKEMcClellandJCookJL. Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. Br J Sports Med. 2017; 51: 1688-94.
22.
IversenERøstadVLarmoA. Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction. J Sport Health Sci. 2016; 5: 115-8.
23.
OhtaHKurosawaHIkedaHIwaseYSatouNNakamuraS. Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthop Scand. 2003; 74: 62-8.
24.
SegalNDavisMDMikeskyAE. Efficacy of Blood Flow-Restricted Low-Load Resistance Training For Quadriceps Strengthening in Men at Risk of Symptomatic Knee Osteoarthritis. Geriatr Orthop Surg Rehabil. 2015; 6: 160-7.
25.
SegalNAWilliamsGNDavisMCWallaceRBMikeskyAE. Efficacy of Blood Flow-Restricted, Low-Load Resistance Training in Women with Risk Factors for Symptomatic Knee Osteoarthritis. PM&R. 2015; 7: 376-84.
26.
TennentDJHyldenCMJohnsonAEBurnsTCWilkenJMOwensJG. Blood Flow Restriction Training After Knee Arthroscopy: A Randomized Controlled Pilot Study. Clin J Sport Med. 2017; 27: 245-52.
27.
KorakakisVWhiteleyREpameinontidisK. Blood Flow Restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading. Phys Ther Sport. 2018; 32: 235-43.
28.
BliddalHChristensenR. The treatment and prevention of knee osteoarthritis: a tool for clinical decision-making. Expert Opin Pharmacother. 2009; 10: 1793-804.
29.
TubachF. Evaluation of clinically relevant states in patient reported outcomes in knee and hip osteoarthritis: the patient acceptable symptom state. Ann Rheum Dis. 2005; 64: 34-7.
30.
Special report: measuring and reporting pain outcomes in randomized controlled trials. Technol Eval Cent Assess Program Exec Summ. 2006; 21: 1-2.
31.
TzorlundJBJuhlCBRoosEMLohmanderLS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015; 350: h2747-h2747.
32.
RioEKidgellDPurdamCGaidaJMoseleyGLPearceAJ, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015; 49: 1277-83.
33.
LuoZDCizkovaD. The role of nitric oxide in nociception. Curr Rev Pain. 2000; 4: 459-66.
34.
LiuCLaValleyMLathamNK. Do Unblinded Assessors Bias Muscle Strength Outcomes in Randomized Controlled Trials of Progressive Resistance Strength Training in Older Adults? Am J Phys Med Rehabil. 2011; 90: 190-6.
35.
McNairPJColvinMReidD. Predicting maximal strength of quadriceps from submaximal performance in individuals with knee joint osteoarthritis. Arthritis Care Res. 2011; 63: 216-22.
36.
LoennekeJPWilsonGJWilsonJM. A Mechanistic Approach to Blood Flow Occlusion. Int J Sports Med. 2010; 31: 1-4.
37.
TakaradaYTakazawaHSatoYTakebayashiSTanakaYIshiiN. Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans. J Appl Physiol. 2000; 88: 2097-106.
38.
FujitaTBrechueWFKuritaKSatoYAbeT. Increased muscle volume and strength following six days of low-intensity resistance training with restricted muscle blood flow. Int J Kaatsu Train Res. 2008; 4: 1-8.
39.
AbeTDeHoyosDVPollockMLGarzarellaL. Time course for strength and muscle thickness changes following upper and lower body resistance training in men and women. Eur J Appl Physiol. 2000; 81: 0174.
40.
ScottBRLoennekeJPSlatteryKMDascombeBJ. Exercise with Blood Flow Restriction: An Updated Evidence-Based Approach for Enhanced Muscular Development. Sports Med. 2015; 45: 313-25.
41.
LoennekeJPWilsonJMWilsonGJPujolTJBembenMG. Potential safety issues with blood flow restriction training: Safety of blood flow-restricted exercise. Scand J Med Sci Sports. 2011; 21: 510-8.
42.
TabataSSuzukiYAzumaKMatsumotoH. Rhabdomyolysis After Performing Blood Flow Restriction Training: A Case Report. J Strength Cond Res. 2016; 30: 2064-8.
