Effect of Blood Flow Restriction Training on Quadriceps Muscle Strength, Morphology, Physiology, and Knee Biomechanics Before and After Anterior Cruciate Ligament Reconstruction: Protocol for a Randomized Clinical Trial
Lauren N Erickson, Kathryn C Hickey Lucas, Kylie A Davis, Cale A Jacobs, Katherine L Thompson, Peter A Hardy, Anders H Andersen, Christopher S Fry, Brian W Noehren, Lauren N Erickson, Kathryn C Hickey Lucas, Kylie A Davis, Cale A Jacobs, Katherine L Thompson, Peter A Hardy, Anders H Andersen, Christopher S Fry, Brian W Noehren
Abstract
Background: Despite best practice, quadriceps strength deficits often persist for years after anterior cruciate ligament reconstruction. Blood flow restriction training (BFRT) is a possible new intervention that applies a pressurized cuff to the proximal thigh that partially occludes blood flow as the patient exercises, which enables patients to train at reduced loads. This training is believed to result in the same benefits as if the patients were training under high loads.
Objective: The objective is to evaluate the effect of BFRT on quadriceps strength and knee biomechanics and to identify the potential mechanism(s) of action of BFRT at the cellular and morphological levels of the quadriceps.
Design: This will be a randomized, double-blind, placebo-controlled clinical trial.
Setting: The study will take place at the University of Kentucky and University of Texas Medical Branch.
Participants: Sixty participants between the ages of 15 to 40 years with an ACL tear will be included.
Intervention: Participants will be randomly assigned to (1) physical therapy plus active BFRT (BFRT group) or (2) physical therapy plus placebo BFRT (standard of care group). Presurgical BFRT will involve sessions 3 times per week for 4 weeks, and postsurgical BFRT will involve sessions 3 times per week for 4 to 5 months.
Measurements: The primary outcome measure was quadriceps strength (peak quadriceps torque, rate of torque development). Secondary outcome measures included knee biomechanics (knee extensor moment, knee flexion excursion, knee flexion angle), quadriceps muscle morphology (physiological cross-sectional area, fibrosis), and quadriceps muscle physiology (muscle fiber type, muscle fiber size, muscle pennation angle, satellite cell proliferation, fibrogenic/adipogenic progenitor cells, extracellular matrix composition).
Limitations: Therapists will not be blinded.
Conclusions: The results of this study may contribute to an improved targeted treatment for the protracted quadriceps strength loss associated with anterior cruciate ligament injury and reconstruction.
Trial registration: ClinicalTrials.gov NCT03364647.
© 2019 American Physical Therapy Association.
Figures
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![Figure 2.](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/6665950/bin/pzz062fig2.jpg)
![Figure 3.](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/6665950/bin/pzz062fig3.jpg)
References
- Griffin LY, Albohm MJ, Arendt EA et al. .. Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting, January 2005. Am J Sports Med. 2006;34:1512–1532.
- McLean SG, Beaulieu ML. Complex integrative morphological and mechanical contributions to ACL injury risk. Exerc Sport Sci Rev. 2010;38:192–200.
- Mather RC III, Koenig L, Kocher MS et al. .. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am. 2013;95:1751–1759.
- Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps strength after ACL reconstruction. Clin Sports Med. 2008;27:405–424., VII–IX.
- Maletis GB, Cameron SL, Tengan JJ, Burchette RJ. A prospective randomized study of anterior cruciate ligament reconstruction: a comparison of patellar tendon and quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws. Am J Sports Med. 2007;35:384–394.
- Jansson KA, Linko E, Sandelin J, Harilainen A. A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med. 2003;31:12–18.
- Feller JA, Webster KE. A randomized comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction. Am J Sports Med. 2003;31:564–573.
- Snyder-Mackler L, Delitto A, Bailey SL, Stralka SW. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am. 1995;77:1166–1173.
- Witvrouw E, Bellemans J, Verdonk R, Cambier D, Coorevits P, Almqvist F. Patellar tendon vs. doubled semitendinosus and gracilis tendon for anterior cruciate ligament reconstruction. Int Orthop. 2001;25:308–311.
- Natri A, Jarvinen M, Latvala K, Kannus P. Isokinetic muscle performance after anterior cruciate ligament surgery. Long-term results and outcome predicting factors after primary surgery and late-phase reconstruction. Int J Sports Med. 1996;17:223–228.
- Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ. Knee strength deficits after hamstring tendon and patellar tendon anterior cruciate ligament reconstruction. Med Sci Sports Exerc. 2000;32:1472–1479.
- 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.
- Lepley LK. Deficits in quadriceps strength and patient-oriented outcomes at return to activity after ACL reconstruction: a review of the current literature. Sports Health. 2015;7:231–238.
- 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.
- Angelozzi M, Madama M, Corsica C et al. .. Rate of force development as an adjunctive outcome measure for return-to-sport decisions after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2012;42:772–780.
- Aagaard P, Simonsen EB, Andersen JL, Magnusson P, Dyhre-Poulsen P. Increased rate of force development and neural drive of human skeletal muscle following resistance training. J Appl Physiol (1985). 2002;93:1318–1326.
- Jordan MJ, Aagaard P, Herzog W. Rapid hamstrings/quadriceps strength in ACL-reconstructed elite Alpine ski racers. Med Sci Sports Exerc. 2015;47:109–119.
- Kline PW, Morgan KD, Johnson DL, Ireland ML, Noehren B. Impaired quadriceps rate of torque development and knee mechanics after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2015;43:2553–2558.
- Hart JM, Ko JW, Konold T, Pietrosimione B. Sagittal plane knee joint moments following anterior cruciate ligament injury and reconstruction: a systematic review. Clin Biomech (Bristol, Avon). 2010;25:277–283.
- Paterno MV, Ford KR, Myer GD, Heyl R, Hewett TE. Limb asymmetries in landing and jumping 2 years following anterior cruciate ligament reconstruction. Clin J Sport Med. 2007;17:258–262.
- Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48:1543–1552.
- Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596–606.
- Tengman E, Brax Olofsson L, Stensdotter AK, Nilsson KG, Hager CK. Anterior cruciate ligament injury after more than 20 years. II. Concentric and eccentric knee muscle strength. Scand J Med Sci Sports. 2014;24:e501–e509.
- 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.
- Krishnan C, Williams GN. Factors explaining chronic knee extensor strength deficits after ACL reconstruction. J Orthop Res. 2010;29:633–640.
- Snyder-Mackler L, De Luca PF, Williams PR, Eastlack ME, Bartolozzi AR 3rd. Reflex inhibition of the quadriceps femoris muscle after injury or reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am. 1994;76:555–560.
- Chmielewski TL, Wilk KE, Snyder-Mackler L. Changes in weight-bearing following injury or surgical reconstruction of the ACL: relationship to quadriceps strength and function. Gait Posture. 2002;16:87–95.
- Noehren B, Andersen A, Hardy P et al. .. Cellular and morphological alterations in the vastus lateralis muscle as the result of ACL injury and reconstruction. J Bone Joint Surg Am. 2016;98:1541–1547.
- Martin-Hernandez J, Marin PJ, Menendez H et al. .. Changes in muscle architecture induced by low load blood flow restricted training. Acta Physiol Hung. 2013;100:411–418.
- Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Exercise with blood flow restriction: an updated evidence-based approach for enhanced muscular development. Sports Med. 2015;45:313–325.
- Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Blood flow restricted exercise for athletes: a review of available evidence. J Sci Med Sport. 2016;19:360–367.
- Slysz J, Stultz J, Burr JF. The efficacy of blood flow restricted exercise: a systematic review & meta-analysis. J Sci Med Sport. 2015;19:669–675.
- Pearson SJ, Hussain SR. A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy. Sports Med. 2015;45:187–200.
- Shoenfeld BJ. Potential mechanisms for a role of metabolic stress in hypertrophic adaptations to resistance training. Sports Med. 2013;43:179–194.
- Nielsen JL, Aagaard P, Bech RD et al. .. Proliferation of myogenic stem cells in human skeletal muscle in response to low-load resistance training with blood flow restriction. J Physiol. 2012;590:4351–4361.
- Thiebaud RS, Yasuda T, Loenneke JP, Abe T. Effects of low-intensity concentric and eccentric exercise combined with blood flow restriction on indices of exercise-induced muscle damage. Interv Med Appl Sci. 2103;5:53–59.
- Scott BR, Slattery KM, Sculley DV, Dascombe BJ. Hypoxia and resistance exercise: a comparison of localized and systemic methods. Sports Med. 2014;44:1037–1054.
- Suga T, Okita K, Takada S et al. .. Effect of multiple set on intramuscular metabolic stress during low-intensity resistance exercise with blood flow restriction. Eur J Appl Physiol. 2012;112:3915–3920.
- Kacin A, Strazar K. Frequent low-load ischemic resistance exercise to failure enhances muscle oxygen delivery and endurance capacity. Scand J Med Sci Sports. 2011;21:e231–e241.
- Abe T, Loenneke JP, Fahs CA, Rossow LM, Thiebaud RS, Bemben MG. Exercise intensity and muscle hypertrophy in blood flow-restricted limbs and non-restricted muscles: a brief review. Clin Physiol Funct Imaging. 2012;32:247–252.
- Loenneke JP, Thiebaud RS, Fahs CA, Rossow LM. Blood flow-restricted resistance exercise: rapidly affecting the myofibre and the myonuclei. J Physiol. 2012;590:5271.
- 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.
- Wernbom M, Apro W, Paulsen G, Nilsen TS, Blomstrand E, Raastad T. Acute low-load resistance exercise with and without blood flow restriction increased protein signalling and number of satellite cells in human skeletal muscle. Eur J Appl Physiol. 2013;113:2953–2965.
- Moritani T, Sherman WM, Shibata M, Matsumoto T, Shinohara M. Oxygen availability and motor unit activity in humans. Eur J Appl Physiol Occup Physiol. 1992;64:552–556.
- Takarada Y, Sato Y, Ishii N. Effects of resistance exercise combined with vascular occlusion on muscle function in athletes. Eur J Appl Physiol. 2002;86:308–314.
- Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, Ishii N. Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans. J Appl Physiol (1985). 2000;88:2097–2106.
- Noehren B, Andersen A, Hardy P et al. .. Cellular and morphological alterations in the vastus lateralis muscle as the result of ACL injury and reconstruction. J Bone Joint Surg Am. 2016;98:1541–1547.
- 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.
- 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.
- Iversen E, Røstad V, Larmo A. Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction. J Sport Health Sci. 2016;5:115–118.
- Fry CS, Johnson DL, Ireland ML, Noehren B. ACL Injury reduces satellite cell abundance and promotes fibrogenic cell expansion within skeletal muscle. J Orthop Res. 2017;35:1876–1885.
- Fry CS, Noehren B, Mula J et al. .. Fibre type-specific satellite cell response to aerobic training in sedentary adults. J Physiol. 2014;592:2625–2635.
- Powell PL, Roy RR, Kanim P, Bello MA, Edgerton VR. Predictability of skeletal muscle tension from architectural determinations in guinea pig hindlimbs. J Appl Physiol Respir Environ Exerc Physiol. 1984;57:1715–1721.
- 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.
- Williams GN, Snyder-Mackler L, Barrance PJ, Buchanan TS. Quadriceps femoris muscle morphology and function after ACL injury: a differential response in copers versus non-copers. J Biomech. 2005;38:685–693.
- Fry CS, Lee JD, Jackson JR et al. .. Regulation of the muscle fiber microenvironment by activated satellite cells during hypertrophy. FASEB J. 2014;28:1654–1665.
- Sato K, Li Y, Foster W et al. .. Improvement of muscle healing through enhancement of muscle regeneration and prevention of fibrosis. Muscle Nerve. 2003;28:365–372.
- Fry CS, Kirby TJ, Kosmac K, McCarthy JJ, Peterson CA. Myogenic progenitor cells control extracellular matrix production by fibroblasts during skeletal muscle hypertrophy. Cell Stem Cell. 2017;20:56–69.
- Handschin C, Chin S, Li P, Liu F, Maratos-Flier E, Lebrasseur NK, Yan Z, Spiegelman BM. Skeletal muscle fiber-type switching, exercise intolerance, and myopathy in PGC-1alpha muscle-specific knock-out animals. J Biol Chem. 2007;282:30014–30021.
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