Blood Restriction Training in older adults with knee osteoarthritis for the Future FrontLine

Blood Restriction Training (BRT) decreases blood flow to a muscle by a constricting device. BRT has been shown to improve muscle strength and hypertrophy (Patterson, 2019). BRT can cause an improvement in strength for knee osteoarthritis, in turn, causing a reduction in pain and enhancement of daily mobility by increasing functional strength in the quadriceps (Aguilar, 2018). The aim for management of KOA is to improve and maintain the quality of Life of the patient through core treatment options such as strengthening of the lower limb, maintain mobility and functionality, ensuring balance and proprioception training is continued.

Who developed Blood Restricted Training? It was developed in 1970 in Japan by a man called Sato. BRT is originally known as KAATSU, published protocols are available online for further research. It is also known as occlusion training, cluster training, blood restriction training and/or partial vascular occlusion training. It involves a tourniquet device (cuff/constricting device) placed proximal (above) to the muscle.

How does it work? The occlusion rate of the muscle is 40% to 80%. It is recommended to have a load of 20%-30% one rep max (1RPM) with high repetitions of 15 to 30 repetitions per session with a 30 to 60 seconds' rest. It can build muscle mass and strength with minimal muscle loading. The mechanism of blood restriction training includes the reduction of oxygen to the muscle.

The anaerobic environment that is created (hypoxic) has been found to promote muscle hypertrophy through micro-mechanisms, hypothesised by researchers that it includes the initiation of cell signalling and hormone changes that stimulate protein synthesis, proliferation of myogenic satellite cells, and preferential activation and mobilisation of type two muscle fibers (Miranda, 2019).

Pearson and Hussein in 2014, stated that exercise induced mechanical tension and metabolic stress is authorised to send a signal for several mechanisms to occur for the induction of muscle growth, including increased fast-twitch fibers, mechanical transduction and muscle damage. The hypoxic environment created through mechanical stress, causes myogenic stem cells are activated, an increase of anabolic hormone levels, especially the human growth hormone (HGH).

It has been stated by Schonfield, 2013, that HGH increased up to 300% from baseline. HGH has various physiological benefits such as muscle strength, endurance and induce anabolic processes, i.e. hypertrophy.

Along with the HGH, there is an increase of protons, lactic acid and cell swelling. Myogenic cells are responsible for the growth of fibers. HGH doesn’t directly cause hypertrophy but it aids recovery and facilitate the strengthening process. The combination of lactic and hydrogen ions also increases the HGH release. Due to the hypoxic environment, the hypoxia-inducible factor (HIF-I Alpha) activates, leading to an increase in lactate and lactate metabolism.

Application:

• The constrictive device/cuff should be 40% to 80% with standard pressure of 180mmHg. The pressure should be relative to the patient’s systolic blood pressure. A Doppler ultrasound can also be used to determine the blood flow.

Clinical Application:

• For clinical application, Hughes et al., 2017, states that be BRT can be used for patients that are unable to tolerate heavy load training. With all exercises, it must be monitored by qualified medical personnel and be viewed with certain amount of caution.

• Low Load (LL) with BRT has been shown to be affective, whilst being more tolerable and therefore may become an easy clinical rehabilitation tool for the specific populations.

• It is also recommended to complete BRT 1 to 2 times per week.

• Takarado (2000), found that the current research indicated that lactate production after blood restriction training is similar to that of high-intensity training.

Supporting literature for BRT: Ferraz, 2018-

The aim was the benefits of resistance training with BRT on the knee osteoarthritis. This included 48 females with knee osteoarthritis randomly placed into three groups. The first group with low load resistance with blood restriction training, the second group included low load resistance without blood restriction training and the third included high-intensity resistance group. They found that blood restriction training and the high-intensity resistance had a similar effect of increasing muscle strength, quadriceps mass and functionality of knee osteoarthritis patients. Blood restriction training had the ability to improve their pain levels while inducing less joint stress; it is merging as a feasible and effective therapeutic adjunct for osteoarthritis management. Blood restriction training improved by 17% compared to classic training of 9%.

Mai, 2018-

Mai 2018, investigated the effects of low, load resistance to blood restriction training and need osteoarthritis. They included 40 females between 45 to 60 years old with mild, moderate unilateral tibiofemoral osteoarthritis.

There were two groups. The first group was 20 females, a conventional high load at 60% one rep max. The second group was 20 females low load with blood restriction training at 30% one rep max. The groups completed three sessions each week for four weeks.

Both groups were an effective treatment option for improving functional mobility. The results were similar. However, as with all studies, articles must be critically evaluated. With regards to Mai, the study had a small sample size and females only.

According to Harper a Pilot RCT 2019, training with BRT in older adults with knee osteoarthritis found that indicated that BRT is a safe and feasible alternative for patients with knee osteoarthritis. Bryk in 2016, found the blood restriction training improve the mass by 42% compared to classic physiotherapy of 30%.

Contraindications:

The safety precautions of blood restriction training. All patients should be assessed for risks and contraindications before blood restriction training application.

• Poor circulatory systems including DVT and uncontrolled diabetes, obesity, arterial calcification, sickle-cell trait, severe hypertension, renal compromise (Dephillipo et al., 2018).

• Most concerning areas while implementing blood restriction training, according to Patterson, 2019 are

• 1) Cardiovascular

• 2) Muscle

• 3) Nerve

• The cardiovascular area concerns are associated with Venus thromboembolism, as acute research did not show a significant increase in blood coagulation through the D dimer ( The most utilised clinical test to rule out the presence of DVT, according to Clark in 2011).

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