Como implementar la terapia de restricción de flujo con entrenamiento de resistencia de baja carga, para la hipertrofia y fortalecimiento del músculo cuádriceps en el consultorio. Nota técnica

• THEODORAKYS MARIN FERMIN - Autor principal(TheMIS Orthopaedic Center)
• EMMANUEL PAPACOSTAS(TheMIS Orthopaedic Center)

El entrenamiento de resistencia con cargas bajas y restricción de flujo sanguíneo ha sido reconocido como una terapia segura para la hipertrofia y fortalecimiento muscular. A pesar de estar bien documentada y apoyada, no existe una guía que describa como implementarla en el consultorio. Presentamos un protocolo, en tres pasos, para su aplicación en la rehabilitación precoz del músculo cuádriceps, en pacientes operados. Describimos la selección del brazalete, el cálculo de la presión y carga, así como las series y repeticiones para personalizar el entrenamiento del m. cuádriceps, con cargas bajas y restricción de flujo sanguíneo, tanto en atletas como en la población no entrenada.

Low-load resistance training with blood flow restriction has been recognized as a potential safe therapy for muscle hypertrophy and strength. Although, well documented and supported, there's no available descriptive explanation on how to implement it in a consultation setting. A three-step approach is presented in a friendly structure to start its application for early quadriceps rehabilitation in orthopedic surgery postoperative patients. Cuff selection, pressure and load calculation and exercise sets and repetitions are described to customize low-load quadriceps resistance training with blood flow restriction in trained and untrained individuals.

Blood flow restriction (BFR) training is a physiotherapy modality, conceived by Kato [1-4], evolving from an empiric approach to a scientifically based procedure with increasing popularity. It refers to exercising while blood flow is limited to the limb muscles via the application of a proximal tourniquet resulting in muscular hypertrophy, strength, and endurance gains [5-10]. In the postoperative rehabilitation of orthopedics’ surgery patients, muscular recovery to the pre-injury condition is one of the main goals. According to the American College of Sports Medicine (ACSM), the adequate intensity to stimulate muscle hypertrophy in the novice to intermediate exerciser corresponds to 60-70% of the 1 repetition maximum (1RM), and up to 80% of 1RM in the experienced strength trainer [6,11]. However, muscle training with the ACSM recommended intensity may be an unattainable task for most of the patients in the postoperative phase because of pain, effusion, weakness and even range of motion limitations after specific procedures [6,12].Resistance training with BFR with loads as low as 20-30% of 1RM can be implemented obtaining similar outcomes as in traditional training, allowing early rehabilitation of upper and lower extremities in postoperative patients without joint stress and cardiovascular risk associated with high-load (HL) resistance training [7][10][12-15]. However, despite the growing evidence of BFR training, many practitioners are using a range of equipment as well as BFR protocols that do not match usage within published literature [12].
 

Quadriceps muscle low-load resistance training with BFR.
Despite the growing evidence of BFR training, many practitioners are using a range of equipment as well as BFR protocols that do not match usage within published literature [12].
Following the current evidence available, we suggest a step-by-step approach to implement this physiotherapy modality in a consultation-based setting. The required equipment is summarized in Table 1.

Table 1. Required equipment for quadriceps low-load resistance training with BFR in a consultation-based setting
 

Inflatable cuffs Skinfold caliper or body composition analyzer Handheld manometer Handheld Doppler Handheld dynamometer Wrist and ankle weight cuffs Chronometer Examination table

Step 1: Cuff selection and pressure calculation

Once in the examination room, pressure cuff should be placed in the lower limb as proximal as possible. For pressure calculation, the best practice is to measure LOP after 5 minutes of supine position resting, raising the cuff pressure until no limb distal pulse can be palpated, and deflating it afterward. The calculation of 40-50% of the LOP is the pressure to set during the training.

Step 2: Load calculation

For trained individuals, pre-injury strength and healthy limb 1RM data should be available in his record. For untrained individuals, we advocate the use of Kanada et al. equation [16]. In a supine position, place the lower limb in approximately 70° of hip flexion and 90° of knee flexion. Upper limbs crossed in front of the chest. A maximum isometric knee extension is asked and held for 5 seconds against a hand-held manometer.

1RM= -5.282 + (0.569 x maximum isometric quadriceps strength) + (0.526 x lean body mass)

Lean body mass can be calculated with caliper skin fold methods or hand-held body composition analyzer.
The optimum load corresponds to 30% of 1RM.

Step 3: Sets and repetitions

Positioning the patient for leg extensions, weight cuffs should be added to fulfill the designated load (Figure 1).
  The patient is instructed to perform 4 sets with 30-15-15-15 repetitions, respectively, with rest periods of 30 seconds. The repetitions should be started as soon as the cuff is inflated to the intended pressure, and rests between sets should be tracked with the chronometer. It is important to monitor the patient's comfort during the training, even though the burning sensation is a normal finding during the procedure it shouldn't hamper the patient's ability to do the repetitions.

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Pre-established pressures were applied during BFR training in its origins, those absolute values have been abandoned in favor of relative pressures. Cuff width, size and limb circumference are variables that directly affect limb blood flow when a certain pressure is applied via manometer. There are no differences between different types of cuffs while relative limb pressures are applied, therefore offering a personalized approach through relative limb occlusive pressure (LOP) must be the goal [2][12][17][18].

LOP is the cuff pressure that occludes blood flow to the distal limb, confirmed by ultrasound, pulse oximeter, digital palpation or auscultation of distal pulses [5][18-20]. Pressures as low as 40% of that value are correlated to the same benefits as the original and abandoned the practice of occlusive and supra occlusive pressures [8][12][18], without the disadvantages of discomfort and delayed onset of muscle soreness (DOMS) experienced by former patients [21].
Pressure should be high enough to restrict venous outflow from muscles, yet low enough to maintain arterial inflow to it [3][12][22].

The load can be calculated by different methods. Patient's pre-injury strength and training program, healthy limb 1RM should be available in trained individuals. Tests as 5RM, 7-10 repetition maximum and Holten’s diagram are described as highly predictive values of 1RM leg press [20][23].

Yet, the safe accomplishment of 1RM testing is not amenable by some populations with pre-existing medical conditions age and untrained subjects [23]. Anthropometric measurements have been proposed as predictors of 1RM [16][24]. Kanada et al. [16] developed a highly predictive equation for 1RM measure by body composition and maximal isometric muscle strength using a hand-held dynamometer. It’s friendly implementation in untrained individuals with no previous record of resistance training in consultation setting motivated our incorporation in our practice.

Training with loads as low as 20-30% of 1RM has similar outcomes as in traditional HL resistance training, allowing postoperative patients and elderly individuals early rehabilitation, muscle hypertrophy, and strength gains [5-8][14-15][20][25].

Some findings suggest that exercise load may have a greater influence on acute changes in muscle size and metabolic accumulation during BFR training than the applied relative pressure [25]. Then, focusing on the correct calculation of loading is crucial.

On the subject of sets and repetitions, two main protocols have been suggested in BFR training besides the heterogeneity in the published studies. The standard BFR protocol includes 4 sets with 30-15-15-15 repetitions with rest periods of 30-60 seconds. And until failure protocols that promote as many repetitions in the last set as the patient can tolerate [3].

Comparable results have been archived using both protocols. Nevertheless, more intense transient DOMS and discomfort have been reported with the last one [21].

According to the evidence, a minimum of 2-3 times per week BFR LL resistance training during >6-10 weeks should be prescribed for strength improvements and >8 weeks for muscle hypertrophy [5-7][10].

BFR training under medical supervision is a safe training alternative for most individuals regardless of age and training status [3-4][17]. Reviewed in depth, with correct implementation under current concepts it represents no greater risk than traditional exercise modalities [10][18][26]. The former practice of using arbitrary and absolute pressures placed some individuals under risk of an adverse event [7]. LOP measurement in supine position results in more accurate values [17]. We also point out as good practice deflating cuff in a supine position to avoid any symptoms resulting from the hemodynamic reflex response.

Nevertheless, contraindication in deep-vein thrombosis, pregnancy [20], venous insufficiency, smoking [7][25][27] has been reported [3]. A major concern in BFR training for the practitioner might be its potential for thrombus formation, but several clinical trials have verified the absence of markers of thrombin generation and intravascular clot formation in blood samples [4].

This three steps approach is an easy way to safely implement low-load resistance training with blood flow restriction for quadriceps hypertrophy and strengthening in a consultation-based setting.

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