Improving recovery from knee surgery using blood flow restriction training

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What is BFR?

For a thorough introduction to BFR, please see our previous blog post:

In general, blood flow restriction training involves the use of a tourniquet or band placed around the upper arm or leg. These bands are then inflated to a certain pressure in order to restrict the amount of blood flow in and out of your leg. This is done in a controlled manner that is specific to your body to allow decreased blood flow without complete restriction. With this cuff inflated you will then perform several exercises at a light load.

When done correctly, the blood flow leaving your leg through your veins will be occluded, while blood arriving to your leg will be partially limited. This change to your circulatory system sets in motion a series of hormonal changes that stimulate improved muscle recruitment, hypertrophy (increased muscle size), and stimulates protein synthesis and regeneration of collagen (important for your tendon and muscle health).

Why is BFR used after surgery?

BFR can be used in the rehab process for many knee surgeries including but not limited to:

  • Total knee replacement
  • Partial knee replacement
  • ACL reconstruction
  • PCL reconstruction
  • Meniscus repair
  • Meniscectomy
  • Arthroscopic debridement

Depending on the type of surgery you have, your surgeon will provide you with a protocol to follow during your rehabilitation and recovery. Protocols can vary based on the surgery you had and the preferences of your surgeon. Typically protocols will include knee range of motion restrictions, weight bearing status (amount of weight you can put on your leg when standing), and/or types of exercise you are able to do and how much load you are able to use. Regardless of your specific protocol, these restrictions are put in place to protect the surgical repair that was done and should be followed carefully. The down side to these restrictions is that there may be very few ways for you to exercise your leg which can result in loss of strength and muscle atrophy, ultimately prolonging your recovery.

Another limiting factor in tolerance for exercise after surgery is pain, even when you may have no post-op restrictions. For some individuals, post-op pain can be challenging to manage which limits tolerance for exercise to maintain and build strength. BFR may allow you to perform easier exercises in pain free ranges, while still enjoying the benefits of more vigorous exercise.

Regardless of the limiting factor, BFR allows you to exercise at a low load (i.e. low weight) but still reap the benefits of higher intensity exercise. This includes hypertrophy  (increased muscle size), strength gains and improved muscle recruitment. All of these benefits allow for quickly regaining strength and muscle following surgery in order to maximize your recovery.

What will BFR treatment include?

Once you have been screened to ensure that BFR is a safe and appropriate treatment for you, your physical therapist will place a BFR cuff around the top of your surgical leg. Once the cuff is inflated, you will complete a series of 3 different exercises. The exercises may vary based on your surgical protocol but some examples are listed below.

Early rehab exercises may include:

  • Quad sets
  • Straight leg raises
  • Heel raises or ankle pumps
  • Terminal knee extension

More advanced rehab may include:

  • Squats
  • Lunges
  • Step-ups
  • Hip abduction

Your PT will work with you to identify the most appropriate exercises in order to challenge you while respecting your stage of recovery and post-op surgical protocol. We work closely with surgeons to ensure that your post-operative treatment in physical therapy aligns with your surgeon’s expectations.

What can you expect to feel after BFR treatment?

A good workout! This tool allows you to feel that muscle burn and fatigue that you may have experienced before after a tough workout. As a result, it is not unusual for your muscle to feel tired and sore following treatment. This feeling may only last for an hour or it can last for 1-2 days.

Who can utilize BFR?

Lots of research has been done in recent years to maximize patient safety with BFR. Because the use of BFR temporarily affects your circulatory system, certain individuals are at higher risk for complications with BFR. This include people with a history of:

  •  Deep vein thrombosis (blood clots)
  • Pulmonary embolism
  • Blood clotting disorders
  •  Peripheral vascular disease
  • Sickle cell anemia
  • Kidney disease
  • Hypertension
  • Tumor
  • Cardiopulmonary conditions
  • Clinically significant acid-base imbalance
  • Use of Creatine supplementation

If any of these conditions apply to you then you will likely go through a more traditional rehabilitation process that does not include BFR. This does not put you at a disadvantage, as there are still plenty of ways to build strength and accelerate tissue healing though traditional PT.

If none of these conditions apply to you then your PT will discuss the option of supplementing your treatment with BFR.

BFR Pre-surgery

It turns out that you can set yourself up for success by doing BFR training before you even have your surgery. “Prehab” is often recommended prior to surgery in order to improve strength and range of motion at your knee. BFR can be used in this process to allow you to exercise using lighter load, particularly if you have knee pain or instability due to your injury that limit your tolerance for exercise. Studies have shown improved quad strength and muscle size post-op when BFR is used prior to surgery. This translates to improving your rate of recovery after surgery!

Planning on having knee surgery?

If you are planning to have knee surgery we encourage you to listen to this discussion between Seattle area orthopedic surgeon and Sports Medicine Specialist Dr. Grant Garcia and Union Physical therapy’s Mitch Owens, which answers common questions and discusses the role of PT in recovery from surgery.

If you are local to the Seattle area and have any questions about your upcoming or recent knee surgery, please schedule an appointment at our Seattle-based physical therapy office. We will walk you through your post-operative recovery and discuss the option of use of BFR if it is appropriate for you.

About the Author:

Shannon Russell, PT, DPT is a physical therapist at Union PT in Seattle. She was initially drawn to physical therapy after a series of injuries while competing both nationally and internationally in rock climbing competitions. She has a passion for blending her rock climbing background and love for outdoor activities into her treatment of local athletes and outdoor enthusiasts.