Blood flow restriction training improves the efficacy of routine intervention in patients with chronic ankle instability

Abstract

As a new means of rehabilitation, blood flow restriction training (BFRT) is widely used in the field of musculoskeletal rehabilitation. To observe whether BFRT can improve the efficacy of routine rehabilitation intervention in patients with chronic ankle instability (CAI). Twenty-three patients with CAI were randomly divided into a routine rehabilitation group (RR Group) and a routine rehabilitation ​+ ​blood flow restriction training group (RR ​+ ​BFRT Group) according to the Cumberland Ankle Instability Tool (CAIT) score. The RR Group was treated with routine rehabilitation means for intervention, and the RR ​+ ​BFRT Group was treated with a tourniquet to restrict lower limb blood flow for rehabilitation training based on routine training. Before and after the intervention, the CAIT score on the affected side, standing time on one leg with eyes closed, comprehensive scores of the Y-balance test, and surface electromyography data of tibialis anterior (TA) and peroneus longus (PL) were collected to evaluate the recovery of the subjects. Patients were followed up 1 year after the intervention. After 4 weeks of intervention, the RR ​+ ​BFRT Group CAIT score was significantly higher than the RR Group (19.33 VS 16.73, p ​< ​0.05), the time of standing on one leg with eyes closed and the comprehensive score of Y-balance were improved, but there was no statistical difference between groups (p ​> ​0.05). RR ​+ ​BFRT Group increased the muscle activation of the TA with maximum exertion of the ankle dorsal extensor (p ​< ​0.05) and had no significant change in the muscle activation of the PL with maximum exertion of the ankle valgus (p ​> ​0.05). There was no significant difference in the incidence of resprains within 1 year between the groups (36.36% VS 16.67%, p ​> ​0.05). The incidence of ankle pain in the RR ​+ ​BFRT Group was lower than that in the RR Group (63.64% VS 9.09%, p ​< ​0.01). Therefore, four-weeks BFRT improves the effect of the routine intervention, and BFRT-related interventions are recommended for CAI patients with severe ankle muscle mass impairment or severe pain.

Keywords

Chronic ankle instability / Blood flow restriction training / Sports rehabilitation / Rehabilitation training

References

1	B.R. Waterman, B.D. Owens, S. Davey, M.A. Zacchilli, P.J. Belmont. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am, 92 (13) (2010), pp. 2279-2284, 10.2106/JBJS.I.01537.
2.	P.A. Gribble, C.M. Bleakley, B.M. Caulfield, et al.. Evidence review for the. Evidence review for the2016 International Ankle Consortium consensus statement on the prevalence, impact and long-term consequences of lateral ankle sprains. Br J Sports Med, 50 (24)(2016), pp. 1496-1505, 10.1136/bjsports-2016-096189.
3.	Y. Xu, B. Song, A. Ming, C. Zhang, G. Ni.Chronic ankle instability modifies proximal lower extremity biomechanics during sports maneuvers that may increase the risk of ACL injury: a systematic review. Front Physiol, 13 (2022), Article 1036267, 10.3389/fphys.2022.1036267.
4.	C. Thompson, S. Schabrun, R. Romero, A. Bialocerkowski, J. van Dieen, P. Marshall. Factors contributing to chronic ankle instability: a systematic review and meta-analysis of systematic reviews. Sports Med, 48 (1) (2018), pp. 189-205, 10.1007/s40279-017-0781-4.
5.	M. Hagen, M. Lemke, M. Lahner.Deficits in subtalar pronation and supination proprioception in subjects with chronic ankle instability. Hum Mov Sci, 57 (2018), pp. 324-331, 10.1016/j.humov.2017.09.010.
6	X. Xue, T. Ma, Q. Li, Y. Song, Y. Hua.Chronic ankle instability is associated with proprioception deficits: a systematic review and meta-analysis. J Sport Health Sci, 10 (2)(2021), pp. 182-191, 10.1016/j.jshs.2020.09.014.
7	R.J. Wortman, S.M. Brown, I. Savage-Elliott, Z.J. Finley, M.K. Mulcahey. Blood flow restriction training for athletes: a systematic review. Am J Sports Med, 49 (7) (2021), pp. 1938-1944, 10.1177/0363546520964454.
8.	J. Sousa, G.R. Neto, H.H. Santos, J.P. Araujo, H.G. Silva, M.S.Cirilo-Sousa. Effects of strength training with blood flow restriction on torque, muscle activation and local muscular endurance in healthy subjects. Biol Sport, 34 (1)(2017), pp. 83-90, 10.5114/biolsport.2017.63738.
9.	S. Amani-Shalamzari, F. Farhani, H. Rajabi,et al.. Blood flow restriction during futsal training increases muscle activation and strength. Front Physiol, 10 (2019), p. 614, 10.3389/fphys.2019.00614.
10	M.E. Lixandrao, C. Ugrinowitsch, R. Berton, et al.. Magnitude of muscle strength. 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, 48 (2) (2018), pp. 361-378, 10.1007/s40279-017-0795-y.
11	L. Hughes, B. Rosenblatt, F. Haddad, et al.. Comparing the effectiveness of blood flow restriction. Comparing the effectiveness of blood flow restriction and traditional heavy load resistance training in the post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: a UK national health service randomised controlled trial. Sports Med, 49 (11) (2019), pp. 1787-1805, 10.1007/s40279-019-01137-2.
12	H.N. Wang, Y. Chen, L. Cheng, Y.H. Cai, W. Li, G.X. Ni. Efficacy and safety of blood flow restriction training in patients with knee osteoarthritis: a systematic review and meta-analysis. Arthritis Care Res, 74 (1) (2022), pp. 89-98, 10.1002/acr.24787.
13	S. Li, S. Shaharudin, K.M. Abdul. Effects of blood flow restriction training on muscle strength and pain in patients with knee injuries: a meta-analysis. Am J Phys Med Rehabil, 100 (4) (2021), pp. 337-344, 10.1097/PHM.0000000000001567.
14	L. Hughes, B. Paton, B. Rosenblatt, C. Gissane, S.D. Patterson. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med, 51 (13) (2017), pp. 1003-1011, 10.1136/bjsports-2016-097071.
15	J.P. Loenneke, J.M. Wilson, G.J. Wilson, T.J. Pujol, M.G. Bemben. Potential safety issues with blood flow restriction training. Scand J Med Sci Sports, 21 (4) (2011), pp. 510-518, 10.1111/j.1600-0838.2010.01290.x.
16	S.D. Patterson, C.R. Brandner.The role of blood flow restriction training for applied practitioners: a questionnaire-based survey. J Sports Sci, 36 (2)(2018), pp. 123-130, 10.1080/02640414.2017.1284341.
17	B. Killinger, J.D. Lauver, L. Donovan, J. Goetschius. The effects of blood flow restriction on muscle activation and hypoxia in individuals with chronic ankle instability. J Sport Rehabil, 29 (2020), pp. 633-639, 10.1123/jsr.2018-0416.
18	P. Werasirirat, T. Yimlamai. Effect of supervised rehabilitation combined with blood flow restriction training in athletes with chronic ankle instability: a randomized placebo-controlled trial. J Exerc Rehabil, 18 (5) (2022), pp. 123-132, 10.12965/jer.2244018.009.
19	19 X.J. Shi, J.F. Rong, B. Cai, Y. Liu, J. Han. Effect of physical therapy on neuromuscular control dysfunction for chronic ankle instability: a systematic review [in Chinese]. Chin J Rehabil Theory Pract, 28 (2)(2022), pp. 132-143, 10.3969/j.issn.1006-9771.2022.02.002.
20	C.J. Powden, J.M. Hoch, B.E. Jamali, M.C. Hoch. A 4-week multimodal intervention for individuals with chronic ankle instability: examination of disease-oriented and patient-oriented outcomes. J Athl Train, 54 (4) (2019), pp. 384-396, 10.4085/1062-6050-344-17.
21	P.A. Gribble, E. Delahunt, C. Bleakley, et al.. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium. J Orthop Sports Phys Ther, 43 (8)(2013), pp. 585-591, 10.2519/jospt.2013.0303.
22	P.A. Gribble, E. Delahunt, C. Bleakley, et al.. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium. Br J Sports Med. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium. Br J Sports Med, 48 (13) (2014), pp. 1014-1018, 10.1136/bjsports-2013-093175.
23	P. Werasirirat, T. Yimlamai. Effect of supervised rehabilitation combined with blood flow restriction training in athletes with chronic ankle instability: a randomized placebo-controlled trial. J Exerc Rehabil, 18 (2) (2022), pp. 123-132, 10.12965/jer.2244018.009.
24	F. Faul, E. Erdfelder, A.G. Lang, A.G. Buchner. ?Power 3: a flexible statistical power analysis program for the social, behavioral,biomedical sciences. Behav Res Methods, 39 (2) (2007), pp. 175-191, 10.3758/bf03193146.
25	J.M. Wilson, R.P. Lowery, J.M. Joy, J.P. Loenneke, M.A. Naimo. Practical blood flow restriction training increases acute determinants of hypertrophy without increasing indices of muscle damage. J Strength Condit Res, 27 (11) (2013), pp. 3068-3075, 10.1519/JSC.0b013e31828a1ffa.
26	P.E. Luebbers, E.V. Witte, J.Q. Oshel, M.S. Butler. Effects of practical blood flow restriction training on adolescent lower-body strength. J Strength Condit Res, 33 (10) (2019), pp. 2674-2683, 10.1519/JSC.0000000000002302.
27	E.A. Hall, A.K. Chomistek, J.J. Kingma, C.L. Docherty. Balance-and strength-training protocols to Improve chronic ankle instability deficits, part I: assessing clinical outcome measures. J Athl Train, 53 (6) (2018), pp. 568-577, 10.4085/1062-6050-385-16.
28	K.B. Kosik, R.S. McCann, M. Terada, P.A. Gribble. Therapeutic interventions for improving self-reported function in patients with chronic ankle instability: a systematic review. Br J Sports Med, 51 (2) (2017), pp. 105-112, 10.1136/bjsports-2016-096534.
29	U. Roijezon, N.C. Clark, J. Treleaven.Proprioception in musculoskeletal rehabilitation. Part 1: basic science and principles of assessment and clinical interventions. Man Ther, 20 (3)(2015), pp. 368-377, 10.1016/j.math.2015.01.008.
3.	K. Tsikopoulos, D. Mavridis, D. Georgiannos, H.S. Vasiliadis. Does multimodal rehabilitation for ankle instability improve patients'self-assessed functional outcomes? a network meta-analysis. Clin Orthop Relat Res, 476 (6) (2018), pp. 1295-1310, 10.1097/01.blo.0000534691.24149.a2.
31	N. Khalaj, B. Vicenzino, L.J. Heales, M.D. Smith. Is chronic ankle instability associated with impaired muscle strength? Ankle, knee and hip muscle strength in individuals with chronic ankle instability: a systematic review with meta-analysis. Br J Sports Med, 54 (14) (2020), pp. 839-847, 10.1136/bjsports-2018-100070.
32	H. Jaber, E. Lohman, N. Daher, et al.. Neuromuscular control of ankle. Neuromuscular control of ankle and hip during performance of the star excursion balance test in subjects with and without chronic ankle instability. PLoS One, 13 (8) (2018), Article e201479, 10.1371/journal.pone.0201479.
33.	J.M. Bordessa, M.C. Hearn, A.E. Reinfeldt,et al.. Comparison of blood flow restriction devices and their effect on quadriceps muscle activation. Phys Ther Sport, 49 (2021), pp. 90-97, 10.1016/j.ptsp.2021.02.005.
34.	E.L. Woon, J. Low, Y.L. Sng, A.B. Hor, Y.H. Pua.Feasibility, correlates, and validity of the one-leg sit-to-stand test in individuals following anterior cruciate ligament reconstruction. Phys Ther Sport, 52 (2021), pp. 280-286, 10.1016/j.ptsp.2021.10.007.
35.	N. Khalaj, B. Vicenzino, M.D. Smith.Hip and knee muscle torque and its relationship with dynamic balance in chronic ankle instability, copers and controls. J Sci Med Sport, 24 (7)(2021), pp. 647-652, 10.1016/j.jsams.2021.01.009.
36.	Y. Li, R.C. Tsang, D. Liu, B. Ruan, Y. Yu, Q. Gao.Applicability of cutoff scores of Chinese Cumberland Ankle Instability Tool and Foot and Ankle Ability Measure as inclusion criteria for study of chronic ankle instability in Chinese individuals. Phys Ther Sport, 48 (2021), pp. 116-120, 10.1016/j.ptsp.2020.12.021
37.	M. Donahue, J. Simon, C.L. Docherty.Critical review of self-reported functional ankle instability measures. Foot Ankle Int, 32 (12)(2011), pp. 1140-1146, 10.3113/FAI.2011.1140.
38	C.J. Wright, S.W. Linens, M.S. Cain.Establishing the minimal clinical important difference and minimal detectable change for the cumberland ankle instability tool. Arch Phys Med Rehabil, 98 (9)(2017), pp. 1806-1811, 10.1016/j.apmr.2017.01.003.
39.	K. Tsikopoulos, D. Mavridis, D. Georgiannos, H.S. Vasiliadis. Does multimodal rehabilitation for ankle instability improve patients' self-assessed functional outcomes? a network meta-analysis. Clin Orthop Relat Res, 476 (6) (2018), pp. 1295-1310, 10.1097/01.blo.0000534691.24149.a2.
40	40 X.J. Shi, J. Han, Y. Liu, et al.. Research progress on pathological mechanism and evaluation diagnosis of chronic ankle instability [in Chinese]. Chin J Sports Med, 38 (9)(2019), pp. 816-824, 10.16038/J.1000-6710.2019.09.015.
41.	L. Yin, K. Liu, C. Liu, X. Feng, L. Wang.Effect of kinesiology tape on muscle activation of lower extremity and ankle kinesthesia in individuals with unilateral chronic ankle instability. Front Physiol, 12 (2021), Article 786584, 10.3389/fphys.2021.786584.
42	M. Burkhardt, E. Burkholder, J. Goetschius. Effects of blood flow restriction on muscle activation during dynamic balance exercises in individuals with chronic ankle instability. J Sport Rehabil, 30 (6) (2021), pp. 870-875, 10.1123/jsr.2020-0334.
43	M.A. Feger, L. Donovan, J.M. Hart, J. Hertel. Lower extremity muscle activation in patients with or without chronic ankle instability during walking. J Athl Train, 50 (4) (2015), pp. 350-357, 10.4085/1062-6050-50.2.06.
44	R.M. Koldenhoven, M.A. Feger, J.J. Fraser, S. Saliba, J. Hertel. Surface electromyography and plantar pressure during walking in young adults with chronic ankle instability. Knee Surg Sports Traumatol Arthrosc, 24 (4) (2016), pp. 1060-1070, 10.1007/s00167-016-4015-3.
45	45 Z.C. Hou, Y.F. Ao, Y.L. Hu, et al.. Analysis of plantar pressure characteristics and related factors in patients with chronic ankle instability [in Chinese]. J Peking Univ (Heal Sci), 53 (2)(2021), pp. 279-285, 10.19723/j.issn.1671-167X.2021.02.008.
46	A. Mettler, L. Chinn, S.A. Saliba, P.O. McKeon, J. Hertel. Balance training and center-of-pressure location in participants with chronic ankle instability. J Athl Train, 50 (4) (2015), pp. 343-349, 10.4085/1062-6050-49.3.94.
47	47 Q.X. Zhang, X.Q. Hua, Y.J. Shi. Development and application of measurement methods for ankle proprioception [in Chinese]. Chinese J Tissue Eng Res, 15 (35)(2011), pp. 6619-6623, 10.3969/j.issn.1673-8225.2011.35.038.
48.	S.A. Hale, J. Hertel, L.C.Olmsted-Kramer. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sports Phys Ther, 37 (6)(2007), pp. 303-311, 10.2519/jospt.2007.2322.
49	P.O. McKeon, J. Hertel. Spatiotemporal postural control deficits are present in those with chronic ankle instability. BMC Muscoskel Disord, 9 (2008), p. 76, 10.1186/1471-2474-9-76.
50	50 X. Wei. Effect of Different Blood Flow Restriction Training Regiments on Lower Limb Function in Athletes with Knee Injury [in Chinese]. Dissertation. Guangzhou Sport University (2021), 10.27042/d.cnki.ggztc.2021.000156.
51.	C. Doherty, C. Bleakley, E. Delahunt, S. Holden. Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis. Br J Sports Med, 51 (2) (2017), pp. 113-125, 10.1136/bjsports-2016-096178.
52	L. Labanca, M. Mosca, M. Ghislieri, V. Agostini, M. Knaflitz, M.G. Benedetti.Muscle activations during functional tasks in individuals with chronic ankle instability: a systematic review of electromyographicalstudies. Gait Posture, 90 (2021), pp. 340-373, 10.1016/j.gaitpost.2021.09.182.
53.	C. Bleakley, J. Wagemans, F. Netterstrom-Wedin. Understanding chronic ankle instability: model rich, data poor. Br J Sports Med, 55 (9) (2021), pp. 463-464, 10.1136/bjsports-2020-103311