Review

Perioperative Blood Flow Restriction

Rehabilitation in Patients Undergoing
ACL Reconstruction
A Systematic Review
Yining Lu,* BA, Bhavik H. Patel,* BS, Craig Kym,* BS, Benedict U. Nwachukwu,* MD, MBA,
Alexander Beletksy,* BS, Brian Forsythe,* MD, and Jorge Chahla,*† MD, PhD
Investigation performed at the Division of Sports Medicine, Midwest Orthopaedics at Rush,
Rush University Medical Center, Chicago, Illinois, USA

Background: Low-load blood flow restriction (BFR) training has attracted attention as a potentially effective method of perio-
perative clinical rehabilitation for patients undergoing orthopaedic procedures.
Purpose: To (1) compare the effectiveness of low-load BFR training in conjunction with a standard rehabilitation protocol, pre- and
postoperatively, and non-BFR interventions in patients undergoing anterior cruciate ligament reconstruction (ACLR) and
(2) evaluate protocols for implementing BFR perioperatively for patients undergoing ACLR.
Study Design: Systematic review; Level of evidence, 2.
Methods: A systematic review of the 3 medical literature databases was conducted to identify all level 1 and 2 clinical trials
published since 1990 on BFR in patients undergoing ACLR. Patient demographics from included studies were pooled. Outcome
data were documented, including muscle strength and size, and perceived pain and exertion. A descriptive analysis of outcomes
from BFR and non-BFR interventions was performed.
Results: A total of 6 studies (154 patients; 66.2% male; mean ± SD age, 24.2 ± 3.68 years) were included. Of these, 2 studies
examined low-load BFR as a preoperative intervention, 1 of which observed a significant increase in muscle isometric endurance
(P ¼ .014), surface electromyography of the vastus medialis (P < .001), and muscle blood flow to the vastus lateralis at final follow-
up (P < .001) as compared with patients undergoing sham BFR. Four studies investigated low-load BFR as a postoperative
intervention, and they observed significant benefits in muscle hypertrophy, as measured by cross-sectional area; strength, as
measured by extensor torque; and subjective outcomes, as measured by subjective knee pain during session, over traditional low-
load resistance training (all P < .05). BFR occlusion periods ranged from 3 to 5 minutes, with rest periods ranging from 45 seconds
to 3 minutes.
Conclusion: This systematic review found evidence on the topic of BFR rehabilitation after ACLR to be sparse and heterogeneous
likely because of the relatively recent onset of its popularity. While a few authors have demonstrated the potential strength and
hypertrophy benefits of perioperative BFR, future investigations with standardized outcomes, long-term follow-up, and more
robust sample sizes are required to draw more definitive conclusions.
Keywords: blood flow restriction; anterior cruciate ligament reconstruction; clinical rehabilitation; KAATSU

High-intensity resistance training can induce limb mus- maximum weight, in the immediate perioperative
cle hypertrophy and strength gains, which are desired period.
outcomes in physical rehabilitation after surgery.2 How- Blood flow restriction (BFR) by the application of a pneu-
ever, patients undergoing anterior cruciate ligament matic cuff to the lower extremity during low-intensity resis-
reconstruction (ACLR) cannot tolerate high-intensity tance training (approximately 20% of 1 repetition
training, defined as 60% to 85% of the 1 repetition maximum weight) has been shown to significantly increase
thigh muscle cross-sectional area, as well as carotid arterial
The Orthopaedic Journal of Sports Medicine, 8(3), 2325967120906822
and venous compliance, in healthy volunteers.1,61 The
DOI: 10.1177/2325967120906822 anaerobic conditions of BFR induce an angiogenic stimulus
ª The Author(s) 2020 through upregulation of vascular endothelial growth

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1
2 Lu et al The Orthopaedic Journal of Sports Medicine

factor.19,38 In addition, the hypoxic stimuli may stimulate in May 2019 with the PROSPERO International prospec-
the mobilization and recruitment of endothelial progenitor tive register of systematic reviews.
stem cells, improving the regenerative potential in healthy
volunteers.54 The muscle hypertrophy induced during low- Inclusion and Exclusion Criteria
intensity resistance training with BFR is an attractive
method of postsurgical rehabilitation in ACLR in that it Eligible studies were included after application of the fol-
avoids placing high loads on the graft in the immediate lowing inclusion criteria: studies involving BFR as a pre-
postoperative period and provides rehabilitation options for habilitation or rehabilitation intervention in patients
the elderly and other patients with severe endurance or undergoing ACLR, English language in a scientific peer-
strength deficiency. reviewed journal, and level 1 or 2 evidence or qualification
To date, there is a paucity of clinical data on BFR train- as a randomized controlled trial. Ongoing level 1 clinical
ing and even fewer randomized controlled trials. The dura- trials without publication of complete data were not
tion of the therapy, the intensity of the BFR (pressure), and included.
that required to produce hypertrophic effects remain
unclear.31,47,60,73 Furthermore, given the recent increased Study Selection and Data Extraction
awareness of this therapy, there is a myriad of new
research with heterogeneous indications and results. For Studies eligible for inclusion were screened independently
the aforementioned reasons, the purposes of the present by 2 reviewers (Y.L. and C.K.). Duplicates and those not
systematic review are to (1) compare the effectiveness of meeting the inclusion criteria were excluded. For the
low-load BFR (LL-BFR) training in conjunction with a included studies, data extraction was inclusive of the fol-
rehabilitation protocol, pre- and postoperatively, versus lowing variables: (1) study design and population charac-
non-BFR interventions in patients undergoing ACLR and teristics; (2) rehabilitation protocol, including device used,
(2) evaluate protocols for implementing BFR periopera- occlusion characteristics, exercise performed, and duration
tively for patients undergoing ACLR. of BFR training; and (3) outcome measures, including mus-
cle strength and size, perceived exertion and pain, and
physical function. Data extraction was then performed with
METHODS a custom spreadsheet. As almost all included studies eval-
uated different outcome measures, precluding a meta-
Search Strategy analysis, we elected to proceed with a descriptive analysis
of outcomes. Pooled demographic variables were calculated
This review was performed according to the PRISMA (Pre- assuming independence of samples.
ferred Reporting Items for Systematic Reviews and Meta-
Analyses) guidelines. A literature search was undertaken
to identify studies evaluating BFR training as a prehabili- Study Quality and Reporting
tation or rehabilitation protocol after ACLR for the period
Quality of the included studies was assessed with the Jadad
between January 1, 1990, and May 14, 2019, within the
score,31 which is a criterion for the evaluation and appraisal
MEDLINE, CINAHL, and EMBASE databases. The follow-
of randomized clinical trials. It is based on a composite
ing search terms were used:
score calculated from the following 3 metrics, with 1 point
for an answer of yes and 0 points for an answer of no: (1) Is
((((((((vascular occlusion) OR blood flow restriction) OR the study self-described as randomized? (2) Is the study
blood flow occlusion) OR kaatsu)) OR partial occlusion))) self-described as double-blinded? (3) Does the study provide
AND (((((((anterior cruciate ligament reconstruction) OR an adequate description of dropouts and withdrawals?
ACLR) OR anterior cruciate ligament surgery) OR ACL After this initial assessment, secondary grading was per-
surgery) OR anterior cruciate ligament)). formed on the basis of the following: an additional point was
given if, for question 1, the method for randomization was
Resulting articles from the search underwent title and described and was appropriate or, for question 2, the
abstract screening, and studies investigating the utility of method of double-blinding was described and was appropri-
BFR before or after ACLR were selected. An additional ate. Conversely, a point was deducted if the methods for
search through the reference list of eligible articles was questions 1 and 2 were described and were inappropriate.
performed. Systematic review registration was performed Final scores for studies assessed may range from 0 to 5.

†
Address correspondence to Jorge Chahla, MD, PhD, Midwest Orthopaedics at Rush, Division of Sports Medicine, 1611 W Harrison St, Chicago,
IL 60612, USA (email: [email protected]).
*Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA.
Final revision submitted November 11, 2019; accepted November 25, 2019.
One or more of the authors has declared the following potential conflict of interest or source of funding: B.U.N. has received educational support from
Smith & Nephew and hospitality payments from Stryker, Wright Medical, and Zimmer Biomet. B.F. has received research support from Arthrex, Smith &
Nephew, and Stryker; educational support from Medwest; consulting fees from Sonoma Orthopedics and Stryker; honoraria from Arthrosurface; and roy-
alties from Elsevier and has stock/stock options in Jace Medical. J.C. has received educational support from Arthrex and Smith & Nephew. AOSSM checks
author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any
liability or responsibility relating thereto.
The Orthopaedic Journal of Sports Medicine Perioperative Blood Flow Restriction Rehabilitation 3

PubMed Embase CINAHL Plus

18 Citation(s) 9 Citation(s) 8 Citation(s)

25 Non-Duplicate
Citations Screened

Blood Flow Restriction Therapy in the setting of Anterior Cruciate Ligament Reconstruction 10 Did not meet topic criteria

15 Articles Retrieved

Level 1 evidence (Randomized Controlled Trial) 7 Level 2,3,4 evidence 2 Final Results not published (see Appendix 1)

6 Articles Included

Figure 1. Flowchart of study selection process.

Additionally, an assessment of each study was performed Study Populations

with the modified Cochrane Risk of Bias tool,24 a method
created and validated by the Cochrane Collaboration to Of the 6 studies, 2 each were from Slovenia and
determine the risk of bias in randomized trials. The tool Japan23,59,73,83 and 1 each from Norway and the United
focuses on the various domains of trial design, conduct, and Kingdom.26,31 Two studied preoperative rehabilitation
reporting and proposes a judgment regarding the relevant before ACLR after a chronic injury,23,83 while 4 stud-
risk of bias within each domain, graded as “high risk,” “low ied26,31,59,73 postoperative rehabilitation. Sample sizes ran-
risk,” or “some concern.” The domains include random ged from 16 to 44. All studies were randomized into 2 study
sequence generation, allocation concealment, blinding of arms with 1 exception, which was stratified into 3 study
participants and personnel, blinding of outcome assess- arms.26 Control arms in the trials were sham BFR in 3
ment, incomplete outcome data, and selective reporting. If studies,23,73,83 nonrestricted activities in 2 studies,31,59 and,
not enough information is provided in the methodology to for the study with 3 arms,26 BFR on healthy knees and
make a judgment, the domain is listed as “not reported.” nonrestricted activity. A total of 154 patients were enrolled
in the 6 studies. Pooled demographics of the included stud-
Statistical Analysis ies are as follows: the mean ± SD age was 29.5 ± 7.7 years;
body mass index was 24.2 ± 3.68 kg/m2; and 66.2% of the
Age and body mass index of the study participants were patients were male (Table 3).
extracted from the included studies and pooled with
weighted means. All statistical analysis was performed BFR Protocol
with RStudio software (v 1.0.143; R Foundation for Statis-
tical Computing). Detailed BFR protocols are provided in Table 4. BFR was
used in conjunction with specifically outlined LL resis-
tance training and/or low- to moderate-intensity postoper-
RESULTS ative rehabilitation. Training load ranged from body
weight to 30% of 1 repetition maximum. Constant occlu-
The database search yielded 25 articles. After initial title sion pressure was applied in 4 studies,23,26,59,83 and esca-
and abstract screening, 15 articles regarded the topic in lating pressures were utilized in 2 studies.31,73 Occlusive
question and were assessed for eligibility. From this selec- pressures ranged from 130 to 238 mm Hg, while cuff width
tion, 6 studies were of level 1 evidence per the PRISMA ranged from 9 to 14 cm. BFR was achieved with occlusion
statement and were included in the analysis, as illustrated cuffs in 2 studies 26,73 and tourniquets in 4 stud-
by Figure 1. An overview of study characteristics is pro- ies.23,31,59,83 Duration of BFR exercise regimen ranged
vided in Table 1. The Jadad scores for the included studies from 1 day25 (to examine acute perceptual and hemody-
ranged from 2 to 4, indicating average to rigorous study namic responses) to 16 weeks, with frequency ranging
quality based on randomization and blinding protocols. from a single session over 48 hours to 6 sessions per week.
Using Cochrane risk assessment we found 1 study26 was One group reported on 2 daily BFR sessions.73 Exercise
at high risk of bias in 1 category and 4 were at high risk in 2 volume ranged from 75 to 100 repetitions per session; in
categories (Table 2). 2 studies, 23,83 volume was determined by number of
4 Lu et al The Orthopaedic Journal of Sports Medicine

TABLE 1
Overview of Study Characteristicsa

Level of Jadad Surgery

Author (Year) Evidence No. Study Design Score Study Arms (No.) Description Graft Type

Zargi83 (2018) 2 20 Prospective single-center quasi- 4 Pre-ACLR BFR (12) Arthroscopic Double-stranded
randomized controlled trial with Pre-ACLR sham single ipsilateral
sham intervention BFR (12) bundle semitendinosus-
Population: chronic ACL rupture gracilis autograft
(>6 mo)
Country: Slovenia
Hughes25 (2018) 2 30 Between-participant partially 2 Uninjured BFR (10) — Hamstring tendon
randomized controlled trial Post-ACLR BFR, autograft
Population: ACL rupture, active light resistance
nonsmokers (10)
Country: United Kingdom Post-ACLR, heavy
resistance (10)
Grapar Zargi22 2 20 Prospective single-center quasi- 4 Pre-ACLR BFR (13) Arthroscopic Double-stranded
(2016) randomized controlled trial with Pre-ACLR sham single ipsilateral
sham intervention BFR (13) bundle semitendinosus-
Population: chronic ACL rupture gracilis autograft
(>6 mo)
Country: Slovenia
Iversen30 (2016) 1 24 Randomized blinded controlled trial 4 Post-ACLR BFR (12) — Hamstring tendon
Population: acute ACL rupture Post-ACLR autograft
(<6 mo) nonrestricted
Country: Norway activity (12)
Ohta59 (2003) 1 44 Prospective randomized controlled 3 Post-ACLR BFR (22) — Semitendinosus
trial Post-ACLR autograft
Population: ACL rupture nonrestricted
Country: Japan activity (22)
Takarada73 (2000) 1 16 Controlled trial 2 Post-ACLR BFR (8) — —
Population: ACL rupture Post-ACLR sham
Country: Japan BFR (8)
a
Dashes signify not available. ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; BFR, blood flow restriction.

TABLE 2
Overview of Study Characteristics

Random Sequence Allocation Blinding of Participants Blinding of Outcome Incomplete Selective

Generation Concealment and Personnel Assessment Outcome Data Reporting

Iversen30 (2016) Low risk Low risk Not reported Low risk Low risk Low risk
Zargi83 (2018) High risk High risk Low risk Low risk Low risk Low risk
Grapar Zargi22 (2016) High risk High risk Low risk Low risk Low risk Low risk
Hughes25 (2018) Low risk High risk Not reported Not reported Low risk Low risk
Ohta59 (2003) High risk High risk Not reported Not reported Low risk Low risk
Takarada73 (2000) High risk High risk Not reported Not reported Low risk Low risk

TABLE 3 Outcome Measures

Pooled Demographic Data of Included Studies
Muscle strength was assessed through measurement of
Patients, No. 154 maximal volitional isometric contraction torque in 2 stud-
ies23,83 and by muscular torque ratio of the knee flexors to
Age, y, mean ± SD 29.5 ± 7.7 the knee extensors in 1 study.23,60,83 Additional measures of
Male sex, % 66.2 muscle strength and activation included surface electromy-
Body mass index (n ¼ 110), mean ± SD 24.2 ± 3.68
ography (EMG) of the vastus medialis, EMG amplitude,
time of sustained contraction, and blood flow to the vastus
repetitions to volitional failure.23,83 BFR occlusion periods lateralis.83 Muscle size was assessed through measurement
ranged from 3 to 5 minutes, with rest periods ranging from of the cross-sectional area and volume of the individual
45 seconds to 3 minutes. muscles, the extensor groups, and the flexor groups, as well
The Orthopaedic Journal of Sports Medicine Perioperative Blood Flow Restriction Rehabilitation 5

TABLE 4
Overview of Study Protocolsa
Occlusion Pressure/
Author (Year) Device Used Cuff Width Exercises Volume and Frequency Duration

Zargi83 (2018) Contoured pneumatic Intervention: 150 mm Hg, Unilateral resisted knee Warm-up: 10-15 reps  0.5 kg 5 sessions over
tourniquet cuff 14 cm extension in open kinetic Working set: 30 s of resting 8 d preop
Sham: 20 mm Hg, 14 cm chain on leg extension occlusion, 6 sets to volitional Last session
machine failure. A metronome at 56 performed
bpm is used to set rhythm/ within 48 h of
speed of exercise: 1 beat for surgery
eccentric contraction, 1 for
eccentric
Rest periods: 45 s without
reperfusion after first, third,
and fifth sets; 90 s with
reperfusion after second and
fourth sets
Hughes25 (2018) Dual-purpose easy-fit Intervention ACLR: Unilateral leg press Warm-up: 5 min, unloaded 1 session of
variable contour 145 mm Hg, 11.5 cm cycling; 10 reps, unilateral familiarization
nylon cuff Intervention uninjured: 138, leg press; 5-min rest and 1 session of
11.5 cm Working sets: low-load BFR BFR
ACLR and BFR uninjured: 4 intervention over
sets (30, 15, 15, 15 reps with 2 d, starting at 22
30-s interset rest) at 30% d postop
1RM (1RM for uninjured
BFR, 161 ± 44 kg; 1RM for
ACLR-BFR, 61 ± 28 kg)
throughout 0 -90 range of
motion and contraction
cycling of 1 s concentric / 1 s
eccentric with BFR
continuous at 80% limb
occlusive pressure
High-load ACLR: unilateral leg
press (3  10 reps with 30-s
interset rest) throughout
0 -90 range of motion at
70% 1RM (57 ± 17 kg)
Grapar Zargi22 Contoured pneumatic Intervention: 150 mm Hg, Unilateral resisted knee Warm-up: 10-15 reps  0.5 kg 5 sessions over
(2016) tourniquet cuff 14 cm extension in open kinetic Working set: 30 s of resting 10 d preop
Sham: 20 mg Hg, 14 cm chain on leg extension occlusion, 6 sets to volitional Last session
machine failure. A metronome at performed
56 bpm is used to set within 48 h of
rhythm/speed of exercise: surgery
1 beat for eccentric
contraction, 1 for eccentric
Rest periods: 45 s without
reperfusion after first, third,
and fifth sets. 90 s with
reperfusion after second and
fourth sets
Iversen30 (2016) Contoured pneumatic Starting pressure set to Isometric quadriceps Warm-up: NA 2 sessions per day
tourniquet cuff 130 mm Hg, increased by contractions Working set: 20 reps during over 12 d,
10 mm Hg daily from Progressing to leg extension each 5-min occlusion period, starting at day 2
postop days 2 to 14 up to over a knee roll totaling 100 reps per postop, ending on
maximum pressure of Straight leg raises training session and 200 day 14 postop;
180 mm Hg or highest reps per day MRI on day 16
tolerable pressure; 14 cm Rest periods: 3 min postop
Ohta59 (2003) Hand-pumped air 180 mm Hg Straight leg raise Warm-up: NA 6 sessions per week
tourniquet Hip joint abduction Working sets: Straight leg for 14 wk,
Half squat raise—performed 2 sets starting at 2 wk
Elastic tube exercise (bending daily, 6 times weekly during postop, ending
knee from 45 to 100 ) weeks 1-8 after surgery. No 16 wk postop
Knee bend walking exercise load during week 1, 1-kg
(walking in half squat for 60 load for weeks 2-4, 2-kg load
steps) for weeks 5-8. Hip joint
adduction—5-s maximum
effort, repeated 20,

(continued)
6 Lu et al The Orthopaedic Journal of Sports Medicine

Table 4 (continued)
Occlusion Pressure/
Author (Year) Device Used Cuff Width Exercises Volume and Frequency Duration

performed 2 sets daily,

6/wk during weeks 1-12.
Half squat—exercise
maintained for 6 s, repeated
20, 2 sets daily, 6 weekly
during weeks 5-16 (5-6 wk, no
load; 7-8 wk, 4- to 6-kg load;
9-12 wk, 8- to 10-kg load;
13-16 wk, 12- to 14-kg load).
Elastic tube exercise—
repeated 20, 1 set daily, 6
weekly during weeks 9-12
postop, and 2 sets daily, 6
weekly during weeks 13-16.
Knee bend walking
exercise—3 sets daily, 6
weekly during weeks 13-16
Takarada73 Pneumatic occlusion Initially 180 mm Hg, Intervention and control Warm-up: NA 2 sessions per day
(2000) cuff increased at groups performed low- Working set: 5 sets of occlusions for 11 d, starting
10 mm Hg intervals, intensity exercise described for 5 min, twice a day at 9 AM at 3 d postop,
maximum pressure at as the “usual program for and 2 PM ending 14 d
238 mm Hg; 9 cm recovery in the hospital Rest periods: 3 min postop
Sham: cuff placed without with their injured knee kept
inflation or occlusion immobilized by means of
knee brace”

a
Values are presented as mean ± SD where indicated. ACLR, anterior cruciate ligament reconstruction; bpm, beats per minute; BFR, blood
flow restriction; MRI, magnetic resonance imaging; NA, not available; postop, postoperative; preop, preoperative; reps, repetitions; RM,
repetition maximum; ROM, range of motion.

as the femoral muscle group en bloc; anatomic cross- atrophy as measured by cross-sectional area of the knee
sectional measurements were performed through magnetic extensor muscles when compared with controls (P < .05).
resonance imaging.31,60,73,83 Subjective outcomes assessed Postoperative BFR was also associated with significantly
included the levels of perceived pain and exertion. Physical greater cross-sectional area of the flexor and total quadri-
function assessments included the single-leg anterior reach ceps muscle group in 1 of 2 studies (all P < .05)73 and with
distance and tests of anterior instability.23,60 Two studies significantly greater strength of the operative limb in the
performed intergroup and temporal comparisons using fac- other study (all P < .05), as measured by muscular torque
torial analysis of variance to assess for differences between ratio of the injured extensor and flexor to their counter-
BFR and sham, between pre- and postsurgery, and between parts in the healthy limb.60 One study comparing subjec-
operative and healthy legs, with post hoc Tukey test for tive outcome measures by Hughes et al found that BFR was
pairwise comparisons where a significant main effect was associated with significantly increased rates of perceived
determined.23,83 For the purposes of this review, only sig- exertion and reduction of muscle pain during session but
nificant intergroup (BFR vs sham) differences are significantly decreased levels of knee pain during and after
reported in Tables 5 and 6. session, as compared with non-BFR ACLR rehabilitation
(all P < .05)26 (Table 5). One study provided data regard-
ing complications, where 2 patients in the LL-BFR group
Descriptive Outcomes dropped out because of lower limb “dull pain” related to
the tourniquet.60
With respect to BFR as a preoperative intervention, 1
study23 observed no significant differences in outcome mea-
sures, including postoperative changes in vastii or rectus Study Quality and Reporting
volume. However, a second study by the same group
observed that several outcome measures were significantly The Jadad score was utilized to assess the quality of the
greater in the BFR group as compared with the sham BFR trials included, with scores ranging from 2 to 4. All studies
controls at 12-week follow-up, including muscle isometric included were self-described as randomized and provided
endurance (P ¼ .014), surface EMG amplitude of the vastus appropriate description of the randomization procedure.
medialis (P ¼ .001), and muscle blood flow to the vastus Four studies23,26,31,83 were double-blinded, while 3 pro-
lateralis (P < .001).83 vided descriptions of appropriate blinding methods.23,31,83
With respect to BFR as a postoperative intervention, Only 1 study included a description of participants who
2 of 3 studies 59,73 observed significantly less muscle dropped out or withdrew from the study.60
The Orthopaedic Journal of Sports Medicine Perioperative Blood Flow Restriction Rehabilitation 7

TABLE 5
Overview of Outcome Measuresa

Time Points of Attrition,

Author (Year) Follow-up Treatment Group % Outcome Measures

Zargi83 (2018) Preop, 4 wk Control: pre-ACLR sham BFR 0 MVIC torque: T:C, P ¼ .519
postop, 12 wk Treatment: pre-ACLR BFR Muscle isometric endurance (time of sustained
postop contraction): T > C, P ¼ .014
Surface EMG of vastus medialis: T > C, P ¼ .001
Median frequency calculation of EMG amplitude: T:C,
P ¼ .730
Muscle blood flow in vastus lateralis: T > C, P < .001
Hughes25 Approximately Control: NI BFR and post-ACLR 0 Blood pressure: T:CNI-BFR; T:CACLR-HL, P > .05
(2018) 23 d after standard rehabilitation, heavy RPE: T > CNI-BFR, P < .01; T:CACLR-HL, P > .05
surgery for resistance Perceived muscle pain during session: T > CNI-BFR,
ACLR groups Treatment: post-ACLR BFR, light P < .05; T > CACLR-HL, P < .01
resistance Perceived knee pain during session: T < CACLR-HL,
P < .05
Perceived knee pain 24 h postexercise: T < CACLR-HL,
P < .01
Grapar Zargi22 Preop, 4 wk Control: pre-ACLR sham BFR 0 Vastii volume: T:C, P > .05
(2016) postop, 12 wk Treatment: pre-ACLR BFR Rectus femoris volume: T:C, P ¼ .113
postop MVIC torque: T:C, P ¼ .556
Single-leg anterior reach distance functional test: T:C,
P > .05
Iversen30 Preop, 16 d Control: post-ACLR nonrestricted 0 CSA of quadriceps at 40% femur length: T:C, P > .05
(2016) postop activity CSA of quadriceps at 50% of femur length: T:C, P > .05
Treatment: post-ACLR BFR Mean change in anatomic CSA: T:C, P ¼ .6265
Ohta59 (2003) Preop, 16 d Control: post-ACLR nonrestricted 4.5 Muscular torque ratio of operative knee extensor/
postop activity contralateral knee extensor:
Treatment: post-ACLR BFR Measured at CC60: T > C, P < .001
Measured at CC180: T > C, P ¼ .004
Measured at IM60: T > C, P < .001
Muscular torque ratio of operative knee flexor/
contralateral knee flexor:
Measured at CC60: T > C, P < .05
Measured at CC180: T > C, P ¼ .04
Measured at IM60: T > C, P < .02
CSA ratio of operative knee extensor muscle group/
contralateral knee extensor muscle group: T > C,
P ¼ .04
Single-fiber diameter ratio for type 1 and 2 fibers: T:C,
P < .05
Range of motion (extension limit and flexion): T:C,
P < .05
Anterior instability: T:C, P < .05
Takarada73 Postop days 3 Control: post-ACLR nonrestricted 0 Total CSA (cm2) of the quadriceps femoris: T > C,
(2000) and 14 activity P < .05
Treatment: post-ACLR BFR Extensor CSA: T > C, P < .05
Flexor CSA: T > C, P < .05
Femur CSA: T:C, P > .05
a
Bold indicates P < .05. ACLR, anterior cruciate ligament reconstruction; BFR, blood flow restriction; C, control; CC, concentric contrac-
tion; CSA, cross-sectional area; EMG, electromyography; HL, high load; IM, isometric; MVIC, maximal voluntary isometric contraction;
NI, uninjured; postop, postoperative; preop, preoperative; RPE, rating of perceived exertion; T, treatment.

DISCUSSION the early postoperative period, when compared with nonre-

stricted postoperative activity. These observations are in
The main findings from this descriptive analysis were as line with existing literature that has demonstrated
follows: (1) literature surrounding the topic of BFR rehabil- increases in muscle hypertrophy with BFR application in
itation in patients with ACLR is limited and heterogeneous, healthy8,51,52,55,80 and injured/postoperative22,35,74 popula-
and (2) some but not all of the available evidence suggests tions. Additionally, comparison of acute subjective out-
that BFR as a pre- or postoperative intervention is benefi- comes between LL-BFR and high-load conventional
cial to muscle volume and strength/endurance, at least in rehabilitation found increased ratings of perceived exertion
8 Lu et al The Orthopaedic Journal of Sports Medicine

TABLE 6
Comparison of BFR and Non-BFR Outcomesa
Author (Year) BFR Outcome Non-BFR Outcome P Value

Zargi83 (2018) Preop: Preop: Time-group interaction:

MVIC, Nm: 238 ± 83 MVIC, Nm: 210 ± 44 MVIC, Nm: P ¼ .519
Muscle isometric endurance, s: 145 ± 47 Muscle isometric endurance, s: 95 ± 90 Muscle isometric endurance: P ¼ .014
Surface EMG amplitude: 0.274 ± 0.16 Surface EMG amplitude: 0.224 ± 0.1 Surface EMG amplitude: P ¼ .001
EMG median frequency: 53.2 ± 11 EMG median frequency: 49.9 ± 5.9 EMG median frequency: P ¼ .730
Muscle blood flow: 1.26 ± 0.3 Muscle blood flow: 1.53 ± 0.4 Muscle blood flow: P < .001
4 wk postop: 4 wk postop:
MVIC, Nm: NA MVIC, Nm: NA
Muscle isometric endurance, s: 153 ± 54 Muscle isometric endurance, s: 95 ± 90
Surface EMG amplitude: 0.391 ± 0.293 Surface EMG amplitude: 0.187 ± 0.103
EMG median frequency: 45.7 ± 10.1 EMG median frequency: 41.7 ± 5.8
Muscle blood flow: 1.92 ± 0.81 Muscle blood flow: 0.97 ± 0.20
12 wk postop: 12 wk postop
MVIC, Nm: 196 ± 48 MVIC, Nm: 181 ± 34
Muscle isometric endurance, s: 199 ± 71 Muscle isometric endurance, s: 187 ± 94
Surface EMG amplitude: 0.256 ± 0.160 Surface EMG amplitude: 0.210 ± 0.086
EMG median frequency: 45.9 ± 4.4 EMG median frequency: 44.1 ± 3.7
Muscle blood flow: 1.49 ± 0.75 Muscle blood flow: 1.36 ± 0.32
Hughes25 (2018) ACLR group with BFR ACLR group with non-BFR high- Between groups analysis at
rehabilitation, 22 d postop: load rehabilitation, 22 d postop: 22 d postop:
Perceived exertion, au: 18 Perceived exertion, au: 15.5 Perceived exertion, ACLR-BFR vs
Perceived muscle pain, au: 8 Perceived muscle pain, au: 3 NI-BFR: P < .01
Perceived knee pain, au: 1.5 Perceived knee pain, au: 2.5 Perceived exertion, ACLR-BFR vs
NI control with BFR rehabilitation, ACLR-HL: P > .05
23 d postop: Perceived exertion, NI-BFR vs ACLR-
Perceived exertion, au: 14.5 HL: P > .05
Perceived muscle pain, au: 5.5 Perceived muscle pain, ACLR-BFR vs
Perceived knee pain, au: NA NI-BFR: P < .05
Perceived muscle pain, ACLR-BFR vs
ACLR-HL: P < .01
Perceived muscle pain, NI-BFR vs
ACLR-HL: P < .05
Perceived knee pain, ACLR-BFR vs
NI-BFR: P > .05
Perceived knee pain, ACLR-BFR vs
ACLR-HL: P < .01
Perceived knee pain, NI-BFR vs
ACLR-HL: P > .05
Time-group interactions
Perceived exertion: P < .01
Perceived muscle pain: P < .01
Perceived knee pain: P > .05
Grapar Zargi22 Preop: Preop: Difference between time points:
(2016) MVIC, Nm: 241 ± 74 MVIC, Nm: 191 ± 59 MVIC, Nm: P ¼ .025
Vastii muscle volume, cm3: 1670 ± 362 Vastii muscle volume, cm3: 1462.7 ± 382 Vastii muscle volume, cm3: P ¼ .00
Rectus femoris muscle volume, cm3: Rectus femoris muscle volume, cm3: Rectus femoris muscle volume, cm3:
225.4 ± 53.9 170 ± 43.7 P ¼ .00
Anterior reach distance, cm: –0.5 Anterior reach distance, cm: –4.0 Anterior reach distance, cm: P > .05
4 wk postop: 4 wk postop: Difference between BFR and non-
MVIC, Nm: NA MVIC, Nm: NA BFR:
Vastii muscle volume, cm3: Vastii muscle volume, cm3: MVIC, Nm: P > .05
1325.9 ± 302.3 1210.3 ± 285.9 Vastii muscle volume, cm3: P > .05
Rectus femoris muscle volume, cm3: Rectus femoris muscle volume, cm3: Rectus femoris muscle volume, cm3:
215.6 ± 45.4 164.1 ± 46.6 P > .05
Anterior reach distance, cm: NA Anterior reach distance, cm: NA Anterior reach distance, cm: P > .05
12 wk postop: 12 wk postop:
MVIC, Nm: 201 ± 47 MVIC, Nm: 172 ± 47
Vastii muscle volume, cm3: Vastii muscle volume, cm3: 1334.2 ± 337.2
1444.3 ± 265.6 Rectus femoris muscle volume, cm3:
Rectus femoris muscle volume, cm3: 171.4 ± 45.6
216.3 ± 56.3 Anterior reach distance, cm: –4.5
Anterior reach distance, cm: –3.75
(continued)
The Orthopaedic Journal of Sports Medicine Perioperative Blood Flow Restriction Rehabilitation 9

Table 6 (continued)
Author (Year) BFR Outcome Non-BFR Outcome P Value
30
Iversen (2016) Preop: Preop: Time point analysis between preop
CSA quadriceps at 40% femur length, CSA quadriceps at 40% femur length, and postop:
cm2: 77.5 ± 2.5 cm2: 75.4 ± 3.2 CSA quadriceps at 40% femur length,
CSA quadriceps at 50% femur length, CSA quadriceps at 50% femur length, cm2: P < .0001
cm2: 87.0 ± 3.6 cm2: 82.8 ± 3.4 CSA quadriceps at 50% femur length,
16 d postop: 16 d postop: cm2: P < .0001
CSA quadriceps at 40% femur length, CSA quadriceps at 40% femur length, Between groups analysis at 16 d
cm2: 67.7 ± 2.7 cm2: 66.1 ± 3.3 postop:
CSA quadriceps at 50% femur length, CSA quadriceps at 50% femur length, Mean change in CSA quadriceps from
cm2: 73.9 ± 3.5 cm2: 71.3 ± 3.2 baseline to 16 d, cm2: P ¼ .6265
Reduction in CSA quadriceps at 40% Reduction in CSA quadriceps at 40%
femur length, cm2: –9.7 ± 1.0 femur length, cm2: –9.2 ± 0.8
Reduction in CSA quadriceps at 50% Reduction in CSA quadriceps at 50%
femur length, cm2: –13.7 ± 0.9 femur length, cm2: –11.5 ± 0.7
Mean change in CSA quadriceps from Mean change in CSA quadriceps from
baseline to 16 d, cm2: –13.8 ± 1.1 baseline to 16 d, cm2: –13.1 ± 1
Ohta59 (2003) Preop: Preop: Between group analysis at 16 wk:
Extensor torque, CC60b: 84 ± 13 Extensor torque, CC60b: 86 ± 14 Extensor torque, CC60b: P < .001
Extensor torque, CC180c: 84 ± 14 Extensor torque, CC180c: 90 ± 9 Extensor torque, CC180c: P ¼ .004
Extensor torque, IM60d: 92 ± 19 Extensor torque, IM60d: 94 ± 21 Extensor torque, IM60d: P < .001
Flexor torque, CC60b: 96 ± 21 Flexor torque, CC60b: 90 ± 16 Flexor torque, CC60b: P ¼ .05
Flexor torque, CC180c: 96 ± 19 Flexor torque, CC180c: 99 ± 16 Flexor torque, CC180c: P ¼ .04
Flexor torque, IM60d: 91 ± 18 Flexor torque, IM60d: 94 ± 17 Flexor torque, IM60d: P ¼ .02
Extensor CSA,e injured:healthy: 91 ± 7 Extensor CSA,e injured:healthy: 92 ± 11 Extensor CSA,e preop:postop: P ¼ .04
Flexor þ adductor CSA,e Flexor þ adductor CSA,e Flexor þ adductor CSA,e preop:postop:
injured:healthy: 99 ± 3 injured:healthy: 97 ± 11 P > .05
Range of motion, extension (deg): Range of motion, extension (deg): Type 1 muscle fiber diameter (mm),
3.1 ± 5.8 0.7 ± 2.4 preop:postop: P > .05
Range of motion, flexion (deg): 144 ± 15 Range of motion, flexion (deg): 146 ± 7.7 Type 2 muscle fiber diameter (mm),
Anterior instability, mmf: 5.3 ± 5.3 Anterior instability, mmf: 5.3 ± 1.6 preop:postop: P > .05
16 wk postop: 16 wk postop: Range of motion, extension (deg):
Extensor torque, CC60b: 76 ± 16 Extensor torque, CC60b: 55 ± 17 P > .05
Extensor torque, CC180c: 77 ± 13 Extensor torque, CC180c: 65 ± 13 Range of motion, flexion (deg): P > .05
Extensor torque, IM60d: 84 ± 19 Extensor torque, IM60d: 63 ± 19
Flexor torque, CC60b: 81 ± 14 Flexor torque, CC60b: 72 ± 15
Flexor torque, CC180c: 84 ± 18 Flexor torque, CC180c: 74 ± 12
Flexor torque, IM60d: 72 ± 11 Flexor torque, IM60d: 62 ± 14
Extensor CSA,e preop:postop: 101 ± 11 Extensor CSA,e preop:postop: 92 ± 12
Flexor þ adductor CSA,e preop:postop: Flexor þ adductor CSA,e preop:postop:
105 ± 19 102 ± 23
Type 1 muscle fiber diameter (mm), Type 1 muscle fiber diameter (mm),
preop:postop: 103 ± 10 preop:postop: 95 ± 11
Type 2 muscle fiber diameter (mm), Type 2 muscle fiber diameter (mm),
preop:postop: 102 ± 8 preop:postop: 97 ± 7
Range of motion, extension (deg): Range of motion, extension (deg):
1.9 ± 3.7 3.1 ± 3.6
Range of motion, flexion (deg): 140 ± 5.9 Range of motion, flexion (deg): 143 ± 8.7
73
Takarada 3 d postop: 3 d postop: Between-group analysis at 3 d:
(2000) Total CSA of thigh, cm2: 167.5 ± 5.1 Total CSA of thigh, cm2: 161 ± 4.7 All P > .05
Extensor CSA, cm2: 54 ± 3 Extensor CSA, cm2: 52.8 ± 3.3 Between-group analysis at 14 d:
Flexor CSA, cm2: 46.2 ± 2.6 Flexor CSA, cm2: 49.1 ± 4.7 Total CSA of thigh, cm2: P < .05
Femur CSA, cm2: 7 ± 0.3 Femur CSA, cm2: 6.4 ± 0.5 Extensor CSA, cm2: P < .05
14 d postop: 14 d postop: Flexor CSA, cm2: P < .05
Total CSA of thigh, cm2: 156.3 ± 6.5 Total CSA of thigh, cm2: 137.5 ± 6.4 Femur CSA, cm2: P > .05
Extensor CSA, cm2: 48.5 ± 2.6 Extensor CSA, cm2: 42.1 ± 3.4
Flexor CSA, cm2: 41.7 ± 2.2 Flexor CSA, cm2: 44.8 ± 5.4
Femur CSA, cm2: 7 ± 0.2 Femur CSA, cm2: 6.5 ± 0.5
a
Values are presented as mean ± SD where indicated. Bold P values indicate P < .05. ACLR, anterior cruciate ligament reconstruction;
BFR, blood flow restriction; CC, concentric contraction; CSA, cross-sectional area; EMG, electromyography; HL, high load; IM, isometric;
MVIC, maximal voluntary isometric contraction; NA, not available; NI, uninjured; postop, postoperative; preop, preoperative; RPE, rating
of perceived exertion.
b
Muscular torque, concentric contraction at 60 deg/s, expressed as operated:healthy ratio.
c
Muscular torque, concentric contraction at 180 deg/s, expressed as operated:healthy ratio.
d
Muscular torque, isometric contraction at 60 of knee flexion, expressed as operated:healthy ratio.
e
CSA expressed as ratio to femur on same image.
f
Anterior instability measured with knee ligament arthrometer KT2000 at 133 N.
10 Lu et al The Orthopaedic Journal of Sports Medicine

and reduced in- and postsession knee pain with LL-BFR. reviews have supported the safety of BFR rehabilitation
With comparable increases in muscle cross-sectional area with regard to ischemic and hemostatic risks.§ With the
between LL-BFR and heavy-load training,60-62,73 this new heterogeneity in quality of evidence, firm recommendations
observation highlights the appeal of LL-BFR as a poten- have been difficult to produce,7,48 but a consensus among
tially effective alternative that can lead to reduced residual clinicians has pointed toward individualizing occlusion
knee pain. Ultimately, definitive assessment of the effects pressures, which has important implications for safety and
of BFR in this population remains uncertain because of the effectiveness.3,17,27,37,46,48,79
quality of the present literature. Currently, it is recommended that individual occlusion
Of the 3 studies assessing strength as an outcome, the 1 pressures be calculated as a percentage of the total arterial
with the longest training duration found a difference in occlusion pressure (AOP), with individual protocols rang-
muscular torque ratio between the operative knee extensor ing from 60% to 80%.35,40,69,84 The gold standard method of
and the contralateral extensor in patients who underwent measuring AOP and true occlusion is Doppler ultra-
84 sessions of LL-BFR, as opposed to unrestricted low-load sound,6,9,29,56,66 although recent investigations have begun
training.60 This was likely due to the presence of a dose- to assess the feasibility of pulse oximetry as a lower main-
dependent relationship between training and strength gain tenance alternative.77,84 A previous method in the litera-
such that more sessions lead to greater differences. 71 ture attempted to predict the AOP as a percentage of the
Evidence on other populations in the literature supports a brachial systolic blood pressure.48 However, a more recent
difference in strength gains between LL-BFR and low- investigation identified thigh circumference as the greatest
resistance training alone prescribed between 6 and 8 weeks predictor of AOP.44 Therefore, limb circumference is being
of rehabilitation.10,22,27,32,33 In contrast, evidence on the investigated as a highly effective nonmodifiable factor that
effect of BFR on post-ACLR muscle atrophy is conflicting. can predict pressures applied for complete to partial occlu-
Of the 2 studies reviewed, 1 found almost a 50% reduction sion.17,28,44,81 Additionally, considerations for setting initial
in muscle atrophy with BFR,73 while the other found no pressures according to tourniquet material (nylon vs elas-
difference in quadriceps cross-sectional area between the tic) has been highlighted.46 Of note, none of the studies
control and intervention groups.30 However, authors of the included in this systematic review completely employed
latter study acknowledged subtherapeutic training inten- these guidelines in their methods.
sity as a possible reason for this difference and suggested The current paradigm in training protocol is experienc-
the incorporation of neuromuscular electrostimulation into ing a similar transition toward individualized prescriptions
future research models to detect the effects of BFR on a to maximize gains. Studies in the literature have observed
more granular level.30 a domain-specific timeline for LL-BFR to demonstrate a
The implementation of BFR has generally been significant advantage over non-BFR low-resistance train-
indicated for patients with debilitation undergoing clinical ing. Significant hypertrophy has been noted after as short
rehabilitation, such as the elderly or surgical candi- as 6 days of training21 and can be effectively achieved by
dates5,11,34,35,68,75,76 or athletes involved in sports at a com- most protocols: rehabilitation trials for patients undergoing
petitive level.2,21,30,68,78 While these 2 populations may surgery typically last 2 to 6 weeks and as long as 20
ostensibly have distinct needs, their goals of rehabilitation weeks.16 Those for the elderly last longer, averaging 10 to
or training make BFR an optimal intervention. Initial stud- 12 weeks.42,54,61,62,65,76 However, there is the observation
ies applied hemodynamic occlusion to low-resistance that improvements in muscle strength require a longer
strength training in healthy and active athletes. Since duration of training.63 A comparative study demonstrated
then, several randomized trials and systematic reviews that while high-load resistance training (without BFR)
have established its effectiveness in improving muscle yielded greater strength increases initially, results were
hypertrophy, strength, and fiber-type distribution, inde- equivalent to LL-BFR at 12 weeks of training. 12 This
pendently and as a complement to conventional training, implies that an appropriate period of familiarization may
while minimizing joint stress and risk of adverse effects.‡ yield hormonal and neural adaptations to more effectively
For this reason, low-intensity resistance training with utilize occlusion training.67
occlusion can be an effective and safe alternative in A comparison of pre- and postoperative BFR training in
patients with sufficient extent of frailty or debility.41,43,76 patients undergoing ACLR in this review found the stron-
BFR also has appeal in rehabilitation of active patients gest evidence of significant improvements in muscle hyper-
after sports-related injuries, for maintenance of muscle trophy and strength over standard rehabilitation protocols
mass and function while injuries heal, to facilitate a more in candidates for postoperative BFR. Of the 2 studies on
rapid return to preinjury competition.27,35,74 preoperative BFR, only 1 found a significant improvement
Isolated incidents of adverse events have been documen- over sham intervention in muscular endurance, activation,
ted in the literature, including 3 cases of syncope,53 1 case of and perfusion. These outcomes were likely confounded by
rhabdomyolysis,72 1 case of vision loss secondary to central the significantly reduced training durations of preoperative
retinal vein occlusion,4 and 1 case of thoracic venous out- BFR (5 sessions over 10 days).23,83 Additionally, both trials
flow obstruction in a patient with thoracic outlet syn- enrolled only patients with chronic ACL rupture, where
drome.59 However, multiple trials and several systematic there is a greater likelihood of functional adaptation after

‡ §
References 2, 10, 14, 33, 40, 45, 49-52, 60, 62, 80. References 1, 13, 15, 20, 25, 39, 48, 57, 58, 70.
The Orthopaedic Journal of Sports Medicine Perioperative Blood Flow Restriction Rehabilitation 11

injury. An ongoing trial is examining 4 weeks of BFR pre- 7. Bond CW, Hackney KJ, Brown SL, Noonan BC. Blood flow restriction
habilitation as part of an overall perioperative protocol for resistance exercise as a rehabilitation modality following orthopaedic
surgery: a review of venous thromboembolism risk. J Orthop Sports
ACLR, providing further insight to the optimal timing of
Phys Ther. 2019;49(1):17-27.
BFR intervention16 (Appendix Table A1). The strong evi- 8. Bowman EN, Elshaar R, Milligan H, et al. Proximal, distal, and con-
dence for the increased benefit of combined pre- and post- tralateral effects of blood flow restriction training on the lower extrem-
operative BFR rehabilitation after orthopaedic surgery18,64 ities: a randomized controlled trial. Sports Health. 2019;11(2):
makes it imperative to continue evaluating BFR as a pre- 149-156.
habilitation intervention. 9. Brown H, Binnie MJ, Dawson B, Bullock N, Scott BR, Peeling P.
There are several limitations to consider while interpret- Factors affecting occlusion pressure and ischemic preconditioning.
Eur J Sport Sci. 2018;18(3):387-396.
ing the results of this study. While significant differences in
10. Bryk FF, Dos Reis AC, Fingerhut D, et al. Exercises with partial vas-
short-term muscle strength and hypertrophy were demon- cular occlusion in patients with knee osteoarthritis: a randomized
strated in some of the studies, none provided follow-up data clinical trial. Knee Surg Sports Traumatol Arthrosc. 2016;24(5):
with regard to changes in primary clinical outcomes or 1580-1586.
return to sports. The heterogeneity in outcome variables 11. Centner C, Wiegel P, Gollhofer A, König D. Effects of blood flow
precluded a meta-analysis. Torque and cross-sectional restriction training on muscular strength and hypertrophy in older
areas are common outcome measurements, are readily individuals: a systematic review and meta-analysis. Sports Med.
2019;49(1):95-108.
obtained,2,5,8,10,11,73,81-83 and warrant inclusion in the
12. Cook SB, LaRoche DP, Villa MR, Barile H, Manini TM. Blood flow
design of future trials. The study by Hughes et al26 exam- restricted resistance training in older adults at risk of mobility limita-
ining immediate subjective perspectives during and after tions. Exp Gerontol. 2017;99:138-145.
BFR performed only a single session. Their results may not 13. Cugno M, Uziel L, Fabrizi I, Bottasso B, Maggiolini F, Agostoni A.
be generalizable to patients who are well-adapted to the Fibrinolytic response in normal subjects to venous occlusion and
volume and intensity of BFR protocols. Overall, there was DDAVP infusion. Thromb Res. 1989;56(5):625-634.
14. Dankel SJ, Jessee MB, Abe T, Loenneke JP. The effects of blood flow
a small number of patients in the collective cohort of studies
restriction on upper-body musculature located distal and proximal to
reviewed and poor reporting of adverse events. Long-term applied pressure. Sports Med. 2016;46(1):23-33.
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16. Erickson LN, Lucas KCH, Davis KA, et al. Effect of blood flow restric-
CONCLUSION tion training on quadriceps muscle strength, morphology, physiology,
and knee biomechanics before and after anterior cruciate ligament
The evidence for the benefits of BFR rehabilitation after reconstruction: protocol for a randomized clinical trial. Phys Ther.
ACLR is sparse and heterogeneous possibly because of the 2019;99(8):1010-1019.
17. Fahs CA, Loenneke JP, Rossow LM, Tiebaud RS, Bemben MG. Meth-
novel nature of the technique. Although several studies
odological considerations for blood flow restricted resistance exer-
have shown potential muscle strength and hypertrophy cise. J Trainol. 2012;1(1):14-22.
benefits in patients undergoing perioperative BFR in the 18. Failla MJ, Logerstedt DS, Grindem H, et al. Does extended preoper-
setting of ACLR, future investigations with standardized ative rehabilitation influence outcomes 2 years after ACL reconstruc-
outcomes, long-term follow-up, and more robust sample tion? A comparative effectiveness study between the MOON and
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2608-2614.
19. Ferguson RA, Hunt JEA, Lewis MP, et al. The acute angiogenic sig-
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APPENDIX

TABLE A1
Protocols of Ongoing Level 1 Trials on Perioperative BFR in Patients Undergoing ACLRa
Author (Year) Device Used Exercises Volume and Frequency Duration

15
Erickson Pressurized cuff to the Primary outcome measure: quadriceps strength Not published in abstract Presurgical blood flow
(2019) proximal thigh that partially (peak torque, rate of torque development) restriction therapy
occludes blood flow as the Secondary outcome measures: knee extensor 3/wk for 4 wk leading
patient exercises movement, knee flexion excursion, knee flexion up to surgery
angle, quadriceps cross-sectional area, Postsurgical blood flow
quadriceps muscle physiology restriction therapy
3/wk for 4-5 mo
Lambert36 Automated tourniquet around Weeks 1-3: quadriceps contractions All exercises preformed at 12 wk of rehabilitation
(2019) the proximal thigh outfitted Weeks 3-12: bilateral leg press 20% predicted 1 (2 sessions/wk)
with Doppler (Delfi) Weeks 4-6: hamstring curl repetition maximum of beginning at 10 d
Weeks 4-12: eccentric leg press contralateral leg postsurgery
Weeks 7-12: eccentric hamstring curl All exercises, 4 sets of 30- Functional assessments
15-15-15 repetitions performed at weeks 8
separated by 30-s rest and 12 postsurgery
BFR group performed DEXA scan performed
exercises with cuff at pre- and postoperatively
80% arterial limb at weeks 6 and 12
occlusion

a
Occlusion pressure/cuff width was not published in either abstract. ACLR, anterior cruciate ligament reconstruction; BFR, blood flow
restriction; DEXA, dual-energy x-ray absorptiometry.