Blood Flow Restriction Training in Knee Osteoarthritic Patients

Overview

The aim of this study was to compare the effect of band tissue flossing method and traditional cuff method for blood flow restriction training on pain, range of motion, muscle strength and functional status in patients with knee osteoarthritis. Symptoms of this condition limit patient's ability to perform high load strengthening. Blood flow restraining training allows strengthening with lower loads. 46 subjects were divided in two groups, 23 subjects in each group. knee extension and knee press exercises were performed. In group A floss band was tied on thigh and in group B pneumatic cuff was applied on thigh. 40-60 years individual with knee osteoarthritis were included. outcome measures were assessed at baseline, after 1st session, after 2nd week and after 4th week.

Osteoarthritis (OA) is a degenerative disorder affecting 528 million people worldwide. It occurs in individuals of age 40 years and above. Most affected joint is knee with prevalence of 60%-85% of total OA cases being 1.39 times higher in women than men. It is characterized by progressive damage to articular cartilage, leading to pain, stiffness, and reduced mobility negatively impacting function and quality of life of affected patients. Obesity, low level of physical activity, joint overload, muscle imbalance in the knee joint, reduced weight and muscle strength in the lower limbs are the factors which can be modified. Quadriceps strengthening is considered as a first-line therapy making resistance training a common practice in OA management. A useful alternative to high intensity exercises which are not tolerable by osteoarthritic patients is blood flow restriction (BFR) training. In BFR a cuff is applied around the proximal aspect of the affected limb, causing partial arterial and full venous occlusion, thereby inducing localized hypoxia and the accumulation of metabolites, imitating the effects of high load resistance training without using heavy load and higher repetition. BFR reduces pain along with improving muscle strength, and function in patients with osteoarthritis (OA) and rheumatoid arthritis. The tissue flossing technique is also called BFR or Kaatsu training. The use of tissue flossing (TF) is a relatively recent treatment modality that gained popularity through the book by Starrett and Cordoza. The mechanisms involved in TF are similar to ischemic preconditioning or BFR training in which an application of an external pressure is used, above or below the muscle or joint, with the application of a tourniquet/inflatable cuff in the most proximal portion of the limb in the case of BFR or an elastic band. Tissue flossing can improve the range of motion or performance, speed up recovery, and decrease the pain caused by various diseases or injuries. The intervention consists of wrapping tissue flossing band around a body region (joint or soft-tissue) using a 50% overlapping in circumferential pattern (distal to proximal), with a relative stretch ranging from 50-75% of the band maximal length, and a treatment duration ranging from 2 minutes to 6 minutes or exercise repetition range from 10 to 30 repetitions. In 2015, research evaluated effects of BFR on older women and concluded that addition of BFR with resistance training significantly increased leg press or quadriceps strength in older women. In 2018, a study included forty-eight women with knee OA who were randomized into three groups: low intensity training with BFRT, low intensity training with partial BFRT, and high-intensity resistance training. BFRT and HI-RT were similarly effective in increasing muscle strength, quadriceps muscle mass, and functionality in knee OA patients. Importantly, BFRT was also able to improve pain while inducing less joint stress, emerging as a feasible and effective therapeutic adjuvant in OA management In 2023, study concluded that Low-intensity resistance training with and without blood flow restriction was similarly effective in enhancing functional status in subjects with knee osteoarthritis. A pilot study performed in 2024 on older adults with knee OA shows that (BFR) significantly reduced pain. In the timed up and go and sit to stand tests, completion times were significantly reduced. Thigh and calf circumferences, as well as thigh muscle thickness significantly increased after exercise. However, isokinetic knee strength did not show significant changes. RCT performed in 2024 investigated the long-term effects of BFRT in patients with knee OA and concluded that BFRT is a promising tool to optimize patient outcomes in the rehabilitation of KOA in the long term. A study in 2021 concluded that compared to the control condition, the flossing treatment showed a positive effect on the maximum voluntary contraction of the knee extensors . Another study in 2020 states, flossing yielded greater improvements in the passive knee extension test and yielded significant improvements in the maximal eccentric knee extension contraction than dynamic stretching flossing on hamstring muscles is more beneficial than dynamic stretching with respect to increasing ROM and muscle exertion. A study in 2021 concluded that floss band intervention can significantly improve the flexibility of the quadriceps and hamstrings, quadriceps muscle force output, and dynamic balance without impeding knee proprioception. According to another study in 2020, flossing bands caused a reduction in perceived knee pain and improved vertical jump performance in young male recreational athlete. A study in 2022 compared flossing and pneumatic cuff for evaluating their hemodynamic responses to blood flow restriction in healthy population. They concluded that floss band can cause blood flow restriction similar to pneumatic cuff. Clinical application of floss band in KOA population remains underexplored. To date, no randomized controlled trial has directly compared therapeutic effects of these two BFR interventions in knee OA patients creating a gap in literature. Therefore, the significance of this study lies in its potential to explore the clinical effectiveness of both methods. By doing so, the findings might help inform future research or clinical protocols regarding the use of practical BFR methods in knee OA rehabilitation.