We implemented a blood flow restriction resistance training (BFR-RT) intervention during an 8-week rehabilitation programme in anterior cruciate ligament reconstruction (ACLR) patients within a National Health Service setting.
To compare the effectiveness of BFR-RT and standard-care traditional heavy-load resistance training (HL-RT) at improving skeletal muscle hypertrophy and strength, physical function, pain and effusion in ACLR patients following surgery.
28 patients scheduled for unilateral ACLR surgery with hamstring autograft were recruited for this parallel-group, two-arm, single-assessor blinded, randomised clinical trial following appropriate power analysis. Following surgery, a criteria-driven approach to rehabilitation was utilised and participants were block randomised to either HL-RT at 70% repetition maximum (1RM) (n = 14) or BFR-RT (n = 14) at 30% 1RM. Participants completed 8 weeks of biweekly unilateral leg press training on both limbs, totalling 16 sessions, alongside standard hospital rehabilitation. Resistance exercise protocols were designed consistent with standard recommended protocols for each type of exercise. Scaled maximal isotonic strength (10RM), muscle morphology of the vastus lateralis of the injured limb, self-reported function, Y-balance test performance and knee joint pain, effusion and range of motion (ROM) were assessed at pre-surgery, post-surgery, mid-training and post-training. Knee joint laxity and scaled maximal isokinetic knee extension and flexion strength at 60°/s, 150°/s and 300°/s were measured at pre-surgery and post-training.
Four participants were lost, with 24 participants completing the study (12 per group). There were no adverse events or differences between groups for any baseline anthropometric variable or pre- to post-surgery change in any outcome measure. Scaled 10RM strength significantly increased in the injured limb (104 ± 30% and 106 ± 43%) and non-injured limb (33 ± 13% and 39 ± 17%) with BFR-RT and HL-RT, respectively, with no group differences. Significant increases in knee extension and flexion peak torque were observed at all speeds in the non-injured limb with no group differences. Significantly greater attenuation of knee extensor peak torque loss at 150°/s and 300°/s and knee flexor torque loss at all speeds was observed with BFR-RT. No group differences in knee extensor peak torque loss were found at 60°/s. Significant and comparable increases in muscle thickness (5.8 ± 0.2% and 6.7 ± 0.3%) and pennation angle (4.1 ± 0.3% and 3.4 ± 0.1%) were observed with BFR-RT and HL-RT, respectively, with no group differences. No significant changes in fascicle length were observed. Significantly greater and clinically important increases in several measures of self-reported function (50–218 ± 48% vs. 35–152 ± 56%), Y-balance performance (18–59 ± 22% vs. 18–33 ± 19%), ROM (78 ± 22% vs. 48 ± 13%) and reductions in knee joint pain (67 ± 15% vs. 39 ± 12%) and effusion (6 ± 2% vs. 2 ± 2%) were observed with BFR-RT compared to HL-RT, respectively.
BFR-RT can improve skeletal muscle hypertrophy and strength to a similar extent to HL-RT with a greater reduction in knee joint pain and effusion, leading to greater overall improvements in physical function. Therefore, BFR-RT may be more appropriate for early rehabilitation in ACLR patient populations within the National Health Service.
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Data availability statement
The datasets generated and analysed during the study are not publicly available due to the nature of patient confidentiality but are available from the corresponding authors on reasonable request with permission.
Thomas AC, Wojtys EM, Brandon C, Palmieri-Smith RM. Muscle atrophy contributes to quadriceps weakness after anterior cruciate ligament reconstruction. J Sci Med Sport. 2016;19:7–11. https://doi.org/10.1016/j.jsams.2014.12.009.
Perraton L, Clark R, Crossley K, Pua Y-H, Whitehead T, Morris H, et al. Impaired voluntary quadriceps force control following anterior cruciate ligament reconstruction: relationship with knee function. Knee Surg Sport Traumatol Arthrosc. 2017;25:1424–31. https://doi.org/10.1007/s00167-015-3937-5.
Grapar Žargi T, Drobnič M, Vauhnik R, Koder J, Kacin A. Factors predicting quadriceps femoris muscle atrophy during the first 12 weeks following anterior cruciate ligament reconstruction. Knee. 2016;24:319–28. https://doi.org/10.1016/j.knee.2016.11.003.
Schmitt LC, Paterno MV, Hewett TE. The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sport Phys Ther. 2012;42:750–9. https://doi.org/10.2519/jospt.2012.4194.The.
Filbay SR. Longer-term quality of life following ACL injury and reconstruction. Br J Sports Med. 2017;52:208–9. https://doi.org/10.1136/bjsports-2017-097552.
Kılınç BE, Kara A, Camur S, Oc Y, Celik H. Isokinetic dynamometer evaluation of the effects of early thigh diameter difference on thigh muscle strength in patients undergoing anterior cruciate ligament reconstruction with hamstring tendon graft. J Exerc Rehabil. 2015;11:95–100. https://doi.org/10.12965/jer.150100.
Christensen JC, Goldfine LR, Barker T, Collingridge DS. What can the first 2 months tell us about outcomes after anterior cruciate ligament reconstruction ? J Athl Train. 2015;50:508–15. https://doi.org/10.4085/1062-6050-49.3.95.
Ithurburn MP, Altenburger AR, Thomas S, Hewett TE, Paterno MV, Schmitt LC. Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later. Knee Surg Sport Traumatol Arthrosc. 2017;26:426–33. https://doi.org/10.1007/s00167-017-4678-4.
Keays SL, Bullock-Saxton JE, Newcombe P, Keays AC. The relationship between knee strength and functional stability before and after anterior cruciate ligament reconstruction. J Orthop Res. 2003;21:231–7. https://doi.org/10.1016/S0736-0266(02)00160-2.
Neuman P, Owman H, Müller G, Englund M, Tiderius CJ, Dahlberg LE. Knee cartilage assessment with MRI (dGEMRIC) and subjective knee function in ACL injured copers: a cohort study with a 20 year follow-up. Osteoarthritis Cartilage. 2014;22:84–90. https://doi.org/10.1016/j.joca.2013.10.006.
Hughes L, Rosenblatt B, Paton B, Patterson SD. Blood flow restriction training in rehabilitation following anterior cruciate ligament reconstructive surgery: a review. Tech Orthop. 2018;00:1–8. https://doi.org/10.1097/BTO.0000000000000265.
Herrington L, Myer G, Horsley I. Task based rehabilitation protocol for elite athletes following anterior cruciate ligament reconstruction: a clinical commentary. Phys Ther Sport. 2013;14:188–98. https://doi.org/10.1016/j.ptsp.2013.08.001.
Beynnon BD, Uh BS, Johnson RJ, Abate JA, Nichols CE, Fleming BC, et al. Rehabilitation after anterior cruciate ligament reconstruction: a prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med. 2005;33:347–59. https://doi.org/10.1177/0363546504268406.
Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. J Orthop Sport Phys Ther. 2006;36:385–402. https://doi.org/10.2519/jospt.2006.2222.
Folland JP, Williams AG. The adaptations to strength training: morphological and neurological contributions to increased strength. Sport Med. 2007;37:145–68. https://doi.org/10.2165/00007256-200737020-00004.
Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43:1334–59. https://doi.org/10.1249/MSS.0b013e318213fefb.
Thomeé R, Kaplan Y, Kvist J, Myklebust G, Risberg MA, Theisen D, et al. Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surg Sport Traumatol Arthrosc. 2011;19:1798–805. https://doi.org/10.1007/s00167-011-1669-8.
Hughes L, Paton B, Rosenblatt B, Gissane C, Patterson SD. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med. 2017;51:1003–11. https://doi.org/10.1136/bjsports-2016-097071.
Lixandrão ME, Ugrinowitsch C, Berton R, Vechin FC, Conceição MS, Damas F, et al. 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. Sport Med. 2018;48:361–78. https://doi.org/10.1007/s40279-017-0795-y.
Giles L, Webster KE, Mcclelland J, Cook JL. Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. Br J Sports Med. 2017;51:1688–94. https://doi.org/10.1136/bjsports-2016-096329.
Ferraz RB, Gualano B, Rodrigues R, Kurimori CO, Fuller R, Lima FR, et al. Benefits of resistance training with blood flow restriction in knee osteoarthritis. Med Sci Sport Exerc. 2017;50:897–905. https://doi.org/10.1249/MSS.0000000000001530.
Bryk FF, dos Reis AC, Fingerhut D, Araujo T, Schutzer M, Cury RPL, et al. Exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial. Knee Surg Sport Traumatol Arthrosc. 2016;24:1580–6. https://doi.org/10.1007/s00167-016-4064-7.
Ladlow P, Coppack RJ, Dharm-Datta S, Conway D, Sellon E, Patterson SD, et al. Low-load resistance training with blood flow restriction improves clinical outcomes in musculoskeletal rehabilitation: a single-blind randomized controlled trial. Front Physiol. 2018;9:1–14. https://doi.org/10.3389/fphys.2018.01269.
Takarada Y, Takazawa H, Ishii N. Applications of vascular occlusion diminish disuse atrophy of knee extensor muscles. Med Sci Sports Exerc. 2000;32:2035–9. https://doi.org/10.1097/00005768-200012000-00011.
Ohta H, Kurosawa H, Ikeda H, Iwase Y, Satou N, Nakamura S. Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthop Scand. 2003;74:62–8. https://doi.org/10.1080/00016470310013680.
Iversen E, Røstad V, Larmo A. Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction. J Sport Heal Sci. 2016;5:115–8. https://doi.org/10.1016/j.jshs.2014.12.005.
Abe T, Loenneke JP, Fahs CA, Rossow LM, Thiebaud RS, Bemben MG. Exercise intensity and muscle hypertrophy in blood flow-restricted limbs and non-restricted muscles: a brief review. Clin Physiol Funct Imaging. 2012;32:247–52. https://doi.org/10.1111/j.1475-097X.2012.01126.x.
Hughes L, Paton B, Haddad F, Rosenblatt B, Gissane C, Patterson SD. Comparison of the acute perceptual and blood pressure response to heavy load and light load blood flow restriction resistance exercise in anterior cruciate ligament reconstruction patients and non-injured populations. Phys Ther Sport. 2018;33:54–61. https://doi.org/10.1016/j.ptsp.2018.07.002.
World Medical Association. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. J Am Med Assoc. 2013;2013(310):2191–4. https://doi.org/10.1001/jama.2013.281053.
Fual F, Erdfelder E, Lang A, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175–91.
Norkin CC, White JD. Measurement of joint motion: a guide to goniometry. 3rd ed. Philadelphia: FA Davis Co; 2003.
Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Exercise with blood flow restriction: an updated evidence-based approach for enhanced muscular development. Sport Med. 2015;45:313–25. https://doi.org/10.1007/s40279-014-0288-1.
Wathan D. Load assignment. In: Beachle TR, editor. Essentials of strength training and conditioning. Champaign, IL: Human Kinetics; 1994. p. 435–9.
Abadie BR, Wentworth MR. Prediction of one repetition maximal strength from a 5–10 repetition submaximal strength test in college-aged females. J Exerc Physiol. 2000;3:1–8.
Reynolds JM, Gordon TJ, Robergs RA. Prediction of one repetition maximum strength from multiple repetition maximum testing and anthropometry. J Strength Cond Res. 2006;20:584–92. https://doi.org/10.1519/R-15304.1.
McNair PJ, Colvin M, Reid D. Predicting maximal strength of quadriceps from submaximal performance in individuals with knee joint osteoarthritis. Arthritis Care Res. 2011;63:216–22. https://doi.org/10.1002/acr.20368.
Cook SB, LaRoche DP, Villa MR, Barile H, Manini TM. Blood flow restricted resistance training in older adults at risk of mobility limitations. Exp Gerontol. 2017;99:138–45. https://doi.org/10.1016/j.exger.2017.10.004.
AORN Recommended Practices Committee. Recommended practices for the use of the pneumatic tourniquet in the perioperative practice setting. AORN J. 2007;86:640–55. https://doi.org/10.1016/j.aorn.2007.09.004.
McEwen JA, Jeyasurya J, Owens J. How can personalized tourniquet systems accelerate rehabilitation of wounded warriors, professional athletes and orthopaedic patients? CMBES. 2016;39(1):1–4.
Hughes L, Jeffries O, Waldron M, Rosenblatt B, Gissane C, Paton B, et al. Influence and reliability of lower-limb arterial occlusion pressure at different body positions. PeerJ. 2018;6:e4697. https://doi.org/10.1074/jbc.M115.641514.
Jaffray DA. World congress on medical physics and biomedical engineering, 7–12 June 2015, IFMBE Proc. Toronto; 2015. https://doi.org/10.1007/978-3-319-19387-8.
Hughes L, Rosenblatt B, Gissane C, Paton B, Patterson SD. Interface pressure, perceptual and mean arterial pressure responses to different blood flow restriction systems. Scand J Med Sci Sports. 2018;28:1757–65. https://doi.org/10.1111/sms.13092.
Fatela P, Reis JF, Mendonca GV, Avela J, Mil-Homens P. Acute effects of exercise under different levels of blood-flow restriction on muscle activation and fatigue. Eur J Appl Physiol. 2016;116:985–95. https://doi.org/10.1007/s00421-016-3359-1.
Lixandrão ME, Ugrinowitsch C, Laurentino G, Libardi CA, Aihara AY, Cardoso FN, et al. Effects of exercise intensity and occlusion pressure after 12 weeks of resistance training with blood-flow restriction. Eur J Appl Physiol. 2015;115:2471–80. https://doi.org/10.1007/s00421-015-3253-2.
Tobalina JC, Calleja-Gonzalez J, De Santos RM, Fernandez-López JR, Arteaga-Ayarza A. The effect of basketball footwear on the vertical ground reaction force during the landing phase of drop jumps. Rev Psicol Del Deport. 2013;22:179–82. https://doi.org/10.1249/MSS.0b013e3181915670.
Kawakami Y, Muraoka Y, Kubo K, Suzuki Y, Fukunaga T. Changes in muscle size and architecture following 20 days of bed rest. J Gravit Physiol. 2000;7:53–9.
Giles LS, Webster KE, McClelland JA, Cook J. Can ultrasound measurements of muscle thickness be used to measure the size of individual quadriceps muscles in people with patellofemoral pain ? Phys Ther Sport. 2015;16:45–52. https://doi.org/10.1016/j.ptsp.2014.04.002.
Turton P, Hay R, Taylor J, McPhee J, Welters I. Human limb skeletal muscle wasting and architectural remodeling during five to ten days intubation and ventilation in critical care—an observational study using ultrasound. BMC Anesthesiol. 2016;16:119. https://doi.org/10.1186/s12871-016-0269-z.
Kubo K, Komuro T, Ishiguro N, Tsunoda N, Sato Y, Ishii N, et al. Effect of Low-Load resistance training with vascular occlusion on the mechanical properties of muscle and tendon. J Appl Biomech. 2006;22:112–9. https://doi.org/10.1123/jab.22.2.112.
Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, et al. Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med. 2001;29:600–13. https://doi.org/10.1177/03635465010290051301.
Collins NJ, Misra D, Felson DT, Crossley KM, Ross EM. Measures of knee function: international knee documentation committee (IKDC) subjective knee evaluation form, knee injury and osteoarthritis outcome score (KOOS), knee injury and osteoarthritis outcome score physical function short form (KOOS-PS). Arthritis Care Res. 2011;63:208–28. https://doi.org/10.1002/acr.20632.
Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985;198:43–9.
Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR. The reliability, validity, and responsiveness of the lysholm score and tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med. 2009;37:890–7. https://doi.org/10.1177/0363546508330143.
Clagg S, Paterno MV, Hewett TE, Schmitt LC. Performance on the modified star excursion balance test at the time of return to sport following anterior cruciate ligament reconstruction. J Orthop Sport Phys Ther. 2015;45:444–52. https://doi.org/10.2519/jospt.2015.5040.
Hertel J, Miller SJ, Denegar CR. lntratester and intertester reliability during the star excursion balance tests. J Sport Rehabil. 2000;9:104–16. https://doi.org/10.1123/jsr.9.2.104.
Samaan MA, Ringleb SI, Bawab SY, Greska EK, Weinhandl JT. Altered lower extremity joint mechanics occur during the star excursion balance test and single leg hop after ACL-reconstruction in a collegiate athlete. Comput Methods Biomech Biomed Eng. 2018;21:344–58. https://doi.org/10.1080/10255842.2018.1452203.
Munro AG, Herrington LC. Between-session reliability of the star excursion balance test. Phys Ther Sport. 2010;11:128–32. https://doi.org/10.1016/j.ptsp.2010.07.002.
Shelbourne KD, Benner RW, Gray T. Results of anterior cruciate ligament reconstruction with patellar tendon autografts: objective factors associated with the development of osteoarthritis at 20 to 33 years after surgery. Am J Sports Med. 2017;45:2730–8. https://doi.org/10.1177/0363546517718827.
Soderberg GL, Ballantyne BT, Kestel LL. Reliability of lower extremity girth measurements after anterior cruciate ligament reconstruction. Physiother Res Int. 1996;1:7–16.
Noh E, An C. Changes in pain, swelling, and range of motion according to physical therapy intervention after total knee arthroplasty in elderly patients. Phys Ther Rehabil Sci. 2015;4:79–86.
Bieler T, Aue Sobol N, Andersen LL, Kiel P, Løfholm P, Aagaard P, et al. The effects of high-intensity versus low-intensity resistance training on leg extensor power and recovery of knee function after ACL-reconstruction. Biomed Res Int. 2014;2014:1–11. https://doi.org/10.1155/2014/278512.
Rubin A. Statistics for evidence-based practice and evaluation. Boston: Cengage Learning; 2012.
Libardi C, Chacon-Mikahil M, Cavaglieri CR, Tricoli V, Roschel H, Vechin FC, et al. Effect of concurrent training with blood flow restriction in the elderly. Int J Sports Med. 2015;36:395–9. https://doi.org/10.1055/s-0034-1390496.
Palmieri-Smith RM, Villwock M, Downie B, Hecht G, Zernicke R. Pain and effusion and quadriceps activation and strength. J Athl Train. 2013;48:186–91. https://doi.org/10.4085/1062-6050-48.2.10.
Aagaard P, Simonsen EB, Andersen JL, Magnusson P, Dyhre-Poulsen P. Neural adaptation to resistance training: changes in evoked V-wave and H-reflex responses. J Appl Physiol. 2002;92:2309–18. https://doi.org/10.1152/japplphysiol.01185.2001.
Brandner CR, Warmington SA, Kidgell DJ. Corticomotor excitability is increased following an acute bout of blood flow restriction resistance exercise. Front Hum Neurosci. 2015;9:1–18. https://doi.org/10.3389/fnhum.2015.00652.
Tagesson S, Öberg B, Good L, Kvist J. A comprehensive rehabilitation program with quadriceps strengthening in closed versus open kinetic chain exercise in patients with anterior cruciate ligament deficiency: a randomized clinical trial evaluating dynamic tibial translation and muscle function. Am J Sports Med. 2008;36:298–307. https://doi.org/10.1177/0363546507307867.
Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after anterior cruciate ligament reconstruction with respect to return to sports: a prospective matched follow-up study. Knee Surg Sport Traumatol Arthrosc. 2000;8:337–42. https://doi.org/10.1007/s001670000143.
Alkner BA, Tesch PA, Berg HE. Quadriceps EMG/force relationship in knee extension and leg press. Med Sci Sport Exerc. 2000;32:459–63. https://doi.org/10.1097/00005768-200002000-00030.
Tennent DJ, Burns TC, Johnson AE, Owens JG, Hylden CM. Blood flow restriction training for postoperative lower-extremity weakness: a report of three cases. Curr Sports Med Rep. 2018;17:119–22.
Hylden C, Burns T, Stinner D, Owens J. Blood flow restriction rehabilitation for extremity weakness: a case series. J Spec Oper Med. 2015;15:50–6.
Laurentino GC, Ugrinowitsch C, Roschel H, Aoki MS, Soares AG, Neves M, et al. Strength training with blood flow restriction diminishes myostatin gene expression. Med Sci Sports Exerc. 2012;44:406–12. https://doi.org/10.1249/MSS.0b013e318233b4bc.
Martín-Hernández J, Marín P, Menéndez H, Loenneke JP, Coelho-e-Silva M, García-López D, et al. Changes in muscle architecture induced by low load blood flow restricted training. Acta Physiol Hung. 2013;100:411–8. https://doi.org/10.1556/APhysiol.100.2013.011.
Ellefsen S, Hammarström D, Strand TA, Zacharoff E, Whist JE, Rauk I, et al. Blood flow-restricted strength training displays high functional and biological efficacy in women: a within-subject comparison with high-load strength training. Am J Physiol Regul Integr Comp Physiol. 2015;309:R767–79. https://doi.org/10.1152/ajpregu.00497.2014.
Timmins RG, Shield AJ, Williams MD, Lorenzen C, Opar DA. Architectural adaptations of muscle to training and injury: a narrative review outlining the contributions by fascicle length, pennation angle and muscle thickness. Br J Sports Med. 2016;50:1467–72. https://doi.org/10.1136/bjsports-2015-094881.
Sharifnezhad A, Marzilger R, Arampatzis A. Effects of load magnitude, muscle length and velocity during eccentric chronic loading on the longitudinal growth of vastus lateralis muscle. J Exp Biol. 2014;217:2726–33. https://doi.org/10.1242/jeb.100370.
Thorpe JL, Ebersole KT. Unilateral balance in performance in female collegiate soccer athletes. J Strength Cond Res. 2008;22:1429–33. https://doi.org/10.1080/10635150701416682.
Pietrosimone B, Lepley AS, Harkey MS, Luc-Harkey BA, Troy Blackburn J, Gribble PA, et al. Quadriceps strength predicts self-reported function post-ACL reconstruction. Med Sci Sports Exerc. 2016;48:1671–7. https://doi.org/10.1249/MSS.0000000000000946.
Korakakis V, Whiteley R, Epameinontidis K. Blood flow restriction induces hypoalgesia in recreationally active adult male anterior knee pain patients allowing therapeutic exercise loading. Phys Ther Sport. 2018;32:235–43. https://doi.org/10.1016/j.ptsp.2018.05.021.
Korakakis V, Whiteley R, Giakas G. Low load resistance training with blood flow restriction decreases anterior knee pain more than resistance training alone. A pilot randomised controlled trial. Phys Ther Sport. 2018;34:121–8. https://doi.org/10.1016/j.ptsp.2018.09.007.
Leffler A, Hansson P, Kosek E. Somatosensory perception in a remote pain-free area and function of diffuse noxious inhibitory controls (DNIC) in patients suffering from long-term trapezius myalgia. Eur J Pain. 2002;6:149–59. https://doi.org/10.1053/eujp.2001.0312.
Tuveson B, Leffler AS, Hansson P. Time dependant differences in pain sensitivity during unilateral ischemic pain provocation in healthy volunteers. Eur J Pain. 2006;10:225–32. https://doi.org/10.1016/j.ejpain.2005.03.010.
Heyman E, Gamelin F, Goekint M, Piscitelli F, Roelands B, Leclair E, et al. Intense exercise increases circulating endocannabinoid and BDNF levels in humans—possible implications for reward and depression. Psychoneuroendocrinology. 2012;37:844–51. https://doi.org/10.1016/j.psyneuen.2011.09.017.
Koltyn KF, Brellenthin AG, Cook DB, Sehgal N, Hillard C. Mechanisms of exercise-induced hypoalgesia. J Pain. 2014;15:1294–304. https://doi.org/10.1016/j.jpain.2014.09.006.Mechanisms.
Herrington L, Al-Sherhi A. A controlled trial of weight-bearing versus non–weight-bearing exercises for patellofemoral pain. J Orthop Sport Phys Ther. 2007;37:155–60. https://doi.org/10.2519/jospt.2007.2433.
Hart JM, Pietrosimone B, Hertel J, Ingersoll CD. Quadriceps activation following knee injuries: a systematic review. J Athl Train. 2010;45:87–97. https://doi.org/10.4085/1062-6050-45.1.87.
Yasuda T, Ogasawara R, Sakamaki M, Ozaki H, Sato Y, Abe T. Combined effects of low-intensity blood flow restriction training and high-intensity resistance training on muscle strength and size. Eur J Appl Physiol. 2011;111:2525–33. https://doi.org/10.1007/s00421-011-1873-8.
This study was supported by Delfi Medical Innovations Inc. who provided a pneumatic variable contour cuff and PT device for the study.
Conflicts of interest
Dr. Luke Hughes, Dr. Benjamin Rosenblatt, Prof. Fares Haddad, Prof. Conor Gissane, Mr. Daniel McCarthy, Mr. Thomas Clarke, Mr. Graham Ferris, Miss. Joanna Dawes, Dr. Bruce Paton and Dr. Stephen David Patterson have no conflicts of interest that are directly relevant to the content of this article.
Ethical approval and consent to participate
Ethical approval for the research was granted by the NHS Health Research Ethics Committee and University Ethics Committee. Written informed consent was obtained from each of the participants in compliance with the Declaration of Helsinki (2013).
Bruce Paton and Stephen David Patterson are joint senior/corresponding authors.
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Hughes, L., Rosenblatt, B., Haddad, F. et al. 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, 1787–1805 (2019). https://doi.org/10.1007/s40279-019-01137-2