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COURSE CODE
Hours
Price
ACL Rehabilitation: A Review of Current Treatment Approaches
4
$72 PTOH04AC-H
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition
4
$72
PTOH04BF-H
6 $105 PTOH06FP-H
Evidence-Based Balance Rehabilitation and Fall Prevention
Introduction to Golf Rehabilitation and Performance: 90 Percent Mental, 90 Percent Physical 3
$55 PTOH03GR-H
Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body
5
$89 PTOH05ML-H
Book Expiration Date: 7/8/2026
INCLUDED IN THIS BOOK
1
ACL Rehabilitation: A Review of Current Treatment Approaches [4 contact hours]
As technology, surgical techniques, and graft options continue to evolve with regards to ACL reconstruction, sports medicine professionals must stay abreast of changes within the literature to assure proper rehabilitation of athletes. The instructor provides a review of the current literature as it pertains to current controversies in anterior cruciate ligament (ACL) reconstruction rehabilitation. Some of the topics to be covered throughout this course include the need for surgical reconstruction, graft choice options, functional bracing, rehabilitation techniques, and return to play decision making. Participants will review the possible benefits of inclusion of a neuromuscular injury prevention program while taking a closer look at appropriate rehabilitation exercises to integrate during different stages of post-operative recovery. Individuals will be able to distinguish between different types of functional tests, which will allow sports medicine professionals to develop a more comprehensive return to play plan. Participants will be able to compare the recommended guidelines presented within the lecture to the participant’s current clinical practice while assessing the need for change within a specific patient population. 8 Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition [4 contact hours] Blood flow restriction training (BFRT) is an exercise technique that is transforming how we prescribe exercises therapy. By partially restricting blood flow to the muscles using specialized cuffs or bands, BFRT offers a range of benefits from muscle activation to advanced rehab training. Discover the benefits of blood flow restriction training with this course. From increasing muscle activation and muscle growth to enhancing strength and endurance. BFRT can even help reduce pain. BFRT is a science-based approach—over 800 articles published in the last 10 years—that can be safely prescribed to diverse populations from young to old, from patients to athletes. 16 Evidence-Based Balance Rehabilitation and Fall Prevention [6 contact hours] This course is intended for physical therapy, occupational therapy and athletic training practitioners who address balance impairments and work to reduce falls in their patients and communities. This course defines balance and its components, describes how the various balance issues fall into these component categories and categorizes these impairments accordingly. It will outline how to assess balance and interpret the many varied assessment tools available. Taking this information, clinicians will see how to systematically approach balance rehabilitation, including how to prioritize needs, account for patient background and resources, and work towards long term falls reduction. Finally, this course discusses current guidelines for community level fall prevention strategies and how therapists can be more involved with this process. 25 Introduction to Golf Rehabilitation and Performance: 90 Percent Mental, 90 Percent Physical [3 contact hours] This course provides a comprehensive review of current approaches to ACL (anterior cruciate ligament) rehabilitation. It covers the latest evidence on surgical reconstruction techniques, graft choices, functional bracing, neuromuscular training, and return-to-play decision making. The course emphasizes the importance of evidence-based practice and staying current with the evolving literature in ACL rehabilitation. Participants will learn about early rehabilitation protocols, specific exercises and techniques, functional testing methods, and how to incorporate psychological readiness into return-to-sport decisions. The course includes case studies and self-assessment questions to reinforce key concepts. 33 Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body [5 contact hours] This course provides learners with an evidence-based approach to combining instrument-assisted soft tissue mobilization (IASTM), cupping, and kinesiology taping on the lower extremities. By focusing on how this technique can stimulate the central nervous system (CNS), clinicians can help reduce pain, enhance mobility, and improve occupational performance.
Colibri Healthcare, LLC’s courses are approved by the Ohio Physical Therapy Association.
FREQUENTLY ASKED QUESTIONS
License Expires
Hours Required
Mandatory Subjects
PT: Expire January 31 of the even year PTA: Expire January 31 of the odd-numbered year
PT: 24 hours PTA: 12 hours
The two-hour ethics requirement an be met by taking the Ohio Jurisprudence Assessment Module (OH JAM) online.
(All hours are allowed through home study)
Are you an Ohio board-approved provider? Colibri Healthcare, LLC’s courses are approved by the Ohio Physical Therapy Association. Are my credit hours reported to the Ohio board? No. The board performs random audits at which time proof of continuing education must be provided. Who must take the OH JAM? All individuals applying for initial PT or PTA licensure in Ohio must take and achieve a passing score on the OH JAM as a licensure requirement. Current PT and PTA licensees, and applicants reinstating an expired Ohio license, must take and achieve a passing score on the OH JAM as a requirement of the renewal or reinstatement process. Information on how to register is available at: https://www.fsbpt.org/Our-Services/Jurisprudence-Assessment- Module-JAM-Services/Ohio Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Physical-Therapy you will see our robust FAQ section that answers many of your questions. Simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll-free at 1-888-857-6920, Monday - Friday 9:00 am - 6:00 pm EST, Saturday 10:00 am - 4:00 pm EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Disclosures: Resolution of conflict of interest Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/commercial support and non-endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer: The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition. ©2025: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.
1
ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
ACL Rehabilitation: A Review of Current Treatment Approaches 4 Contact Hours
ACCESS THE FULL VIDEO PRESENTATION Scan the QR CODE ► to start video or visit https://uqr.to/ACLRehab
Author J.D. Boudreaux, EdD, PT, LAT, ATC, SCS
J.D. Boudreaux is a dual-credentialed sports medicine professional with extensive experience in physical therapy and athletic training. He is licensed as an athletic trainer in Louisiana and Texas and is a board-certified sports clinical specialist. Dr. Boudreaux has seven years of experience working with collegiate athletes, particularly in football and baseball. He has served as a visiting lecturer for athletic training education programs and is currently the director of sports medicine for an outpatient sports medicine clinic. Dr. Boudreaux completed his doctorate in curriculum and instruction with a concentration in health professions in 2018.
LEARNING OUTCOMES ● Explain the importance of surgical reconstruction for young, active patients with ACL injuries ● Compare and contrast different graft types and sources for ACL reconstruction ● Describe the role of functional bracing in ACL rehabilitation ● Design evidence-based neuromuscular rehabilitation plans for ACL patients
● Identify appropriate exercises and progressions for different stages of ACL recovery ● Implement a battery of functional tests to assess readiness for return to play ● Incorporate psychological readiness measures into return-to-sport decision making ● Apply current best practices to case scenarios involving ACL rehabilitation
SELF-ASSESSMENT QUESTIONS
1.
Which of the following is NOT an essential component during early ACL rehabilitation? a. Enhancing sport-specific ability b. Establishing full knee extension c. Diminishing pain and inflammation d. Restoring volitional quad control Which of the following is NOT a component of the traditional functional hop test? a. Triple hop for distance b. Tuck jump c. Crossover hop for distance d. Single hop for distance Which of the following flawed techniques with foot placement are assessed for quality within the tuck jump assessment? a. Excessive landing noise b. Equal timing of foot contacts c. Feet landing shoulder width apart d. All of the above are assessed for quality
4.
Which of the following is NOT a directional component of the Y-balance test? a. Anterior b. Posteromedial c. Posterior d. Posterolateral Which of the following is NOT a psychological variable that may influence return to play in sports? a. Gear of reinjury b. Age/competition level of the athlete c. Athletic confidence d. Psychological and subjective readiness
2.
5.
3.
ANSWERS: 1: a 2 : b 3: d 4 : c 5 : b
2
ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
REVASCULARIZATION/REMODELING TIMELINE • Weeks 0-2 : Avascular necrosis ○ Significant reduction in graft strength • Weeks 3-20 : Revascularization • Weeks 6-12 : Disorganization of collagen ○ Careful with exercises • Weeks 12-24 : Remodeling and proliferation (collagen maturing) • Week 12-20 : Exercise progressions • Week 24 : Sport specific drills Early Rehabilitation Phase The evolution of ACL rehabilitation protocols has shifted towards more accelerated programs. Accelerated Programs: 1. Range of Motion : Aim to achieve unrestricted range of motion by week 4 post-surgery 2. Brace Weaning : Typically wean from the post- operative brace between 2 and 6 weeks 3. Open Chain Exercises : Introduce open chain full extension exercises as early as week 6 or even earlier 4. Closed Chain and Functional Tasks : Begin full range squatting and some functional sports-specific drills around 5-6 weeks Non-Accelerated Programs: 1. Range of Motion : Unrestricted range of motion is typically achieved around week 8 2. Brace Weaning : Usually occurs between 4 and 6 weeks post-surgery 3. Open Chain Exercises : Delay introduction of open chain full extension exercises until around week 12 4. Closed Chain and Functional Tasks : Full range squatting and functional drills are typically introduced around week 12 The majority of current practices lean towards accelerated protocols. The key differences lie in the timing of introducing certain exercises and achieving specific milestones. It is important to understand that these classifications are based on exercise introduction and range of motion goals, not on return-to-play timelines. Regardless of the protocol used, return-to-play decisions should be based on meeting functional criteria rather than solely on time from surgery. Accelerated protocols have shown similar outcomes to non-accelerated programs in terms of knee laxity, functional measures, and patient-reported outcomes. However, there is minimal to no scientific evidence supporting return to sport at less than four months post- surgery, regardless of the rehabilitation protocol used. The debate between accelerated and non-accelerated protocols may be becoming less relevant, as most clinicians now implement some form of accelerated protocol. The
INTRODUCTION
INTRODUCTION AND IMPORTANCE OF EVIDENCE-BASED PRACTICE
There is a big emphasis on the importance of staying current with the evolving literature in ACL rehabilitation. Learners are challenged to evaluate their current practices critically and be open to new evidence-based approaches. ACL rehabilitation practices have changed significantly over the years, including surgical techniques/ technology, graft choices, rehab-ilitation protocols, and return-to-play criteria . Clinicians need to update their knowledge and practices continually to provide the best care for their patients. Key statistics to underscore the importance of optimizing ACL rehabilitation: • Only about 55% of athletes return to competitive sport at their pre-injury level following ACL reconstruction • Up to 30% of young, active individuals who return to high-risk sports experience a second ACL injury within the first two years after returning to sport These sobering statistics highlight the need for improved rehabilitation strategies and return-to-play decision-making processes. Surgical Considerations and Graft Choices The literature supports ACL reconstruction in young, active adults due to the risk of: • Episodes of instability • Potential for pathological laxity • Injuries to other structures of the knee (i.e., meniscus) The various graft options available for ACL reconstruc- tion include: 1. Autografts : ○ Patellar tendon 2. Allografts: For young, competitive athletes, autografts are strongly preferred over allografts: ○ Autografts had a 6% failure rate ○ Non-irradiated allografts had a 9% failure rate ○ Irradiated allografts had a 34% failure rate (statistically significant) While there is some debate between patellar tendon and hamstring autografts, recent literature suggests a slight preference for patellar tendon grafts in terms of long-term outcomes and reduced failure rates. ○ Hamstring tendon ○ Quadriceps tendon
3
ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
• Open kinetic chain exercises should begin in a limited range (90-45 degrees) and gradually progress to the full range as healing allows "ACL-friendly" position : This is approximately 20-30 degrees of knee flexion. This position minimizes stress on the ACL graft and can be used as a starting point for many exercises. Clinicians should address hip and core strength in ACL rehabilitation, as these muscle groups play a crucial role in lower extremity control and injury prevention. Neuromuscular Training and Injury Prevention Neuromuscular training can be beneficial as part of the rehabilitation process and as a strategy for preventing future injuries. There is significant evidence supporting the use of neuromuscular training programs to reduce the risk of ACL injuries, particularly non-contact injuries. Key components of effective neuromuscular training programs include: 1. Plyometric exercises 2. Balance training 3. Strengthening exercises 4. Agility drills 5. Sport-specific movement patterns These programs should be performed at least 2-3 times per week and should be continued as a maintenance program, even after return to sport. Consistent implementation of such programs can reduce ACL injury risk by up to 50%. Clinicians should be aware of the importance of proper landing mechanics. The tuck jump assessment can be used as a tool for evaluating neuromuscular control and identifying athletes who may be at higher risk for ACL injury. Return to Running Progression The course provides a detailed overview of a return to running progression, typically implemented around 3-4 months post-surgery. It outlines the following stages: 1. Straight-line running on a consistent surface (e.g., turf or track) 2. Curved running (e.g., around a track or field) 3. Acceleration/deceleration drills ("buildups") 4. Figure-8 running 5. Cutting drills 6. Sport-specific agility patterns It is crucial to monitor the athlete's response to each stage, including pain, swelling, and movement quality. It is not recommended to progress to the next stage until the athlete can complete the current stage without adverse effects. Endurance running (e.g., distance running) can typically be introduced around the figure-8 stage, assuming the athlete has progressed through the earlier stages without issues.
focus has shifted towards individualized, criterion-based progression that respects the physiological healing process of the graft while optimizing functional outcomes. The early phase of rehabilitation is critically important in setting the foundation for successful recovery. Early weight-bearing and range of motion within the first week has been supported by research after ACL reconstruction. Key goals of this phase are: 1. Diminish pain and inflammation 2. Restore full knee extension 3. Gradually increase knee flexion 4. Restore volitional quadriceps control 5. Maintain patellar mobility (superior glide of patella and external rotation of tibia) 6. Restore independent ambulation
LEARNING TIP! Negative effects can present themselves during the early stages of rehabilitation when pain and inflammation are not appropriately controlled. These include limited ROM, quad inhibition, and abnormal gait patterns.
Achieving full knee extension is crucial and should be a top priority. Failure to achieve full knee extension can lead to arthrofibrosis and long-term functional deficits. Aggressive measures are recommended to achieve this, including: • Prone hangs • Low-load, long-duration stretching • Heel props Continuous passive motion (CPM) machines : While they were once common, current evidence does not strongly support their routine use. CPM machines may be beneficial in select cases where achieving range of motion is particularly challenging. It is crucial to restore quadriceps control, with a focus on neuromuscular electrical stimulation (NMES) if patients struggle to activate their quadriceps voluntarily within the first few days post-surgery. Progression of Rehabilitation Exercises As the rehabilitation progresses, there is great importance to gradually introducing more challenging exercises. There is a debate surrounding open vs. closed kinetic chain exercises, particularly for the quadriceps. Key points: • Closed kinetic chain exercises can be safely introduced early in the rehabilitation process • Open kinetic chain exercises for the quadriceps should be introduced cautiously, typically starting around 4-6 weeks post-surgery
4
ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
Psychological Readiness and Subjective Measures One of the key themes throughout the course is the importance of psychological readiness in return-to-sport decision making. There is significant evidence that fear of re-injury is one of the primary reasons athletes do not return to their pre-injury level of sport participation. There are several subjective measures to assess psychological readiness and overall knee function: 1. International Knee Documentation Committee (IKDC) Subjective Knee Form : ○ Assesses symptoms, sports activities, and function ○ Provides a total score out of 100 2. ACL-Return to Sport after Injury (ACL-RSI) Scale : ○ 12-item questionnaire specifically designed to assess psychological readiness for return to sport after ACL reconstruction ○ Aim for a score of 90% or higher 3. Lysholm Knee Scoring Scale : ○ Assesses various aspects of knee function ○ Total score out of 100 4. Subjective Knee Score : ○ Adapted from Noyes, it covers pain, swelling, stability, and function ○ Total score out of 100, with 80-100 considered an excellent function Of these measures, the ACL-RSI scale is preferred due to its focus on psychological readiness and fear of re-injury. Even if an athlete performs well on objective functional tests, a low score on the ACL-RSI may indicate the need for additional time or interventions before Functional knee bracing after ACL reconstruction is a controversial topic. The current literature does not strongly support the use of functional bracing after isolated ACL reconstruction in terms of reducing re-injury risk . However, bracing may provide psychological benefits and may be considered in certain cases, particularly for the first year after surgery. A patient-specific approach to bracing is recommended, considering factors such as the type of sport, position played, and the athlete's comfort level. Post-operative Bracing : While it was once standard practice, many surgeons now opt for an early range of motion without a brace, depending on the specific procedure and any concomitant injuries. Blood flow restriction (BFR) training : BFR is an emerging technique in ACL rehabilitation. While promising, more research is needed to fully establish its role and optimal protocols. clearing them for a return to sport. Bracing and Other Considerations
LEARNING TIP! Some common deviations that clinicians should look for during return to running program after ACL reconstruction may include lack of drive from hip flexors during early swing, weakness of hip abductors during stance, and tightness in hip adductors causing a scissoring pattern.
Functional Testing for Return to Play A critical component of the course is the discussion of functional testing to assess readiness for return to play. There is no single test that is sufficient, and a battery of tests should be used to comprehensively evaluate the athlete. The course covers the following functional tests: 1. Isokinetic Strength Testing : ○ This is considered the gold standard for assessing quadriceps and hamstring strength ○ Look for limb symmetry index (LSI) of at least 90% for quadriceps and hamstring strength ○ Consider the hamstring-to-quadriceps ratio, aiming for at least 60-70% 2. Functional Hop Tests : ○ Single hop for distance ○ Triple hop for distance ○ Cossover hop for distance ○ 6-meter timed hop ○ Aim for LSI of at least 90% on all hop tests 3. Y-Balance Test : ○ Assesses dynamic balance and neuromuscular control ○ Look for less than 4 cm difference in anterior reach between limbs ○ Aim for less than a 6 cm difference in posteromedial and posterolateral reach between limbs 4. Tuck Jump Assessment : ○ This evaluates neuromuscular control and landing mechanics ○ This is scored based on various technique flaws (knee and thigh, foot placement, and plyometric technique) observed during 10 seconds of continuous tuck jumps While these tests provide valuable objective data, they should be considered alongside other factors such as the quality of movement, sport-specific demands, and psychological readiness.
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ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
CASE STUDY AND CLINICAL DECISION MAKING
A 16-year-old high school football player (junior in school) injured his knee while participating in a playoff game. The athlete injured the knee when he went to plant and made a cut, causing him to feel a pop in his knee with immediate pain. He was unable to continue to participate on the day of the injury. The subsequent office exam and imaging revealed a complete tear of the ACL along with a lateral meniscus tear. The athlete has undergone a surgical procedure consisting of ACL reconstruction with a patella tendon graft along with a lateral meniscus repair. The time frame of the surgery is in the middle of December, and the athlete also plays baseball.
Key considerations: • The patient's age and skeletal maturity • Graft choice (patellar tendon autograft in this case) • Concomitant lateral meniscus repair • Timing of surgery (mid-December) and its impact on return-to-sport timeline • The fact that the athlete also plays baseball, requiring consideration of multiple sport demands A comprehensive approach to return-to-play decision making should be initiated and multiple factors should be considered, including: • Time from surgery (typically 9-12 months for full return to high-risk sports) • Achievement of functional test benchmarks • Sport-specific readiness • Psychological readiness Return-to-play decisions should be based on meeting functional criteria rather than solely on time from surgery. KEY LEARNINGS The course concludes by summarizing key take-home points: 1. Use a battery of tests for return-to-play assessment, including both objective and subjective measures.
2. Include open tasks and reactive decision-making elements in return-to-play testing. 3. Assess psychological readiness as a crucial component of return-to-sport decisions. 4. Monitor workload throughout the return-to-sport transition. 5. Implement and maintain neuromuscular training programs to reduce injury risk.
There is an ongoing need for clinicians to stay current with the evolving literature in ACL rehabilitation and to crit- ically evaluate their practices. There is a need to encourage participants to implement evidence-based strategies to improve outcomes for their ACL reconstruction patients.
6
ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
FINAL EXAM QUESTIONS
1.
Which of the following have consistently evolved with regards to management of ACL injuries? a. Graft options b. Rehabilitation protocols c. Surgical techniques d. All of the above have consistently evolved in this patient population Which of the following is an appropriate reason to surgically reconstruct an insufficient ACL in a young adult (18-35 years old) population? a. Decreasing risks of subsequent injury like meniscus tears b. Reducing episodes of instability c. Decreasing pathological laxity d. All of the above are reasons to surgically reconstruct an insufficient ACL in a young adult According to the evidence presented in this course, which graft option has demonstrated the highest failure rates? Which of the following is true regarding the routine use of functional knee bracing after isolated ACL reconstruction? a. The use of functional knee bracing after isolated ACL reconstruction showed improvements in functional hop test results b. The use of functional knee bracing after isolated ACL reconstruction showed significant improvement in knee laxity measurements with the use of functional knee bracing c. There is no demonstrated efficacy to the routine use of functional knee bracing after isolated ACL d. The use of functional knee bracing after With respect to timeframe implementation, which of the following is NOT an area of difference between an accelerated and nonaccelerated ACL rehabilitation protocol? a. Use of modalities to alleviate pain b. Unrestricted range of motion (ROM) c. Closed chain and functional tasks d. Weaning from post-surgical brace a. Hamstring autograft b. Irradiated allograft c. Quadriceps tendon autograft d. Patellar tendon autograft isolated ACL reconstruction showed improvements in subjective scores
6.
Which of the following stages occurs first throughout the healing process of an ACL graft? a. Revascularization b. Remodeling and proliferation c. Avascular necrosis d. Disorganization of collagen Which of the following is supported by consistent literature to be beneficial toward recovery after ACL reconstruction? a. Early weightbearing and range of motion within the first week b. Use of continuous passive motion (CPM) machines c. Use of post-surgical hinged braces d. Use of post-surgical leg immobilizers Which of the following is a negative effect during early rehabilitation when pain and inflammation is not controlled appropriately? a. Limited range of motion (ROM) b. Abnormal gait patterns c. Decreased quad contraction and muscle inhibition d. All of the above have negative effects Which of the following mobilizations will assist in regaining full terminal knee extension after ACL reconstruction? a. Inferior glide of patella and external rotation of tibia b. Superior glide of patella and external rotation of tibia c. Inferior glide of patella and internal rotation of tibia d. Superior glide of patella and internal rotation of tibia deviation during return to running discussed in this course? a. Lack of hamstring strength causing reduction in knee flexion during the swing phase b. Weakness of hip abductors during stance phase causing noticeable hip drop c. Lack of drive during hip flexors during early swing d. Tightness in hip adductors causing a scissoring pattern
7.
2.
8.
3.
4.
9.
10. Which of the following is NOT a common
5.
7
ACL Rehabilitation: A Review of Current Treatment Approaches: Summary
11. Which of the following are true regarding return-to-play decision making for athletes after ACL reconstruction? a. Knee pain, range of motion, and strength of the surgical extremity compared to contralateral extremity should not be part of the consideration for readiness for return to play b. Multiple factors should be considered when making the return-to-play decision c. Return-to-play decision making should be based solely on post-operative healing time frames d. Psychological readiness and confidence of the athlete should not influence the return-to-play decision making of the clinician 12. Which of the following are areas that a clinician should look for flaws during the tuck jump assessment? a. Foot placement b. Knee and thigh region c. Plyometric technique d. All the above areas should be assessed during tuck jump assessment
13. According to Arden, Webster, Taylor, and Feller (2011), what is the most common reason listed for cessation of sport after ACL reconstruction? a. Lack of overall strength in the lower extremity b. Reduction in sport specific skills, such as running and jumping c. Fear of re-injury d. Residual knee pain and discomfort 14. Which of the following tools have been identified to measure subjective reporting and psychological readiness in the ACL reconstructed individual? a. International Knee Documentation Committee (IKDC) subjective score b. Athletic confidence (ACL-RSI) scale c. Lysholm knee score
d. All of the above are scales to measure subjective reporting and psychological readiness in individuals undergoing ACL reconstruction
To Complete this Course: n Scan the QR code o Proceed to exam p Log into your account
Course content code: PTOH04AC-H
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 8
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy,
ACCESS THE FULL VIDEO PRESENTATION Scan the QR CODE ► to start video or visit https://uqr.to/BFR_Training
2nd Edition 4 Contact Hours
Author Pieter L. de Smidt, PT, DPT, MDT, MTC
Dr. Pieter L. de Smidt has 36 years of experience as a physical therapist. He holds certifications in McKenzie Mechanical Diagnosis and Therapy (Cert. MDT), manual therapy (MTC), and sports therapy (STC). With his post-professional doctorate in physical therapy, he specialized in the management of musculoskeletal injuries of the spine and extremities. Dr. de Smidt uses an evidence-based, integrated approach of manual therapy and exercise that includes instrument assisted soft tissue mobilization (IASTM), cupping, dry needling, and joint mobilization. His main professional goal is to bridge the gap between rehab and fitness and to empower clients to embrace a healthy lifestyle.
LEARNING OUTCOMES ● Learn about the science behind BFRT ● Learn about the research that supports use of BFRT ● Learn about safety precautions for BFRT ● Learn how to determine the limb occlusion pressure (LOP) and understand why knowing the LOP is important in the use of BFRT
● Discuss the different types of BFRT ● Understand indications and contraindications for BFRT ● Understand how to program BFRT during exercise therapy
SELF-ASSESSMENT QUESTIONS
1.
What is blood flow restriction training (BFRT)? a. A technique that fully blocks blood flow to muscles during exercise b. A technique that partially restricts blood flow to muscles during exercise c. A technique that increases blood flow to muscles during exercise d. A technique that has no effect on blood flow during exercise What are some of the potential benefits of BFRT? a. Increased muscle mass and strength b. Enhanced aerobic capacity c. Reduced pain d. All of the above
3.
What percentage of 1 repetition maximum (1RM) is typically used for resistance exercises with BFRT? a. 20-40% b. 50-70% c. 80-100% d. There is no specific percentage used How long does it typically take to see benefits from BFRT? a. 1-2 weeks b. 2-4 weeks c. 8-12 weeks d. 6 months or more
4.
2.
ANSWERS: 1: b 2 : d 3: a 4 : b
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 9
LEARNING TIP! Some of the key benefits that have been demonstrated through research include: • Increased muscle mass • Improved strength • Enhanced aerobic capacity • Faster recovery • Reduced pain • Potential improvements in bone health • Possible aid in weight loss • Improvements in tendon mechanical and morphological properties
INTRODUCTION
INTRODUCTION TO BLOOD FLOW RESTRICTION TRAINING
Blood flow restriction training (BFRT) is an exercise technique that is transforming how exercise therapy is prescribed in physical therapy and other fields . BFRT involves partially restricting blood flow to muscles during exercise using specialized cuffs or bands. This restriction causes muscles to experience fatigue, swelling, and oxygen depletion more quickly than during normal exercise. The body responds to this restriction by sending messages to the brain that the limbs are not getting enough oxygen, which triggers responses from the endocrine system. This temporary decrease in oxygen levels, while safe when applied properly, is essential for BFRT to produce its beneficial effects. BFRT has been shown through extensive research to be safe and effective when used appropriately. Over 800 scientific articles have been published on BFRT in the last 10 years alone, demonstrating its efficacy and safety for diverse populations ranging from young athletes to older adults. HISTORY OF BFRT BFRT has been around for decades, starting as early as the 1970s in Japan (known as KAATSU). More research started coming out in the 1990s and KAATSU started to become more widely practiced by the 2000s. It was brought to the U.S. in 2011 when the military began using it for rehabilitation of veterans. By 2018, the APTA stated BFRT was within the scope of practice for physical therapists. It was then made more popular by the body building world for its role in “muscle pumping.” Benefits of Blood Flow Restriction Training BFRT offers a wide range of potential benefits when used as an adjunct to low intensity resistance exercise (LIRE) or aerobic exercise (AE).
Benefits can be seen as quickly as 2-4 weeks. Importantly, these benefits can often be achieved using much lower loads by creating metabolic stress. Metabolic stress induces physiologic adaptations without causing any of the normal muscle damage from the mechanical stress of high intensity resistance training. Traditionally, strength gains require loading of 75-100% of 1 rep max. With BFRT, these results can be achieved with as low at 20-40% 1 rep max . This makes BFRT particularly valuable for populations that may not be able to tolerate high-load training, such as those recovering from injury or surgery. Disuse of muscles and inability to load after injury or surgery can lead to a 12% reduction in strength each week, making BFRT even more valuable in this population. THE SCIENCE BEHIND BFRT The two primary mechanisms thought to drive the benefits of BFRT are: 1. Metabolite-induced fatigue 2. Cell swelling BFRT creates an environment of low oxygen availability, causing the activation of type II muscle fibers and anaerobic metabolism. This leads to a build-up of metabolites in the muscle, which stimulates several physiological changes required for muscle and bone strengthening. LEARNING TIP!
The hypoxic (low oxygen) environment created by BFRT, combined with the accumulation of metabolites, stimulates neural afferents. This causes a significant increase in growth hormone and other anabolic factors.
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 10
Studies have shown dramatic increases in growth hormone levels after BFRT sessions-one study reported a 290-fold increase compared to baseline. BFRT has been shown to affect several key physiological pathways and factors: • Increased activation of the mTOR pathway, which is crucial for protein synthesis and muscle growth • Increased levels of human growth hormone (HGH) • Increased insulin-like growth factor 1 (IGF-1) • Decreased levels of myostatin, a protein that normally limits muscle growth • Increased vascular endothelial growth factor (VEGF), which promotes the growth of new blood vessels Compared to traditional high-intensity resistance training, BFRT with low-load exercise produces similar or greater increases in these anabolic factors while causing minimal tissue damage. This allows for faster recovery and the potential for more frequent training sessions. TYPES OF BLOOD FLOW RESTRICTION TRAINING There are several ways BFRT can be applied: • Passive BFRT . This involves applying blood flow restriction without exercise, primarily to promote cell swelling and potentially improve tissue healing, such as after surgery. • BFRT during aerobic exercises (BFRT-AE) . This combines blood flow restriction with low-intensity aerobic activities like walking or cycling to improve aerobic capacity and muscle strength. • BFRT during resistive exercises (BFRT-RT) . This involves using blood flow restriction during low-load resistance training to improve muscle mass and muscle strength. All types of BFRT can potentially contribute to building muscle strength and mass, though BFRT-RT is typically most effective for this purpose. • Intermittent BFRT (I-BFRT) . This approach involves alternating periods of blood flow restriction and normal blood flow, either during exercise or rest periods, commonly used for weight loss. Safety and Precautions While BFRT has been shown to be safe by many when applied correctly, including Odinesson & Finsen, 2006; Clark et al., 2011, and Poton & Polito, 2016, it is crucial to understand the proper application and potential risks.
Some key safety considerations include: • Proper screening of patients for contraindications • Using the correct cuff pressure based on individual limb occlusion pressure (LOP): ○ Wider cuffs are generally safer as they require less pressure • Gradual progression of training intensity and duration • Monitoring for signs of excessive discomfort or adverse reactions Risk factors for
Developing Venous Thromboembolism
Signs and Symptoms of VTE
• Cyanosis • Edema • Erythema • Pitting edema • Superficial dilation of veins • Tenderness to palpation/warmth • Positive clinical signs such as Homan’s test
• Previous VTE • Cardiovascular disease • BMI >25 kg/m 2 • Family history of VTE • Varicose veins • >40 years old • Having multiple risk factors
Contraindications
• Pregnancy • Extremities with dialysis port • Sickle cell anemia • Open fracture/wounds and/or poor wound healing • Severe crush injury • Venous thrombo- embolism • Excessive swelling in post-surgical limb • Known clotting risk • Severe hypertension • Acidosis • Infection within extremity
• Increased intracranial pressure • Cancer • Previous revascular- ization of limb • Lymphedema • Vascular graft • History of mastectomy or axillary node dissection (avoid on affected arm) • Those in hemodialysis who have arterial or venous fistulas
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 11
Exercise pressures are then set as a percentage of LOP, typically: • 30-50% of LOP for upper body exercises • 60-80% of LOP for lower body exercises • Generally, higher pressures are used with lower resistance levels Tips for Taking LOP: • Have patients relax the muscle • Do not talk • Take in the same position in which the exercise will be performed (or least intense if in multiple positions) • A pulse ox can be used for the upper body but not the lower • This should not change much over an 8 week period of time, so there is no need to reassess every session unless there is swelling How to take LOP: • Place the cuff as proximal as possible. Find the pulse with the doppler, listening for 20 seconds. Inflate the tourniquet in 10-15 mmHg increments. Stop once the pulse cannot be located. Slowly deflate the cuff. When the pulse is heard again, this is the LOP: ○ For the upper extremity, use the radial artery ○ For the lower extremity, use the posterior tibial or dorsalis pedis Resistance training with BFRT typically uses loads of 20-40% of one repetition maximum (1RM), much lower than traditional strength training. Aerobic exercise with BFRT is usually performed at low intensities, around 40% of VO2 max or 45% of the heart rate reserve. ACSM suggests using the heart rate to estimate the percent of VO2 max as follows: • 40% VO2 max = 55% HR max • 60% VO2 max= 70% HR max • 80% VO2 max= 85% HR max • 85% VO2 max= 90% HR max Proper Intensity of BFRT Resistance Training: • Use 3-4 sets of an exercise, starting with lower reps (10) and progressing to high reps (75) • Initially use longer rest periods (90 seconds) and progress to less rest (30 seconds) • Use a total session duration of 10-20 minutes • This can be used several times per week, up to 2 times per day • Progressions:
GUIDELINE: NO BFRT IF MORE THAN 4 POINTS • History of DVT • Acute sickness or fever • Blood pressure >180/100mmHg • Early postoperative period • High class arrhythmia or coronary ischemia 5 points • Pregnancy 4 points • Varicose veins 3 points
• Prolonged inactivity • A-Fib or heart failure • Blood pressure: 160-179/95-99mmHg
• Age >60 years • BMI >30 kg/m 2 • Malignancy • Hyperlipidemia • Estrogen therapy • Age 40-58 years • Women • BMI 25-30 kg/m 2
2 points
1 point
Rhabdomyolysis Rhabdomyolysis is very rare after exercise with BFRT, but it is important to be aware of the signs and symptoms. Symptoms start 48-72 hours after exercise, reporting muscle pain, weakness, and myoglobinuria (tea colored urine) due to muscle breakdown releasing high amounts of myoglobin in the blood. Application and Programming LEARNING TIP!
Determining the appropriate cuff pressure is crucial for safe and effective BFRT. It is important to note that brands of cuffs will vary in width, number of bladders, and availability of the cuff to optimize pressure. The cuff width is a significant factor for determining safe pressure.
The pressure should be moderate in order to reduce arterial blood flow, but not occlude the vessels. This is typically done by measuring the limb occlusion pressure (LOP) - the minimum pressure required to completely occlude blood flow to a limb. This is done using a doppler.
○ Start with passive BFRT for cell swelling ○ Progress to aerobic exercises/return to sport/HIIT with BFRT
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KEY POINTS 1. Proper cuff placement: For lower body exercises, the cuff should be placed as high on the thigh as possible, close to the hip joint. 2. Monitoring patient response: Constantly check for signs of excessive fatigue, numbness, or tingling. 3. Gradual progression: Start with easier exercises and lower volumes, progressively increasing as the patient adapts. 4. Importance of form: Maintain proper form throughout the exercises, even as fatigue sets in. 5. Individualization: Adjust the protocol based on the patient's condition, pain levels, and response to the exercises. 6. Education: Inform patients about the expected soreness and the difference between exercise-induced soreness and pain.
These practical demonstrations provided a clear illustration of how BFRT can be integrated into a rehabilitation program for various conditions, from post- surgical recovery to chronic pain management. Emphasis
on safety, proper technique, and individualization underscored the importance of thorough training and understanding of BFRT principles before implementing this technique in clinical practice.
RESEARCH EVIDENCE Numerous studies have demonstrated the efficacy of BFRT for various outcomes:
• A meta-analysis by Hughes et al. (2017) found that BFRT combined with low-load exercise was effective in augmenting changes in both muscle strength and size, with effects consistent across both resistance and aerobic exercise. • Studies have shown that BFRT can produce similar strength and hypertrophy gains as traditional high-load training, but with much lower loads (Lixandrão et al., 2018). • BFRT has been shown to be effective in populations with various conditions, including rheumatoid arthritis (Rodrigues et al., 2020) and following ACL reconstruction (Hughes et al., 2019). • Aerobic exercise with BFTR has demonstrated both improvements in aerobic capacity (VO2 max), anaerobic performance, and strength, even in highly trained athletes (Held et al., 2020; Park et al. 2010). • Although parameters have been varied, BFRT with HIIT enhances physiological improvements in aerobic, muscular, and, to some extent, anaerobic performance.
CASE STUDIES
ACL RECONSTRUCTION
The course presented a detailed protocol for using BFRT following ACL reconstruction. The protocol begins 2 weeks post-op, provided the patient has achieved 90 degrees of flexion, can perform a single leg stance for over 5 seconds, has no quad lag with repeated straight leg raises, and shows no additional swelling after activity. The protocol progresses as follows: • Weeks 1-2 : Passive BFRT with neuromuscular electrical stimulation (NMESTIM) • Weeks 3-4 : BFRT during cycling and low-load exercises • Weeks 5-6 : Progress to long-arc quadriceps exercises, hip bridges, and single-leg leg press • Weeks 7-8 : Introduce step-ups and continue single-leg leg press • Weeks 9-12 : Progress to split squats, medial step-downs, and single-leg leg press The protocol uses 60-80% LOP, with 30/15/15/15 reps for each exercise, performed in two sessions per week.
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ACHILLES TENDON REPAIR
The sample program for Achilles tendon repair begins 4 weeks post-op. Patients start with ambulation as tolerated with a cam walker boot and non-weight-bearing exercises. The program is divided into two phases: Phase 1 (weeks 4-8 post-op) : • BFRT-AE with cycling • BFRT-RT with non-weight bearing exercises (straight arc quads, long arc quads, straight leg raise flexion/ abduction, bridging) Phase 2 (weeks 8-12 post-op) : • BFRT-RT with weight-bearing exercises (leg press, step ups/downs, calf raises for soleus and gastrocnemius) The program emphasizes gradual progression and monitoring of patient response.
ELITE ATHLETES
Elite athletes can use BFRT for: • In-season training. BFRT allows athletes to maintain or even increase strength and muscle mass without the fatigue and muscle damage associated with heavy lifting • Recovery. Intermittent BFRT can be used post-exercise to enhance recovery. One protocol involves applying occlusion cuffs for 2 x 3-min periods with 3 min rest in between, using a pressure of 100% LOP or more • Performance enhancement. A sample program for high-intensity interval training (HIIT) with BFRT was presented. This protocol aims to enhance both aerobic capacity and muscular adaptations simultaneously. It involves: • Warm-up: ○ 4 sets of interval training on a cycle: ■ 3 min at 90% of max HR (~ 85% VO2max), without BFRT ■ 3 min rest with BFR at 40% of LOP ○ Cool-down
Conclusion Blood flow restriction training represents a powerful tool in the arsenal of physical therapists, trainers, and other health professionals. When applied correctly, it offers the potential for significant improvements in muscle strength, size, and function, as well as cardiovascular fitness, using much lower loads than traditional training methods. This makes it particularly valuable for populations that may not tolerate high-load training. However, proper application, including thorough screening, correct pressure determination, and appropriate exercise prescription, is crucial for safety and efficacy. As research continues to expand our understanding of BFRT, it is likely to play an increasingly important role in rehabilitation, fitness, and sports performance settings.
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