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Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body Management of Sports-Related Concussions: Staying Ahead of the Game, 2nd Edition ACL Rehabilitation: A Review of Current Treatment Approaches Introduction to Golf Rehabilitation and Performance: 90 Percent Mental, 90 Percent Physical Utilizing Clinical Practice Guidelines for Treatment of Low Back Pain
4
4
$72.00 PTTX04BF-H
5
5
$89.00 PTTX05ML-H
4
4
$72.00 PTTX04MC-H
4
4
$72.00 PTTX04AC-H
3
$55.00 PTTX03GR-H
2
$37.00 PTTX02LB-H
Evaluation and Treatment of Rotator Cuff Impairments
2
$37.00 PTTX02RC-H
Introduction to Aquatic Therapy
3
$55.00 PTTX03AT-H
PACKAGE PRICE $196.00 $126.00
Book Expiration Date: 11/30/2027
INCLUDED IN THIS BOOK
1 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. 9 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. 19 Management of Sports-Related Concussions: Staying Ahead of the Game, 2nd Edition [4 contact hours] Concussions continue to be a serious epidemic in youth and competitive sports. With approximately 1.6 million to 3.8 million sports-related concussions occurring every year, these injuries are considered among the most complex injuries in sports medicine to diagnosis, assess, and manage. The instructor will provide an overarching review of the recent literature, including the 6th International Conference on Concussion in Sport, as it pertains to concussion management from prevention techniques to reducing the risk of injury to returning to play after a concussive episode. The modules within this course include an introduction to concussions, recognition and sideline evaluation, clinical evaluation, neuropsychological testing, rehabilitation techniques, and academic modifications. As the literature and practice guidelines/recommendations are reviewed, participants will be able to assess their current practice to make appropriate modifications to their own concussion management plan. The mission of this course is to provide a concise resource on how to properly manage concussions from risk reduction techniques, acute injuries, and return to play by implementing a multimodal process and enhancing multidisciplinary communication to keep the athlete at the forefront of care. 27 ACL Rehabilitation: A Review of Current Treatment Approaches [4 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.
Continued on the next page ►
INCLUDED IN THIS BOOK
34 Introduction to Golf Rehabilitation and Performance: 90 Percent Mental, 90 Percent Physical [3 contact hours] This course will provide value for practitioners of all experience levels, from those who have never touched a golf club or set foot on a golf course to the seasoned professional. It will include a thorough introduction to basic golf language and concepts, a review of the relevant anatomy and biomechanics, a novel approach to evaluation of the patient or client’s physical capabilities, and specific strategies to improve the neuromotor processes that promote recovery from injury and higher quality golf performance. 42 Utilizing Clinical Practice Guidelines for Treatment of Low Back Pain [2 contact hours] This course is intended for healthcare professionals who treat clients with low back pain. The course integrates the most recent research and clinical practice guidelines for low back pain. Participants will learn how to classify low back pain and which interventions are deemed most effective based on these classifications. 52 Evaluation and Treatment of Rotator Cuff Impairments [2 contact hours] Rotator cuff injuries affect between 2 to 4 million Americans each year. They are often incurred during sports which involve throwing or overhead lifting but can also result from repetitive motion of a job, hobby, or for others reason, some are which are difficult to pinpoint. The very term “torn rotator cuff” is quite familiar to any fan of football, baseball or weight training. Despite being so frequently mentioned, the rotator cuff is poorly understood by most Americans. This course will provide concise definition of the rotator cuff and other major components of the shoulder joint. It will define the movements of the shoulder and the muscles produce those movements, and it will furnish the allied health professional with a simple approach to address structural imbalances which are often the root cause of rotator pain and injury. 58 Introduction to Aquatic Therapy [3 contact hours] “Introduction to Aquatic Therapy” is an informative course for those health professionals who would like to expand their skills into aquatic therapy and rehab. Aquatic therapy and rehabilitation is a growing market and provides an excellent service to clients. As a health professional, here’s the opportunity to enhance your career with the most current essential information you need to get started. Feel confidence in the concepts including waters properties, fluid dynamics, physiological responses to immersion, precautions/contraindication to aquatic therapy. Aquatic exercise equipment as well as the basic concepts of Bad Ragaz, Halliwick, Ai Chi, Watsu, Aquastretch and the Burdenko are covered.
Colibri Healthcare, LLC is an approved provider by the Texas Physical Therapy Association (Provider #2711048TX). The assignment of Texas CCUs does not imply endorsement of specific course content, products, or clinical procedures by the TPTA or TBPTE. Unless otherwise indicated, all PT courses meet continuing competence requirements for license renewal in Texas.
FREQUENTLY ASKED QUESTIONS
License Expires
CE Hours Required
30 - Physical Therapists (28 CCUs allowed through home study) 20 - Physical Therapy Assistants (18 CCUs allowed through home study)
Biennial renewal. Licensees are required to renew by the end of their birth month every two years.
Mandatory Subjects 1-hour Human Trafficking: A free Texas HHSC-approved human trafficking course is available on the HHSC website: https://www.hhs.texas.gov/services/family-safety-resources/texas-human-trafficking-resource-center/health-care-practitioner-human- trafficking-training 2 CCUs of Texas Jurisprudence Assessment Module (TX JAM): Available on the board website Are you a Texas board-approved provider? Colibri Healthcare, LLC is an approved provider by the Texas Physical Therapy Association (Provider #2711048TX). The assignment of Texas CCUs does not imply endorsement of specific course content, products, or clinical procedures by the TPTA or TBPTE. Unless otherwise indicated, all PT courses meet continuing competence requirements for license renewal in Texas. Are my credit hours reported to the Texas board? The Texas Board of Physical Therapy Examiners performs random audits at which time proof of continuing education must be provided. How do I complete the TX JAM? Individuals renewing their license will be required to take the Texas Jurisprudence Assessment Module (TX JAM). This will cover both the Jurisprudence Exam and the Ethics/Professional Responsibility requirement. To complete this requirement you will need to go to the board website www.ptot.texas.gov and follow the link for registration and access. 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? 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 .
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 1
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 2
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 3
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
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.
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 4
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
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 5
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.
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 6
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.
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 7
F INAL EXAM QUESTIONS
1.
What are the different types of BFRT? a. Passive BFRT, BFRT-AE, BFRT-RT b. Post surgery/injury BFRT, return to sport BFRT, performance BFRT c. Low intensity BFRT, moderate intensity BFRT, high intensity BFRT d. All of the above What is NOT true about the history of BFRT? a. BFRT started in Japan b. BFRT was first used for body building c. In the United States, BFRT was first used in the military d. BFRT was included in the scope of PT practice by the APTA What is TRUE about research studies regarding BFRT? a. Hundreds of studies have been done supporting the safe use of BFRT b. Studies have shown that BFRT can stimulate pain relief c. Studies on BFRT started in the 1990s d. All of the above
8.
What is TRUE about studies regarding BFRT and aerobic conditioning? a. Studies have shown increased VO2 max as a result of training with BFRT b. Study parameters for aerobic conditioning with BFRT have had great variability c. Studies have shown that BFRT with aerobic exercise can lead to strength and aerobic capacity gains at the same time d. All of the above What is NOT true about BFRT and aerobic conditioning? a. BFRT into HIIT enhances physiological improvements in aerobic, muscular, and, to some extent, anaerobic performance b. BFRT with aerobic exercise has been studied with walking and cycling programs c. Aerobic exercise with BFRT increases aerobic capacity but does not alter strength d. The intensities used during BFR-AE are
2.
9.
3.
generally low in nature (45% heart rate reserve or 40% of maximal oxygen consumption (VO2 max) 10. Which of the following authors showed that BFRT is safe to use? a. Clark b. Odinsson and Finsen a. Increase muscle size and strength b. Increase aerobic conditioning c. Increased flexibility d. Faster recovery 12. What is a typical amount of cuff pressure for BFRT? a. 20-40% 1RM b. 30-50% of LOP for the arms c. 60-80% of LOP for the arms d. 30-50% of LOP for the legs 13. What is true of the science behind BFRT? c. Poton and Polito d. All of the above 11. What is not a benefit of BFRT? a. BFRT increases growth hormone and decreases myostatin b. BFRT decreases insulin-like growth factor 1 c. BFRT decreases mTor and mTORc d. All of the above
4.
The BFRT abbreviation means: a. Blood fuel restriction training b. Blood flow resistance training c. Blood flow restriction training d. Blood flow restriction technique What is NOT an indication for BFRT? a. Weakness b. Muscle atrophy c. Poor wound healing d. In-season weight training
5.
6.
What mechanisms do we think explain the benefits of BFRT? a. Increased human growth hormone b. Decreased insulin-like growth factor 1 c. Increased myostatin d. All of the above What is NOT true about strength training? a. Exercise for 3-8 weeks, 3x/week, with 50-75% 1RM will result in increased strength b. Exercise for 3-8 weeks, 3x/week, with 75-100% of 1RM results in increased strength c. HIRT causes muscle damage, which initiates the body’s response that leads to increased strength d. Exercises with BFRT, with 20-40% 1RM, are sufficient to increase strength
7.
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 8
14. All of the following are precautions or contra- indications for BFRT, except: a. Pregnancy b. Sickle cell anemia c. Acidosis d. General weakness 15. What types of BFRT can be used to build muscle strength and muscle mass? a. BFRT-AE b. I-BFRT c. Passive BFRT d. All of the above 16. The ACSM suggests that: a. 40% VO2 max corresponds to 70% HR max b. 30% VO2 max corresponds to 70% HR max c. 80% VO2 max corresponds to 85% HR max d. 85% VO2 max corresponds to 100% HR max a. Increased muscle mass and strength b. Faster recovery c. Decreased pain d. All of the above 18. Why do you need to know the patient's limb occlusion pressure (LOP)? a. It is used for dosing the treatment, as it relates to pressure used in the cuff b. We obtain LOP using an MRI machine c. You do not need to LOP d. Most protocols use 60-80% of LOP for upper body exercise and 30-50% of LOP for lower body exercises 19. What is TRUE regarding different brands or products of BFRT devices? a. Some brands have narrow bands and others have wider bands b. Some brands have a single bladder c. Some brands have built-in mechanisms to optimize pressure in the cuff d. All of the above 20. What is TRUE for patients who have been immobilized or have been inactive? a. Disuse of muscles leads to atrophy and loss of muscle strength at about 12% per week b. Limb immobilization for 3 days can lead to 44- 47% atrophy 17. What is a benefit of BFRT? c. Atrophy can be reversed by isometric exercises d. Dirks showed no decline in cross-sectional area (CSA) with 1 week of bed rest
21. What is NOT true about studies regarding BFRT with aerobic exercises? a. Park showed improvement of VO2 max with a walking program b. All studies used around 40% of resting heart rate for intensity c. Studies have been done with cycling and walking d. Many studies showed improvement in aerobic capacity, but results varied 22. What is TRUE about benefits of BFRT? a. This exercise therapy can increase muscle mass, muscle strength, and balance b. Some studies suggest the possibility of weight loss and improved bone health c. Participants in studies had either improved aerobic capacity or improved strength d. Pain relief with BFRT has not been studied 23. What is true about high and low pressure BFRT? a. Lixandrão showed that with low resistance levels we should use high-pressure BFRT to increase strength b. Both low and high pressure have similar results c. All BFRT has been studied with low pressure d. Low-pressure BFRT has been shown to reduce pain better than high-pressure BFRT 24. What is TRUE about the amount of pressure used for BFRT? a. Studies have used the same levels of pressure b. Most commonly in recent studies we have seen 30-50% LOP pressure for the upper body and 60-80% LOP in the lower body c. The amount of pressure does not affect the results of BFRT d. All of the above 25. What is true about the use of BFRT? a. BFRT is safe when done with individual parameters in the absence of contraindications b. BFRT can be effective for the trained and untrained patient c. BFRT can help to improve muscle strength, reduce atrophy, and improve aerobic conditioning d. All of the above
To Complete this Course: n Scan the QR code o Proceed to exam p Log into your account
Course content code: PTTX04BF-H
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Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body: Summary 9 Move Better, Feel Better:
ACCESS THE FULL VIDEO PRESENTATION Scan the QR CODE ► to start video or visit https://uqr.to/movelower
A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body 5 Contact Hours
Author Pieter L. de Smidt PT, DPT, cert DN, MTC
Graduated in from Hogeschool West-Brabant in Breda, The Netherlands. Completed DPT with Evidence In Motion, Institute of Health Professions. Over 35 years experience as a physical therapist. Achieved certifications in McKenzie Mechanical Diagnosis and Therapy, Manual Therapy, Dry Needling, and Sports Physical Therapy. Specializes in management of musculoskeletal injuries of the spine and extremities, and combining hands-on treatment with pain science education and exercise therapy.
LEARNING OUTCOMES • Review the evidence that supports the use of IASTM, cupping therapy, and kinesiology taping • Differentiate indications and contraindications for IASTM, cupping therapy, and kinesiology taping • Categorize different techniques available for cupping and AISTM
• Predict how to effectively utilize IASTM, cupping therapy, and kinesiology taping for the lower body • Relate how pain science education and the biopsychosocial (BPS) Model can be used to help your patients with their pain and improve occupational performance
SELF-ASSESSMENT QUESTIONS
1.
How can you incorporate movement with soft tissue mobilization? a. You can ask a client if they have pain with certain movements b. You can perform STM during stretching exercises c. You can’t use movement during STM because the patient is lying on the treatment table during STM d. A and B
3.
How do you explain why patients/clients have pain? a. Pain is the result of tissue damage: you may have degenerative changes in your joint, or you have a tear in your rotator cuff b. Pain comes from muscles that are too tight c. Pain is an unpleasant signal that something hurts. It is a complex experience that differs greatly from person to person d. All of the above What do we know about instrumented-assisted soft tissue mobilization? a. IASTM has strong research to support its benefits b. IASTM, like gua sha, has to be intense to be successful c. IASTM scan/should not be done over scar tissue d. None of the above
2.
How does STM reduce pain? a. STM improve gliding of the tissues b. STM stretches the fascia c. Blood flow improve with STM d. None of the above
4.
ANSWERS: 1: d 2 : d 3 : c 4 : d
Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body: Summary 10
RESEARCH SUMMARIES • Improved pain thresholds following 6 sessions of IASTM in the upper trap. • IASTM can improve hamstring flexibility. • Cupping affects hemodynamic, immune regulation and metabolism and can offer pain relief. • Cupping resulted in reduced pain in patients with fibromyalgia after 18 days. • Kinesiotaping reduced pain and performance on SL hop test for patients with patellofemoral pain at 6 and 12 weeks post follow up. • KT resulted in reduced knee pain with walking in patients with OA. THE SCIENCE Pain Science Education (PSE) • Pain is not just about tissue damage. It is very complex and different for everyone • Nociception is neither sufficient nor necessary for pain (phantom limb pain) • Peripheral sensitivity: an enhanced sensitivity to local stimulus via decreased activation threshold of the nociceptors • Central sensitivity: altered CNS processing of nociceptive signals (increased responsiveness from the brain): more difficult to treat, less is more • 4 R’s of PSE: ○ Rule out red flags ○ Reassure ○ Reconceptualize ○ Recalibrate • Biopsychosocial model: ○ 40% of health outcomes is based on social and economic circumstance ○ 30% of health outcomes are associated with health behaviors and lifestyle Therapeutic Alliance Improved therapeutic alliance leads to overall improved outcomes and reduced pain for the patient. Key characteristics to good therapeutic alliance include trust, care, and respect. This requires the clinician to have good verbal/nonverbal communication skills and the ability to collaborate with the patient. This is further enhanced by the actions of the clinician. Both spending time listening to the patient’s needs and concerns and providing hands-on care have been associated with improved therapeutic alliance.
INTRODUCTION Instrument assisted soft tissue mobilization (IASTM), cupping therapy, and kinesiology taping can stimulate the central nervous system, helping with pain, mobility, and performance. Passive treatments are meant to
enhance active treatments, not replace them. Concepts of Movement-Based Soft Tissue Mobilization (STM)
• Movement is the focus of the approach: ○ Restricted? Painful? Not well controlled? Important to the client? ○ Incorporate movement in your treatment • Test → treat → retest: this is the foundation of manual therapy • Regional interdependence: ○ All joints need mobility and stability ○ If one joint lacks mobility, another will make up for it to compensate ○ Always assess above and below the affected joint • Facilitated vs inhibited: ○ Some muscles are too tight (facilitated) and others are therefore inhibited due to not being in an optimal position • Hands-on treatments only have short term effects: combine treatments and encourage movement for greatest response Foundations of Movement-Based Soft Tissue Mobilization (STM) STM incorporates multiple layers including the fascia, muscle, and central nervous system (CNS). Different techniques stimulate different mechanoreceptors, which allows for increased neurosensory input to the brain. Pain relief is thought to primarily be a result from this increase in afferent stimulus to the CNS and improved proprioception. This neuro-physiological response is explained by several theories and concepts: • Gate theory : Non-noxious input suppresses pain input to the brain • Diffuse noxious inhibitory control (DNIC) : Descending modulation from CNS reduces pain, triggered by sustained nociceptive input. (Chronic pain is thought to be the failure of this system) • Cortical mapping : There are anatomically discrete areas of the brain that represent movement, position, and health: ○ Chronic pain “smudges” these maps, altering motor control
○ Increasing afferent input can improve neuroplasticity and help to “reshape” this map
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Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body: Summary 11
• PSE • BPS model • Research
• Movement • Nutrition • Sleep
Science
Lifestyle
Whole-Body Approach
Comprehensive Treatment
• IASTM • Cupping • Taping
• Fascia • Muscles • CNS
Indications/Contraindications for Manual Techniques Indications Contraindications
Precautions
• Movement dysfunction • Musculoskeletal pain • Peripheral neuropathic pain • Muscle inhibition • Hyper/hypotonicity • Tendinopathies • Edema reduction
• Open wound • Skin infection • Unhealed fracture • DVT/thrombophlebitis • Uncontrolled hypertension • Inflammatory conditions due to infection • Hematoma/myositis ossificans • Osteomyelitis • Decreased sensation in affected area • Pregnancy (1st trimester over abdomen)
• Pregnancy (2nd and 3rd trimester) • Anticoagulants • Varicose veins • Cancer • Autoimmune disorders • Chronic heart failure • Hematoma • Rheumatoid arthritis
IASTM
Proposed Benefits • Pain relief/improved mobility • Neurophysiologic response (gate theory, DNIC or CMP, neuroplasticity) • Mechanical mechanisms (mechano-transduction, gliding of tissues, fluid dynamics) Application • Can use tools made of different materials (plastic, stainless steel) and different shapes: ○ Concave edge: more gentle; convex tool is more aggressive ○ The more vertical the tool, the more aggressive • Scan the tissue first to assess for texture (bumpy, gritty) • Start treatment in direction of least resistance/pain (proximal to distal, distal to proximal) • Start with tissue on slack and then can add stretch to increase intensity for reducing tone
Pros
Cons
• Patients report relief and improved mobility • Can be an effective adjunct treatment to exercise
• No strong research • Might not be better than placebo • Not a stand alone treatment
Research • Reduced pain via DNIC and neuroplasticity • Increased fibroblast proliferation in tendons • Improved collagen formation and orientation in ligaments • Reduced size/improved tissue quality for chronic tears • Physiological changes via: ○ Increased blood flow ○ Reduced tissue viscosity ○ Myofascial release ○ Interruption of pain receptors ○ Improvement of flexibility
Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body: Summary 12
Goal of Treatment: Stimulate Mechanoreceptors • Reduce pain via light touch with sharper edge (interstitial fibers) ○ Use faster strokes • Reduce tone via slow deep strokes with beveled side/dull edge (Ruffini):
○ Move from superficial to deep, starting with tissue on slack ○ Greater angle of the tool, the more intense • Facilitate muscle via faster, medium deep stroke with beveled side (Pacinian)
Lower Body Treatment Body Region
Movement Assessment
IASTM with Movement
Decrease Pain
Decrease Tone
Lower Thoraco- Lumbar Spine
Flexion, extension, side bending
Paraspinals, QL, along iliac crest, inferior ribcage, superior SIJ
QL in sidelying
Prayer stretch QL stretch Forward bending with IASTM Diaphragm: with deep breathing Rectus abdominis with pelvic tilts Passive supine hamstring stretch Active/passive knee ROM in prone ITB stretch, Clam shells (over greater trochanter) Bent knee fall out PROM/AROM knee flexion
Abdominals
Spine ROM, Thomas test, PROM hip flex, ext, IR, ER
Diaphragm (along ribcage in hooklying), rectus abdominis (supine legs straight) Junction zones between semis/ biceps femoris, semis/adductors, biceps/tib Greater trochanteric area (C shape) Hamstring/ITB and quad/ITB junction Junction between ADD and quads, patellar tendon, patellofemoral area, medial/lateral Plantar fascia, medial/ lateral rear foot, Achilles tendon, medial/lateral lower leg (protect tibia)
Diaphragm and rectus abdominis with deeper strokes
Hamstring
Spine ROM, straight leg raise test, Ober test
Same areas with deep, slower strokes
Iliotibial band
TFL (lateral to ASIS), biceps femoris and vastus lateralis
Quads and ADD
Squat, single leg stance, prone flexibility, Thomas test
Junction between ADD and quads, rectus femoris
Calf and Foot
Overhead deep squat, single leg stance
Medial/lateral gastroc heads, junction between gastroc heads
Dorsiflexion in prone (gastroc) or supine tibialis
anterior), inversion/ eversion, with heel raise (eccentrically to reduce tone)
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Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body: Summary 13
CASE STUDY
John is a 45-year-old male who has low back pain with forward bending. At work he does a lot of standing, which sometimes causes sciatica in his right hamstring.
What type of IASTM technique could we use for John? Answer: • Gentle IASTM along paraspinals: ○ Progress to deeper strokes to reduce tone: neutral or prone → child’s pose/seated forward bending • Reduce sciatica: gentle strokes to right hamstring: ○ Progress to deeper stroke ○ Prone with knee bend
CUPPING
Proposed Benefits • Neurophysiological Effect : may stimulate inhibitory neural pathways by creating a “counterirritation” that temporarily increases pressure pain thresholds: ○ Gait theory, DNIC or CMP, neuroplasticity (pain mapping) • Mechanical Effects : suction force produces a stretch and compression on the tissue causing dilation and rupture of the superficial capillaries (reddish colored circles): ○ Marks are NOT bruises ○ Does NOT break up fascia adhesions Application • Different type of cups (plastic, glass, silicone): ○ Silicone is more gentle and glides better for dynamic treatments • Static cupping (cup is still) both with and without patient movement • Dynamic cupping (cup is moving) both with and without patient moving: ○ Lubrication should be used for dynamic cupping ○ AKA: Tissue distraction with movement (TDM) • “Wet cupping” is NOT a part of clinical practice for PTs • Apply for 30 seconds to 2 minutes first to assess for tissue response then progress treatment up to 10 minutes
Pros
Cons
• Patients report relief and improved mobility • Can be an effective adjunct treatment • Research shows some support for pain relief
• No strong research • Might not be better than placebo • Not a stand alone treatment
Research • Altered local metabolic activity (inducing anaerobic metabolism) may contribute to pain relieving effect (not strong research) • Activation of Heme oxygenase system could account for local and systemic health benefits • Increased skin temperature can help with reducing pain • Greatest research supports neurophysiologic effects to reduce pain
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