This interactive Texas Physical Therapy Summary Ebook contains 28 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
MEETS YOUR HOMESTUDY CE!
Elite Learning
TEXAS Physical Therapy Continuing Education
CONVENIENT PACKAGES TO HELP YOU MEET YOUR REQUIREMENTS Physical Therapists - 28-Hour Package Physical Therapy Assistants - 18-Hour Package Mandatory Human Trafficking Prevention Training is included in this book ONE CONVENIENT BOOK for PT’s and PTA’s Colibri Healthcare, LLC is an approved provider by the Texas Physical Therapy Association (Provider #2711048TX).
Scan the QR code to take your exam, or visit ELITELEARNING.COM/BOOK and enter book code: PT - Use book code: PTTX2825HB PTA - Use book code: PTATX1825HB
Physical Therapists Scan Here
PT Assistants Scan Here
Flexible Learning Designed to Fit Your Life
This book includes FREE access to professionally developed on-demand video courses, complete with in-depth reviews. We’re excited to bring you this flexible learning experience to meet you where you are in your day.
How this book works:
LEARN
Review these courses on your time.
Go online to take your exam • Visit elitelearning.com/book • Enter book code: PTTX2825HB - Physical Therapists PTATX1825HB - PT Assistants • Log In or create an account • Pass your exam
APPLY
(PASS BEFORE YOU PAY!)
Physical Therapists Scan Here
PT Assistants Scan Here
DONE
Complete the purchase process to receive course credit and your certificate of completion.
Find the course code found in the table below and enter it at EliteLearning.com/Book Don’t need all 28 hours but want to complete an individual course, we have you covered!
COURSE CODE
PT 28 hours
PTA 18 hours
Price
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition (Mandatory) 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 Evaluation and Treatment of Rotator Cuff Impairments
1
1
$19.00 PTTX01TT-H
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
2
$37.00 PTTX02RC-H
Introduction to Aquatic Therapy
3
$55.00 PTTX03AT-H
Book Expiration Date: 7/1/2026
INCLUDED IN THIS BOOK
1 Recognizing and Responding to Human Trafficking in Texas, 2nd Edition (Mandatory) Meets the human trafficking prevention training requirement [1 contact hour] This course focuses on an overview of human trafficking; how human trafficking occurs; ways to identify those who may be trafficked, including the health and mental health impact; response and safety protocols; and victim resources. It meets the one-hour Texas requirement for healthcare professionals. 7 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. 17 Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Lower Body [5 contact hours] If you want to learn how a combination of soft tissue treatments can help your clients to feel and move better: this course is for you. Understanding how pain works and being able to educate your clients on how to manage their pain is critical to patient outcomes. This course uses principles of the BPS model and Pain Scienced Education as a roadmap to make your treatments even more effective. This treatment approach does not just look at the area of pain, but considers the entire person, and treats the entire dynamic chain that is affected. 28 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. ... Continued on the next page ►
INCLUDED IN THIS BOOK
37 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. 45 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. 54 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. 66 Evaluation and Treatment of Rotator Cuff Impairments [2 contact hours] This course takes the learner through a clear, yet comprehensive tour of the gross and fine mechanisms of movement. Students will see and apply foundational rules of human movement and build their ability to predict and assign the appropriate agonists, antagonists, and synergists to each movement. The class brings a series of supporting information based on the names of the structures along with rationales for terms and designations, and it offers the learner a set of resources to build genuine comprehension of the intricate design of the scapulohumeral joint and the most common rotator cuff injuries. Both newly credentialed and experienced professionals will increase their mastery of the human shoulder/arm and leave with new skills that they can immediately apply in service to their clients. 73 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 exericse 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. The course Recognizing and Responding to Human Trafficking in Texas, 2nd Edition has been approved by the Texas Health and Human Services Commission (HHSC).
FREQUENTLY ASKED QUESTIONS
License Expires
CE Hours Required
Mandatory Subjects
Must complete a Human Trafficking Prevention Training course approved by Texas Health and Human Services Commission. 2 CCUs of Texas Jurisprudence Assessment Module (TX JAM) which is available on the board website.
Physical Therapists (30) 28 CCUs allowed through home study Physical Therapy Assistants (20) 18 CCUs allowed through home study
Biennial renewal. Licensees are required to renew by the end of their birth month every two years.
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. The course Recognizing and Responding to Human Trafficking in Texas, 2nd Edition has been approved by the Texas Health and Human Services Commission (HHSC). 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? I ndividuals 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? 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 in the areas covered. It is not meant to provide medical, legal or professional services 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 or circumstances and assumes no liability from reliance on these materials.
Elite Learning
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition: Summary 1
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition (Mandatory) 1 Contact Hour
ACCESS THE FULL PRESENTATION
Scan the QR CODE ► to start video or visit https://uqr.to/TraffickingTX
Author: Laura Palombi, PharmD, MPH, MAT
Laura Palombi, PharmD, MPH, MAT, is an associate professor at the University of Minnesota College of Pharmacy in Duluth. Her work focuses on community engagement to address public health problems. Dr. Palombi has extensive experience in presenting and publishing on the healthcare response to human trafficking. She acknowledges Anders E. Rasmussen, a fourth-year pharmacy student, for assistance on this update.
LEARNING OUTCOMES ● Understand definitions that relate to human trafficking ● Describe the types of human trafficking and dynamics of human trafficking in the U.S. ● Describe identification and assessment strategies that can be utilized when working with potential trafficking victims
● Discuss the importance of safety planning and protocols ● Identify ways to respond and follow up when encountering a potential trafficking victim, including resources for reporting suspected victims of human trafficking
SELF-ASSESSMENT QUESTIONS
1. Which of the following is not an example of human trafficking (either labor or sex trafficking)? a. Migrant/undocumented workers coerced into working as farmhands after being transported into the U.S. b. A consenting adult (>18 years of age) engaging in sexual acts in exchange for money c. Massage therapists at an unregistered massage parlor compelled to engage in sexual acts under threat of legal action being taken against them if they refuse d. Hospitality/housekeeping service workers
2. All of the following are potential indicators that a patient is a victim of human trafficking except: a. Presenting with frequent and repeated injuries b. Being accompanied by an individual who frequently accompanies other individuals for similar acute illness/injuries
c. Presenting for reproductive care with a history of several STI screenings and multiple terminated pregnancies d. None of the above
made to work for little to no pay due to threats made against members of their family
ANSWERS: 1: B
2 : D
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition: Summary 2
Important Terms: Victim or Survivor The terms victim and survivor can both be used to refer to individuals who were trafficked : • Victim : Has legal implications within the criminal justice process, generally referring to someone who suffered harm due to criminal conduct. The term victim generally indicates an individual suffered harm because of criminal conduct. • Survivor : Used in the health services field to recognize the strength it takes to heal after a traumatic experience, often referring to someone who has been rescued from trafficking. Survivor is a term used by many in the health services field to recognize the strength it takes to continue a journey toward healing in the aftermath of a traumatic experience. HUMAN TRAFFICKING IN TEXAS The Texas Human Trafficking Prevention Task Force, created in 2009, coordinates anti- trafficking efforts at various levels. Texas has one of the highest volumes of human trafficking signals in the U.S., with significant incidents of both sex and labor trafficking. A report released by the National Human Trafficking Hotline indicated that Texas has one of the highest signal volumes among all 50 states and Washington, D.C. The Task Force serves as a collaborative and multidisciplinary body that strives to coordinate anti-human trafficking efforts across local, state, and federal levels. The Texas Human Trafficking Prevention Task Force serves as a communication hub for sharing best practices.
INTRODUCTION
Human trafficking is a severe violation of human rights involving the exploitation of victims for labor or commercial sex acts through force, fraud, or coercion. LEARNING TIP!
Human trafficking is an extreme and heinous violation of human rights that persists around the globe. Vulnerable victims are typically women and children, but anyone can be a victim.
Accurate data on human trafficking is challenging to obtain due to various systemic difficulties. There is currently no consensus on the total number of trafficking victims in the U.S. despite the fact that multiple organizations publish data and statistics concerning human trafficking. Many victims of human trafficking never disclose the nature of their situation, and because of this, it is impossible to estimate the actual number of human trafficking victims. Because of this, healthcare providers and organizations involved with trafficked persons have been asked to increase their capacity to identify and refer people in trafficking situations and provide sensitive and safe services to people post-trafficking. Healthcare professionals are uniquely positioned to identify and intervene on behalf of trafficking victims, as outside of law enforcement, healthcare settings are among the few places where the lives of human trafficking victims may intersect with the rest of society, if only for brief periods.
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition: Summary 3
Health Impact of Human Trafficking Victims often suffer from physical, sexual, and emotional abuse, leading to chronic health issues, mental health disorders, and substance use disorders. Poor living conditions further exacerbate these health problems. LEARNING TIP!
Barriers to acquiring accurate data include victims avoiding the criminal justice system due to fears of reprisal, deportation, or incarceration; the failure of healthcare workers or emergency responders to ask about human trafficking or to probe causes of apparent violence; and a lack of coordination and data integration between the various levels of governmental agencies (local, state, federal) and other organizations (e.g., nonprofits, hospitals) that may have data on human trafficking. These barriers and the limitations of existing data suggest that the true scope of human trafficking is larger than can be reliably estimated at any given time. TYPES OF HUMAN TRAFFICKING Human trafficking includes sex, labor, and organ trafficking. Victims can be found in both legitimate and illegitimate labor industries. The difference between sex trafficking and consensual sex work is often misinterpreted. All instances of commercial sex involving minors under the age of 18 are cases of human trafficking. Vulnerability Factors Factors increasing the risk of becoming a trafficking victim include: • Children in welfare/juvenile justice systems • Unhoused youth • Migrant laborers • Patients with limited English abilities or disabilities • Individuals with a history of abuse Victim–Trafficker Dynamics Traffickers use various tactics to control and intimidate victims, such as violence, threats, withholding necessities, social isolation, economic coercion, and confiscation of identification documents.
Many trafficking victims suffer serious health issues, which may include reproductive health problems, symptoms of post- traumatic stress disorder, and signs of physical abuse. ROLE OF HEALTHCARE PROVIDERS
Healthcare providers are uniquely positioned to identify and support trafficking victims. They should provide patient-centered care, empower victims, and respect their autonomy. A trauma-informed approach is crucial. The healthcare environment is ideal for identifying and intervening on behalf of a trafficking victim. Red flags may be seen in a victim’s companion/ guest and include behaviors such as refusal to leave when trying to conduct one-on-one patient interviews, insistence on speaking/translating for the patient, controlling/interrupting the flow of care, having the patient’s documents in their possession, and an employer demanding access to medical information. Traffickers may employ strategies such as pretending to be the victim’s partner, family member, or close friend. Another potentially obvious red flag is a trafficker accompanying multiple victims to the same healthcare facility. Some traffickers may visit a certain healthcare facility so frequently that they try to build rapport with providers in order to deceive these of their “goodness.”
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition: Summary 4
CASE STUDY
A young woman named Rebecca presents to a local urgent care requesting evaluation for genital sores and vaginal discharge. You notice on her intake information that she does not have insurance listed and indicates she is paying cash for this visit. Further review of her medical records shows that she does not have a permanent address listed and that she has presented on multiple occasions to this urgent care—in addition to other clinics/healthcare facilities—with similar symptoms.
She is accompanied by a man named Derek, whom she claims to be her cousin, and who largely speaks for Rebecca, answering questions while she remains sitting quietly on the examination table. Rebecca appears nervous and avoids making eye contact with you and other staff members. She has superficial abrasions and bruises around her eyes and mouth as well as on both upper extremities. Take a moment to consider any potential red flags that you, as the healthcare provider caring for Rebecca, notice that would indicate Rebecca is a victim of human trafficking. Continuing Rebecca’s visit, you are now ready to begin her physical examination. Derek insists he would like to stay in the room during the examination, and Rebecca consents to his presence. He remains standing at the head of the bed during the pelvic examination. The exam helps you determine Rebecca’s presentation is consistent with an outbreak of genital herpes, and microscopic examination of the discharge reveals trichomoniasis. These are two sexually transmitted infections. Derek seems unusually undisturbed by the diagnoses. You are concerned about Rebecca’s current living situation and would like to question her privately. While discussing the diagnoses with Rebecca and Derek, you inform them that you would like Rebecca to have a urine pregnancy test done before beginning treatment and request that she accompany you to the restroom to provide a urine sample. Derek states he will go with her and wait outside of the restroom. You explain that this is not possible because the route to the restroom passes other patients’ rooms and that this may result in an unintentional disclosure of protected patient information. Derek quickly replies that it is impossible for Rebecca to be pregnant and insists she has been compliant with her oral contraceptives and her periods are normal. Then he begins to question the necessity of the test. You inform them that she will not be treated until the test is complete, and Derek reluctantly agrees. You lead Rebecca to a private conference room and emphasize that everything the two of you discuss will remain confidential. Before continuing, you say to Rebecca, “I have a few concerns and would like to ask you some questions about your current living conditions and situation. Would that be alright?” • What questions would you ask Rebecca to help determine if she is a victim of human trafficking? • If Rebecca discloses that she is a human trafficking victim, what are ways that you could help her? What resources would you provide Rebecca? Who else would you contact/involve in the situation? • How might you respond if Rebecca declines to make an explicit disclosure or refuses to answer any questions?
Conclusion Healthcare providers must be educated on identifying, assessing, and responding to human trafficking victims to provide necessary care and support. This education is crucial for helping victims transition to survivors.
ACCESS THE FULL PRESENTATION
Scan the QR CODE ► to start video or visit https://uqr.to/TraffickingTX
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition: Summary 5
F INAL EXAM QUESTIONS
1. Which of the following is not true? a. Human trafficking is an extreme and heinous violation of human rights that persists around the globe b. Human trafficking is a crime involving the exploitation of victims for the purpose of compelled labor or commercial sex acts through the use of force, fraud, or coercion c. The most vulnerable victims of human trafficking are young men d. There is currently no consensus on the total number of trafficking victims in the U.S. despite the fact that multiple organizations publish data and statistics concerning human trafficking a. Many victims of human trafficking never disclose the nature of their situation b. Healthcare providers and organizations involved with trafficked persons must increase their capacity to identify and refer people in trafficking situations c. Healthcare providers must increase their capacity to provide sensitive and safe services to people posttrafficking d. The healthcare environment is less than ideal for identifying and intervening on behalf of a trafficking victim 3. Which of the following is not true? a. The terms victim and survivor can both be used to refer to individuals who were trafficked b. The term survivor has legal implications within the criminal justice process c. The term victim generally indicates an individual suffered harm because of criminal conduct d. Survivor is a term used by many in the 2. Which of the following is not true?
4. Which of the following is not true about human trafficking in Texas? a. A report released by the National Human Trafficking Hotline indicated that Texas has one of the lowest signal volumes among all 50 states and Washington, D.C. b. The Texas legislature created the Texas Human Trafficking Prevention Task Force to respond to the growing human trafficking crisis and designated the attorney general as the presiding officer c. The Texas Human Trafficking Prevention Task Force serves as a collaborative and multidisciplinary body that strives to coordinate anti-human trafficking efforts across local, state, and federal levels d. The Texas Human Trafficking Prevention Task Force serves as a communication hub for sharing best practices 5. Barriers to acquiring accurate data about human trafficking include all of the following except: a. Avoidance by victims of the criminal justice system due to fears of reprisal, deportation, or incarceration b. Failure of healthcare workers or emergency responders to ask about human trafficking or to probe causes of apparent violence c. A lack of coordination and data integration between the various levels of governmental agencies (local, state, federal) and other organizations (e.g., nonprofits, hospitals) that may have data on human trafficking d. Community and healthcare provider education on recognizing potential signs of human trafficking
health services field to recognize the strength it takes to continue a journey toward healing in the aftermath of a traumatic experience
Recognizing and Responding to Human Trafficking in Texas, 2nd Edition: Summary 6
6. Which of the following statements is correct? a. Human smuggling is a component of human trafficking b. All instances of commercial sex (i.e., sex work) are forms of human trafficking c. Human trafficking occurs only when victims are transported across state or international borders d. All instances of commercial sex involving minors under the age of 18 are cases of human trafficking 7. Which of the following is not a vulnerability factor related to human trafficking? a. Children in the juvenile justice systems (especially children ages 12–14) b. Well-educated individuals c. Unhoused youth d. Individuals with disabilities 8. Which of the following is not a known tactic that a trafficker may use to isolate, control, and intimidate/threaten victims? a. Violence b. Threats or intimidation of victims or victims’ family members c. Withholding basic necessities d. Provision of friendship and social support 9. Many trafficking victims suffer serious health issues, which may include all of the following except: a. Reproductive health problems, including sexually transmitted diseases, urinary tract infections, pelvic pain, and injuries from sexual assault or forced abortions b. Symptoms of post-traumatic stress disorder, phobias, panic attacks, anxiety, and depression c. Lyme’s disease from exposure to the elements d. Signs of physical abuse, such as bruises, broken bones, burns, and scarring
10. Which of the following is an example of suspicious behaviors often exhibited by traffickers attempting to conceal their true identities? a. Being overly accommodating, open, and talkative with healthcare providers and staff b. Providing additional background information to supplement the patient- reported history and acute illness/injury c. Advocating for a particular method of treatment or care but deferring to the provider’s judgment d. Controlling the patient’s identification documents
TO ACCESS THE FINAL EXAM TO THIS COURSE ►
Course content code: PTTX01TT-H
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 7
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition 4 Contact Hours
ACCESS THE FULL VIDEO PRESENTATION Scan the QR CODE ► to start video or visit https://uqr.to/BFR_Training
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
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 e. The correct answer is (a) 20-40% 4. How long does it typically take to see benefits from BFRT?
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 2. 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
a. 1-2 weeks b. 2-4 weeks c. 8-12 weeks d. 6 months or more
ANSWERS: 1: b 2 : d 3: a 4 : b
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 8
Benefits of Blood Flow Restriction Training
INTRODUCTION
BFRT offers a wide range of potential benefits when used as an adjunct to low intensity resistance exercise (LIRE) or aerobic exercise (AE). 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 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. • Possible aid in weight loss • Improvements in tendon mechanical and morphological properties
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.”
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 9
THE SCIENCE BEHIND BFRT The two primary mechanisms thought to
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
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.
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.
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 10
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
Risk factors for Developing Venous Thromboembolism • 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
Signs and symptoms of VTE
• Cyanosis • Edema • Erythema • Pitting edema • Superficial dilation of veins • Tenderness to palpation/warmth • Positive clinical
3 points
• Prolonged inactivity • A-Fib or heart failure • Blood pressure: • Age >60 years • BMI >30 kg/m 2 • Malignancy • Hyperlipidemia • Estrogen therapy • Age 40-58 years • Women • BMI 25-30 kg/m 2
signs such as Homan’s test
160-179/95-99mmHg
2 points
• Increased
intracranial pressure
• Cancer • Previous
1 point
revascularization of limb
• Lymphedema • Vascular graft • History of mastectomy or axillary node
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
dissection (avoid on affected arm)
• Those in
hemodialysis who have arterial or venous fistulas
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.
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 11
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. 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
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: ○ Start with passive BFRT for cell swelling ○ Progress to aerobic exercises/return to sport/HIIT with BFRT 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.
○ 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.
Blood Flow Restriction Training: Understanding the Safety, Mechanisms, and Efficacy, 2nd Edition: Summary 12
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 13
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
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. ACCESS THE FULL VIDEO PRESENTATION Scan the QR CODE ► to start video or visit https://uqr.to/BFR_Training
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
Page i Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60 Page 61 Page 62 Page 63 Page 64 Page 65 Page 66 Page 67 Page 68 Page 69 Page 70 Page 71 Page 72 Page 73 Page 74 Page 75 Page 76 Page 77 Page 78 Page 79 Page 80 Page 81 Page 82 Page 83 Page 84 Page 85 Page 86 Page 87 Page 88 Page 89Powered by FlippingBook