Blood flow restriction training is a great technique to be able to help people gain strength in a low load environment. So using BFR after knee surgery is a great idea.
But there are a few different ways we use blood flow restriction training after surgery. Here are some ways that we apply BFR after knee surgery.
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#AskMikeReinold Episode 276: Using BFR After Knee Surgery
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Show Notes
Transcript
Student:
Right. So we got, “Using BFR after knee surgery”. Tom from Maryland, “I recently purchased Mike and Dan Lorenz’s online course on blood flow restriction training. And I’m excited to start using BFR with my patients. I’d love to hear how you all utilize BFR in a postoperative patient. Maybe discuss a case example of a knee surgery patient and how you started using BFR and how you progressed it over their rehab.”
Mike Reinold:
Awesome. Good job Eric. I like it. Yeah. You know what? I actually think that’s a fairly common question. We see that a lot online, like on social media, you guys probably seen that a little bit too is I think everybody’s … blood flow restriction traits getting more popular, right? BFR is definitely more popular, but I think a lot of people lack the creativity of exactly how to apply it. And I don’t blame him. It’s new. You don’t want to do it wrong. You don’t want to waste time. You don’t want to like, have any safety things. So, Dan Lorenz and I, that teamed up for that course. Kind of talk about this a little bit all the time is that a lot of people need a little guidance.
Mike Reinold:
So we have some case studies in our course and stuff like that. But I like this question from Tom here where he is like, look, just walk me through like how you would use it on somebody and we can kind of go from there. So I don’t know if anybody, I know we have a few people just off the top of my head. I know, Dan’s doing it on a couple people. Dave’s doing it on a couple people. I haven’t been a sector right now. Len’s done some ACL. So, why don’t we each take turns and just share, when did you start using it? How’d you start using it and how’d that progress over time? Like as case studies, but Dave, you want to start it off?
Dave Tilley:
Yeah, sure. So I think probably the most classic one that I recently had was just a soccer player, ACL hamstring graft. And I think we started probably like three or four weeks. The doc was really just worried about incisions. So once the incisions closed and they felt comfortable, we were able to do it because they’re worried about the pressure, obviously popping some stitches or stuff. So it was like three or four weeks after, but I saw her maybe like week two when she was there. So the first week was kind of more just basic education and swelling, but we were pretty fast on doing it for BFR and stem together. And I actually started her at like 60% limb occlusion pressure because I was a little nervous about, obviously she’s never done it before. The response is high she’s exercising for the first time after surgery, she’s doing stem with the BFR.
Dave Tilley:
So we started at 60% and just did all her open chain stuff. And then some of her hit manuals that we were doing like manually. So she did all of her, leg raises, all her stuff over the side of the table and the hands-on stuff with me. And that was it. That was really all we did for the first couple days after then we added like the weight shifting the close chain, mini squat she started to do with her protocol. And I would say it kind of started as the bulk of her exercise. Like pretty much to the time in treatment she was using that. And then as we just went through the natural 4, 6, 8 week progression up to like maybe when she was in the gym, she started doing stuff in the gym around like 10 weeks or 12 weeks.
Dave Tilley:
I just started putting at the end of her rehab as like a burnout set. So she would just do quad and at that point, after her hamstring graft, we were doing a lot of hamstring and quad stuff together. So it went from kind of all her exercises towards, increasing the limb occlusion pressure up to 80 when she could handle it. And then finally just doing like a burnout set of quad, hamstring, calf stuff at the very, very end. And yeah, she’s doing really well and she’s eight months now, but she did have a couple times where she got a little lightheaded and we had to like kind of chill a little bit, but overall she crushed it and she’s doing really well now.
Mike Reinold:
Awesome. Well, so, when you started that at the beginning, Dave, you just did your normal set rep scheme that you’d normally do. Right? And essentially what you did is you took your normal, early postoperative stuff and you just added blood flow restriction to it, but you didn’t change the set rep scheme. Is that accurate?
Dave Tilley:
Yeah, because in my mind, and I mean, obviously like to hear everyone’s opinion, but I feel like there’s a lot to get to early on. There’s so much stuff to do in an hour between manual stuff, range of motion, swelling, soft tissue, all the exercise. There’s so much stuff I want to get to biking, that I’d rather kind of just have it on there as like a low level stimulus than being all right on three by 30 for every single quad set, leg raise, that’s going to be a lot. And I think like it easily gets to like 20 minutes of limb occlusion pressure, that you’ll want to go over. So I was just cautious about that.
Mike Reinold:
Yeah. I like that. And then as she progressed, like you said, you started doing it more towards the end, but then you were focusing on fatigue at, at the end. I like that. Awesome. All right, who else wants to share how they used it as like a case with somebody? I know a lot of people have been doing it. Who wants to go next? Dan?
Dan Pope:
Sure. Yeah. I agree largely with Tilley. I think one of the big question marks in my head is when is it okay to start? You know? And I think it kind of comes down to a couple different things. One we’re kind of scared about circulation, clots, that type of thing. And I think for the majority of folks, it’s we don’t really know when it’s safe to start. I think making sure the wound is healing appropriately is important. And a lot of docs maybe don’t want you to start BFR until someone’s actually ambulating, which is going to be pretty tough for, let’s say like a postop meniscus repair when someone’s non-weightbearing for a period of time. So I don’t have a great answer for you, but I would say you want to start BFR as soon as possible. The only caveat I’ll say, and I’ve made this mistake in the past is that BFR is tough off and you’re taking someone that really hasn’t exercised much for a period of time.
Dan Pope:
They’re probably painful before the surgery and they’re deconditioned from the surgery. And then if you ask them to do sets to failure in the beginning, you really may hurt them. So you have to be a little careful. What I’d like to do is I’ll actually start people in the exercise that I want to do BFR on eventually, and I’ll slowly ramp up the repetitions. And if they’re tolerating that well, then I throw the BFR on. But that being said, I think you’re fighting this battle of, all right we want to protect the surgical site, but the longer we wait to load this area, the weaker they’re going to be long term, the harder it’s going to be to get back the atrophy or the muscle mass they lost.
Dan Pope:
So I would say you want to start as soon as you can but once you start applying it start easy and make sure they’re responding well, they’re not getting a lot of swelling. They’re not getting more painful. The range of motion is still progressing. Well, that being said, and I’m going to piggy back on Tilley. I think a lot of PTs I hear tend to make this mistake is that BFR is great for low level stress to the body, which is phenomenal in the early stages of rehab. These folks are not going to be able to tolerate a lot of stress in general because we want to protect the surgical site, but if we do too much, we’re just going to piss the area off and then set ourselves back. So it’s phenomenal early stage, but once someone’s able to load, I try to make that transition over to loading as soon as we’re able to, because again, we want to get back to a sport specific activity and we need to protect the surgical site.
Dan Pope:
But the other part is that we want to get started as soon as we can without irritating that area. So BFR ends up becoming adjunct eventually. So, when someone’s able to tolerate more squatting, lunging, deadlifting, those type of things, I actually want to try to load those things without BFR. And then I may put some BFR at the end of the program and I have a patient right now, a post-op meniscus repair. She’s a power lifter and she has fallen in love with BFR training and she does it twice a week, still on top of all of other training she loves it. She’s doing really well and she’s PR in her squad and everything and tributes a lot of that to BFR. But I think the large majority of her success comes from her training first. And the BFR is just a little small adjunct at that point, you know?
Mike Reinold:
Right. Yeah. Well said there, Dan, I think that’s great. And to your point on the safety, I mean, I think we still pretty much recommend, wait a couple weeks for the incisions to calm down, the swelling, to calm down, the research out shows the safety it’s there. It is safe. There aren’t correlations with clots and stuff like that. So safety’s there. But what I really like that you both kind of said, Dave said he starts with 60% limb occlusion pressure, for example, for the lower body, which is kind of in the medium range, right? So certainly not at the high end. And Dan kind of said something similar where we kind of like ease into it, right? I see a lot of people make the mistake where let’s just say it’s a early postop, let’s say it’s a patellar tendon graft ACL.
Mike Reinold:
And they go to a BFR course and they say that, well, I’m supposed to do four sets of 30 reps, 15, 15, 15 reps. That’s the protocol. Right? And, and they’re doing that week two with knee extension after patellar tendon graft ACL, right? And that’s like 75 wraps, with not necessarily a heavy load, but when you add the limb occlusion pressure that that increases the fatigue and that increases essentially the perceived load, to the tissue. Right. So we see a lot of people, but blindly applying it like that. So I love what you guys both said is ease into it. Right. It’s an adjunct and it’s something that you want to slowly apply. I think that’s kind of fantastic and make sure you’re doing regular load too. Right. Like, Diwesh and I, we talk about this all the time when we talk about our training programs in the gym, but we like to train all qualities of athleticism, right?
Mike Reinold:
So let’s say strength and power, for example, I think it’s the same thing with load here. You can argue that BFR is one type of stimulus, but we also need to do heavy load for tissue, right? With lower set rep schemes as well, and if you do them both in one session, you could argue, you’re working on two sets of qualities at once, and for both strength gains as well as tissue capacity loading. So, I think that’s kind of neat too. So anyone else want to share their experience? I do have one too, but I want to, just make sure everybody, anybody has anything different to add or is that pretty similar?
Lenny Macrina:
I was just curious if anybody has an opinion on diminishing returns, meaning like, do you ever just pull it out because they’re eight months out of an ACL, 10 months out of ACL, 18 months out of an ACL. And you’re like, man, I’d rather just have them do five sets of five deadlifts, squats and what’s somebody doing, 20 pound knee extensions of BFR. Is there ever a time where it’s like, just not worth it anymore? You know what I mean?
Dave Tilley:
That’s exactly what I did with a patient that I was talking about up until six months, we were doing like burnout sets and at six months I was like, we have so much stuff we have to do with like cutting, agility, and speed. Like it was impossible to fit it all in an hour. Honestly, she was there for like an hour and 45 minutes. I’m like, we can’t do anymore. And she was dead. She was crushed after her workout.
Lenny Macrina:
Right. Yeah. So, I can see that is just so fatigue from everything else. Like, you’re just like adding this new … like they just got nothing left in the tank. I can see that. I just didn’t know if there was a point where it was just like, we just doing it to get that stimulus. And do we have enough weight on them? Do we have too much weight on them? Are they hurting, diminishing other things, other abilities to do during the session? And I don’t know. I’m always trying to figure that out in my patients that I use it on like my ACLs and other things, but I mean, we may not know. I was just curious if anybody had a …
Mike Reinold:
Well, it makes sense to me. Like if you go by what Dan just kind of said, and if you are still using it in later phases, you are still doing some heavy load without occlusion and some of this together. I think it comes down to like, in addition, obviously, do you have enough time? Is it the most important thing to use in your time? Maybe it just comes down to do they still have strength, deficits? Are they still behind? And once they’re not behind, then you just transition to a normal training program. Right.
Lenny Macrina:
Right. Because I don’t know if I’d rather do 90 pound knee extensions versus 20 pounds to four sets of fatigue versus just really overload if I’m doing a knee extension, for example, after an ACL. I’m always torn, I guess we don’t have 90 pounds of knee extension. So, [crosstalk 00:13:53].
Mike Reinold:
Do you have 90 pound ankle weight? That’s pretty good.
Lenny Macrina:
Exactly.
Mike Reinold:
You just started a Twitter firestorm right there. I love that part. So I’ll just share briefly kind of like my experience too. Very similar to Dave and Dan, but as we go through this, we learn a lot. Right. So I have a great patient right now. That is, he tells us his symptoms quite well. I’ll leave it at that. We’ll just leave it at that. But in a good way, like in somebody that is articulate about how they’re feeling all the time, a little bit more on the cautious side, but in a good way. Right. So post-op, metastasectomy, we started about two weeks. We started using it just like Dave with neuromuscular stem during his table exercise.
Mike Reinold:
No change in the set rep scheme, just as it was progressing. That was kind of the first thing we did. Then remember, it’s a metastasectomy, right? It’s not like a patellar tendon graft or something. So pretty quickly after that, once his volitional or voluntary control of his quad was pretty good, I had him start doing knee extensions with it. And then we started using knee extensions with more of a fatigue type protocol, like a 30, 15, 15, 15 protocol. But I didn’t start that way, right? Because I wanted to make sure we had volitional quad control. First, once we had that, we started adding that to the program to kind of get some strength gains. So a couple of things that we’ve done with him over time, which we kind of found out is we started doing some like isometric, mid thigh pulls on our force plates.
Mike Reinold:
And we started doing that towards the middle portion of his program. If we did the BFR prior to that, his ability to perform the isometric mid thigh pulls on the force plate was down of probably about 20, 30, sometimes even 40% like Mike and I saw that with this particular person. His ability to produce force on the force place was so down, because he was so tired. So I actually found that I think we were tiring him out. Mike said the same thing kind of made the same pivot in the program. We’re tiring him out too early in the program, so we shifted the BFR towards after everything. Sometimes people get completely fatigue, one exercise, sometimes they don’t. So, we put it towards the end and he’s kind of doing more of a normal program now.
Mike Reinold:
But then at the end, like Dave, he’s doing that kind of fatigue protocol, then he’ll ride the bike with it. We’re keeping it under 20 minutes. He’s still getting a little bit of the benefits of that. But we thought that was really interesting. The other thing that a lot of people have said, but this particular person talks about this too, is when he does it with the neuromuscular stem, he’s way more tired at the end than when he does it without the neuromuscular stem. So keep that in mind too, BFR plus neuromuscular stem in these early phases, it’s not just for volitional control, but it helps get more of the muscles to contract perhaps. And if he’s more tired, it’s definitely getting more of like a physiological response. So kind of keep that in mind as well.
Mike Reinold:
So, those are good few examples. I think that’s great. I mean, I think this is an important episode over people just getting started with BFR is that you don’t just blindly follow a protocol. You have to use some common sense and BFR is just something we can just add. Right? You can just add to kind of just like supplement what you’re currently doing. You don’t necessarily have to change your set rep schemes or what you’re doing or the exercise selection. You can just make it part of your process. Then as the person evolves, you can kind of pick and choose when to use it, maybe when to scale back and do some heavy load stuff too. But I think what we’re trying to get across here is that it’s a supplement, there’s lots of ways to apply it. And I think if we use our brains with a little of experience through this, it’s going to be much more successful, right?
Mike Reinold:
Every time there’s something new in your hands, in your clinic, everybody tries to use it the same way on a lot of different people. And then you find, areas that it works well, areas that maybe it doesn’t and how you refine it. I think that was a little bit of our evolution of how we refined it. So hopefully that helps you as well. So, awesome. So, great episode. Thanks guys for the answers. That was a good case. Tom, that was a good question, I appreciate that. Again, if you have a question like that, head to mikereinold.com, click on that podcast link, you fill out the form to ask us questions and please go to Apple Podcast, Spotify rate, review, subscribe, and we’ll see you on the next episode. Thanks so much.
