Background
I had never really heard of what blood flow restriction (BFR) really was until I saw it as a research topic that Jon Hacke was interested in. Since he was interested in using BFR in the geriatric population, this sparked my interest in joining his team because I really enjoy working with the older folks. I hadn’t fully decided to commit to this topic for my Capstone just yet until a few weeks later. I was a patient in physical therapy for a case of patellar tendonitis and my therapist (who is also one of my committee members for this project, Stephen Harris, PT) had just taken a course on using BFR and decided to try it with me. It is truly a unique muscular challenge and sensation that I have never felt before. I never knew squats could be so difficult! It was a great experience and I knew then that this was a topic I wanted to dive into, but specifically for the geriatric population.
Using BFR as a treatment intervention is within a PT’s scope of practice with proper training¹, but I had not learned about its specifics until experiencing it myself and then completing the research for this project. This Capstone project will dive into the strength outcomes for geriatric patients that participate in BFR – I hope you find it as interesting and encouraging as I did and can add it to your intervention toolbox!
Statement of Need
Decreased muscle mass is a natural process in the elderly population that is associated with a decrease in independent functional mobility and self-care.² Furthermore, decreased muscle mass is a risk factor for developing osteoarthritis, which leads to even further functional decline secondary to pain.² Geriatric patients can participate in strength training (if medically able) and experience muscle hypertrophy to prevent the development of various co-morbidities, but are often unable to do so because of pain being a limiting factor.² Without loading the joints sufficiently, the muscles are unable to effectively hypertrophy and thus the patient is unable to gain strength.² This is a very common clinical issue where therapists want to help their patients get stronger to help them increase their level of safe independence, but are unable to determine a safe and effective treatment approach. BFR is a unique tool that allows the patient to use only low loads for resistance training while still producing muscle hypertrophy and strength and not increasing pain, thus leading to improved function and quality of life.² This project was necessary to determine if using BFR with low-load training does produce comparable results to high-load training alone for the geriatric population. Additionally, since increased quadriceps strength is associated with decreased osteoarthritis symptoms at the knee², this project was necessary for focusing on the outcomes for elderly patients with osteoarthritis to be able to determine a safe and effective treatment intervention for this specific population.
Purpose
The purpose of this Capstone Project was largely to review the current literature on the efficacy and effectiveness of using BFR with low-load training in the geriatric population to produce comparable strength and functional outcomes to traditional high-load training. Furthermore, the purpose was to draw clinical implications from the results of the evidence that can be applied to geriatric patients in a PT clinic. The products of this Capstone serve to provide consolidated evidence and clinical conclusions for PTs and PT students to read and determine whether or not BFR is an appropriate option for their geriatric patient. Since BFR is not heavily discussed in PT school, this project also serves to increase awareness of BFR’s existence and utility as a treatment intervention to add to one’s toolbox for the geriatric population.
Products
I have created an evidence table that consists of ten high-level evidence articles (systematic reviews, meta-analysis, and randomized controlled trials). This table highlights the specifics of each article including the outcomes measured, results, and clinical applications. Additionally, I created a brief Summary of Evidence that highlights the overarching results from the ten studies assessed and the clinical implications for such. Lastly, I created a brief PowerPoint that presents the information from the summary of evidence in a manner that can be easily shared with clinicians, patients, or current PT students.
Self-Reflection
The beginning of this project essentially started in Fall 2020 with the CAT I completed in the Evidence-Based Practice II Class, so it has been a long and intricate process. I have learned a lot about the determination and patience it takes for combing through articles to find the best evidence. I feel much more confident with my ability to assess an article and determine its clinical effectiveness and application by weighing its results with its risk of bias. It has been encouraging for me to now feel comfortable as a new clinician to search through current literature when deciding whether to use an intervention with a patient and combine results in the evidence with my clinical judgment. If you had told me on my first day of PT school that I would have these products to demonstrate my research efforts and evidence-based practice skills, I would have never believed you. I am really proud of myself for creating valuable clinical products that are relevant to my clinical interests, and I’m excited to keep it up throughout my career. I have also received and included valuable feedback throughout this process via evaluation of my products from my advisor and committee members.
Acknowledgements
Thank you so much to Jon Hacke, my amazing Capstone Advisor, for giving me the opportunity to pursue this research topic, and for providing your wisdom and guidance throughout this process. You are an absolutely amazing clinician and even more wonderful human being. Congrats to your retirement – I am so happy that you will be able to experience more adventures with the lovely Linda! Thank you to Stephen Harris, PT, for being one of my committee members and for being a huge part of the reason why I am even about to be a PT in the first place! I wouldn’t be here without you and you are always an inspiration. And thank you to Dr. DeFreese for being one of my committee members and providing your support, friendship, and research expertise with me since 2016! I also would not be here in PT school without your guidance and support. You all have been wonderful throughout this entire process and I appreciate your time and help so much!
Thank you to every single professor and guest lecturer that has taught me so much about the opportunities this profession has to help people improve their quality of life. You all are wonderful teachers and people and I am so grateful! Thank you to my wonderful family, friends, and God, who have provided continuous encouragement and support these last 3 years! Lastly, thank you to the Class of 2021 for being the best group of intelligent, compassionate, innovative, fun people to learn with. I can’t wait to watch you all grow into amazing clinicians!
References
- Blood-Flow Restriction Training (BFRT). APTA American Physical Therapy Association. https://www.apta.org/PatientCare/BloodFlowRestrictionTraining/. Last updated May 24, 2019. Accessed Apr 15, 2020.
- Vopat BG, Vopat LM, Bechtold MM, Hodge KA. Blood flow restriction therapy: where we are and where we are going. J Am Acad Orthop Surg. 2020;28(12):e493-e500. doi:10.5435/JAAOS-D-19-00347
10 Responses to “Effectiveness of Blood Flow Restriction Therapy in the Geriatric Population”
Debbie Thorpe
Hi Maddy
Very well done project! I knew nothing about BFR until reading your project. I think it might work for some of my clients with IDD since it is hard for them to lift heavier loads at the appropriate frequency and duration and many have joint contractures which also limit them. I do think turning this into a voicethread would be very valuable, especially if faculty would like to use it as supplemental material for students to view for this content in the curriculum. Nice contribution!
Best
Debbie
Madison Bell
Thank you so much for your kind feedback, Debbie! I am so glad you enjoyed it and I would love to hear your experience if you try it with patients with IDD one day!
az3ft
Really interesting project, Maddy! I have only ever considered BFR in athletic and military populations but after seeing your products, I think that it is certainly worth considering with a geriatric population. Given their physical limitations when it comes to traditional %1RM training, I think that the ability to use loads of 60% or less is a huge advantage for this population. Especially with some older adults that have never exercised, taking out the taxing effort and time needed to coach traditional strength training is a huge bonus. After looking at your summary of evidence guide, I wanted to find out the percentage of occlusion they were going for with BFR. Most of the research I have seen aims for 80% occlusion of the particular limb in question. Did you find that this number was consistent in the geriatric population as well? Also, what are your thoughts on the pain tolerance aspect for BFR training? As someone who has tried it myself, I can certainly say the burning muscle pain with exertion during BFR is not for the faint of heart. Given your athletic background, I can imagine you were able to tolerate your rehabilitation using BFR. However, I have met plenty of older adults that dislike regular sit to stands. If you have tips on coaching, motivational interviewing, or smooth talking, please share. Again, wonderful project!
Madison Bell
Alan,
Thank you so much for your kind comments and helpful clinical feedback! You make a great point that a lot of these older adult patients may have never been a regular exerciser. To push them into heavy resistance training could do more harm than good. Unfortunately, there were not a lot of consistencies with the reported BFR occlusion percentages, so further research is definitely needed in this population. From the articles I assessed, most reported percentages were anywhere from 60-80%, so a little lower than the athletic population. I have definitely considered the pain aspect of BFR in this population. It may be that with a lower occlusion rate, it is hopefully a little less painful but still able to produce clinically significant results. It would definitely requires some efficient and effective coaching along with detailed education. I have found that the older adult population really appreciates being told why what they’re doing is effective because otherwise they just view it as a waste of time. Taking the time to provide education can be very helpful for their outcomes! Thanks again for your feedback!
Melissa Carr
Hi Maddy!
I enjoyed learning more about BFR training, as this is a topic that is frequently discussed on the “DPT students” Facebook page, but I had very little insight into the mechanism and purpose of this unique intervention. I appreciate how you described the physiological mechanism in great detail, because this helped me further understand how and why this BFR training with low resistance could be so beneficial in increasing strength when compared to low resistance without BFR. As someone who is interested in working in an outpatient orthopedic setting in the future and will likely have a large geriatric population, this topic was very interesting to me to increase interventions options, while ensure the best possible outcomes. In my current clinical, the majority of patients are older adults who present with significant deconditioning and chronic pain, and many have co-moribidities, like osteoarthritis or degenerative joint disease, that make high resistance exercises painful. This often limits the interventions that are included in the plan of care. I am very interested to try out BFR training in the clinic with this more vulnerable population. Thank you for the detailed and consolidated research on this relatively novel intervention and opening my eyes to alternative interventions to expand my “clinician toolbox!”
Madison Bell
Hi Melissa! Thank you so much for your kind words and feedback! I am happy to know that the physiological mechanisms of BFR were helpful since that was a last minute addition to the project. I appreciate your clinical applications here, and I am glad you are able to add this research to your clinical toolbox to be able to use with your patients one day. You are going to be an amazing clinician!!
Ashley Sanchez
Hi Maddy,
As I have a strong interest and passion for working with the geriatric population, I was excited to see another capstone project tailored towards older adults in the context of physical therapy (PT) practice. While reading the background of your project, it was interesting to learn about your decision-making process for embarking on this capstone topic as far as combining your personal experience in PT along with your enjoyment for working with older adults. On my current clinical rotation, I work in a clinic that mainly specializes in treating the geriatric population for chief complaints ranging from post-operative orthopedic conditions (i.e.- total knee replacement, rotator cuff repair) to progressive neurological diagnoses (i.e.- cognitive impairment, Parkinson’s disease). Despite the varying chief complaints and/or presenting diagnoses, the most common challenge that presents with nearly all the older adults is generalized deconditioning secondary to decreased muscle mass attributed to aging. As you mentioned, the presence of decreased muscle mass can lead to the development of osteoarthritis further leading to degradations in independent functional mobility and self-care with or without the presence of pain. While reviewing your capstone products/deliverables, I was intrigued by the wealth of evidence-based literature paired with clinically applicable takeaways on the substantially positive impact of blood flow restriction (BFR) therapy in the geriatric population. Thank you for completing this capstone project on this topic, as these resources will be indispensable to students, patients and families, caregivers, and healthcare practitioners. Best of luck on your future personal and professional endeavors!
Madison Bell
Hi Ashley! I actually thought of you and your love for the geriatric population several times while working on this project, so I am glad you found your way to my page. Thank you so much for your kind words and feedback! And thank you for providing your own clinical experiences that this research could be applicable for. As you stated, generalized deconditioning is a huge problem in older adults simply due to the decreased muscle mass that occurs with aging. I hope you are able to add this information about BFR to you clinical toolbox! Best of luck to you for your personal and professional future – I know you will be awesome!
Ashley Hite
Hi Maddy!
This is so cool! I honestly had never heard of blood flow restriction therapy until you started using it for your personal rehab. I remember thinking what an interesting and exciting technique that was and how it was something I wished to explore deeper. When I started reading of the impact BFR can have, I also thought this could possibly be a great option for many geriatric patients. You did an awesome job outlining the relevant literature in your evidence table and power point presentation. I also believe your summary of evidence was a great addition as a quick reference guide. I am excited to discuss and share the findings of your research with family members and future patients. I love how this provides an option for strength training while placing less mechanical stress on the joints compared to other alternatives. This is a great tool for us to have as clinicians. I believe your products will be of great benefit to students, clinicians, and patients. Thank you for your dedication to this research. Best of luck as you begin your career. I know you will be great and enhance the lives of so many patients!
Madison Bell
Hi Ashley! Thank you so much for your kind words, feedback, and clinical applications! It’s encouraging to see the goals of my products have been translated effectively. I hope you’re able to use this research moving forward with your clinical practice by adding it to your “toolbox.” 🙂 You are going to make a wonderful clinician!!