前交叉韧带重建术后患者高血流限制训练康复效果的系统综述

doi:10.3969/j.issn.1006-9771.2024.07.006

摘要/Abstract

摘要：

目的系统综述前交叉韧带重建术(ACLR)后患者实施高血流限制训练(BFRT)的康复效果。
方法采用主题词检索方式，在PubMed、Web of Science、Embase、Cochrane Library、中国知网、CBM、万方数据库和维普数据库中检索相关文献，自建库至2024年5月1日。采用物理治疗证据数据库量表对纳入文献进行方法学质量评估，提取相关数据进行系统综述。
结果纳入7篇，涉及受试者183例，来自6个国家，干预地点主要是医院康复科和康复中心。发表时间集中于2016年至2023年。BFRT组在常规康复训练时对下肢进行加压，组间放气休息0.5~2 min或不放气。BFRT组的改善作用体现在肌肉力量、肌肉形态和身体功能等方面，能促进肌力增加、肌肉肥大，改善膝关节功能。干预总时长和训练强度会影响改善效果。
结论高BFRT可以改善ACLR术后膝关节周围肌肉状况、促进功能恢复。为确保训练的安全性和康复效果，采用低强度肌力训练，每组15~30次重复动作，每次训练4~5组，每周训练2~3次，训练总时长≥ 3周。

关键词: 前交叉韧带重建术, 血流限制训练, 膝关节功能, 系统综述

Abstract:

Objective To systematically review the effect of high blood flow restriction training (BFRT) on patients after anterior cruciate ligament reconstruction (ACLR).
Methods Relevant literature was searched in PubMed, Web of Science, Embase, Cochrane Library, CNKI, CBM, Wanfang data, and VIP databases using subject term search methods from the inception to May 1st, 2024. The methodological quality of the included literatures was assessed using Physiotherapy Evidence Database (PEDro) scale, and relevant data were extracted for systematic review.
Results A total of seven articles were finally included, involving 183 subjects from six countries. The intervention sites were mainly hospital rehabilitation departments and rehabilitation centers. The publication dates ranged from 2016 to 2023. In BFRT group, lower limbs were compressed during conventional rehabilitation training, with intermittent of 0.5 to 2 minutes or without deflation. BFRT would increase muscle strength, muscle hypertrophy, and improved knee joint function. Total duration of intervention and training intensity affected the improvement.
Conclusion High BFRT can improve the condition of the muscles around the knee joint and promote functional recovery after ACLR. To ensure the safety and effectiveness of the training, low-intensity strength training should be employed, with 15 to 30 repetitions per set, four to five sets per session, two to three sessions per week, and a total training duration of at least three weeks.

Key words: anterior cruciate ligament reconstruction, blood flow restriction training, knee joint function, systematic review

中图分类号:

R687.4

唐乐天, 黄兆欣, 刘超, 肖晓飞. 前交叉韧带重建术后患者高血流限制训练康复效果的系统综述[J]. 《中国康复理论与实践》, 2024, 30(7): 789-796.

TANG Letian, HUANG Zhaoxin, LIU Chao, XIAO Xiaofei. Effect of high blood flow restriction training on patients after anterior cruciate ligament reconstruction: a systematic review[J]. Chinese Journal of Rehabilitation Theory and Practice, 2024, 30(7): 789-796.

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纳入文献基本特征"

纳入文献	国家/地区	n (C/T)	年龄/岁	移植物类型	干预地点	干预方法		干预方案(BFRT)	加压强度	康复效果
纳入文献	国家/地区	n (C/T)	年龄/岁	移植物类型	干预地点	C	T	干预方案(BFRT)	加压强度	康复效果
Li等^[21] (2023)	中国	23(6/17) T₁：9 T₂：8	18~40	自体肌腱	康复科	等长抗阻训练、抗阻膝关节屈曲和伸展训练训练负荷：低负荷	BFRT+对照组训练训练负荷：低负荷	康复训练每周2次，共8周；训练中加压，休息阶段放气放松30 s，至训练结束	试验组1：40% LOP 试验组2：80% LOP	股直肌和股中间肌的厚度、等速屈伸膝峰力矩测试、YBT测试、IKDC评分均改善；试验组2改善更显著
Okoroha 等^[22](2023)	美国	38(22/16)	14~40	自体骨-髌腱骨移植、半腱肌腱移植或股四头肌腱移植	康复科	常规康复训练训练负荷：低负荷	BFRT+对照组训练训练负荷：低负荷	康复训练每周2~3次，共12周；训练中加压，休息阶段放气放松1 min，至训练结束	80% LOP	屈伸肌力、股四头肌围度、VAS评分、IKDC评分、关节活动范围改善更显著
Vieira de Melo等^[23](2022)	巴西	24(12/12)	18~59	自体腘绳肌腱	康复科	常规康复训练训练负荷：低负荷	BFRT+对照组训练训练负荷：低负荷	康复训练每周2次；共12周训练全程加压，至训练结束	80% LOP	两组膝关节屈伸力量和功能均改善；干预时间越长，BFRT组改善效果更优
Curran等^[24](2020)	美国	34(16/18)	14~30	自体骨-髌腱-骨移植、半腱肌腱移植或股四头肌腱移植	康复科	常规康复训练训练负荷：高负荷	BFRT+对照组训练训练负荷：高负荷	康复训练每周2次；共8周训练中加压，休息阶段放气放松2 min，至训练结束	80% LOP	两组股四头肌肥大、股直肌体积、膝关节屈伸力量和IKDC评分均没有改善
Hughes等^[25](2019)	英国	28(14/14)	29±7	自体腘绳肌腱	康复科	常规康复训练训练负荷：高负荷抗阻训练	BFRT+常规康复训练训练负荷：低负荷	康复训练每周2次，共8周；训练中加压，休息阶段放气放松2 min，重复至训练结束	80% LOP	肌肉厚度、10 RM强度、等速屈伸膝峰力矩、ROM、Lysholm评分、KOOS评分、IKDC评分改善更明显，疼痛减轻更明显
Kacin等^[26](2021)	斯洛文尼亚	12(6/6)	18~45	未提及	康复科	BFRT＋常规康复训练训练负荷：低负荷	BFRT+常规康复训练训练负荷：低负荷	康复训练每周3次，共3周；训练中加压，组间放气放松45 s/90 s/45 s	C: 20 mmHg T: 150 mmHg	膝关节伸肌横截面积、肌力和耐力改善，膝关节屈肌的肌力和耐力改善，但对屈肌肥大无作用
Iversen等^[27](2016)	挪威	24(12/12)	18~40	自体腘绳肌腱	康复科	常规康复训练训练负荷：低负荷	BFRT+常规康复训练训练训练负荷：低负荷	康复训练每天2次，共2周；训练中加压，休息阶段放气放松3 min，至训练结束	130~180 mmHg	两组股四头肌横截面积均无改善

表3

参考文献 46

[1]	CÓRDOBA L L, RODRIGUES M C, CORRÊA DE FREITAS R, et al. Physiotherapeutic approach to the preoperative period for the anterior cruciate ligament reconstruction: a systematic review[J]. J Bodyw Mov Ther, 2023, 33: 88-94. doi: 10.1016/j.jbmt.2022.09.001 pmid: 36775532
[2]	JACK R A, LAMBERT B S, HEDT C A, et al. Blood flow restriction therapy preserves lower extremity bone and muscle mass after ACL reconstruction[J]. Sports health, 2023, 15(3): 361-371.
[3]	季程程, 王兴, 杨鹏飞, 等. 近10年前交叉韧带运动损伤研究热点的可视化分析[J]. 中国康复理论与实践, 2019, 25(12): 1400-1407. doi: 10.3969/j.issn.1006-9771.2019.12.007
	JI C C, WANG X, YANG P F, et al. Hotspot of sports injury of anterior cruciate ligament last decade: a visualization analysis using CiteSpace[J]. Chin J Rehabil Theory Pract, 2019, 25(12): 1400-1407.
[4]	ARIMAA A, KNIFSUND J, KESKINEN H, et al. Return to work following anterior cruciate ligament reconstruction[J]. Acta Orthop, 2022, 93: 554-559. doi: 10.2340/17453674.2022.3139 pmid: 35700049
[5]	NORTE G E, HERTEL J, SALIBA S A, et al. Quadriceps function and patient-reported outcomes after anterior cruciate ligament reconstruction in patients with or without knee osteoarthritis[J]. J Athl Train, 2018, 53(10): 965-975.
[6]	ØIESTAD B E, JUHL C B, CULVENOR A G, et al. Knee extensor muscle weakness is a risk factor for the development of knee osteoarthritis: an updated systematic review and meta-analysis including 46819 men and women[J]. Br J Sports Med, 2022, 56(6): 349-355.
[7]	TELFER S, CALHOUN J, BIGHAM J J, et al. Biomechanical effects of blood flow restriction training after ACL reconstruction[J]. Med Sci Sports Exerc, 2021, 53(1): 115.
[8]	KOTSIFAKI R, KORAKAKIS V, KING E, et al. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction[J]. Br J Sports Med, 2023, 57(9): 500-514.
[9]	VAJAPEY S P, MILLER T L. Effect of native ligament versus graft reconstruction on sensitivity of clinical tests used to diagnose anterior cruciate ligament tears[J]. J Orthop, 2021, 26: 42-44.
[10]	赵正吕, 李彦林, 王旭, 等. 后交叉韧带重建移植物的特点与选择[J]. 中国组织工程研究, 2022, 26(10): 1615-1619.
	ZHAO Z L, LI Y L, WANG X, et al. Characteristics and selection of grafts for posterior cruciate ligament reconstruction[J]. Chin J Tissue Engin Res, 2022, 26(10): 1615-1619.
[11]	GRAPAR ŽARGI T, DROBNIČ M, VAUHNIK R, et al. Factors predicting quadriceps femoris muscle atrophy during the first 12 weeks following anterior cruciate ligament reconstruction[J]. Knee, 2017, 24(2): 319-328.
[12]	GERBER J P, MARCUS R L, LELAND E D, et al. The use of eccentrically biased resistance exercise to mitigate muscle impairments following anterior cruciate ligament reconstruction: a short review[J]. Sports Health, 2009, 1(1): 31-38. doi: 10.1177/1941738108327531 pmid: 23015852
[13]	DEPHILLIPO N N, KENNEDY M I, AMAN Z S, et al. Blood flow restriction therapy after knee surgery: indications, safety considerations, and postoperative protocol[J]. Arthrosc Tech, 2018, 7(10): e1037-e1043.
[14]	DEPHILLIPO N N, KENNEDY M I, AMAN Z S, et al. The role of blood flow restriction therapy following knee surgery: expert opinion[J]. Arthroscopy, 2018, 34(8): 2506-2510.
[15]	BOWMAN E N, ELSHAAR R, MILLIGAN H, et al. Proximal, distal, and contralateral effects of blood flow restriction training on the lower extremities: a randomized controlled trial[J]. Sports Health, 2019, 11(2): 149-156. doi: 10.1177/1941738118821929 pmid: 30638439
[16]	JUNG W S, KIM S H, NAM S S, et al. Effects of rehabilitation exercise with blood flow restriction after anterior cruciate ligament reconstruction[J]. Appl Sci, 2022, 12(23): 12058.
[17]	ILETT M J, RANTALAINEN T, KESKE M A, et al. The effects of restriction pressures on the acute responses to blood flow restriction exercise[J]. Front Physiol, 2019, 10: 1018. doi: 10.3389/fphys.2019.01018 pmid: 31456694
[18]	LU Y, PATEL B H, KYM C, et al. Perioperative blood flow restriction rehabilitation in patients undergoing ACL reconstruction: a systematic review[J]. Orthop J Sports Med, 2020, 8(3): 2325967120906822.
[19]	WENGLE L, MIGLIORINI F, LEROUX T, et al. The effects of blood flow restriction in patients undergoing knee surgery: a systematic review and meta-analysis[J]. Am J Sport Med, 2022, 50(10): 2824-2833.
[20]	CASHIN A G, MCAULEY J H. Clinimetrics: Physiotherapy Evidence Database (PEDro) Scale[J]. J Physiother, 2020, 66(1): 59. doi: S1836-9553(19)30092-X pmid: 31521549
[21]	LI X, LI J, QING L, et al. Effect of quadriceps training at different levels of blood flow restriction on quadriceps strength and thickness in the mid-term postoperative period after anterior cruciate ligament reconstruction: a randomized controlled external pilot study[J]. BMC Musculoskel Dis, 2023, 24(1): 360. doi: 10.1186/s12891-023-06483-x pmid: 37158913
[22]	OKOROHA K R, TRAMER J S, KHALIL L S, et al. Effects of a perioperative blood flow restriction therapy program on early quadriceps strength and patient-reported outcomes after anterior cruciate ligament reconstruction[J]. Orthop J Sports Med, 2023, 11(11): 23259671231209694.
[23]	VIEIRA DE MELO R F, KOMATSU W R, FREITAS M S, et al. Comparison of quadriceps and hamstring muscle strength after exercises with and without blood flow restriction following anterior cruciate ligament surgery: a randomized controlled trial[J]. J Rehabil Med, 2022, 54: jrm00337.
[24]	CURRAN M T, BEDI A, MENDIAS C L, et al. Blood flow restriction training applied with high-intensity exercise does not improve quadriceps muscle function after anterior cruciate ligament reconstruction: a randomized controlled trial[J]. Am J Sport Med, 2020, 48(4): 825-837.
[25]	HUGHES L, ROSENBLATT B, HADDAD F, et al. Comparing the effectiveness of blood flow restriction and traditional heavy load resistance training in the post-surgery rehabilitation of anterior cruciate ligament reconstruction patients: a UK national health service randomised controlled trial[J]. Sports Med, 2019, 49: 1787-1805.
[26]	KACIN A, DROBNIČ M, MARŠ T, et al. Functional and molecular adaptations of quadriceps and hamstring muscles to blood flow restricted training in patients with ACL rupture[J]. Scand J Med Sci Sports, 2021, 31(8): 1636-1646.
[27]	IVERSEN E, RØSTAD V, LARMO A. Intermittent blood flow restriction does not reduce atrophy following anterior cruciate ligament reconstruction[J]. J Sport Health Sci, 2016, 5(1): 115-118. doi: 10.1016/j.jshs.2014.12.005 pmid: 30356481
[28]	ANGELOPOULOS P, TSEKOURA M, MYLONAS K, et al. The effectiveness of blood flow restriction training in cardiovascular disease patients: a scoping review[J]. J Frailty Sarcopenia Falls, 2023, 8(2): 107-117.
[29]	HASEGAWA M E, DELOS REYES C D, RIMM J B, et al. Update on current concepts of blood flow restriction in the perioperative period of anterior cruciate ligament reconstruction[J]. Orthopedics, 2023, 46(6): e333-e340.
[30]	WERNBOM M, APRO W, PAULSEN G, et al. Acute low-load resistance exercise with and without blood flow restriction increased protein signalling and number of satellite cells in human skeletal muscle[J]. Eur J Appl Physiol, 2013, 113(12): 2953-2965. pmid: 24078212
[31]	MAHMOUD W S, RADWAN N L, IBRAHIM M M, et al. Effect of blood flow restriction as a stand-alone treatment on muscle strength, dynamic balance, and physical function in female patients with chronic ankle instability[J]. Medicine (Baltimore), 2023, 102(44): e35765.
[32]	NIELSEN J L, AAGAARD P, BECH R D, et al. Proliferation of myogenic stem cells in human skeletal muscle in response to low-load resistance training with blood flow restriction[J]. J Physiol, 2012, 590(17): 4351-4361.
[33]	YAMANAKA T, FARLEY R S, CAPUTO J L. Occlusion training increases muscular strength in division IA football players[J]. J Strength Cond Res, 2012, 26(9): 2523-2529. doi: 10.1519/JSC.0b013e31823f2b0e pmid: 22105051
[34]	PEARSON S J, HUSSAIN SR. A review on the mechanisms of blood-flow restriction resistance training-induced muscle hypertrophy[J]. Sports Med, 2015, 45(2): 187-200. doi: 10.1007/s40279-014-0264-9 pmid: 25249278
[35]	HARRIS J D, ABRAMS G D, BACH B R, et al. Return to sport after ACL reconstruction[J]. Orthopedics, 2014, 37(2): e103-e108.
[36]	施明, 潘文平, 曾明, 等. 虚拟现实平衡训练对前交叉韧带重建术后膝关节本体感觉的效果[J]. 中国康复理论与实践, 2020, 26(12): 1458-1463. doi: 10.3969/j.issn.1006-9771.2020.12.015
	SHI M, PAN W P, ZENG M, et al. Effects of virtual reality balance training on proprioception of knee after anterior cruciate ligament reconstruction[J]. Chin J Rehabil Theory Pract, 2020, 26(12): 1458-1463.
[37]	JESSEE M B, MOUSER J G, BUCKNER S L, et al. Effects of load on the acute response of muscles proximal and distal to blood flow restriction[J]. J Physiol Sci, 2018, 68(6): 769-779. doi: 10.1007/s12576-018-0593-9 pmid: 29349721
[38]	BURKHARDT M, BURKHOLDER E, GOETSCHIUS J. Effects of blood flow restriction on muscle activation during dynamic balance exercises in individuals with chronic ankle instability[J]. J Sport Rehabil, 2021, 30(6): 870-875. doi: 10.1123/jsr.2020-0334 pmid: 33547257
[39]	MAY A K, RUSSELL A P, WARMINGTON S A. Lower body blood flow restriction training may induce remote muscle strength adaptations in an active unrestricted arm[J]. Eur J Appl Physiol, 2018, 118: 617-627. doi: 10.1007/s00421-018-3806-2 pmid: 29350278
[40]	DANKEL S J, JESSEE M B, ABE T, et al. The effects of blood flow restriction on upper-body musculature located distal and proximal to applied pressure[J]. Sports Med, 2016, 46: 23-33. doi: 10.1007/s40279-015-0407-7 pmid: 26446893
[41]	刘凯, 宋伟, 阮槟, 等. 前交叉韧带损伤后膝关节功能评估量表的研究进展[J]. 中国康复理论与实践, 2019, 25(12): 1395-1399. doi: 10.3969/j.issn.1006-9771.2019.12.006
	LIU K, SONG W, RUAN B, et al. Advance in knee functional scales for anterior cruciate ligament injury (review)[J]. Chin J Rehabil Theory Pract, 2019, 25(12): 1395-1399.
[42]	LOENNEKE J P, THIEBAUD R S, ABE T, et al. Blood flow restriction pressure recommendations: the hormesis hypothesis[J]. Med Hypotheses, 2014, 82(5): 623-626. doi: 10.1016/j.mehy.2014.02.023 pmid: 24636784
[43]	LOGERSTEDT D S, SCALZITTI D A, BENNELL K L, et al. Knee pain and mobility impairments: meniscal and articular cartilage lesions revision 2018[J]. J Orthop Sports Phys Ther, 2018, 48(2): A1-A50.
[44]	MYER G D, PATERNO M V, FORD K R, et al. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase[J]. J Orthop Sports Phys Ther. 2006, 36(6): 385-402.
[45]	梁馨文, 韩亚兵, 王世林, 等. 血流限制下低强度增强式跳跃训练干预功能性踝关节不稳的效果[J]. 中国康复理论与实践, 2024, 30(3): 352-361. doi: 10.3969/j.issn.1006-9771.2024.03.014
	LIANG X W, HAN Y B, WANG S L, et al. Effect of blood flow restriction combined with low-intensity plyometric jump training on functional ankle instability[J]. Chin J Rehabil Theory Pract, 2024, 30(3): 352-361.
[46]	ŽARGI T, DROBNIČ M, STRAŽAR K, et al. Short-term preconditioning with blood flow restricted exercise preserves quadriceps muscle endurance in patients after anterior cruciate ligament reconstruction[J]. Front Physiol, 2018, 9: 1150. doi: 10.3389/fphys.2018.01150 pmid: 30197599

纳入文献	资格标准	随机分配	分配隐藏	基线相似	被试施盲	评估者施盲	被试流失率≤15%	意向性分析	组间统计比较	报告点测量和变异量值	总分
Li等^[21](2023)	√	√	√	√			√	√	√	√	7
Okoroha等^[22](2023)	√	√	√	√			√	√	√	√	7
Vieira de Melo等^[23](2022)	√	√	√	√			√	√	√	√	7
Curran等^[24](2020)	√	√	√	√			√	√	√	√	7
Hughes等^[25](2019)	√	√	√	√		√	√	√	√	√	8
Kacin等^[26](2021)	√	√	√	√	√	√	√	√	√	√	9
Iversen等^[27] (2016)	√	√		√		√	√	√	√	√	7