The world of rehabilitation following surgery, especially knee surgery, is ever evolving. Years ago following an ACL repair a person was placed in a cast and was non weight bearing for an extended period of time. Jump to today and you will be in a brace for a short period of time, but for the most part it is recommended to start weight bearing, range of motion and protected strengthening immediately following surgery. Although rehab following knee surgery has for the most part become more of an accelerated approach, there are times when it is necessary to limit range of motion and weight bearing following surgery. For example, following a meniscus repair or cartilage repair, you will be non weight bearing for a period of time. No matter what the surgery, the research is consistent in showing that a person loses a significant amount of strength and muscle mass, in particular the quadriceps muscle.

In a situation where a person is non weight bearing for two to three weeks, they can loose up to 300 grams of muscle mass (approximately the size of a human heart)! Along with the decrease in muscle mass there are other issues that put a person behind the eight ball when trying to gain back their strength and function. Research shows that there is a decrease in protein synthesis following surgery. Protein synthesis is an important part of how our body maintains muscle size and strength as well as assisting with recovery of our injured tissues.

In order to minimize muscle loss, strength loss and decreased protein synthesis one usually needs to perform high intensity training, meaning 65-75% of one repetition max (1-RM) three to four days per week. The issue is that following surgery a person is not able to participate in this type of high intensity training due to surgical restrictions and the need for healing to occur. Although low intensity rehab exercises are necessary to help restore range of motion and appropriate coordination of muscle contraction and movement patterns, we have not been able to provided a true strengthening component for our surgical patients. That is until now. With the introduction of the use of blood flow restriction (BFR), rehab specialists now have a tool that allows these patients to perform low level rehab exercises and still get similar effects of high intensity training that help stimulate muscle growth, minimize strength loss and helping increase protein synthesis as well as promoting natural tissue healing factors to assist in recovery.

Five Reasons you should be adding BFR to your post operative recovery!

1. 

   Promote release of natural growth factors needed for tissue healing and muscle growth ☞ Using BFR during even low intensity exercise creates lactic acid in muscle. Lactic acid is what causes that “muscle burn” that you feel after completing a hard workout. Lactic acid is important because it signals our body to release other factors in our body, most importantly growth hormone and insulin like growth factor. These are two major players in our body’s process of healing and recovery. Without BFR, one would need to rely on performing high intensity training to get similar effects of lactate production.

2. Not able to exercise, No problem ☞ By simply inflating the tourniquet system used in BFR, muscle cells are stimulated to increase protein synthesis and ultimately decrease the risk of post operative disuse muscle atrophy (muscle shrinking). Studies have shown that following two weeks on non weight bearing, those who used BFR drastically decreased muscle strength losses and thigh circumference. This means that if you are going to be unable to put weight through your leg due to a surgery, the application of BFR can potentially help prepare you for a quicker recovery due to less loss of leg strength along with promoting release of specific growth factors as mentioned above.
3. Maintain endurance ☞ Once healing time and range of motion allow, performing BFR while on the stationary bike can assist in maintenance/improvement in cardiovascular endurance. Studies have shown that low intensity biking can not only improve your VO2 max (maximum amount of oxygen consumption during exercise) but also shows improvement in lower body muscle strength and size.
4. Promotes use of fast twitch muscle fiber units ☞ Usual rehab exercises live in the slow twitch muscle fiber world. Slow twitch fibers are the first muscle fibers to be used during lower level exercise and are commonly known to be more of an endurance muscle type. In order to improve strength, power and muscle size a person must be able to perform exercise that will use fast twitch fibers. Fast twitch fibers are known to be power muscle fibers used during running, jumping and lifting heavy weight. Early on in recovery from injury you are going to be forced to use lower intensity exercise which primarily uses those slow twitch fibers. Now, with the addition of BFR, rehab experts now have a tool to allow you to tap into the fast twitch muscle fibers even when you are limited due to injury!
5. Possibly reduce amount of muscle scarring/fibrosis following injury ☞ There is a protein in our body that is known as myostatin. One of myostatins main roles is to turn off muscle growth, its other role is to allow for scarring of tissues following injuries. Scarring of muscle tissue is our bodies way of providing a quick fix to muscle to allow us to continue to perform activities while continued healing occurs over time. Performing high intensity training provides a short term decrease in myostatins effectiveness, which is great, as that is how we get bigger with lifting heavy weights. However, if you just injured yourself, your rehab expert would not suggest that you go perform high intensity training to assist in decreasing the scar tissue formation. Now, if you have access to BFR, you can perform low intensity exercise and still get the effect of decreasing the short term affect of myostatin and therefore, reducing the amount of tissue scarring that occurs and assisting in the regeneration/healing process.

How much do you really understand about your plan?

Do you really understand your health insurance? Do you know what your deductible is? Do you know what your copay is? Do you know the difference in going in network versus out of network? Have you been to the doctors office, experienced a hospital stay or have had physical therapy in the past and were shocked by the cost of those services when the bill arrived two or three months after your care? Ill bet you were not expecting the cost of the band-aid, throat lozenge or 30 minute therapy session to cost as much as it did, were you? That is because there is absolutely no transparency in our health care. If you are like me and most of the US, then no, you probably do not truly have a good understanding of your benefits. It is unfortunate but that is the way that insurance companies would like it. They have made it so confusing that most of us do not care to look into the specifics of our benefits. If we are sick or injured we just go to the doctor because we “have” insurance and it will be fine because insurance will cover it. The fact of the matter is that they will cover it, its just a matter of how much is it going to cost you before they cover it and what services will they actually cover? We will be taking some time to discuss some common insurance issues with respect to Physical Therapy services. But first, lets go over some definitions to make sure we all have a basic understanding of some insurance terms.

1. Premium: the amount of money an individual/business pays in order to obtain an insurance policy.
2. Deductible: the amount of money an individual pays out of pocket prior to your insurance plan picking up the bill.
3. Co Pay: A fixed amount of money an individual pays on the spot each time they need to use their insurance.
4. In Network: healthcare providers or healthcare systems that have contracted with your insurance company in order to receive negotiated (discounted) rates. 5.
5. Out of Network: healthcare providers or healthcare systems that have chose not to negotiate discounted rates with an insurance provider

Now that we have covered the most common health insurance definitions, we can start to get a more transparent look at how you should go about making your decisions. Again, we are going to focus on where to start when deciding on which PT clinic you are going to go to.

The first thing I would suggest looking into is what your deductible is. In some cases, you may have one deductible that goes toward both in network and out of network and other plans you may have separate deductibles for each. Once you know what your deductible is you can find out if you have paid anything toward that deductible for the year. If you have not met your deductible, any of your visits to the PT will actually be “out of pocket” until that deductible is met. For example, lets say you have a $5000 deductible. Your initial visit may cost $400 and each follow up visit may cost $300 (rough estimate) . So, now it is 2 months and 10 PT visits (1 evaluation and 9 sessions) later and you receive your bill in the mail and you see that you owe $3100. You have not yet met your deductible so that money is coming out of your pocket.

On top of this, you may have an associated copay for each visit to the PT. It is not uncommon now to have a copay for a PT visit of $40 and in some cases way more! Now you have added an extra $400 to your PT bill (10 visits and $40 per visit). The unfortunate thing is that in a lot of cases when people pay their copay they think that is all they are required to pay for their PT session and its not until two months later when they receive their bill in the mail that they see it actually cost them another $3100. Can you now see how not having transparency in health care can be a huge issue? I know I do not like to be surprised by a bigger bill than I was expecting!

Once you have determined deductibles and copays it is now time to make a decision. Do I go with an in network or out of network clinic? Based on your plans deductibles it may not be a huge difference as either way you will be paying “out of pocket” until that deductible is met. Once it is met, your in network plan most likely will cover sessions at a higher percentage than out of network. For example in network may pay 80% of of your session while out of network may pay 60%. Obviously there are going to be differences based on your specific plan but this gives you a general idea.

Often times, out of network clinics can actually keep have lower cost since they are not accepting a discounted price from the insurance company. In network clinics usually have to raise their cost due to the the discounted rate they negotiated in order to remain profitable.

Another thing to remember is that you have a choice! If you are going to PT because your doctor said you should have it, it does not mean that you have to go to the PT clinic affiliated with your doctors office. Do your research, find a location and a PT that you match well with and has experience working with the issues that you are dealing with.

At Paramount we believe in transparency. We understand that people value their money and time. After all, we all work hard to have enough of both. When there is an open understanding on both sides, the provider and the client, we can make sure that we are working towards a common goal with your best interest in mind!

Blood Flow Restriction training 

If you have not heard about this unique training and rehabilitation tool then get ready to read up on how this technique could benefit your recovery from injury or surgery, improve your strength and build muscle mass as well as the capability to improve your endurance. Blood flow restriction (BFR) training is a tool that has actually been around for a long time but is just now, within the last few years making its way into the physical therapy and performance training scene. BFR training was introduced primarily in the realm of the Army as there was a desperate need to find ways to help our wounded soldiers build up strength and muscle mass following traumatic injuries that lead to large losses of muscle and amputations. It has since then found its way into the training rooms of many professional sports teams including NFL, NBA, MLB, NCAA and Olympic training facilities. This is not a training tool just for professional athletes though. BFR research shows positive effects on people of all ages when it comes to improving strength, building muscle mass and increasing endurance.

What exactly is BFR?

Blood flow restriction utilizes a personalized tourniquet system to partially occlude blood flow to either the upper arm or upper thigh. The pressure provided by the tourniquet system is enough to stop blood from passing back towards the heart but partially allows new blood coming from the heart to the working muscle. Since BFR has become more popular in the training realm there has been an increase in products that claim to be safe for BFR training. However, if you are considering partially occluding blood flow to any part of your body you want to make sure that it is being done safely. The only system on the market that meets FDA standards for application of a tourniquet is the Delphi personalized tourniquet system. By using any other system you are putting yourself at risk!

How does BFR work?

Let’s take the leg for an example, by placing the tourniquet at the uppermost part of the thigh it will partially restrict the new oxygen rich blood from entering the working muscle and will prevent the oxygen depleted blood to pool around the working muscle. This is advantageous for many reasons, all of which revolve around the chemical byproducts that occur during exercise of muscles. One of the biggest effects is the creation of something called lactate. This is the byproduct of working muscle that is commonly known as “the burn” that you feeling during and after your work out. Usually it requires a high intensity exercise to increase the release of lactate and along with high intensity exercise comes small amounts of actual muscle damage. The other cool and important thing about lactate is that it is needed to set off certain pathways in our body that promote the release of growth factors that are needed to help facilitate recovery following exercise. Furthermore, the release of growth hormone signals the release of another important protein in our body, insulin like growth factor, which promotes muscle growth.

The cool thing about BFR is that you are able to create a similar environment around the muscle with low intensity exercise and see similar improvements in strength and muscle gains without the muscle damage associated with high intensity workouts. For example, the American College of Sports Medicine (ACSM) states that its guidelines for strength training is 2-3 times per week at or above 70% of your one repetition maximum. The literature supports that there is an absolute need for this level of work load to see maximal gains in muscle strength and size and in no way is BFR training a replacement for high intensity exercise. However, for individuals who do not tolerate that level of intense training, for example, people rehabbing from an injury, athletes who are in season and trying to keep decrease the extra load on their joints and body or the general aging population. The literature for BFR training shows that you can get very similar training responses with a load of 20-30% of your one repetition maximum, pretty cool, huh?

Five reasons why BFR training could be right for you!

1. Recovery from an injury Immediately following any injury, for example an ankle sprain, there is damage to the ligaments and possibly muscle tissue as well. By using BFR following this injury it can assist in activating the necessary pathways that help collagen formation, an integral part in the repair and recovery process. Not to mention preventing possible loss of strength during the time period where your tissues will not tolerate high intensity exercise.
2. Prevent muscle loss following a surgery Literature has shown that following a surgery, for example following an ACL reconstruction, that the thigh muscle loses muscle mass and size, up to 20% loss within the first two weeks following surgery. This occurs for several reasons including disuse of the leg muscle and the inability to work the muscle at a high enough intensity to maintain muscle strength and size (due to post operative restrictions). BFR has been shown to help minimize this loss and help facilitate recovery and strength gains due to the chemical pathways that are triggered by working the muscle in low oxygen state.
3. Promote strength and muscle mass gains By restricting the outflow of blood from working muscle, as done during BFR, it allows a build up of physiological components necessary to facilitate strength gains and increase in muscle size. Not only can you see similar gains when compared to high load (heavy) weight training, you can do it without the muscle damage that occurs during heavy resistance training. Although BFR can help facilitate the protein synthesis process necessary for muscle growth, it does need proper nutrition to help reap the benefits!
4. Decrease joint and body stresses during exercise Are you looking for a way to help decrease the stress and strain your body endures through your in-season or off season program? Have muscle and joint aches and pains that prevent you from training and seeing strength gains? BFR training’s unique approach allows individuals to work at much lower loads (lighter weights) which ultimately leads to less stress on your spine, hips, knees and ankles with similar strength and mass gains seen with heavy load strength training.
5. Improve your endurance tolerance Whether you are a high level competitive athlete or just looking for a way to stay healthy and active BFR training could be right for you. As we age it has been shown that we start loosing muscle mass and strength. As we get older it is harder for our bodies to process protein (the main source of nutrition to help build muscle). On top of all that, it gets harder for some us to to tolerate the increased intensity of training necessary to see strength and endurance gains. Luckily, BFR has been showing to improve both strength and endurance with as little as 15 minutes of walking on the treadmill over a six week span!

Dr. Kyle Schwebke DPT, OCS

Board Certified Specialist in Orthopedic Physical Therapy

Ever felt overwhelmed by the number of options you have when it comes to picking the right strength and conditioning coach? Hundreds of different facilities. Thousands of different trainers. All telling you that they are the best option for you. Well believe me, strength coaches are not all created equal. Here are some tips that will help you sift through the thousands of pieces of coal and help you find your diamond in the rough.

• What do they call themselves? Do they refer to themselves as a “personal trainer”, “strength coach” or a “performance coach/specialist”? If they don’t take themselves seriously then you shouldn’t either.
• What is their cliental? Look for a performance coach that works with athletes that are similar to you and with athletes that are better than you. If you are the best athlete working out with your trainer then you may have reached their ceiling.
• Check their education. Where did they go to college? What certifications do they have. If you are an athlete I would highly recommend looking for someone that is a Certified Strength and Conditioning Specialist (CSCS). This is not the end all be all but is a good start.
• Are they continuing their training? Do they go to conferences, read books and articles, etc. Ask them to explain some of the new stuff they have been learning about.
• Are they educating YOU!? A good performance coach should be empowering you mentally as well as physically. Make sure they educate you on lifts, theory, strategy, etc. Knowledge is power!
• Are they hands on? A good performance coach should be putting their hands on you and constantly correcting your technique and form. If you have worked out with a performance coach for 30 minutes and they have not physically touched you to cue you or fix something then you are likely with the wrong person.
• Do they give you corrective exercises? No one is perfect and everyone has stuff that needs to be worked on outside of your time with your performance coach. Make sure they are giving you things to work on at home to help you correct these limitations.
• Is your program cookie cutter or personalized? You should be looking for a performance coach that will design or modify the strength and conditioning program to fit your needs. You should not be doing all the same things as the other people in your group.
• Do they make you do a screen prior to training? A good Performance Coach will want to have you screened by a Physical Therapist or other professional prior to working with you so they know what your needs are and how to build a program to fit it.
• What types of lifts are you doing? Your workout should be mostly total body movements that work in a variety of planes and should be always changing. You should not be doing more than 1-2 single joint exercises (bicep curls, seated knee extension, calf raises) during a workout unless you are a body builder.
• Is there progression? Lifting and conditioning programs should be changing as you grow and as the seasons change. Reps, sets, frequency and weights should all be changing throughout the year.
• Do they communicate with other professionals? Your performance coach should be asking who your athletic trainer, physical therapist, or skills coach are so that they can communicate with them and modify your program as needed based on their feedback and input.
• Do you like their personality? When it is all said and done, you will be spending a lot of time with your performance coach. Make sure it’s someone you can stand to be around.

Do not be afraid to ask any or all of these questions when you meet with a Performance Coach. You are paying good money with the anticipation that they will positively effect your life. Make sure they are the right fit for you.

For more information on how to select your ultimate performance team or for more information on how to safely and efficiently increase your performance please check out paramountperformancept.com and follow us on facebook.