Using BFR with Chronic Ankle Instability

This conversation explores the advancements in Blood Flow Restriction (BFR) technology, personal anecdotes related to injury recovery, and insights from recent conferences. The speakers discuss the significance of chronic ankle instability in sports, the effectiveness of BFR in enhancing muscle activation during rehabilitation, and the importance of interdisciplinary collaboration in sports medicine. They also reflect on their experiences and the evolving nature of BFR technology, emphasizing the need for continuous research in this field. This conversation delves into the application of blood flow restriction (BFR) training in rehabilitation, particularly focusing on its effects on muscle activation, balance training, and the challenges faced in research. The speakers discuss various studies, their methodologies, and the implications of using BFR in clinical settings, especially for ankle rehabilitation. They explore the differences between internal and external loads, the importance of programming, and the potential benefits of mobilization techniques combined with BFR. The discussion highlights the need for further research and standardization in BFR protocols to optimize rehabilitation outcomes. Faltus J, Owens J, Hedt C. THEORETICAL APPLICATIONS OF BLOOD FLOW RESTRICTION TRAINING IN MANAGING CHRONIC ANKLE INSTABILITY IN THE BASKETBALL ATHLETE. doi:10.26603/ijspt20180552 Killinger B, Lauver JD, Donovan L, Goetschius J. The Effects of Blood Flow Restriction on Muscle Activation and Hypoxia in Individuals with Chronic Ankle Instability. J Sport Rehabil. Published online May 16, 2019:1-25. doi:10.1123/jsr.2018-0416 Nagdi MG, Elsayed WH, Abouzied M, Ali RR. Effect of Blood Flow Restriction and Proprioception Training in Recurrent Ankle Sprain Patients. doi:10.33472/AFJBS.6.Si3.2024.10-22 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 Sport Rehabil. 2021;30(6):870-875. doi:10.1123/jsr.2020-0334 Clark K, Trickett J, Donovan L, Dawson J, Goetschius J. Effects of Blood Flow Restriction on Balance Performance During Dynamic Balance Exercises in Individuals With Chronic Ankle Instability. J Sport Rehabil. Published online February 13, 2024:1-8. doi:10.1123/jsr.2023-0182 Werasirirat P, Yimlamai T. Effect of supervised rehabilitation combined with blood flow restriction training in athletes with chronic ankle instability: a randomized placebo-controlled trial. Eur J Cardiovasc Prev Rehabil. 2022;18(2):123-132. doi:10.12965/jer.2244018.009 Kim H, Jung J, Lee S. Contributory effect of additional blood flow restriction in active joint mobilization for young adults with chronic ankle instability: A pilot randomized controlled trial. Phys Ther Rehabil Sci. 2023;12(4):486-492. doi:10.14474/ptrs.2023.12.4.486

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SPEAKER_01 0:01

This is the Owens Recovery Science Podcast. Welcome back to uh Owen Recovery Science Podcast.

SPEAKER_02 0:09

A long time since we've been doing this. And so great to be back with all you fellas here. Actually, uh Kyle and Zach, y'all did do the Memorial Day podcast. Thanks for thanks for doing that, man. I've already got some comments. My uh sister from another Mr. Alicia White, who's at the VA, she texted me and said, Thanks for uh VA shout out. Um, so that was cool of you guys to do that. But we're back. We're here to talk blood flow restriction again. We have new gear. We're like a pro studio here.

SPEAKER_05 0:42

You and better all you guys twinkied it up today, huh? Yeah, well, we're representing. I didn't get the memo.

SPEAKER_01 0:48

No, I didn't get it. Brandy, bitch. We're brandy. We're we're on video now.

SPEAKER_05 0:52

Yeah.

SPEAKER_01 0:53

God dog.

SPEAKER_02 0:55

The first question is do these headphones make me look weird or or not cool?

SPEAKER_01 1:01

I'll drop this podcast quality in a minute. Do they make me look more bald?

SPEAKER_05 1:09

Do these headphones make my butt look big?

SPEAKER_01 1:11

Five head any worse.

SPEAKER_02 1:12

All right. So uh we get into things here, man. Let's just kind of do a little catching up. I'm in a time for change, fellas. My oldest daughter graduated high school uh two weeks ago. Jesus, I'm about to lose one. Um she's going to ASU, Arizona State. Ass is sunny side up, as I say at that school. It's it's uh I walked around that campus visit with her and I was like, man, why didn't I go to ASU? It's um it's a beautiful campus. There's some there's some other beauty there. So uh yeah, I heard that they go to classes and the parties there in their swimsuits. I'm a little bit worried, but anyways, so losing losing one. I have a turtle that I lost as well last week around the same time as graduation. So did I tell you about my turtle? No, this is news to me. Yeah, man. So um, you know, I have this koi pond in my backyard. And one day, there's this freaking turtle, like a big turtle, like not as big as like a flower tortilla, but as big as a corn tortilla in the koi pond. But he's real flat, like a different-looking turtle. And um, he's just sitting there messing around. So I became enamored with this dude. I'm like feeding him, and the koi pond looked like a super salad. It had all this like lettuce and shit and like carrots I was throwing in there. He's pissing the fish off. And then this dummy would just run and get into the swimming pool. And so um I would get it, and then Melissa and my wife would text me, like, hey, the the turtle's back in the pool. And so uh I'd have to go pull it out of the pool again, and then I started worried about it. Like, well, like, could I leave it in the pool? And um, I called the the animal control people, and they said, Well, no, it's not good for them, obviously. And he said, Farley, the first thing that's gonna happen is he'll go blind from the chlorine. This isn't a joke, this is from a fruit story.

SPEAKER_06 3:08

It's like you called animal control.

SPEAKER_02 3:10

Yeah, I'm worried about it. Freddie, I love this guy, man. And so um then I started worrying because I would have to go fish him out of the pool like four times a day. And he was like, he started getting the point where I'd go after him and he would run like right into the wall. So I'm like, shit, I'm blinding this dude, right? Taking him out. And so I took him to my front yard. We have this um big kind of um fountain, and I put him in the fountain there, and he was doing great. And I overfilled the fountain one day on Memorial Day. We had family over, there might have been drinking involved, and um, he's doing weird things, like he kept popping his head up and spinning around. And so everyone was telling me he's drowning. He's a freaking water turtle. And so they made me build this little stack of rocks for him, and the next day, gone. Left me too. So I lost my. I still won't talk to these motherfuckers. I'm sorry, these losers in my house who made me lose my turtle, my daughter.

SPEAKER_01 4:06

I asked my wife who's next you. So, anyways, enough about me.

SPEAKER_05 4:12

Um does your uh does your pool smell like chlorine, Johnny?

SPEAKER_02 4:16

Yeah, it's got chlorine in it.

SPEAKER_05 4:18

You know the you know why this it smells like chlorine? I just learned this. The joke? No, okay, this is the real thing. Like that pool smell, you know? I I get it. It's because pea in the pool. You're that's no, it's not there is pea experiment. No. I saw the experiment. That Mark Roberg guy on YouTube, look it up. So chlorine doesn't smell like water unless there's pea chlorine. Unless there's pea in it. Yeah.

SPEAKER_03 4:46

So every pool ever been in had peas. Exactly. Yep. Isn't that chlorine smell? Chlorine doesn't have the smell unless there's pee. So do they pee in it before you have a mixture?

SPEAKER_01 5:00

Open it box of chlorine and it'll make your chlorine face like fall off.

SPEAKER_04 5:04

What do they smell like?

SPEAKER_01 5:05

Yeah. What do they do? I saw it on YouTube. I'm a passed up at YouTube when I and held the chlorine pot.

SPEAKER_02 5:12

Yeah, what are they I had them pee in the container?

SPEAKER_04 5:16

They smell like chlorine. Just saying.

SPEAKER_01 5:19

It's the peak. We're off into a good start. We're we're we're digressing. This is why we don't do podcasts anymore. We can't stay focused. This is entertaining.

SPEAKER_05 5:28

So I feel like I've learned more in this first five minutes then.

SPEAKER_02 5:33

That's good. Um, today we're gonna talk about a blog that I wrote. I've written two blogs in the last month. Have you mofos read any of them? Yeah.

SPEAKER_06 5:44

I thought it was good.

SPEAKER_02 5:46

What'd y'all think? Yeah. Pretty good. I liked it. Yeah. Not chat GBT either. My own self.

SPEAKER_04 5:53

Put that out there. The the screenshots of the pictures from the studies were very unique. I I'm sure that uh copyright.

SPEAKER_01 6:03

Copyright. Damn it, Z.

SPEAKER_02 6:07

Oh, so anyways, so go to our website and check out. I did one about um our recent um unit going up in SpaceX. Um, and NASA and SpaceX working together. Um, I don't know if you guys know. I spoke at NASA uh about a month ago. Yeah. Yeah. That's the most nervous I've ever been at a talk. And I've I've had to be in front of some some some serious people that talks, but dude, you don't know who is in that crowd. They're all like five PhDs. Only a quarter of them spoke English. Um, you know, like from all over the world, like bone expert, and so you just don't know the questions that are coming. But the coolest thing there is you're in front of a freaking IMAX for your talk. So the slides are like on an IMAX. That was pretty cool. But yeah, so, anyways, we launched um on SpaceX the first BFR system. They might have sent two up there, but they only used one, which was uh what the other one was told, yeah. Um the Delphi system, and we're getting the data back, and we're gonna have Luke Hughes on to share the data, so that's that's pretty cool. So that's that's what's happened. Um I'll let you guys kind of fill everyone in too. So um Kyle and I just finished a BFR and Achilles paper with Dr. Dracos uh from HSS. Um what else is out there? Um Gen 3. We just kind of just getting out, but yeah, Delphi has a new dope system coming out. Um just saying. Um starting next.

SPEAKER_05 7:45

No, we just do a whole podcast on that. Yeah.

SPEAKER_02 7:47

Yeah, so it's gonna be pretty cool. Got a lot of new features. Um, and then I will roll into the blog talk next here. But you guys got anything y'all want to plug? Go to our website, check out our courses. We've still got a bunch of courses everywhere.

SPEAKER_05 8:00

Courses coming. Zach's writing a chapter, he just told me.

SPEAKER_04 8:04

With Mark. Uh Minago and the with Minagou? Yeah, Minago.

SPEAKER_02 8:12

Monago. Yeah, Mark and I. Um no, when you say it the real Portuguese way, that's how you say it. Monaggio.

SPEAKER_01 8:25

Is that Italian or each other? It's me. Marco Monaggio loves his lasagna, yeah. He works away with the Parkinson's patients.

SPEAKER_05 8:37

Yeah, the when you spoke at NASA. NASA what I was gonna tell us about your when I spoke at NASA, you didn't know. Yeah, go ahead. When you spoke at NASA, what why why were you there?

SPEAKER_02 8:54

Because I was presenting about BFR in space.

SPEAKER_05 8:57

Well, I know I was trying to plug the conference that we helped sponsor. Oh, the shop.

SPEAKER_02 9:02

It's for the shop conference. Um yeah. What uh what is it? Space Spaceflight, Human Optimization and Performance. Spaceflight Human Optimization Performance. Corey Twine runs it, good friend of ours. We've been working with the folks at NASA. We were one of the founding sponsors there and have been. And so um, yeah. Luke normally speaks, and this year they're like, let's bring in the real deal. So they brought me in with Luke. Um we spoke together. No, I I was like clueless of what they were talking about half the time. So thank God Luke was there. I'm just like, here's what BFR is, it's safe.

SPEAKER_01 9:42

Try it.

SPEAKER_05 9:45

You should do it. But it's a cool conference. I mean, it's multidisciplinary. Yeah, I mean, there's probably not a more broad spectrum of expertise at that conference than at any other conference that I can think of. It's really impressive. No, for sure. Yeah, smart, smart. Diet dietitians, engineers, physiologists, physicians, surgeons, astronauts, astronauts, astronauts. Um, yeah, just all all walks of expertise in space flight.

SPEAKER_03 10:20

Yeah.

SPEAKER_05 10:20

Ultimately.

SPEAKER_03 10:21

So yeah. I mean, that like Johnny was saying, though, that group of people in that room. I've I don't think I've ever been in a room and felt like I was lower on the totem pole as far as mental capability than that group of people. I bet that's almost your everyday of your life. Well, it's a hey, I'm in a room by myself right now, Johnny, so the bar is pretty low.

SPEAKER_02 10:43

So it is it is for sure. Yeah. Okay. What else? Anything else going on? Zach, you spoke of AOSSM.

SPEAKER_04 10:54

Yeah, that was back in uh back in March, I think.

SPEAKER_02 10:57

That's how long it's been since we freaking done this.

SPEAKER_04 11:00

Yeah, yeah. Yeah, that was that was good talk out there. Um basically talking about trauma. Um and uh it was the limb salvage uh kind of uh special interest group. Um so talked uh there about you know the benefit of BFR. Um and uh it was unique to have a good perspective of the different stuff out there. Um I think I sent you the picture of the one guy um who spoke from the University of Colorado where they were basically uh on amputees with the prosthetic, they were just literally going right into the femur. Um versus endigration versus a socket or like a vacuum type system. Uh and the one thing I I mean for for folks who work with amputees, I'm sure that it's common knowledge, but the one thing I never really thought of or considered is the effect that uh you have up the chain, like into the basically into the hip and how much it wears the hip, and then you accelerate OA into the hip, and then you just lead into uh total hip uh and so on, whereas you don't really get that abnormal loading or those abnormal forces into the joint, and it helps preserve um up the chain.

SPEAKER_02 12:19

So maybe we hope, yeah. Still waiting to see, but yeah, it's pretty cool. That was like the holy grail when the war started. You know, it was like, dude, one day, if they could just put this in the bone, and it was like, that's like Star Trek, bro, no way. Um, but yeah, we were one of us and Walter Reed were one of the first sites where they were really started looking at doing that. So it's pretty cool.

SPEAKER_04 12:41

It's it's it's so much like uh, I mean, if if you've ever really worked with an amputee, between them donning and doffing the the prosthetic, I mean it takes so long. Um, whereas with these guys, man, dude, it's just on and go.

SPEAKER_02 12:57

Well, the skin breakdown, you know, and then the the fatty infiltrate and the loss of the soft tissue envelope, it's just bone, basically, as you get older. So, Zach, if you could do osteointegration and they said, we're gonna make your prosthetic three feet tall, so you make it makes you six foot tall. Would you go for it?

SPEAKER_01 13:21

I mean, I you know, I I would I always freak out when I've messed with Zach because of his sniper background.

SPEAKER_03 13:29

You don't know if he's ever too far away to take a shot at you, Johnny.

SPEAKER_04 13:33

I I think that the the blades that they're coming out with, I mean, I just really wonder one day if we were if we will get to the point where mechanically, from a mechanical advantage standpoint, that we develop a material that is far more advantageous to what our tendons are able to do. Yeah, yeah, and I mean, and and that was and that was the whole uh argument with Oscar Petroius. Yeah, right. That that he he had an advantage. Um yeah, I mean, like that that would be the deal.

SPEAKER_05 14:07

Till he started shooting people. I mean well.

SPEAKER_02 14:13

Well, he was fast at least. Um, man, so that's enough band.

SPEAKER_04 14:20

Back to Chronic back to uh chronic ankle instability.

SPEAKER_02 14:24

Chronic Anklein. Okay, here is our podcast. So hopefully I haven't lost our whole two listeners. Um here is my genesis of coming up with this block. So we did the baseball winter meetings. And by the way, that's another podcast we're gonna have because we got something pretty cool potentially coming out with with baseball and throwing with BFR with some some research being done. Anyways, we're there, and it was about recovery and arm and blah, blah, blah, blah, blah. And then we did the NFL meetings, and it was all a lot more about recovery, but also post-surgical and things like that. And then I'm gonna speak at the MBA Combine meetings a couple weeks ago. And um, Jeremy Linnicke and I, and Britney Forbes and Jeremy, you know, he gets like the my NASA thing. Tell us about BFR and then tell us it's safe, you know, just chip shot. He didn't even change his slides from our talk we did like seven years ago. Um so and then they're like, Johnny, and then will you give us an update on BFR and basketball injuries like soft tissue and ankle sprains? And I'm like, there's I done got nothing, man.

SPEAKER_01 15:38

I mean, can I do Jeremy's and he does the hamstrings and you want to go, haven't you all done the research? You're the basketball people.

SPEAKER_02 15:47

Yeah, yeah. Well, as you know, there's there there, I there wasn't a lot, I didn't think. And so we wrote, me, John Faltis, Corbin Head, um, a hypothesis paper, like 2018 or so, about how you could use BFR potentially for chronic ankle instability. Um, and so we put that paper out. And here's the things we're talking about because of the low load nature, the short lever arm of the foot ankle, and then is there something to balance and proprio reception we could do with this? And we'll get into why we think this could be advantageous for people after ankle sprains. And so, since that paper, there's been seven chronic ankle instability studies that have been done, which I didn't know there was that many, um, which was pretty interesting once I started looking at it. So some of them are crap. Um, hopefully those people aren't listening. Um, but but some of them are interesting, and I think it's just gonna set the stage of why this could be an intervention for something like an ankle sprain or carnic ankle instability. Here's the background then. Ankle sprains, again, for the MBA, the story, it's 25% of injuries. It's the number one injury in the MBA. That was Dr. Dracos, actually, our buddy who put that paper out about that. But people who have an ankle sprain, about 40% go on to be a chronic ankle instability um person where it's a nagging issue and they're rolling their ankles all the time. So it so it's a problem. Happens a lot and it can become a chronic problem. Um I had a soldier who had so many ankle sprains and just dusted off his cartilage so much. They had to fuse his ankle. Um, because you know, we just didn't have an ankle replacement, and it just became so arthritic. So, I mean, that's that's kind of an extreme. So, what we want to do now is get into the concepts and into these papers. So I set the stage. Do you guys have anything y'all want to add before we talk about these papers?

SPEAKER_05 17:49

I thought the I thought the recurrent injury rate was interesting and how it's you know, basically doesn't matter gender. Um the recurrence is like five percent. Which kind of got my brain sort of wandering a little bit on injury rates and recurrence and supposedly they because you know how like you when you start talking gender differences, people immediately start to go into ACL because there's such a difference there. Um but apparently when you start talking to re-injury, the gender differences just kind of go away. Um they're not they're not a thing. And so it just makes me kind of wonder even more like well why and why do women tear their ACLs more frequently? Um and it seems to maybe only affect ACL, not so much the ankle. I don't know. Um I haven't seen gender differences on the initial injury, but I didn't see anything out there, but definitely on ACL though.

SPEAKER_02 18:45

That's a whole another podcast for sure.

SPEAKER_05 18:47

Yeah, for sure. Okay.

SPEAKER_02 18:50

Um have you guys ever done this for ankle?

SPEAKER_04 18:53

Yeah, acute sprains. Acute sprains, and then people who are kind of chronic out. Yeah.

SPEAKER_05 19:02

That's his axe whole uh story on his uh wife and his initial his first uh son. Axle fracture. Remember because the axe hole was real big?

SPEAKER_02 19:12

She fractured because your son was too big?

SPEAKER_05 19:18

No.

unknown 19:20

Yeah.

SPEAKER_02 19:21

I thought Cobb said because he was so big.

SPEAKER_05 19:23

He came out because he was so big. What 10 pounds? He came out really big. So Zach was convinced that it was because his wife did BFR.

SPEAKER_02 19:30

But the BFR thing, yeah. That's just like Alicia, her son was big. But no, I did it.

SPEAKER_04 19:35

Um I sprained my ankle man two, roughly probably 60 hours or so before the first time I went to Montana to hunt. Um, and I mean, I I have pictures in a video like the pitting edema that I ended up getting. And I kid, I mean, I tell people all the time, I kid you not. Um that was a that was on a Wednesday that night. I just did heel raises and like mini squats with the cuff on the next day, no pain whatsoever. Friday, I did hop test everything. Um on Friday. This is on I I mean, I I I got video and uh pictures of this. I then flew to Montana on Saturday and I hunted all on foot, backcountry, walking. I put in probably close to 60 to 70 miles on foot in the mountain um without issue. And I mean, yeah, I have pictures, video, I got pictures of my leg. It's the bruising is still there, like in my tent, but yeah. Honest to God's truth.

SPEAKER_02 20:51

That would have been nice for my blog, Zach.

SPEAKER_01 20:54

Um pictures instead of my screenshots of pictures.

SPEAKER_04 21:00

I got video like legit uh pitting edema. Um it was that was on Thursday or Friday, and then yeah, flew to Montana Saturday, Saturday morning.

SPEAKER_02 21:15

So definitely the paint thing we've talked about before, the edema thing, I think, will be interesting to talk about because I've we all get that question. Um, I I think enough. So interesting. Okay, so here's kind of I'm gonna follow the flow of some of the way I looked at the papers and and what we think. So the first one um is Killinger, and it's Brian, I never can say Brian's last name right. Goach, Gochis. Um Getchius. Get us. Yeah, he's a friend of ours. Um does does um has been doing some decent amount of BFR research. So, anyways, what they wanted to look at was because ankle exercises are inherently always gonna probably be low load if you're Just isolating the ankle? Is there a way because it's low load, you could just do BFR and see higher muscle activation and lower oxygen. So more hypoxia locally in the muscle. If you have more hypoxia in the muscle and it's working, then you inherently should start getting some of those larger motor threshold units. And here's the problem with the foot and ankle. If you're trying to do eversion, inversion, dorsiflexion with your stupid theraband, the lever is so short of the foot and ankle that you can't ever get enough leverage on it. So even if you add more theraband, you basically your patients just sit there and they're doing hip external rotation almost. You just can't get like a 70-80% of a rep max, probably with these theraband exercises. So it's inherently low load. So they put the cuffs on. They use the Delphi at 80% limb occlusion pressure in this study. So it's just an acute study. Come in, do these inversion dorsiflexion exercises without BFR, and then come back another time and do it with BFR, measure EMG, and measure did you get hypoxia locally, which means you should get fast twitch. And they showed that it did increase muscle activation and it reduced oxygen content. So e-version strength was significantly higher, um, 5.6%, dorsiflexion, 7.7%, not strength, I'm sorry, muscle activation. And oxygen levels were reduced by around 31 to 44 percent. Lastly, the subject said it was hard to moderately hard when they were doing BFR. So the RPE also shows if you use RPE scales for lifts, um, it was hard versus the just regular exercises, they said it was easy. So any anything you guys want to add to that or any thoughts on that? Makes total sense to me.

SPEAKER_03 23:56

I think you were getting there with your description, but I don't know if you said it specifically that it was isometric contractions in this study. So it was two-second hold, two-second rest for for reps um that they did and the you know, the images that may or may not have been copied show the setup where they're uh they're actually showing how they set up the isometric exercise, which is I think pretty cool to to look at how they set it up so you could easily set it up yourself.

SPEAKER_02 24:26

Yeah, yeah. And isometric with BFR is hard. Um I was doing it in Ben's office the other day with the new Gen 3, and it's got it might have an EMG sensor with it. Um spoiler alert. And just trying to get that muscle activation isometrically. Holy crap, dude. I could barely get through the first set. I was smoked um when I did it. Now, it would be nice to have a dynamometer so I know like how much output I'm really doing, but but yeah, it it definitely wore me down. Okay. Anything else you guys want to add to that? It's pretty straightforward.

SPEAKER_05 25:00

No, that was the the isometric was the main one. The I mean, because we get we get asked that a lot. Yeah. How would you do isometrics? And so time, reps. Yeah, I mean that that's usually what I say, but I I mean I think they did two second, you know, two second contractions. So 30, 15, 15, 15.

SPEAKER_02 25:18

But they did it solve those changes that they did it at 30 percent of a 1RM.

SPEAKER_03 25:22

Yeah, and that was the thing. They have a percent of an isometric max. And yeah, so they they were doing it with some sort of visual feedback so they can actually see when they're getting to that 30% mark. Um, so yeah, which you didn't get with your EMG.

SPEAKER_05 25:37

Yeah. Exactly.

SPEAKER_02 25:38

Or not with your EMG, sorry, with biofeedback. Biofeedback, yeah. Yeah. Dynamometer type.

SPEAKER_05 25:43

Okay. So I thought that was I thought that was cool that they that we had, you know, uh at least an example of isometrics. Whether or not that's the absolute best way to do it is remains to be seen, I think. How did you do it when you were doing it in Ben's office, Johnny?

SPEAKER_02 25:59

I was doing rotator cuff against the wall, and I just did the first 30 and I said, get this damn thing off me. I'm snowed.

SPEAKER_05 26:05

But would you what were your holds? What were your hold durations?

SPEAKER_03 26:08

Like 2-2. Okay. He was yeah, kind of going with the stuff. I was trying to make the EMG. The the other new feature on the device, the metronome. So he's trying to kind of keep it biofeedback following the metronome, which is also a kick in the ass.

SPEAKER_02 26:22

Like we need a whole podcast, like you said, on this gen three, but with the metronome and the biofeedback or the EMG, first it breaks your brain because you're trying to figure it out, but it's in a good way. But dude, it's I have a picture of me doing leg extensions in my gym, and I had to drop set like every four reps because trying to get that muscle activation. I did not get through the first set of what I normally could do with BFR because that effort was just so much harder with that EMG. And I talked to Jeremy and he's like, Yeah, well, that's why we get good results in the lab. And you guys clinic results suck because we kind of use those type of things, you know. So this will take it, I think, to the lab type setting. So this paper was set up for this next paper, Nagdi. Um, so this was actually an RCT. And so they did four weeks of exercises with or without blood flow restriction, three times a week in chronic ankle instability athletes. And their exercises were four-way ankle. Um, they didn't say band or weights. I think it's actually, I think it did say cuff weights. And then they did a sequence of balance exercises for both groups. But during the ankle exercises, they had BFR. They didn't have BFR on during the balance training, just the ankle exercises. Yeah, I had to really read into that, Ben. I'm pretty sure that's what it was. I see you side eye, but don't send it to me. Well, I was I if if it's a blog, bitch.

SPEAKER_03 27:58

I thought I thought they had BFR on only for the proprioceptive balance exercises and not the resistance exercises. But I that was just it was kind of wonky to read.

SPEAKER_04 28:09

Nagdi?

SPEAKER_03 28:10

Yeah. No, that was mine.

SPEAKER_04 28:12

I'm pretty sure, but yeah. I I think it was uh with resistance is uh Yeah, I I could be wrong. Yeah. The other note that I've said as you were just reading the papers today. Patients allocated to the BFR training groups receive low load resistance exercise 24 20 to 40 percent 1RM using a tourniquet around the thigh approximately to the knee joint to occlude blood flow 50 to 80 percent. Um and then there is there's it doesn't really mention anything about BFR and the proprioception. The the methods were definitely a little vague in this, but uh yeah, they um perform proprio deceptive exercises for 30 minutes um three times a week for four weeks, um progressing from static to dynamic.

SPEAKER_02 29:08

Yeah, and so unfortunately they only tested dorsiflexion, plantar flexion strength. Um so that was a problem, but they did show when they retested their strength, they had gotten significantly stronger on dorsiflexion and planner flexion. Let's see, dorsiflexion increased 73% versus 19% in the control group, planner flexion increased 67% versus 27% in the control group. Part of why Kyle and I are suggesting this for Achilles repairs. Um, and then they checked um the foot and ankle um assessment, the FAM and the BFR group, which checked stability and you know, giveaways and all that sort of stuff. The BFR group significantly improved, 24% versus the control group, which didn't was only 13% improvement. So self-reported and stability improved, strength improved. Um, but what we don't have is any long-term, you know. I wish on these like, could you just call them at six months and see if they've had any re recurrent injuries? I mean, it wasn't that many, like 34 people, but okay. Um I think if anyone's ever tried to do isokinetic inversion, evert eversion, inversion on a biotex, it's just stupid. It's I don't think the validity is hard enough. Yeah, that's why. Just do isometric. Um, so that might be why they only did. I think dorsiflexion, plant flexion at least has some validity um compared to inversion, eversion. But improved strength, improved, they're self-reported. You guys have anything y'all want to add to that one?

SPEAKER_04 30:52

That's there's a another paper we'll talk about, but the outcome measure that they looked at was the uh foot and ankle disability index, and there was about a similar change over the same four-week period. It's like a four, I think it was a 14-15 point change. So it tracks with that um that you're getting not just the strength change, but like this is actually translating um translate to things that are relevant to the individual. Um, so yep.

SPEAKER_02 31:23

The next one, then kind of my progressions of thought here was the Burkhart paper again from John's Coach's lab. Um, and this time they looked at balance. And then we can also look at from their group as well, Clark looked at balance. And this is similar to their first trial where we talked about they were measuring muscle activation. They had a crossover design where you did Y balance exercises with BFR on or without BFR on. So we'll talk about the Burkhart one first. And what they wanted to see was um was there an increase in muscle activation in the lower extremity that you're doing balance on with BFR compared to without BFR? And with BFR, they did show a significant increase in muscle activation. It was primarily in the vastus lateralis, um, and it did increase quite a bit, had a really large effect size, 0.86 or a large effect size. So you really forced the quad to start working more in the BFR group. And then the soleus also had a significant increase, although the effect size wasn't giant. It was 0.32, so a smaller effect size, but there was increased muscle activation whenever you did blood flow restriction compared to the same exercises without. They didn't see changes in the in the inverter. What was it? It was the just everters, right? Fibularis longus, I think. Yeah. Maybe in Tib anterior, tib anterior and fibularis longus. Um postural instability. They reported it was harder with the BFR on, so they felt like it was, they were more unstable. So that might be why the muscles really working more, as well as the hypoxia and rate and perceive exertions were all up significantly higher in the BFR group compared to just doing the Y balance exercises without. Again, 80% LOP doing that same uh 30, 15, 15, 15. So each reach on the Y balance was a rep. Um, and so instead of timing, they did that, which is also pretty cool. Just to jump into Clark next, since they're similar, then we can discuss this. Same thing, same group, crossover design. Um, these are and both these are all with chronic ankle instability people. So these aren't with healthies. Again, 80% LLP. This one was another Y balance one. But what they wanted to see this time, um, and this was done actually before the other one, I believe, is do you get more instability while you're doing balance exercises with blood flow restriction? And they showed that it they did. So significantly reduced their anterior reach. Um, and the overall star um composite score was down by like 9.3%, which was significant. And the RPE, the the subjects all said it was much harder doing these balance exercises with blood flow restriction versus without. So I've got lots of thoughts. You guys, what are y'all's thoughts? More muscle activation, but it's harder when you're doing it, even though it's kind of like low load exercise with BFR. It's harder, but the load's lower. The balance exercises were not that challenging, but significantly it was it was much harder for them to do.

SPEAKER_05 34:46

I kind of wonder if this works sort of in reverse, as how like we think downstream fatigue works proximally, where you you know you kind of fatigue out that quad and then start to challenge the ankle musculature more over time. I wonder if you're you know not seeing sort of effect. You know, more proximal control.

SPEAKER_02 35:05

For sure.

SPEAKER_05 35:06

Definitely could be.

SPEAKER_02 35:09

Well, this gets into the whole internal versus external load. So um myself, Alex Franz, um, I'm forgetting everyone that was on it. I think Luke did a paper last year in Frontiers of Physiology about BFR's internal um versus external um effort that you get. Who is that?

SPEAKER_05 35:30

Wooden Patterson on that?

SPEAKER_02 35:32

Probably, yeah. Yeah. Um and so what BFR does is it gives you this an internal load that you don't get with regular exercises. So external load would be how much weight you're putting on there, what your exercise is, how many reps you're doing. Internal load is all the muscle metabolites that are building up, the muscle activation that's happening, the central command that's having to deal with what in the heck is going on here and why do I have all these metabolites. And so that internal load can be a way maybe to safely challenge something like balance exercises. You're forcing people to feel like what they would feel like during a game or later phase in the game, even though you're not having to make them do circus tricks like stand on a Swiss ball or BOSU. Um you're you're challenging them internally first to kind of get them primed to then start working on more of an external locus.

SPEAKER_03 36:33

Yep.

SPEAKER_02 36:34

I just wanted to plug my paper, really.

SPEAKER_03 36:36

So um I I like the way that they set up the uh the target reps. I mean, it it essentially trying to follow the 30, 15, 15, 15. And just since they were doing these multi-directional movements and there was you know three touch points, they just kind of broke it down that way where each touch was a rep. So you've got, you know, the first time you're doing it 10 times through, then you've got five, five, and five. Um, because again, like the the common question that I get when people are talking about it with balance, like, can I use it with balance training? Sure. Okay, how? It's like, well, I mean, it's kind of up to you. You could do it for time, maybe you could do it for reps, but it's nice to have a model that's rep-based that we could share.

SPEAKER_02 37:18

So yeah, everyone likes standardization and protocol, but then I I think if you look at this internal load type thing, it's like this, let's get them to fatigue. Whatever way you want to get them to fatigue is is what we're doing there. And I'm sure 30, 15, 15, 15 dynamic exercises is gonna get you to fatigue for sure. Um, so yeah.

SPEAKER_05 37:40

About six minutes of exercise, right? Or more. Six minutes of balance training. You get reps. Yeah, I go the it's funny, Ben. I go, I I would have read the reps and been like, oh, god dang it, here we go again. You know, because like when people start asking protocols, I just start thinking, I I think you're missing the point on BFR entirely. You know, you're not understanding that this is just a means of kind of you know, in some ways adding load because you're adding something that fatigues. Um, and so yeah, I I would have gone more Johnny's direction, but I I I see your point, you know, could be could be a good thing. At least that works and does something, you know. Yeah, it's not doing nothing, it's doing more than without BFR.

SPEAKER_04 38:31

Anything for you, Zach? No, I mean I think the uh from from an acute standpoint is pretty consistent. Um, what you get is earlier onset of fatigue, you get an increase in RPE, uh, an increase in rated perceived instability. Um, so it lets you know you're taxing what you need to tax or what you ultimately want to address, muscle activation increases. So from the acute standpoint, we get all that. And then now, I mean, I think it's a matter of are we going to build from that acute standpoint what does this translate to um to this individual, you know, over a period of time. Um, but you know, like laying the groundwork on, you know, an acute session, we do see that difference, and let's you know, go from there.

SPEAKER_02 39:26

Yeah, that's I think just from programming, right? You get acutely, and it's like now I can get you in here and I can just have you do a standing on the ground doing maybe just static balance or a little bit of dynamic reaches day one or two post-ankle sprain. And I'm not freaking out like I I actually re-injured a young service member having her do too much, I think, balance-wise. She rolled her ankle again. Um, so this is a way I think, especially if you're limited in visits, man, let's just go. You get this internal like load and it's challenging them early on. Because you probably don't get 12 visits for a sprained ankle anymore. I don't know.

SPEAKER_04 40:05

Yeah, I I think it it it it really ties in with, you know, what I how I think about BFR is you have that acute injury or whatever the acute situation is, you're limited in what you can do. How do we maximize what we want to get out of the session? Then how do we use this to progress to where we ultimately want and need to go? Um, and if we can get that RPE effect and and the rating of perceived instability, like this person feels taxed and they feel like unstable with what they're doing, that's what we want to do. And we can do this in a very controlled, low, lower level environment, and then hopefully build from there, make them increase their confidence, increase their perception of stability, and then start to progress them into the more kind of taxing um type things in in the later phases.

SPEAKER_02 41:01

Yeah, and it's it's like six minutes done. Then just go, then maybe do some functional things when you're in that fatigue state. So maybe and program this where it's earlier in your in your treatment session.

unknown 41:15

Right.

SPEAKER_02 41:16

Okay. The next paper. A little bit not as amazing. Um I've never this name. There's no fuck freaking way. We're a Razor Railroad. Um we'll we'll have the citations in our show notes or or go to our website and look at my blog. I have like 40 citations in it. Chronic, I mean, uh college folks with chronic ankle instability three times a week for six weeks. They did BFR or the same exercises without BFR. Um, and their exercises were heel raises, squats, double leg ombosu, single leg Y balance, and then they would progress the balance exercises over time. This one showed so, anyways, they progressed out over time. They did not see changes in balance in this study, um, or changes, I believe, in self-reported. They did see increases in strength in the plantar flexors and the everters, um, even though they didn't even do any eversion exercises. And they also saw that there was an increase in cross-sectional area of the fibularis longus, but really didn't see much change other than the little bit of strength, um, but didn't see change in balance and didn't see change in self-reported in this one. Here's maybe one of my problems with it. They said they did 80% limb occlusion pressure and they used a pump-up cuff. So I don't know if they maintain pressure with these folks. If you want to get an internal load and your cuff is just like losing pressure over time, your internal load is probably going down as the pressure's leaking as well. Because the the ones before they actually use surgical grade. You guys have any thoughts on that one? It was a H plus cuff. And that would be a lot of BFR. Bilateral hill raises, bilateral squats, double leg bosu balance, single leg Y balance. That's one session at the start, and then they just made it more challenging with their balance exercises over time. Dude, if you're doing that with like serious BFR, you're you're freaking smoked, bro. I don't I just don't understand the bilateral thing. Yeah, unilateral injury to begin with.

SPEAKER_03 43:53

The ankle sprain, and we're gonna be doing squats. Was this also the one where they measured with uh Different cuff than the cuff they actually applied the BFR with? Or is that Lord really? I don't think so.

SPEAKER_02 44:07

I don't know. I I didn't see that, but that would be stupid.

SPEAKER_03 44:10

Yeah.

SPEAKER_02 44:11

Um we've seen people do that before.

SPEAKER_03 44:13

Yeah.

SPEAKER_02 44:15

Alright. So, yeah, whatever. I I don't know if they were able to keep occlusion, especially if you're doing that many exercises and trying to to keep it at 80% the whole time. The next one it's a little bit interesting to me. So they did ankle joint mobes for dorsiflexion and ankle sprains, chronic ankle instability. Or they did ankle joint mobes without BFR. One round. Stay with me. Stay with me. And then they checked their Y balance after that one round to see if the increased dorsiflexion improved their Y balance. And it did, especially an anterior reach, which is one of the main ones you want to look at with chronic ankle instability, because they do start to lose some of that dorsiflexion. And it improved. Um I don't have the numbers here, but it's a 1.25 effect size. So like friggin' massive improvement if you did a MOBE with blood flow restriction and chronic instability for dorsiflexion. Thoughts, fellas? Y'all want me to do this in my 1920s again?

unknown 45:35

Yeah.

SPEAKER_02 45:37

Sorry, remarkable improvements in dorsiflexion. He was able to do the cha-cha-cha all night as Antonio Reach was impressing the ladies.

SPEAKER_01 45:45

Does that make it better?

SPEAKER_05 45:46

Yep. I I feel like I totally understand it now. Yeah.

SPEAKER_02 45:50

Um I don't like this being recorded because while I was doing that, I could see my eyeballs were getting bigger the whole time. Okay, Kyle, you have a question.

SPEAKER_05 45:58

Yeah, so tell me again the groups. There was a group that got mobes with BFR. Yes. And then the other group did what? Just got Mobes? Mobes. No. Just got Mobs. No BFR. So there was no There was like a Mulligan, whatever they call it movement.

SPEAKER_01 46:15

Yeah, I took that BFR. Do you do NBAs and uh snags and I had that little book?

SPEAKER_02 46:27

Yeah, that was that was a dirty. I took that mulligan thing a long time ago. Yeah. Look, it's probably it's all crap, but sometimes it it really helps. No, it's there's I've I've had some stuff. I've found my wife with her shoulder problem. I did probably an MWM, maybe a snagger or nag. It's just some of it's so wonky, like wrapping the towel. Yeah. Yeah.

SPEAKER_01 46:50

I'm like, okay, you got that for home? Patients are like, yeah, sure. I'm gonna do this one at home. Okay, so anyways, you got it, Kyle?

SPEAKER_05 46:59

Yeah, I've got it now.

SPEAKER_02 47:00

Improved. I didn't I don't remember if they measured dorsiflexion, which you would hope they would. I didn't see that. Um, but it significantly improved their anterior reach. So I don't know, maybe if you've got an acute ankle and you or a chronic ankle and you want to restore dorsiflexion, I I will say this. My wife had a frozen shoulder. Um, and I put BFR on her because I was just having her do some little exercises and it was frozen, but it was also pain limiting up to a point. Um when I had the I just had the cuff on her. I was like, let me try and I didn't do it in MWM, just trying to work on her range. I definitely got more range with the cuff on. And it's probably like the hammer on your thumb with a headache. Like she's probably like, all I feel is a stupid cuff and everything. But I was able to get more range when she had the cuff on.

SPEAKER_04 47:53

So back to what I was saying when I sprained my ankle and I did standing. Oh, it always comes back to your little ankle. I with I was able to kill a moose later that week. With this. So I don't I don't do it in like in open chain doing the mobilization. I I what I do and what I've had patients do is close chain. And what I tell them is no standing, like and like mini squats, but I said I don't care how far you squat down, it's all about how far your knee goes over your toe. So I need the I need your knee to go far over the toe, as far as you can get it with intolerance, what have you. Um, so it's a closed chain dorsiflexion movement. I really believe that that is what made the difference to and you know it purely anecdotal. Yeah, but that is the thing like I've done with patience, and I got you know, so I think there's something to the mobilization aspect with it.

SPEAKER_02 48:58

And do exactly what your protocol would be then. You put the cuff on 80% and you do the squats for what like 30, 50, 50, single, single leg, and they can use and they can use the table for support.

SPEAKER_04 49:09

Like, I don't care about any of that type of stuff. All I care about is closed chain dorsiflexion. Um, and I I mean, like I I had a lady. This this lady was um, she had a PhD in in something, she had a very significant sprain. The doctor put her in a boot, and I saw her right when she came out of the boot. She continues, she still had pain, like walking and all this stuff. And then, like throughout the treatment, after like a few weeks, I'm like, like, how do you feel? Like, how's your pain? And she's like, you know, I haven't had pain since the first visit. And I was like, Oh, that's fine. We've all had that.

SPEAKER_02 49:48

Well, I mean, I'm not saying I'm not saying that is yeah, no, but I get what you're saying.

SPEAKER_04 49:53

Yeah, I can like I do like that is what I do with people, and I the there I I've had really good results with closed chain door sufflexion with the cuff on, set of 30, three sets of 15. Again, it's not about how far they squat down, it's closed chain door sufflexion, and then work into some heel raises, like whatever they can tolerate, and things have tip tip typically have done pretty pretty decent.

SPEAKER_02 50:23

Yeah, I like it. Well, and we've heard this even when we had Morcos on this podcast, he was talking about how he likes to do this with his mobs. And I remember Ben, do you remember Walt Lowe at Memorial? Yep. And so he's the surgeon, was the Texan surgeon, Rockets. He was saying that his therapists were able to get the knee extension back, post-op ACL, if they would work on it while they had the cuff still inflated. And that that was kind of something that that he was like, have you heard of that? That was a long time ago. No, not really, but that's pretty cool. So okay. All right, so maybe we can get the dorsiflexion back. Maybe try it with a cuff on if you're struggling. Uh maybe it just distracts them.

SPEAKER_03 51:09

Yeah.

SPEAKER_02 51:09

Maybe don't do it the way they did it in this paper. Yeah. Do it the way Zach does it. I think that's close chain's the best. No, I like it. I like it. Yeah, balance internal load can happen with it. Do it for time, do it for reps, however you want to do it. Um, you can maybe start it early. And then BFR is made for low load. Ankle exercises are lots of times low load, and when they're open chain, especially. Um, so BFR can be something that will make it more hypoxic and increase muscle activation. I just solved all your ankle problems right there, MBA.

SPEAKER_05 51:44

Boom. Boom.

SPEAKER_02 51:45

You're welcome. You are welcome. There was no time for questions because I spoke too long, so I don't know. No one asked me. No.

unknown 51:54

Yeah.

SPEAKER_02 51:56

I only had six minutes. 30 slides. 32 slides. 32 slides.

SPEAKER_05 52:03

Heck yeah. Oh my word. Well, I know I saw the slides, so yeah.

SPEAKER_02 52:08

Yeah, they look good. It was pretty cool because I had to use the BFR template. So they made them look sexy. Any final thoughts on chronic ankle instability and BFR? Give it a shot. Why not? I think there's something to it. Maybe we'll get a really good RCT that looks at this. Maybe MBA fund us with some of that MBA grant money that's out there.

SPEAKER_05 52:31

I think I think principally, um, you know, it's it's a similar you would you would approach it similarly in like the hand, the wrist hand, you know, just in terms of mechanical advantage of of things and your ability to really elicit kind of those internal loads. Um, I just think of them as kind of being similar. You know, you don't ever think of giving people exercises for their for their fingers or hands that really creates fatigue. If you've ever done just a seated row with BFR at a light load, your grip is gassed. You know?

SPEAKER_02 53:10

Well, it's the whole lateral epi thing. You know, how do you really load that tendon? Exactly. And then it's like one pound weight when you have lateral epi. And you can barely grip because it hurts, so you get that analgesic effect.

SPEAKER_05 53:23

Yeah, so I think conceptually the um uh BFR makes a lot of sense in those regions. Uh it's just hard to it's hard to put it into words to help people kind of understand why, if you will. Um ChatGPT. Yeah. I'm not sure what words to load in to ChatGPT to get it to spit it back out.

SPEAKER_02 53:53

So when is ChatGPT gonna just give me answers without me having to ask it?

SPEAKER_03 54:01

Think for you.

SPEAKER_01 54:02

Is that is that the next update?

SPEAKER_03 54:04

Yeah.

SPEAKER_01 54:05

All right, man. Any closing thoughts?

SPEAKER_02 54:11

Go to our website, sign up for courses, read these blogs, find my lost turtle, Freddie.

SPEAKER_01 54:21

Freddie? Don't buy me a turtle. I don't want one, I just want Freddie back. My daughter, whatever. She's good.

SPEAKER_05 54:28

I think there's probably some kind of editing thing we could do to where we could turn you into a turtle for part of the podcast, Johnny. That's great. Go for that. If you wanna. Yeah.

SPEAKER_02 54:37

All right. This is good to do it. Let's get this going again. So when's this gonna come out, Kyle?

SPEAKER_05 54:43

This will probably come out quick. I'm gonna edit it today. I'm gonna try to get it.

SPEAKER_02 54:47

We're not supposed to talk about that because no one knows when we recorded it or when it actually. Within a day.

SPEAKER_05 54:51

Within a day or two. Okay.

SPEAKER_02 54:53

Awesome. Good talking with you, fellas. Yeah. Talk soon.

SPEAKER_00 54:58

Thanks for listening to the Owens Recovery Science Podcast. Owens Recovery Science is a single source for PCs, OTs, ATCs, DCs, MDs, and other medical professionals seeking certification in personalized blood flow restriction rehabilitation training. Find them online. It's OwensRecoveryScience.com.

SPEAKER_05 55:20

One last thing before we get out of here. First, I want to say uh sincere thank you for listening all the way through. But also wanted to remind you that this podcast should not be considered medical advice. It is strictly entertainment. It's a way for us to try to keep up with what is ongoing within the BFR world. If you require some sort of medical attention, medical advice, please seek that from a licensed individual within your state. Thanks, and we'll talk to you soon.