BFR Exercise Part III: Knee Osteoarthritis Reducing Pain and Improving Function through Physical Therapy
By Dr. John R. Mishock, PT, DPT, DC
Approximately 14 million people in the US have knee osteoarthritis (OA). By the age of 60, about 10% of men and 13% of women are affected by symptomatic knee OA. Knee osteoarthritis is a chronic joint disorder characterized by the breakdown of cartilage, leading to pain, stiffness, weakness, and reduced function in the affected joint. If the OA progresses significantly to “bone on bone,” many elect to have a total knee joint replacement. There are roughly 800,000 knee joint replacements done each year for those with severe OA. Approximately 4.7 million adults are living with total knee replacements. (Ogrezeanu et al. J Strenghth & Cond, 2024) Before joint replacement, physical therapy is the gold standard treatment for early arthritis.
What causes pain with knee OA?
Many structures in the knee, such as the meniscus, bone, ligaments, muscles, and tendons, can cause pain due to OA. With OA, the muscles around the knee (knee extensors) and hips can become significantly weak, leading to instability, wear and tear, pain, and a lack of function.
Can manual therapy help with OA?
Manual therapy is a specialized form of physical therapy or chiropractic delivered by the clinicians’ hands to muscles or joints to decrease pain and improve body function. Much OA-related pain comes from the soft tissues around the knee (muscles, fascia, and tendons). Manual therapy reduces that pain and prepares the joint for therapeutic exercise. There is an extensive body of literature supporting the effectiveness of manual therapy in improving pain and dysfunction in patients with musculoskeletal disorders, which is a testament to its value. (Eur Appl Physiol 2017) (Journal of Jah Univ of Med Sci., 2012) (Journal of Strength and Conditioning, 2014)
Can exercise help relieve pain?
American College of Rheumatology, American Academy of Orthopaedic Surgeons, and the Centers for Disease Control strongly recommend exercise as a core therapy for the management of OA. There have been 152 randomized controlled trials with 17,431 participants (knee or hip osteoarthritis) demonstrating that exercise has a similar effect to NASAID’s in relieving pain from OA. Beyond pain relief, exercise improves strength, balance, and motor control, improving the individual’s function and quality of life.
Why should I see a physical therapist to prescribe my exercise program for my OA?
Physical therapists are doctorate-trained healthcare providers who are experts in movement and exercise. They can diagnose and treat pain, improve function, and enhance the individual’s quality of life. The physical therapist would perform a comprehensive history and physical exam. This evaluation would determine the cause of pain and the functional deficits leading to poor quality of life at home, work, or recreation. The physical therapist would prescribe therapeutic exercise, manual therapy, and education on ergonomics and body mechanics, which can reduce the load of the painful joints.
What is the difference between therapeutic exercise and gym-based exercise?
Therapeutic exercise is not exercising like “going to the gym.” Therapeutic exercise is a specific functional movement based on the deficits found during the physical therapy examination. Certain types of exercise (isometric and eccentric) have been shown to reduce pain. Other types of exercise are used to improve strength, endurance, power, motor control, balance, and flexibility. All exercises are scientifically validated and performed in a controlled, graduated, pain-free fashion based on the patient’s needs.
What is BFR, and how can it help with my knee OA?
BFR is the brief intermittent occlusion of arterial and venous blood flow using a medical-grade tourniquet while at rest or exercising. In 2018, the American Physical Therapy Association added BFR as part of the professional scope of practice for physical therapy. It is also widely promoted and applied to college and professional athletes in the NFL, NBA, MLS, and NHL. Studies have confirmed the positive effect of BFR training on healthy basketball, rugby, football, track and field, cycling, rowing, tennis, and volleyball athletes. Research has shown that the BFR exercise can enhance athleticism in squat jumps, explosive power, maximum and repetitive sprinting ability, first-step quickness, and change directions. (Wang et al. 2022)
Is BFR safe?
Even regular exercise creates muscle damage and some risk of injury. A study of 12,600 individuals who had experienced BFR training found that the most common side effects of BFR were muscle pain and soreness due to exercise. Some had temporary numbness, but this response diminished and disappeared as the cuff was released. (Nakajima et al. 2006)
Another study showed minimal side effects with venous thrombus (0.055 %), pulmonary embolism (0.008%), and rhabdomyolysis at (0.0008%). The authors concluded that BFR was safe and effective for most individuals. To optimize safety, BFR is contraindicated in individuals with a history of deep venous thrombosis, hereditary thrombotic tendency, pregnant women, a-fib or heart failure, malignancy, lymphedema, infection, Sickle cell anemia, and those with significant cardiovascular risk factors. As with all exercise, consulting your doctor before beginning any exercise program is advised.
Can BFR reduce pain?
BFR can cause pain reduction during or after a single bout of exercise. Nine studies on lower extremity pain showed a 61% reduction compared to a control. (Shuoqi et al. Am J Phys Med Rehabil, 2021) The pain reduction is due to a phenomenon widely known as exercise-induced hypoalgesia. BFR increases the release of our body’s natural pain relievers (endogenous opioids and endocannabinoid mechanisms). Pain relief is found at a local or remote site and is higher than conventional exercise for patients with foot, ankle, knee, hip, lower back, wrist, elbow, and shoulder pain. (Karanasios et al. 2023)
Can BFR improve osteoarthritis and Rheumatoid arthritis?
BFR allows the OA patient to gain better strength versus control of the muscles around the knee while reducing joint cartilage loads. (Ogrezeanu et al. J Strength & Cond 2024) BFR studies have shown pain relief, increased muscle mass and strength, and increased walking ability with greater gait speed in individuals with OA. (Dos Santos et al. PloS 2021)
We can help!
Visit our website for more articles on physicla therapy. Learn more about our treatment philospophy, physical therapy staff, and our five convenient locatios in Gilbertsville, Skippack, Phoenixville, Boyertown & Limerick at www.mishockpt.com.
Dr. Mishock is one of only a few clinicians with doctorate-level degrees in both physical therapy and chiropractic in the state of Pennsylvania. He has authored two books; “Fundamental Training Principles: Essential Knowledge for Building the Elite Athlete”, “The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury,” both can be bought on Amazon.
