Effects of Blood Flow Restriction on Muscle Activation During Dynamic Balance Exercises in Individuals With Chronic Ankle Instability

in Journal of Sport Rehabilitation
Restricted access

Purchase article

USD  $24.95

Student 1 year online subscription

USD  $76.00

1 year online subscription

USD  $101.00

Student 2 year online subscription

USD  $144.00

2 year online subscription

USD  $192.00

Context: Dynamic balance exercises are commonly utilized during ankle sprain and chronic ankle instability (CAI) rehabilitation. Blood flow restriction (BFR) has been used to enhance muscle activity during exercise and improve outcomes of traditional rehabilitation exercises in clinical populations. Objective: Examine the effects of BFR on lower-extremity muscle activation during dynamic balance exercises in individuals with CAI. Design: Crossover study design. Setting: Laboratory. Patients or Other Participants: Twenty-five (N = 25) young adults with a history of CAI. Interventions: Participants performed dynamic balance reaching exercises during 2 randomized order conditions, BFR, and control. For each condition, participants performed 2 trials of balance exercises. Each trial included 4 sets (30 × 15 × 15 × 15) of reaches in anterior, posteromedial, and posterolateral directions. For the BFR condition, the authors placed a cuff around the proximal thigh at 80% of arterial occlusion pressure. For the control condition, no cuff was worn. Main Outcome Measure(s): The authors recorded normalized electromyography muscle activation of the vastus lateralis, soleus, tibialis anterior, and fibularis longus during balance exercise trials and recorded participants’ ratings of perceived postural instability and exertion after each trial of balance exercises. Results: The authors observed greater vastus lateralis (P < .001, d = 0.86 [0.28 to 1.44]) and soleus (P = .03, d = 0.32 [−0.24 to 0.87]) muscle activation during balance exercises with BFR than control. The authors observed no differences in tibialis anterior (P = .33, d = 0.09 [−0.46 to 0.65]) or fibularis longus (P = .13, d = 0.06 [−0.50 to 0.61]) muscle activation between the conditions. The authors observed greater ratings of perceived postural instability (P = .004) and exertion (P < .001) during balance exercises with BFR than control. Conclusions: Individuals with CAI demonstrated large increases in vastus lateralis and small increases in soleus muscle activation during dynamic balance exercises with BFR. The BFR had no effect on fibularis longus and tibialis anterior muscle activation. Individuals with CAI perceived greater postural instability and exertion during dynamic balance exercises with BFR.

Burkhardt and Burkholder are with Adrian College, Adrian, MI, USA. Goetschius is with James Madison University, Harrisonburg, VA, USA.

Goetschius (goetscjw@jmu.edu) is corresponding author.
  • 1.

    Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311319. doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Gribble PA, Delahunt E, Bleakley CM, et al. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the international ankle consortium. J Athl Train. 2014;49(1):121127. doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Hubbard-Turner T, Turner MJ. Physical activity levels in college students with chronic ankle instability. J Athl Train. 2015;50(7):742747. PubMed ID: 25898110 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Donovan L, Hetzel S, Laufenberg CR, McGuine TA. Prevalence and impact of chronic ankle instability in adolescent athletes. Orthop J Sport Med. 2020;8(2):2325967119900962. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Simon JE, Docherty CL. Health-related quality of life is decreased in middle-aged adults with chronic ankle instability. J Sci Med Sport. 2018;21(12):12061209. PubMed ID: 29803734 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    McKeon PO, Donovan L. A perceptual framework for conservative treatment and rehabilitation of ankle sprains: an evidence-based paradigm shift. J Athl Train. 2019;54(6):628638. PubMed ID: 31135210 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Donovan L, Hart JM, Saliba SA, et al. Rehabilitation for chronic ankle instability with or without destabilization devices: a randomized controlled trial. J Athl Train. 2016;51(3):233251. PubMed ID: 26934211 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Gribble PA, Hertel J, Plisky P. Using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train. 2012;47(3):339357. PubMed ID: 22892416 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Feger MA, Donovan L, Hart JM, Hertel J. Lower extremity muscle activation during functional exercises in patients with and without chronic ankle instability. PM R. 2014;6(7):602611. PubMed ID: 24412672 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Jaber H, Lohman E, Daher N, et al. Neuromuscular control of ankle and hip during performance of the star excursion balance test in subjects with and without chronic ankle instability. PLoS One. 2018;13(8). doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    Scott BR, Loenneke JP, Slattery KM, Dascombe BJ. Exercise with blood flow restriction: an updated evidence-based approach for enhanced muscular development. Sports Med. 2015;45(3):313325. PubMed ID: 25430600 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Hughes L, Paton B, Rosenblatt B, Gissane C, Patterson SD. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med. 2017;51(13):10031011. PubMed ID: 28259850 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Loenneke JP, Kearney ML, Thrower AD, Collins S, Pujol TJ. The acute response of practical occlusion in the knee extensors. J Strength Cond Res. 2010;24(10):28312834. PubMed ID: 20885201 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training. J Appl Physiol. 2006;100(5):14601466. PubMed ID: 16339340 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, Ishii N. Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans. J Appl Physiol. 2000;88(6):20972106. PubMed ID: 10846023 doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    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. 2020;29(5):633639. doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Robertson RJ, Goss FL, Rutkowski J, et al. Concurrent validation of the OMNI perceived exertion scale for resistance exercise. Med Sci Sports Exerc. 2003;35(2):333341. PubMed ID: 12569225 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Simon J, Donahue M, Docherty C. Development of the identification of functional ankle instability (IdFAI). Foot Ankle Int. 2012;33(9):755763. PubMed ID: 22995264 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    DePhillipo NN, Kennedy MI, Aman ZS, Bernhardson AS, O’Brien L, LaPrade RF. Blood flow restriction therapy after knee surgery: indications, safety considerations, and postoperative protocol. Arthrosc Tech. 2018;7(10):e1037e1043. PubMed ID: 30377584 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Espy D, Reinthal A, Meisel S. Intensity of balance task intensity, as measured by the rate of perceived stability, is independent of physical exertion as measured by heart rate. J Nov Physiother. 2017;7(4):343. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21.

    Patterson SD, Hughes L, Warmington S, et al. Blood flow restriction exercise position stand: considerations of methodology, application, and safety. Front Physiol. 2019;10(May):115. doi:

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22.

    Martin RRL, Irrgang JJ, Burdett RG, Conti SF, Van Swearingen JM. Evidence of validity for the foot and ankle ability measure (FAAM). Foot Ankle Int. 2005;26(11):968983. PubMed ID: 16309613 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J Appl Sport Sci. 1985;10(3):141146. PubMed ID: 4053261

  • 24.

    Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Mahwah, NJ. L. Erlbaum Associates; 1988.

  • 25.

    Loenneke JP, Fahs CA, Wilson JM, Bemben MG. Blood flow restriction: the metabolite/volume threshold theory. Med Hypotheses. 2011;77(5):748752. PubMed ID: 21840132 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Counts BR, Dankel SJ, Barnett BE, et al. Influence of relative blood flow restriction pressure on muscle activation and muscle adaptation. Muscle Nerve. 2016;53(3):438445. PubMed ID: 26137897 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Feger MA, Donovan L, Hart JM, Hertel J. Lower extremity muscle activation in patients with or without chronic ankle instability during walking. J Athl Train. 2015;50(4):350357. PubMed ID: 25562453 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Koldenhoven RM, Feger MA, Fraser JJ, Saliba S, Hertel J. Surface electromyography and plantar pressure during walking in young adults with chronic ankle instability. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):10601070. PubMed ID: 26856315 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Johansson H, Djupsjöbacka M, Sjölander P. Influences on the gamma-muscle spindle system from muscle afferents stimulated by KCl and lactic acid. Neurosci Res. 1993;16(1):4957. PubMed ID: 8387164 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Scott BR, Slattery KM, Sculley D V, Dascombe BJ. Hypoxia and resistance exercise: a comparison of localized and systemic methods. Sports Med. 2014;44(8):10371054. PubMed ID: 24715613 doi:

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 623 623 150
Full Text Views 29 29 8
PDF Downloads 19 19 2