Volume 6, Issue 3 (12-2020)                   J Sport Biomech 2020, 6(3): 190-203 | Back to browse issues page


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Hadavi S M, Sedaghati P, Mottaghitalab M. Comparison of the Effect of Strength Training With and Without Blood Flow Restriction on Motor Function in Active Females With Dynamic Knee Valgus. J Sport Biomech. 2020; 6 (3) :190-203
URL: http://biomechanics.iauh.ac.ir/article-1-242-en.html
1- Department of Sport Injuries and Corrective Exercise, Faculty of Physical Education and Sports Sciences, University of Guilan, Rasht, Iran.
2- Department of Sport Biomechanics, Faculty of Physical Education and Sport Sciences, University of Guilan, Rasht, Iran.
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1. Introduction
ynamic Knee Valgus (DKV) is a common risk factor for acute lower extremity injuries and overuse. Generally, excessive movement of the knee in the frontal plane during sports activities is a known cause for many acute and chronic knee injuries [1]. Researchers have identified DKV as a risk factor for lower limb injuries, including Patellofemoral Pain Syndrome (PFPS) and ACL rupture So that the reduction of knee valgus by maintaining proper alignment during activity has been reported to be an influential factor in preventing non-collision ACL injuries and PFPS [2]. 
DKV is a combination of adduction and internal rotation of the thigh with the abduction and external or internal rotation of the tibia during landing or squat maneuvers. The knee valgus is caused by a combination of femoral and tibia movements affected by the knee’s proximal and distal joints, including the trunk, thighs, and ankles [3]. Since reducing valgus loads can effectively reduce the incidence of ACL injuries, so far, many researchers have investigated the effect of ACL injury prevention exercises on neuromuscular function and variables [6]. However, despite the importance of using preventive exercise programs in people with DKV, which is one of the most critical risk factors for ACL injury, few studies have addressed this issue. On the other hand, the existing training approaches to improve knee joint function are very diverse, and research on identifying the best training methods to improve motor function is ongoing. Many kinds of research suggest quadriceps muscle strengthening exercises as a useful method [56789]. 
In some studies, strengthening the external rotator cuff muscles and thigh abductors has improved patients’ patellofemoral angle with patellofemoral pain [10]. Earl and Hatch (2011) consider supporting the hip joint muscles as an effective way to improve people’s motor function with patellofemoral pain. By doing these exercises and the thigh’s external rotation, the patellar movement path is better positioned between the thigh’s two condyles. As a result, it improves pain and subsequent function [11]. 
Nowadays, exercises with obstruction of blood flow are used as a side strategy after surgery or before gaining health and complete recovery from injuries in muscle weakness cases around the injured joints, intending a rapid recovery [17]. Since no research has compared the effect of strengthening exercises on quadriceps, abductors, and external rotator cuff muscles compared to these exercises along with blood flow obstruction in people prone to knee injuries, including people with DKV; therefore, in this study, we will compare the effect of conventional resistance training with and without restricting blood flow on the motor function of women with DKV.
2. Materials and Methods
This research was a quasi-experimental and interventional study with three groups and pre-test and post-test. The present study’s statistical population consisted of active women with DKV deformity in Chalous city at 18-28. To determine the number of samples required for this study based on similar reviews [16] was used. Thirty-six people were purposefully selected from women with DKV as research samples. Subjects were evaluated for the patellofemoral joint’s direction with a goniometer, static and dynamic balance through Stork and Yaw Tests, and lower limb strength with Sargent Jump Test. Subjects were randomly divided into control, conventional resistance training without restricting blood flow, and traditional resistance training restricting blood flow. Exercises were given for 8 weeks in three sessions per week. The Guilan University of Medical Sciences approved this research (Code: ID IR.GUMS.REC.2020.202).
3. Results 
The results showed a positive effect of exercise programs on static balance (P=0.001), dynamic balance (P=0.001), patellar alignment, and lower limb strength (P=0.001) in women with DKV. Also, the results of the analysis of covariance showed a significant difference between control and training groups (Table 1). 


4. Discussion and Conclusion
The results of the present study showed the positive effect of exercise programs on the results of pre and post-tests of static balance, dynamic balance, the direction of the patellofemoral joint, and lower limb strength in women with VDK defect. Also, comparing the results between the groups showed a significant difference between the control group and the two training groups and was determined by examining Post Hoc Test differences. Comparing the two experimental groups showed a significant difference in the lower limb strength variable between the two training groups.
In confirmation of the results of this study on the improvement of static and dynamic balance variables in both experimental groups, we can refer to Farahani and Riahi’s (2019) study, which examined the effect of exercises restricting blood flow soldiers’ balance. Their result showed that exercise program restricting blood flow significantly impacts improving balance [25]. The positive effect of using exercises with blood flow obstruction on improving balance can be due to lower extremity strengthening exercises, which is an effective factor in balance. In this regard, the results of research by Willardson et al. (2013) examined the effect of exercise by restricting the blood flow in different parts of the body with varying intensities in improving endurance and strength [26].

Ethical Considerations
Compliance with ethical guidelines

This study was approved by the Ethics Committee of the Guilan University of Medical Sciences (Code: IR.GUMS.REC.1399.202). 

Funding
The paper was extracted from the MSc. thesis of Seyedeh Mahshid Hadavi at the Department of Sport Injuries and Corrective Exercise, University of Guilan, Guilan.

Authors' contributions
All authors equally contributed to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.


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Type of Study: Research | Subject: Special
Received: 2020/12/3 | Accepted: 2020/12/18 | Published: 1901/12/14

References
1. Sigward, S.M., S. Ota, and C.M. Powers, Predictors of Frontal Plane Knee Excursion During a Drop Land in Young Female Soccer Players. Journal of Orthopaedic & Sports Physical Therapy, 2008. 38(11): p. 661-667 [DOI:10.2519/jospt.2008.2695] [PMID]
2. Bell, D.R., D.A. Padua, and M.A. Clark, Muscle Strength and Flexibility Characteristics of People Displaying Excessive Medial Knee Displacement. Archives of Physical Medicine and Rehabilitation, 2008. 89(7): p. 1323-1328. [DOI:10.1016/j.apmr.2007.11.048] [PMID]
3. Barrios, J.A., et al., Three-dimensional hip and knee kinematics during walking, running, and single-limb drop landing in females with and without genu valgum. Clinical Biomechanics, 2016. 31: p. 7-11. [DOI:10.1016/j.clinbiomech.2015.10.008] [PMID]
4. Hewett, T., et al., Understanding and preventing ACL injuries: Current biomechanical and epidemiologic considerations-update 2010. North American journal of sports physical therapy : NAJSPT, 2010. 5: p. 234-51.
5. Campolo, M., et al., A comparison of two taping techniques (kinesio and mcconnell) and their effect on anterior knee pain during functional activities. International journal of sports physical therapy, 2013. 8(2): p. 105.
6. Coughlan, G.F., et al., A comparison between performance on selected directions of the star excursion balance test and the Y balance test. Journal of athletic training, 2012. 47(4): p. 366-371. [DOI:10.4085/1062-6050-47.4.03] [PMID] [PMCID]
7. Wood, L., S. Muller, and G. Peat, The epidemiology of patellofemoral disorders in adulthood: a review of routine general practice morbidity recording. Primary health care research & development, 2011. 12(2): p. 157-164. [DOI:10.1017/S1463423610000460] [PMID]
8. Meira, E.P. and J. Brumitt, Influence of the hip on patients with patellofemoral pain syndrome: a systematic review. Sports Health, 2011. 3(5): p. 455-465. [DOI:10.1177/1941738111415006] [PMID] [PMCID]
9. Nejati P, Forugh B, Moeineddin R, Nejati M. Patellofemoral Pain Syndrome in Iranian Female Athletes. Ann Mil Health Sci Res. 2008; 6 (3) :177-181.
10. Ireland, M.L., et al., Hip strength in females with and without patellofemoral pain. Journal of orthopaedic & sports physical therapy, 2003. 33(11): p. 671-676. [DOI:10.2519/jospt.2003.33.11.671] [PMID]
11. Earl, J.E. and A.Z. Hoch, A proximal strengthening program improves pain, function, and biomechanics in women with patellofemoral pain syndrome. The American journal of sports medicine, 2011. 39(1): p. 154-163. [DOI:10.1177/0363546510379967] [PMID]
12. bagheri S, shojaeddin S, nazarian A B, naderi A. The Effect of Hip Abductors and External Rotators Strengthening In Male with Patellofemoral Pain Syndrome. sjimu. 2016; 23 (6) :29-39
13. Colclough A, Munro AG, Herrington LC, McMahon JJ, Comfort P. The effects of a four week jump-training program on frontal plane projection angle in female gymnasts. Physical Therapy in Sport. 2018 Mar 1;30:29-33. [DOI:10.1016/j.ptsp.2017.11.003] [PMID]
14. Goto, S., The Effects of an Integrated Exercise Program On Lower Extremity Biomechanics In Females with Medial Knee Displacement., in Department of Exercise and Sport Science2015, University of North Carolina at Chapel Hill Graduate School: Chapel Hill, NC. p. 351.
15. Fujita, S., et al., Blood flow restriction during low-intensity resistance exercise increases S6K1 phosphorylation and muscle protein synthesis. Journal of applied physiology, 2007. 103(3): p. 903-910. [DOI:10.1152/japplphysiol.00195.2007] [PMID]
16. Giles, L., et al., Quadriceps strengthening with and without blood flow restriction in the treatment of patellofemoral pain: a double-blind randomised trial. Br J Sports Med, 2017. 51(23): p. 1688-1694. [DOI:10.1136/bjsports-2016-096329] [PMID]
17. Mason, M.J.S., J.G. Owens, and L.W.J. Brown, Blood Flow Restriction Training: Current and Future Applications for the Rehabilitation of Musculoskeletal Injuries. Techniques in Orthopaedics, 2018. 33(2): p. 71. [DOI:10.1097/BTO.0000000000000301]
18. Tyler, T.F., et al., The role of hip muscle function in the treatment of patellofemoral pain syndrome. The American journal of sports medicine, 2006. 34(4): p. 630-636. [DOI:10.1177/0363546505281808] [PMID]
19. Powers, C.M., The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. journal of orthopaedic & sports physical therapy, 2010. 40(2): p. 42-51. [DOI:10.2519/jospt.2010.3337] [PMID]
20. Tyler, T.F., et al., The role of hip muscle function in the treatment of patellofemoral pain syndrome. The American journal of sports medicine, 2006. 34(4): p. 630-636 [DOI:10.1177/0363546505281808] [PMID]
21. Herrington, L. and A. Munro, Drop jump landing knee valgus angle; normative data in a physically active population. Physical Therapy in Sport, 2010. 11(2): p. 56-59. [DOI:10.1016/j.ptsp.2009.11.004] [PMID]
22. McCurdy, K., et al., The Effects of Short-Term Unilateral and Bilateral Lower-Body Resistance Training on Measures of Strength and Power. Journal of strength and conditioning research / National Strength & Conditioning Association, 2005. 19: p. 9-15. https://doi.org/10.1519/14173.1 [DOI:10.1519/00124278-200502000-00003] [PMID]
23. Page, P. and T.S. Ellenbecker, The scientific and clinical application of elastic resistance. 2003: Human Kinetics.
24. Khayambashi, K., et al., The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial. Journal of Orthopaedic & Sports Physical Therapy, 2012. 42(1): p. 22-29. [DOI:10.2519/jospt.2012.3704] [PMID]
25. Farhani, F. and S. Riyahi, Comparison of Three Methods of Resistance Training with Blood Flow Restriction on Functional Factors and Cardio Respiratory Preparedness in Military Soldiers. Journal of Military Medicine, 2019. 21(1): p. 73-81.
26. Pope, Z.K., J.M. Willardson, and B.J. Schoenfeld, Exercise and blood flow restriction. The Journal of Strength & Conditioning Research, 2013. 27(10): p. 2914-2926. [DOI:10.1519/JSC.0b013e3182874721] [PMID]
27. Cynthia AT. The effects of strength and plyometric training on joint position, joint moments and joint stiffness at the knee. [PhD Thesis]. Provo, UT: Faculty of Brigham Young Uni 2004.
28. Docherty, C.L., J.H. Moore, and B.L. Arnold, Effects of strength training on strength development and joint position sense in functionally unstable ankles. Journal of athletic training, 1998. 33(4): p. 310.
29. Keen, D.A., G.H. Yue, and R.M. Enoka, Training-related enhancement in the control of motor output in elderly humans. Journal of Applied Physiology, 1994. 77(6): p. 2648-2658. [DOI:10.1152/jappl.1994.77.6.2648] [PMID]
30. Koorosh-fard, N., et al., Effect of Feedback Corrective Exercise on Knee Valgus and Electromyographic Activity of Lower Limb Muscles in Single Leg Squat. Archives of Rehabilitation, 2015. 16(2): p. 138-147.
31. Winby, C., et al., Correlation between EMG-based co-activation measures and medial and lateral compartment loads of the knee during gait. Clinical biomechanics, 2013. 28(9-10): p. 1014-1019. [DOI:10.1016/j.clinbiomech.2013.09.006] [PMID]
32. Mohammadi, H., H. Daneshmandi, and M. Alizadeh, Effect of Corrective Exercises Program on Strength، ROM, and Performance in Basketball Players with Dynamic Knee Valgus. The Scientific Journal of Rehabilitation Medicine, 2019. 8(3): p. 29-41.
33. Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd edition. ST Louis, Missouri: Mosby, 2009.
34. Aglietti P, Insall JN, Cerulli G. Patellar pain and incongruence. I: Measurements of incongruence. Clin Orthop Relat Res 1983; (176): 217-24. [DOI:10.1097/00003086-198306000-00032]
35. Hewett, T., et al., Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes A Prospective Study. The American journal of sports medicine, 2005. 33: p. 492-501. [DOI:10.1177/0363546504269591] [PMID]
36. Saki F, Madhosh M, Sedaghati P. The Effect of Selective Plyometric Training on the Lower Extremity Functional Performance Indexes of Female Athletes With Dynamic Knee Valgus. Physical Treatments-Specific Physical Therapy Journal. 2019 Jan 10;9(1):31-8. [DOI:10.32598/PTJ.9.1.31]
37. Anabestani, M., A. Hosseini-Kakhk, and M. Hamedinia, Comparison of combined training with and without vascular occlusion on selected physical fitness components in postmenopausal women. Sport Physiology, 2014. 6(21): p. 123-136.
38. Karabulut, M., et al., The effects of low-intensity resistance training with vascular restriction on leg muscle strength in older men. European journal of applied physiology, 2010. 108(1): p. 147. [DOI:10.1007/s00421-009-1204-5] [PMID]
39. Mason, M.J.S., J.G. Owens, and L.W.J. Brown, Blood Flow Restriction Training: Current and Future Applications for the Rehabilitation of Musculoskeletal Injuries. Techniques in Orthopaedics, 2018. 33(2): p. 71. [DOI:10.1097/BTO.0000000000000301]
40. Ford, K.R., et al., An evidence-based review of hip-focused neuromuscular exercise interventions to address dynamic lower extremity valgus. Open access journal of sports medicine, 2015. 6: p. 291-303. [DOI:10.2147/OAJSM.S72432] [PMID] [PMCID]

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