Chinese Journal of Tissue Engineering Research ›› 2019, Vol. 23 ›› Issue (15): 2415-2420.doi: 10.3969/j.issn.2095-4344.1142
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Li Xintong1, Pan Weimin2, Qin Huasheng1, Qu Lei1, Zhang Hengyin1, Zhu Xinrui1
Received:
2018-12-28
Online:
2019-05-28
Published:
2019-05-28
Contact:
Pan Weimin, PhD, Professor, Department of Health Sciences, Xi’an Physical Education University, Xi’an 710068, Shaanxi Province, China
About author:
Li Xintong, Master candidate, Graduate School, Xi’an Physical Education University, Xi’an 710068, Shaanxi Province, China
Supported by:
the National Natural Science Foundation of China, No. 81201409 (to PWM); the Key Research & Development Project of General Administration of Sport of China, No. 10B019 (to PWM)
CLC Number:
Li Xintong1, Pan Weimin2, Qin Huasheng1, Qu Lei1, Zhang Hengyin1, Zhu Xinrui1. Blood flow restriction training: a new method for accelerating musculoskeletal rehabilitation[J]. Chinese Journal of Tissue Engineering Research, 2019, 23(15): 2415-2420.
2.1 血流限制训练概述 血流限制训练起源于日本,亦称Kaatsu训练,是将加压袖带置于训练部位并充气至指定压力后,肢体在血流限制基础上进行不同程度的抗阻训练。血流限制训练的最佳压力设置应使局部肢体静脉回流受阻,但与此同时保持正常动脉血液流入[6]。有研究者为了避免因袖带宽度以及大腿围度等因素所致的个体间血流限制压力差异,使用动脉闭塞压的百分比以衡量血流限制程度[7]。其评估方法是在肢体近端进行袖带加压后,通过彩色多普勒超声观察肢体远端动脉血管的血流情况,血流完全被阻断时的压力即为肢体闭塞压。通常认为使用40%-80%的肢体闭塞压进行血流限制训练安全且有 效[8]。当血流限制与抗阻训练相联合时,一般认为血流限制与20%-30%1RM的低强度抗阻训练相结合可以明显增加肌肉的体积和强度,达到高强度抗阻训练效果,而更高强度的负荷并未带来更多的益处[9]。在此基础上,又有研究证明30%1RM的血流限制训练在肌肉力量改善方面优于20% 1RM的血流限制训练,推荐30% 1RM作为血流限制训练最适宜的负荷强度[10-11]。目前,血流限制训练已应用于包括肌肉骨骼损伤康复在内的多个领域。 2.2 血流限制训练机制 血流限制训练可以减少II型肌纤维萎缩,增加肌肉体积和力量[12]。虽然产生这种作用的决定性机制尚未完全阐明,但目前主要认为是在缺血缺氧环境中代谢应激水平和机械应力增加所致。 代谢应激水平增加是肌肉生长的主要机制之一。Suga等[13]通过肌内代谢物、pH值、肌纤维募集等评估血流限制训练的肌内代谢应激水平,研究表明间歇性血流限制训练期间肌内代谢物和pH值的变化大于单独的低强度训练,但低于高强度训练。持续性血流限制训练期间肌内代谢物、pH值以及快肌纤维募集的变化与高强度训练相似,表现出与高强度阻力训练相同的代谢应激水平。额外的肌内代谢物,可能引起生长激素分泌率的变化。Pierce等[14]在受试者大腿近端血流限制下进行单侧膝关节伸展运动,强度为20%的最大自主收缩,保持向心收缩和离心收缩各2 s的速度,运动至力竭。对运动结束时收集的血样进行分析后发现,生长激素的浓度增加了9倍,这对于肌肉生长起到了很好的促进作用[15]。另有研究指出,血流限制下低强度的膝关节伸展运动导致血浆容量减少和肌纤维横截面积的急性增加,使肌细胞肿胀。但这种明显细胞肿胀仅出现在血流限制下低强度向心运动[16]。机械张力增加对于肌肉生长的诱导与代谢应激水平变化同样重要。施加到骨骼肌的机械负荷可以导致肌肉质量增加[17]。尽管血流限制所造成的机械应力水平较低,但机械张力以及代谢性应激引起的影响实际上可能是累加的,这最终有助于血流限制训练的运动适应[18]。 无论是代谢应激水平,还是机械应力的改变,从分子水平来看,均最终影响了骨骼肌细胞中蛋白质周转状态。代谢应激水平增加所致的生长激素分泌增多对肌肉蛋白质合成具有重要作用,通过增强胰岛素生长因子1的释放等途径来促进骨骼肌肥大过程[15]。而急性细胞肿胀可以通过刺激蛋白质合成并抑制蛋白质水解同样对骨骼肌肥大产生作用[16]。另有学者将加压袖带放置于Wistar大鼠大腿近端以限制肢体血流,对胫骨前肌进行30 Hz电刺激以诱发低强度等长收缩。研究表明通过血流限制训练诱导下的缺氧可以增加葡萄糖转运蛋白和线粒体生物合成,增加表层肌纤维横截面积,使得肌肉肥大[19]。另外,骨骼肌因受到机械负荷影响所导致的机械应力改变,可以诱导各种信号通路的显著激活,进而促进肌肉生长。有研究对信号通路的激活进行了进一步的研究,发现血流限制训练主要通过MAPK信号传导增加蛋白质合成来促进肌肉肥大,同时通过抑制蛋白酶体和肌肉生长抑制素,防止肌肉萎缩[20]。除此之外,mTOR信号通路的激活也是一种重要的细胞机制,可能有助于解释经血流限制训练后增强的肌肉蛋白质合成过程[21-22],见图2。"
2.3 血流限制训练在肌肉骨骼康复中的应用 急性或慢性的肌肉骨骼系统疾病均可造成骨骼肌的进行性萎缩,出现肌纤维缩短、氧化能力降低以及肌肉顺应性降低[5,11]。因此,为了更好地增加肌肉体积和力量,提升肌肉性能,通常建议进行70%-80% 1RM的高强度抗阻运动[23]。但是对于肌肉骨骼损伤患者等特殊人群,这种训练方式存在一定风险。血流限制训练可以通过使用袖带加压从而在细胞水平上通过产生相对厌氧环境来减少Ⅱ型肌纤维萎缩,既能起到增加肌肉体积及力量的作用,又极大地避免了高强度抗阻训练的潜在风险,这使得血流限制训练在肌肉骨骼损伤康复中变得日趋流行[24]。 2.3.1 髌股关节痛 髌股关节痛多因下肢生物力学改变,髌骨运动轨迹异常所致。常规股四头肌抗阻训练可以通过增加股四头肌体积和力量,纠正异常生物力线,提高髌股关节稳定性,对于髌股关节痛具有很好的缓解作用。但是,高强度的抗阻锻炼可能会进一步加重髌股关节痛症状[25]。因此,Giles等[26]通过血流限制训练以强化股四头肌,达到治疗髌股关节痛的目的。研究纳入了18-40岁来自各个行业的髌股关节痛患者。血流限制训练组袖带充气至60%肢体闭塞压,以30%1RM为强度进行8周,每周3次、每次4组的股四头肌强化训练。除第1组进行30次重复外,其余3组各15次重复,每组之间休息30 s,袖带在4组运动后移除。而标准化股四头肌强化训练组则是在使用不加压袖带作为安慰剂基础上进行每次3组,每组7-10次重复的70%1RM阻力训练。研究表明,与标准的股四头肌强化训练相比,血流限制训练可以显著减少髌股关节痛患者日常活动时产生的疼痛。而在抗阻伸膝疼痛的髌股关节痛患者中,血流限制训练比标准股四头肌强化训练在股四头肌增强方面更有效,但这并没有导致疼痛的更大改善。根据第5届国际髌股关节疼痛研究会的建议,现多通过综合治疗的方式以减轻髌股关节痛患者的疼痛,治疗内容除股四头肌抗阻训练等运动疗法外,还要包括足部矫形器、髌骨贴扎、手法治疗中的至少一项[27]。因此,将血流限制训练与其他康复措施相结合或可更好地改善髌股关节痛,但目前未有研究报道。 2.3.2 膝关节骨关节炎 膝关节骨关节炎是一种膝关节的慢性退行性病变,严重影响患者的下肢功能及生活质量。Segal等[3]通过30%1 RM负荷强度的膝关节血流限制训练对具有膝关节骨关节炎危险因素的女性进行股四头肌强化,纳入人群为45-65岁,伴有膝关节损伤史、手术史、膝关节骨关节炎史或身体质量指数升高的女性群体。研究发现,干预4周后,30% 1RM的血流限制训练组在提高股四头肌力量方面显著高于只进行30% 1RM抗阻训练的对照组。但在股四头肌体积及膝关节疼痛改善方面两组之间没有显著差异。另有研究通过相似的方式对具有膝关节骨关节炎危险因素的男性进行股四头肌强化训练。干预4周后,与只进行30% 1RM强度训练的对照组相对比,额外增加血流限制的组并未导致有膝关节骨关节炎风险或有此症状的男性大腿肌肉力量的显著差异,且对照组在膝关节疼痛改善方面优于血流限制组[28]。一方面,造成实验结论不同的原因可能与患者性别、职业、爱好等有关;另一方面或可从定量差异角度更好地弥补传统检验方法所得P值的不足,进一步说明数据的平均值差异及其所代表生物医学意义[29]。此后,Ferraz等[30]观察血流限制训练对膝关节骨关节炎患者临床预后的影响。将48例膝关节骨关节炎患者随机分为30% 1RM的低强度训练组,30% 1RM的血流限制训练组和80% 1RM高强度阻力训练组。12周康复训练后,血流限制训练和高强度阻力训练组股四头肌肌肉力量和功能均得到提高,但血流限制训练组在膝关节骨关节炎患者疼痛改善方面效果更加显著。这可能与血流限制训练负荷小、膝关节所受压力较低有关。 2.3.3 膝关节术后 对于膝关节术后患者,由于疼痛和关节积液使得关节负重减少和继发性肌肉抑制,Ⅱ型肌纤维的减少,造成肌肉萎缩和肌肉功能下降,导致恢复时间延长以及患者较差的预后。而且部分术后患者由于需要足够时间进行组织结构修复或移植物重建后愈合,因此无法进行较为有效的肌肉功能训练。Ohta等[31]对使用自体半腱肌肌腱移植物的前交叉韧带重建患者进行康复介入,血流限制组和非血流限制组均进行相同的训练计划,但从2周起血流限制组在血流限制下进行训练。根据患者恢复情况血流限制组和非血流限制组进行直腿抬高、髋关节外展和内收、半蹲等练习并逐步增加难度。16周后,血流限制组股四头肌的横截面积和肌肉力量较无血流限制组显著增加。然而,Iversen等[32]研究表明运动员群体中,前交叉韧带重建术后的前14 d应用血流限制并未减缓股四头肌萎缩,这可能与研究中受试者职业、康复训练时间等有关。另有研究将血流限制训练康复训练作为3例全膝关节置换术后患者康复训练的一部分。在进行8周,每周3次的血流限制训练后,3例患者股四头肌峰力矩增大,力量得到改善[33]。 此外,Tennent等[34]报道了3例因持续性膝关节疼痛等原因进行膝关节镜术后的患者,在分别接受2-4周时间不等的30% 1RM强度的血流限制康复训练后,3例患者股四头肌力量均显著增加,下肢功能水平也得到恢复和提高。刘莉等[35]进一步探究了血流限制训练在膝关节镜术后患者中的应用,患者皆因半月板损伤接受手术,并于术后15 d在完成直腿抬高练习休息10 min后,进行血流限制下30% 1RM强度的抗阻伸膝训练。2周后与只进行直腿抬高练习的患者相比,进行血流限制训练的患者在伸膝肌力及膝关节功能评分方面得到了很大改善,且并未因血流限制训练而产生额外的下肢肿胀及局部压痛、深静脉血栓等。 2.3.4 跟腱损伤 踝关节是兼顾稳定性与灵活性的负重关节,一但出现损伤将极大程度地影响人们的日常活动。有研究报道了2例将血流限制训练纳入康复计划的跟腱断裂患者。其中一名29岁的现役士兵,在进行足球运动时致左侧跟腱断裂,行跟腱修复术后6个月,出现踝关节活动严重受限、防痛步态,需要在辅助下步行。5周后该患者跖屈能力得到极大改善,能够在没有辅助器具的情况下行走。另一名左侧跟腱急性撕裂患者在进行非手术治疗4个月后,开始进行为期6周血流限制训练,方案与第1位患者类似,最终恢复了跑步能力[36]。虽然现研究多集中于踝关节损伤后功能障碍的康复训练,但理论上血流限制训练同样可以降低踝关节损伤早期阶段的肌肉萎缩和力量下降程度,缓解损伤部位的疼痛,促进组织愈合。对于跟腱损伤等踝关节损伤患者特别是运动员,在恢复或促进组织愈合期间,不宜进行场地专项训练活动。此时,在不引起患者疼痛的情况下,血流限制训练可与步行等有氧运动方案相结合,进一步补充和完善康复训练计划,改善运动员心血管健康水平。而当运动员恢复至能够进行专项训练时,血流限制训练与传统力量训练相结合在发展力量方面或将发挥重要作用[37]。上述研究中血流限制训练方案总结后见表1。"
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