Greetings all! This month I wanted to share some information and resources with you that will relate to your use of BFR, but is also very relevant to our current healthcare climate and has great potential to be impactful for your patients, community, friends, or family members. Should you use BFR in this population? I don’t know. I’ll offer up some thoughts at the end of this blog, but I hope you’ll spend a bit of time learning about Long COVID and its unique challenges before you ever consider the appropriateness of BFR.
A few months back I posted in our Inside Circle group on Facebook asking if anyone had any experience using BFR in patients that had Long COVID. To my surprise I got no affirmative responses. So let me define that term real quick and then I want to lay out some these resources for y’all. Long COVID is very much an umbrella term with no clear clinical presentation. It broadly refers to protracted symptoms following Sars-COV-2 infection that range from mild and gradually resolving to unpredictable, severe and recalcitrant. The important thing about the term is that it’s been patient driven.
You also might not know that physios around the world have really been leading in this space as very early on so many were infected and noted poor recoveries. This lead to the formation of group called Long COVID Physio. Here’s their website: https://longcovid.physio/
Here’s a JOSPT blog that the Long COVID Physio folks wrote outlining what exactly Long COVID is: https://www.jospt.org/do/10.2519/jospt.blog.20210203
One of the big mis-steps that so many physios made early on was pushing too hard. The Long COVID Physio crew addressed that in a follow-up blog: https://www.jospt.org/do/10.2519/jospt.blog.20210210
One of the people I owe a lot of credit to for enlightening me to what was inevitable is Todd Davenport, PT, DPT. Todd has worked in the Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS) space for years and he was immediately sharing that there were going to be some predictable impacts on people’s long term health from Sars-COV-2 infection. He wrote a wonderful JOSPT blog on that here: https://www.jospt.org/do/10.2519/jospt.blog.20210310
Todd and his colleagues at the WorkWell Foundation followed up Todd’s piece with a nice set of blog’s for JOSPT on how what we’ve learned from ME/CFS can be used in the management of those with Long COVID:
Part One: Post Exertional Symptom Exacerbation
Part Two: Physiological Characteristics of Acute Exercise
Part Three: Energy System First Aid
Part Four: Hear Rate Monitoring to Manage
Todd also has a Medbridge course available if you’re interested in learning more in a different format: Medbridge Long COVID Course
And if you really love learning in conference format…they've got you!! Long COVID Physio is hosting an international forum on September 9th and 10th! You can attend live online or you can watch at a later time!
Long COVID Physio International Forum: https://longcovid.physio/forum
And of course, if you don’t have a podcast…do you even physio? :))
Long COVID Physio Podcast
So after doing some learning on Long COVID, what do you think? Should we consider using BFR in this population? Well let me be more specific, because as we said earlier, Long COVID is quite broad. Should we use BFR in people who experience post exertional symptom exacerbation and dysautonomia as part of their clinical presentation of Long COVID?
I’d suggest we can use the same clinical reasoning strategies we use every day in clinic to determine if using BFR is feasible and how to begin. As you’ve undoubtedly learned from the information above, monitoring heart rate is the best way to pace daily activity for your patient and control post-exertional symptom exacerbations. So once you’ve done the foundational work of teaching your patient pacing, the next question to answer would be whether or not you can provide any additional value in clinic that would justify them returning beyond monitoring their pacing strategy. This is when I might consider grabbing my Delfi and manipulating some variables. However, it is imperative that you understand two things: 1) the following is hypothetical with the goal of demonstrating the wealth of options you have and 2) persons experiencing dysautonomia do not respond in typical ways to activity. Please keep this context as you read on and if you choose to consider using this approach clinically.
You’ve got a heart rate monitor and you can use your Delfi to get a personalized pressure. I’d start on the upper extremity as there’s less tissue and the pressures are not as high. Does just taking LOP have an effect on HR? It could. If it does, then perhaps BFR isn’t the best choice. However, if HR comes down or the elevation was mild and there’s no exacerbation the following day, then perhaps you could just measure LOP 2 times the following visit. If that goes well, perhaps you increase the duration of the pressure, but reduce the magnitude to say 40% LOP. You know what responses to monitor and those will help determine duration. If that goes well could you just add another inflation the next visit? Hopefully you see where I’m going here. There are a lot of options you have at your disposal with the addition of a Delfi to your repertoire. I’ve perhaps given an extreme example here but the purpose was to show you just how far you can regress things. Once you have a starting place you incrementally manipulate the magnitude of pressure, the lengths of inflations and deflations, and the number of both inflations and deflations. I think building a tolerance toward a typical ischemic preconditioning stimulus is a good goal. At that point I’d consider further modifications, perhaps using bilaterally, or moving to the lower extremity to involve more tissue and greater pressures, maybe you add some isometric contractions or just a bit of AROM. There’s no protocol. There’s no data. But we know what to watch for and how to gradually progress the interventions we have at our disposal, no to mention we have a client in front of us that can help us understand the effect of our intervention.
Thank you Kyle Kimbrell, MPT for the write up and resources.