Effect of Instrument-Assisted Soft Tissue Mobilizatio combined with blood flow restriction training on function, pain and strength of patients with patellofemoral joint pain

doi:10.21203/rs.3.rs-2615239/v1

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Research Article

Effect of Instrument-Assisted Soft Tissue Mobilizatio combined with blood flow restriction training on function, pain and strength of patients with patellofemoral joint pain

https://doi.org/10.21203/rs.3.rs-2615239/v1

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published 31 Aug, 2023

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Background: Patellofemoral pain syndrome is a prevalent sports injury that affects athletes both in their daily lives and during training. This condition causes pain in the area where the kneecap and thigh bone meet, and it can be quite debilitating. Whether an athlete is simply going about their day or pushing themselves to the limit during a workout, patellofemoral pain can be a significant hindrance.

Purpose: The purpose of this study is to investigate the impact of combining Instrument-Assisted Soft Tissue Mobilization (IASTM) treatment with blood flow restriction training on individuals with patellofemoral pain. Specifically, the study will assess improvements in pain levels, functional ability, strength, and joint mobility resulting from this treatment approach.

Methods: Twenty-six patients diagnosed with patellofemoral pain were selected as observation subjects and randomly divided into two groups: the IASTM combined with blood flow restriction training treatment group (n=13) and the IASTM treatment group alone (n=13). The treatment period was 4 weeks. In this study, we conducted a comparison and analysis of the knee's visual analogue pain scale (VAS), Lysholm score, and a modified version of the Thomas test (MTT) at three different time points.In this subject paper, we compared and analyzed the VAS score of the knee, Lysholm score of the knee, and MTT at three different time points - before treatment, immediately after the first treatment, and after four weeks of treatment. Additionally, we recorded data using a maximum isometric muscle strength testing system for the lower extremity extensors four weeks before and after treatment.

Results: In the intra-group comparison of Lysholm score, after the first treatment and 4 weeks of treatment, the scores of the two groups were significantly different from those before treatment (P<0.05), and the VAS scores after the first treatment and 4 weeks of treatment were significantly different from those before treatment (P<0.05), and the pain was significantly improved. After 4 weeks of treatment, the strength of the extensor muscle of the lower extremity was significantly improved (P<0.001), but there was no significant change in the strength test between groups (P>0.05). After MTT test, there were significant changes in the three joint angles before and after treatment (P>0.05).

Conclusion: The combination of IASTM treatment and blood flow restriction has been shown to significantly reduce pain and improve periprosthetic soft tissue flexibility. Additionally, IASTM treatment alone was found to be more effective in improving knee pain and muscle flexibility, ultimately leading to increased knee strength in a pain-free state.In terms of the overall treatment outcome, it was found that the combined treatment was significantly more effective than the adjuvant soft tissue release treatment alone.

Instrument-Assisted Soft Tissue Mobilization

Patellofemoral Pain Syndrome

Blood Flow Restriction Training

Patellofemoral pain syndrome (PFPS) is a prevalent cause of knee pain in clinical settings. This condition is typically identified by anterior knee pain during physical activities, including walking, running, jumping, and stair climbing[1]. The development of PFPS is linked to an abnormal patellofemoral trajectory and increased local stress on the joint[2].Various factors contribute significantly to the development of this condition, with abnormal patellar motion trajectory being a primary cause. This condition is often linked to lower limb force line disorders, which can result from a range of factors such as abnormal lower limb structural anatomy, weakened lower limb muscles, muscle tone imbalances around the knee joint, and sports-related injuries. In the meantime, Sinaei et al. [3] have demonstrated that the weakened strength of the biceps femoris muscle, delayed activation of the medial femoral muscle, and over-activation of the lateral femoral muscle relative to the medial test may be the root cause of PFPS symptoms.The above information highlights the significance of muscle tone imbalance in the muscle tissue surrounding the knee joint as a leading cause of pain. To address this issue, the study focused on conservative treatment methods, specifically utilizing Instrument-Assisted Soft Tissue Mobilization (IASTM) treatment and blood flow restriction compression training. The results showed an improvement in the symptoms of patients suffering from PFPS.

The IASTM treatment technique is a relatively new method for muscle release. In this experiment, the fascial knife was utilized as a treatment tool to alleviate symptoms of pain and abnormal tension in the myofascia. This treatment allows for quick identification and removal of fascial adhesions, effectively preventing soft tissue fibrosis and muscle degeneration. Leiomyosarcoma (LMS) is a rare tumor that occurs in the small intestine, arising from either the muscua-ris mucosa or muscularis propria. The jejunum is the most common site for LMS in the small intestine, followed by the ileum and the duodenum. Typical symptoms include an abdominal mass, abdominal pain, or gastrointestinal bleeding. LMS is predominantly seen in the sixth decade of life and is slightly more common in males. Fascial knife technology, also referred to as the fascial spatial balancing technique, is a treatment method for joint problems [4]. This technique involves a combination of assessment, screening, and a special knife technique that applies pressure to the skin. The entire process is painless and safe. By targeting high-stress fascia, this technique can effectively improve joint range of motion. Due to its bloodless nature, the fascial knife is often referred to as a "bloodless scalpel." This study aimed to improve knee mobility by releasing the overstressed muscles and tendons around the knee joint through IASTM treatment.

Blood Flow Restriction (BFR) training has been a widely-used technique in musculoskeletal pain rehabilitation for some time. It has proven particularly effective in clinical rehabilitation of lower extremity knee disorders, where it can significantly improve muscle atrophy, strengthen muscle strength and lower extremity endurance, and reduce pain and associated symptoms. As a result, BFR training can greatly enhance patients' motor ability.BFR training can be used for various target groups when combined with lower load resistance or aerobic training [5, 6, 7]. The training mechanism is to control the blood circulation of the limbs by applying a certain mechanical pressure to the proximal end of the limb with a bandage or cuff while the patient is at rest or exercising, thus improving the training efficiency, muscle strength and nerve recruitment of the target muscle groups[8] .The combination of deep soft tissue release through IASTM therapy and the safe and efficient low-load BFR training appears to have a beneficial impact on the recovery of symptoms in PFPS subjects.

1.1Study Object

Students in school who reported knee pain or discomfort were assessed for patellofemoral pain or dysfunction using four tests: patellar sliding trajectory, passive patellar sliding test, lateral patellar tilt assessment, and Waldron test. Those who tested positively were included as experimental subjects. This experiment has been registered on the ISRCTN platform (www.isrctn.com; 07/02/2023; ISRCTN88098928) for transparency and accountability.

The inclusion criteria for this study are as follows: participants must be between the ages of 18 and 35, and must be able to fully cooperate with rehabilitation physical therapy and training, as well as follow-up appointments. Additionally, participants must commit to remaining in the study unless there is a valid reason for withdrawal.

The study's exclusion criteria include: ① exogenous knee injuries such as bruises, cuts, burns, and contusions, without any external bleeding or subcutaneous bleeding from skin rupture; ② abnormalities in innate bony structures; ③ the presence of inflammation, patellar dislocation or subluxation, or knee ligament injury; ④ a history of knee static surgery within the past year; and ⑤ any other injuries or discomfort in different parts of the body.

The trial recruited a total of 46 people, and ultimately selected 26 subjects with different specializations who met the criteria for PFPS, based on exclusion and inclusion criteria. These patients were then randomly divided into control (n=13) and test groups (n=13) using the random number table method (see Figure 1). Importantly, there were no significant differences in age, disease duration, or gender between the two groups (P > 0.05).See Table 1

Table 1. Comparison of general information between the two groups

Projects	Control group (n=13)	Test group (n=13)	t-value	p-value
Gender (m/f, n)	5/8	11/2	-2.132	0.054
Age (years)	22±2.12	20.92±2.18	-1.176	0.263
Height (cm)	176.08±7.24	170.54±6.63	-2.274	0.042
Body mass (kg)	74.54±13.87	60.71±10.33	-3.619	0.004
Duration of illness (weeks)	12.92±8.34	22.12±19.19	1.740	0.107

1.2 Research Methodology

The control group received IASTM treatment exclusively, while the experimental group received both IASTM treatment and Blood Flow Restriction (BFR) pressure training.

1.2.1 Control group

In order to assess the effectiveness of the treatment, the subjects were instructed to perform it in various positions. These included supine thigh flexion and knee abduction to release the anteromedial quadriceps, lateral knee flexion to target the lateral femoral muscle, supine knee flexion to release the soft tissue around the patella in the neutral knee, and the prone position to focus on the popliteal muscle group, with particular emphasis on the posterior lateral biceps femoris.To perform this technique, begin by applying fascial lubricant evenly on the treatment area. Next, use different knives to perform probing, clearing, spotting, and pressure pushing during a static relaxation period of 8 minutes per site. Then, perform muscle centripetal and centrifugal contractions on the treated area while using the fascial knife to apply pressure and slide to release for 3 minutes per site. Finally, spot relax any agonizing pain points for 1 minute per site.

1.2.2 Test group

In this subject paper, it was noted that the IASTM treatment was combined with blood flow restriction training, which utilized pressurized equipment. The treatment plan included specific movements such as seated and standing leg curls, as well as weighted hip flexion squats. Over the course of several weeks, the number of sets performed during each session increased by 3-6 sets. In this study, BFR compression training was performed 30 minutes after the subject received IASTM treatment. The compression band was placed in the proximal third of the thigh and the pressure was adjusted prior to training. The pressurization value was set at 80% of individualization based on lower extremity dimensions and self-perception. During the training, there was no further pressurization. A professional trainer supervised the entire process, correcting errors and regulating pressure values as needed.See Table 2

Table 2. Specified actions of test group

Exercise	Procedure	Frequency	Intensity	Pressurization value	Progression
Seated leg extensions	During the treatment, the subject will be positioned at the side of the bed and will alternate between sitting and standing. The compression band will be placed on the upper third of the thigh, and the subject will perform knee flexion and extension exercises. To engage the muscles fully, the subject will exhale for three seconds during a centripetal contraction and inhale for three seconds during a centrifugal contraction. At the peak of the muscle contraction, the subject will hold the position for one second.	2 times a week for 4 weeks	15-25 times in group 1 A total of 4-6 groups	Individualized 80%	In the first week, there were four groups with 15 participants in each group. In the second week, there were five groups with 20 sessions per group. The third week consisted of Group 6 with 25 sessions per group. Additionally, Group 4 had six participants and underwent 25 sessions per group.
Standing Leg Curl	In this exercise, the subject should stand with their thighs still and complete a retroflexion of the knee. They should exhale for 3 seconds during knee flexion and inhale for 3 seconds during knee extension. Additionally, they should hold the position for 1 second at the peak of muscle contraction.	2 times a week for 4 weeks	15-25 times in group 1 A total of 4-6 groups	Individualized 80%	4 groups in the first week, 15 in each group; 5 groups in the second week, 20 sessions per group; Group 6 in the third week, 25 sessions per group; Group 4, n = 6, 25 sessions per group
Weighted Hip Flexion Squat	In this subject paper, it is stated that the proper stance for a squat involves standing with your feet slightly wider than shoulder width apart, with your knees facing your toes. To perform the exercise, you should complete a hip flexion squat, inhaling for three seconds as you lower your body. Then, exhale as you extend your knees and stand up for three seconds.	2 times a week for 4 weeks	15-20 times in group 1 A total of 4 groups	Individualized 80%	4 groups in the first week, 15 in each group; 4 groups in the second week, 20 sessions per group; Group 4 in the third week, 25 sessions per group; In the fourth week in group 4, 20

1.3 Observation indicators

1.3.1 Lysholm knee score

The Lysholm score was utilized to evaluate the functional status of patients' knee joints both pre- and post-treatment. The score encompasses eight different aspects, including pain, instability, occlusion, swelling, limp, stair climbing ability, kneeling posture, and brace usage. The total score possible is 100.The instability and pain criteria were each worth 25 points, with a survey score below 65 being considered poor. A score between 65 and 83 was qualified, while a score between 84 and 94 was considered good, and a score between 95 and 100 was excellent. The higher the score, the better the lower function, allowing for the treatment effect to be judged based on the score.

1.3.2 VAS score

The level of patellofemoral pain was assessed prior to and following treatment using the Visual Analogue Scale (VAS). This scale ranges from 0 to 10, with increasing levels of pain intensity. A score of 0 indicates no pain, while a score of 10 represents intolerable pain.

1.3.3 Maximal isometric muscle strength test of lower limb extensors

The study utilized the Dr. Wolff Sports & Prevention lower extremity extensor maximum isometric strength testing system to measure strength before and after treatment. The subject was positioned with their waist and hips against the device, and both lower limbs were tested for knee extension force at a fixed angle of 90°. The test was stopped once the peak value was reached in one muscle strength test.

1.3.4 Modified Thomas test

During the MTT, the subject was instructed to sit with their hip half on the side of the bed and lie down while holding their tibia near the knee end of their healthy leg with both hands. This position allowed for observation of the femur's alignment with the bed surface. If there was an angle between the femur and the bed surface, it was considered an indication of a shortened and tense hip flexor muscle (iliopsoas muscle).During this examination, it is important to assess the condition of the affected leg. If the hip appears to be excessively abducted, the tension of the broad fascia tensor muscle should be evaluated. Conversely, if the hip is overly inward, it is necessary to assess the tension of the pubococcygeus muscle. Additionally, if the leg is in a position where the calf is inward and the femur is outward, similar to the shape of a shuttlecock, the tension of the internal femoral rotator muscle (including the suture muscle and semi-kinematic semimembranosus muscle) should be evaluated.If the angle between the knee and calf is too large, it can cause tension in the rectus femoris muscle. To accurately test this, interference from iliopsoas tension factors was excluded. The position of the mechanical axis and each joint center point of the hip-knee-ankle and lower limb hip-knee-ankle (HKA) were determined [23].In this subject paper, we use the center of the hip joint as a reference point. Specifically, we refer to the large trochanter of the femur, which is flush with the center of the femoral head and located deep in the central inguinal region. Additionally, we use the midpoint of the talus width as the axis for the center of the ankle joint.The study recorded the primary muscle groups that impact the knee joint's condition. After the IASTM treatment, the researchers performed MTT and measured the knee extension angle (at the center of the medial knee joint), hip abduction angle (at the center of the hip), and knee offset mechanical axis angle (at the center of the ankle joint, aligned with the center of the hip joint as the axis).

1.4 Statistical analysis

The data in this study were analyzed and processed using SPSS 26.0 statistical software. SPSS was used to read, test, and statistically analyze the data. The general data were analyzed using the independent samples t-test. The measurement data were found to conform to a normal distribution. Additionally, the presence of three time point measurement indicators was analyzed using repeated measures ANOVA.Paired t-tests were used before and after treatment for two time point measures. p<0.05 was considered a statistically significant difference.

2.1 Lysholm knee score

The ANOVA by repeated measurements of Lysholm knee at various time points was conducted to determine the impact of treatment on the scores. The results indicated that there was a significant effect of group change on Lysholm score (F=4.32, p=0.048), as well as a significant effect of different time point measurements on Lysholm score (F=27.97, p<0.001). These findings suggest that treatment had a positive effect on Lysholm scores, and that the scores varied significantly depending on the time point of measurement; However, there was no significant effect of group when comparing between them. It was noted that there was no significant change in Lysholm scores in either the test or control groups until after 4 weeks of treatment (P=0.005).There was a significant difference observed between two treatments and pre-treatment after the first treatment and after 4 weeks of treatment (P0.05), which was not statistically significant. The statistical results are presented in Tables 3 and 4.

Table 3. Results of two-factor repeated measures ANOVA for changes in test indicators at three time points of the Lysholm rating scale

Lysholm repeated evaluation F-test
	F	P	Bias η2
Group main effect	4.32	0.048	0.153
Point-in-time main effect	27.97	0.000	0.538
Group x time point	0.71	0.49	0.029

Table 4. Results of the comparison of the changes in test values with the mean values at three time points of the Lysholm rating scale

	Before treatment	After the first treatment	After 4 weeks of treatment	Multiple are comparable
	M±SD	M±SD	M±SD	Multiple are comparable
Test group	61.62±12.64	82.77±18.75*&	84.08±9.71*#&	Before treatment < after the first treatment < after 4 weeks of treatment
Control group	70.85±17.20	86.00±11.05*&	94.54±7.23*#&	Before treatment < after the first treatment < after 4 weeks of treatment

Note; * represents significant difference in change in Lysholm score compared to pre-treatment (p<0.05); # represents significant change between test and control groups (p=0.005); & represents no significant change in comparison between time points within groups (p>0.05).

2.2 VAS scale score results

The ANOVA with repeated measurements of the VAS scale was conducted to analyze the impact of group change and time point measurements on VAS scores. The results indicated that group change did not have a significant effect on VAS scores (F=0.45, P=0.509). However, the study found a significant effect of different time point measurements on VAS scores (F=39.20, P<0.001). Additionally, the interaction of VAS scores was significantly affected by both group and time point change (F=6.48, P=0.004).When comparing between groups; there was a significant change in VAS scores between the test and control groups only before treatment and immediately after the first treatment (P < 0.05). There was a significant difference between groups when comparing immediately after the first treatment, twice after 4 weeks of therapy, and before treatment (P< 0.05). In contrast, there was no statistically significant difference in VAS scores between the two time points immediately after the first treatment and 4 weeks later within the test group (P > 0.05), and no statistically significant difference in VAS scores between the pre-treatment and immediately after the first treatment within the control group (P > 0.05). Tables 5 and Tables 6 present the statistical findings.

Table 5. Two-factor repeated measures ANOVA results for changes in test metrics at three time points on the VAS rating scale

VAS repeated evaluation F-test
	F	P	Bias η2
Group main effect	0.45	0.509	0.018
Point-in-time main effect	39.20	0.000	0.620
Group x time point	6.48	0.004	0.265

Table 6. Results of the comparison between the changes in test values and the mean values at three time points of the VAS rating scale

	Before treatment	After the first treatment	After 4 weeks of treatment	Multiple are comparable
	M±SD	M±SD	M±SD	Multiple are comparable
Test group	23.23±13.91#	4.00±4.30*#&	2.77±3.22*&	Before treatment > after the first treatment > after 4 weeks of treatment
Control group	14.54±5.98#&	8.69±6.37*#&	2.92±5.75*	Before treatment > after the first treatment > after 4 weeks of treatment

Note; * represents significant difference in change in VAS scores compared to pre-treatment (p < 0.05); # represents significant change between test and control groups (p < 0.05); & represents no significant change in comparison between time points within groups (p > 0.05).

2.3 Comparison of pre- and post-treatment data for maximum strength of lower limb extensors

Maximum lower extremity extensor strength was only tested before treatment versus after 4 weeks of treatment. Within-group comparison; lower extremity extensor strength increased before and after treatment in both the control and test groups, with a significant difference (P < 0.001). Between-group comparison; the tested strength values did not change significantly (P > 0.05) was not statistically significant. See Table 7.

Table 7. Comparison of lower limb strength data between the two groups before and after treatment

Group	n	Before treatment	After 4 weeks of treatment	t-value	p-value
Control group	13	100.77±53.63	118.06±52.04	-5.888	<0.001
Test group	13	61.50±37.90	79.62±38.00	-6.345	<0.001
t-value		-2.045	-2.131
p-value		0.063	0.054

2.4 Modified Thomas experiment

The results of ANOVA by repeated measurements of the MTT test at different time points before treatment, after the first treatment, and at 4 weeks of treatment showed that all three groups of angle measurements had a non-significant effect on angle change, (F=0.04, F=2.37, F=1.39), (P=0.85, P=0.14, P=0.25); there was a significant effect of different time point measurements on angle change, (F= 189.95, F=119.11, F=41.18), (P<0.001); there was a non-significant interaction between group and time point on angle change for knee extension angle and knee offset angle, (F=1.83, F=1.92), (P=0.17, P=0.16); there was a significant interaction between group and time point on angle change for hip joint angle ( F=4.59, P=0.03).

When comparing between groups; there was no significant change in the values of the three angle measurements between the test group and the control group before treatment and immediately after the first treatment (P > 0.05). In the intra-group comparison; there was a significant change in the three angle measurements between immediately after the first treatment and twice after 4 weeks of treatment, and before treatment (P < 0.05). In contrast, there was no significant change (P > 0.05) in angle measurements between the immediate after first treatment and two time points after 4 weeks of treatment for knee extension angle within the test group, and no significant change (P > 0.05) in angle measurements between the immediate after first treatment and two time points after 4 weeks of treatment for knee excursion angle within the control group. The statistical results are shown in Tables 8 ，Tables 9 .

Table 8. Two-factor repeated-measures ANOVA results for joint angle change in MTT test

	Knee extension angle			Hip abduction angle			Knee joint offset angle
	F	P	Bias η2	F	P	Bias η2	F	P	Bias η2
Group main effect	0.04	0.85	0.002	2.37	0.14	0.090	1.39	0.25	0.055
Point-in-time main effect	189.95	0.000	0.888	119.11	0.000	0.832	41.18	<0.001	0.632
Group x time point	1.83	0.17	0.071	4.59	0.03	0.160	1.92	0.16	0.074

Table 9. MTT test joint angle value changes compared with the mean value results

Group	Projects	Before treatment	After the first treatment	After the final treatment	Multiple are comparable
Group	Projects	M±SD	M±SD	M±SD
Test group (n=13)	Knee extension angle	123.36±7.62	103.88±7.35*&	102.26±7.23*&	Before treatment > after the first treatment > after 4 weeks of treatment
	Hip abduction angle	29.67±10.57	13.67±4.92*a	7.13±4.24*a	Before treatment > after the first treatment > after 4 weeks of treatment
	Knee joint offset angle	16.92±10.51	7.78±3.60*a	5.38±3.13*a	Before treatment > after the first treatment > after 4 weeks of treatment
Control group (n=13)	Knee Extension	125.69±4.89	105.15±4.23*a	99.85±6.26*a	Before treatment > after the first treatment > after 4 weeks of treatment
	Hip abduction angle	40.21±15.06	13.53±6.25*a	8.47±3.01*a	Before treatment > after the first treatment > after 4 weeks of treatment
	Knee joint offset angle	12.66±4.72	6.12±2.76*&	5.43±2.89*&	Before treatment > after the first treatment > after 4 weeks of treatment

Note; * represents significant difference in angular change compared to pre-treatment in within-group comparisons (p < 0.05); a represents significant difference in angular change after first treatment and 4 weeks of treatment in within-group comparisons (p < 0.05); & represents no significant change in within-group comparisons at different time points (p > 0.05).

As the most complex joint in the body, the knee joint has a high usage rate in coordinating and stabilizing lower limb movements, which inevitably leads to injury and pain, resulting in a high incidence of knee-related disorders year-round. Most patients with knee disorders share common characteristics such as poor movement patterns, lifestyle habits and abnormal body posture. Among them, PFPS[1] has a complex and unclear pathogenesis that correlates with lower extremity functional deficits, injuries during sports, and long-term poor quality of life, and there is early evidence that abnormal pressure on the medial and lateral sides of the joint and weakness of the lower extremity joint stabilizing muscles, especially the quadriceps, hip abductors and external rotators, are associated with knee pain[9] . It is also widely accepted that knee pain may be associated with its own morphology or damaged tissues, including abnormal tension of the periprosthetic muscles and the iliotibial bundle, damaged ligaments (anterior and posterior cruciate ligaments, medial and lateral collateral ligaments), abnormal Q-angle, meniscal tears, abnormal tibial position, knee hyperextension, and limited hip motion[10-14] . However, there is no direct study to reveal the underlying cause of PFPS production. Therefore, in this study, we used IASTM treatment combined with BFR training as a therapeutic intervention for patients with PFPS by conservative treatment means to loosen the soft tissues around the knee joint and strengthen the strength of the balanced periarticular muscle groups, so as to reduce or eliminate pain, strengthen the lower limb strength, restore knee function, and improve the range of motion of the joint.

BFR training does not exert excessive joint stress on the patient. At the same time, the mechanism of action of the compression device allows for blood filling of the periarticular muscles, adequate protection of the joint, and increases the sense of muscle strength and recruitment, which has the characteristics of high safety and high training efficiency. According to Erickson[15] et al, BFR compression training helps to improve and enhance the neuromuscular recruitment of the Quadriceps Femoris Muscle (QFM) in patients with Anterior Cruciate Ligament Reconstruction (ACL-R). (QFM) neuromuscular recruitment capacity. This appears to have the same effect as IASTM treatment, and is supported by Bobes[16] et al, who showed a significant increase in QFM strength and cross-sectional area after having patients with ACL-R and knee osteoarthritis trained with BFR low load. Also Van[17] et al, by Mata analysis included eight studies implementing lower load strength training combined with BFR versus traditional QFM strength training on symptoms and function in patients with knee disorders and found that BFR increased knee extensor strength and QQFM thickness. However, traditional single quadriceps strength training has the potential to exacerbate knee symptoms. Therefore, in this study, BFR compression training was performed to strengthen knee extension strength in addition to knee flexor muscle groups and external rotation ability to improve knee stabilization strength in multiple dimensions.

IASTM therapy is effective in improving the patient's joint range of motion pain and strength[18] . It is commonly used as a non-invasive treatment modality for soft tissue (skeletal muscles, ligaments, fascia) injuries and post-operative rehabilitation[19，20] . At the same time, the pushing of the release tool on the soft tissue surface seems to activate or inhibit the fascia mesoreceptors[21] , which has been shown to be effective for delayed activation of inactivated muscle groups around the knee joint. It has been shown[22] that the IASTM intervention can raise the skin temperature of the hamstrings and maintain it for more than one hour. This external pressure stimulation increases the skin blood flow and accelerates the local metabolism, providing the fascial space for muscle congestion and tension expansion, creating the conditions for muscle strength training. Therefore, the combined follow-up BFR compression training has a multiplier effect.

Through the results of this study, it was found that IASTM had a significant effect immediately after the treatment, with immediate effect in improving soft tissue flexibility and, regulating the abnormal tension in the soft tissues of the stabilized joint, reducing the unbalanced stress on the knee joint, reducing the wear and tear within the joint, and creating a good mechanical environment for it, thus reducing or eliminating musculoskeletal pain. Then, the patient uses BFR training in the pain-free state of the lower limb joints, after the equipment pressure makes the lower limb as a whole, especially the knee joint, blood filling, strength increase, muscle proprioception enhancement, and training the peripheral muscle groups of the knee joint in the correct movement trajectory, which can greatly improve the efficiency and efficiency of the training and make the stability of the knee joint in three-dimensional space enhanced. In summary, IASTM treatment combined with BFR compression training improves the symptoms of patellofemoral joint pain, limited range of motion, and muscle weakness in order to improve knee mobility, strengthen the muscle strength of the flexor and extensor groups, and restore the knee joint and other functions. Ultimately, the patient's motor ability is enhanced, and the strength and function of the lower extremity is improved to achieve the purpose of treating PFPS. Due to the low sample size, short treatment intervention period, lack of comprehensive and objective quantitative indexes, and the fact that the study population was mostly athletes, this study has some limitations. In future studies, we can expand the sample size, target multiple populations, and adopt more objective indicators to make the effect of combined therapy more reliable.

Ethics approval and consent to participate

It is confirmed that informed consent has been obtained from all subjects and/or their legal guardians, and that the experiment has been approved by the Wuhan Sports University ethical review of human experimentation.Confirm that all methods are carried out in accordance with the relevant guidelines and regulations.This experiment has been registered on the ISRCTN platform（www.isrctn.com；07/02/2023；ISRCTN88098928）.

Consent for publication

Not Applicable.

Data Availability Statement

The data underlying this paper, which includes the privacy of the individuals involved, cannot be made public for the following reasons. These data will be shared with the respective authors upon reasonable request.If you need the data, you can contact me via my email.[email protected]

Competing interests

All authors declare that they have no competing interests.

Funding

This research received no external funding.

Author Contributions:Liuyang completed the design and implementation of the experiments, the processing of the data, and the writing of the thesis. Wulianqing was responsible for the final review and revision of the thesis.All authors have read and agreed to the published

version of the manuscript.

Acknowledgment;Not Applicable

Author details：¹Wuhan Sports University, No. 461 Luoyu Road, Hongshan District, Wuhan, Hubei Province, China.1The first author is a master's student, majoring in sports training, research direction sports rehabilitation and injury.Liuyang has been a physiotherapist and sports rehabilitator for five years and currently works as a physiotherapy and physical rehabilitation training coach for the national team.

Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral pain syndrome[J]. Am Fam Physician. 2019;99(2):88–94.
Xu L, Ma M, Zhao XH, et al. Efficacy of core muscle group stability training on patellofemoral joint pain syndrome [J]. Chin J Rehabilitation Med. 2018;33(11):1314–7.
Sinaei E, Foroozantabar V, Yoosefinejad AK, Sobhani S, Motealleh A. Electromyographic comparison of vastus medialis obliquus facilitatory versus vastus lateralis inhibitory kinesio taping in athletes with patellofemoral pain: a randomized clinical trial.J Bodyw Mov Ther.2021Oct;28:157–163.
Ikeda N, Otsuka S, Kawanishi Y, Kawakami Y. Effects of Instrument-assisted Soft Tissue Mobilization on Musculoskeletal Properties. Med Sci Sports Exerc. 2019 Oct;51(10):2166–72.
David XU, Jian WU, Peijun GUI, Ying XIE. Effects of lower limb blood flow restriction based on limb linkage training on cardiopulmonary endurance, lower limb muscle endurance and balance function in healthy young adults[J].Chinese Rehabilitation Theory and Practice,2021,27(12):1470–1475.
Whiteley R. Blood Flow Restriction Training in Rehabilitation: a Useful Adjunct or Lucy's Latest Trick? J Orthop Sports Phys Ther. 2019 May;49(5):294–8.
Wortman RJ, Brown SM, Savage-Elliott I, Finley ZJ, Mulcahey MK. Blood Flow Restriction Training for Athletes: A Systematic Review. Am J Sports Med. 2021 Jun;49(7):1938–44.
Miller BC, Tirko AW, Shipe JM, Sumeriski OR, Moran K. The Systemic Effects of Blood Flow Restriction Training: A Systematic Review. Int J Sports Phys Ther. 2021 Aug;16(2):978–90.
Lack S, Barton C, Sohan O, Crossley K, Morrissey D. Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. br J Sports Med. 2015;49(21):1365–76.
Zou L, Yang Y, Wang Y. a Meta-Analysis of Systemic Evaluation of Knee Ligament Injury or Intervention of Knee Proprioceptive Function Recovery.J Healthc Eng. 2022 Feb 17;2022:9129284.
Cronström A, Creaby MW, Ageberg E. Do knee abduction kinematics and kinetics predict future anterior cruciate ligament injury risk? A systematic review and meta-analysis of prospective studies.BMC Musculoskelet Disord. 2020 Aug20;21(1):563.
Markström JL, Tengman E, Häger CK. ACL-reconstructed and ACL-deficient individuals show differentiated trunk, hip, and knee kinematics during vertical hops more than 20 years post-injury. Knee Surg Sports Traumatol Arthrosc. 2018 Feb;26(2):358–67.
Giesche F, Stief F, Groneberg DA, Wilke J. Effect of unplanned athletic movement on knee mechanics: a systematic review with multilevel meta-analysis.Br J Sports Med.2021Dec;55(23):1366–1378.
Akpinar B, Thorhauer E, Irrgang JJ, Tashman S, Fu FH, Anderst WJ. Alteration of Knee Kinematics After Anatomic Anterior Cruciate Ligament Reconstruction Is Dependent on Associated Meniscal Injury. Am J Sports Med. 2018 Apr;46(5):1158–65.
Erickson LN, Lucas KCH, Davis KA, Jacobs CA, Thompson KL, Hardy PA, Andersen AH, Cs F. Noehren Bw.Effect of Blood Flow Restriction Training on Quadriceps Muscle Strength, Morphology, Physiology, and Knee Biomechanics Before and After Anterior Cruciate Ligament Reconstruction: Protocol for a Randomized Clinical Trial. Phys Ther. 2019 Aug 1;99(8):1010–1019.
Bobes Álvarez C, Issa-Khozouz Santamaría P, Fernández-Matías R, Pecos-Martín D, Achalandabaso-Ochoa a, Fernández-Carnero S, Martínez-Amat A, Gallego-Izquierdo T. Comparison of Blood Flow Restriction Training versus Non-Occlusive Training in Patients with Anterior Cruciate Ligament Reconstruction or Knee Osteoarthritis: A Systematic Review. j Clin Med. 2020 Dec;27(1):68.
Van Cant J, Dawe-Coz A, Aoun E, Esculier J. Quadriceps strengthening with blood flow restriction for the rehabilitation of patients with knee conditions: a systematic review with meta-analysis. j Back Musculoskelet Rehabil. 2020;33(4):529–44.
Seffrin CB, Cattano NM, Reed MA, Gardiner-Shires AM. Instrument-Assisted Soft Tissue Mobilization: a Systematic Review and Effect-Size Analysis. J Athl Train. 2019 Jul;54(7):808–21.
Jones ER, Finley MA, Fruth SJ, Mcpoil TG. Instrument-Assisted Soft-Tissue Mobilization for the Management of Chronic Plantar Heel Pain: A Pilot Study. j Am Podiatr Med Assoc. 2019 May;109(3):193–200.
Kim J, Sung DJ, Lee J. Therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application.j Exerc Rehabil. 2017 Feb28;13(1):12–22.
Ge W, Roth E, Sansone A. A quasi-experimental study on the effects of instrument assisted soft tissue mobilization on mechanosensitive neurons. j Phys Ther Sci. 2017 Apr;29(4):654–7.
Fousekis K, Varda C, Mandalidis D, Mylonas K, Angelopoulos P, Koumoundourou D, Tsepis E. Effects of instrument-assisted soft-tissue mobilization at three different application angles on hamstring surface thermal responses. J Phys Ther Sci. 2020;32(8):506–9.
Pei Y, Yang W, Wei S, Cai r, Li J, Guo S, Li Q, Wang J, Li X. Automated measurement of hip-knee-ankle angle on the unilateral lower limb X-rays using deep learning. Phys Eng Sci Med. 2021 Mar;44(1):53–62.

No competing interests reported.

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Effect of Instrument-Assisted Soft Tissue Mobilizatio combined with blood flow restriction training on function, pain and strength of patients with patellofemoral joint pain

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