A Physical Therapist’s Choke-hold

If you play an aggressive game of tennis and develop tennis elbow, would you want me to choke you? If you are a patient ready to undergo a total knee replacement, would you want me to choke you? If you are an athlete who repeatedly hits your head in a game, would you want me to choke you? Sounds scary right? No asphyxiation fans in the audience? Well I’m here to tell you that choking is not necessarily a bad thing. In fact, it may help you recover if you are injured — and it may even save an organ.

I am a physical therapist who has practiced for close to 15 years, primarily in New York City. I continue to rely on my best and wisest tools, my hands, to help patients recover from a variety of orthopedic injuries. I have never been the kind of PT who puts people into a corner and asks them to do a few exercises. I am an involved “manual” therapist.

A manual therapist is a physical therapist who uses their hands to help facilitate injury recovery by employing a variety of techniques. As a manual therapist with a long history of using touch in my practice I recognized that there are patterns in patient responses to therapy.

Here’s one example. I’ve used belts in my practice ever since I can remember. In fact, I still have the very first belt I purchased in 2004. It was while performing “a lateral glide of the hip joint,” a common technique used in physical therapy to improve hip mobility, that I discovered that patients were feeling pulses in their inner thigh. When I released the belt, these same patients would describe a feeling of warmth in their leg, a warm surge, or washout of blood, and suddenly not only was their hip improved, but so was the knee pain they had been experiencing. In some people their ankle range of motion suddenly increased. They described this feeling of instant magic and a sense of mysticism about what they had just experienced. They called me a witch or magician. I appreciated their flattery, but as a scientist I was offended. I needed to understand the logic behind what they were experiencing. What was it about doing a “lateral hip glide,” a relatively mundane mobilization technique that most physical therapists learn in school, that could improve other ailments, and why wasn’t there any discussion of the blood flow response in the PT literature?

After digging further, I learned that when I partially blocked the blood flow at the hip with the belt, in a sense choking off the blood supply to the femoral artery, something was accumulating in the blood that then distributed to the rest of the limb during the washout to impact the knee and the ankle. Conventional wisdom and theory have stated that healing happens when there is an abundance of blood supply, but what I was producing was the opposite. Less was turning out to be more.

Since I am a manual therapist, my natural next step was to see if I could replicate the effect of the belt with my hands as well as perform this technique on other areas of the body. It turns out that I was able to use my hands and get similar responses in the upper limbs and many other areas of the body, like parts of the trunk and face, which are normally difficult areas to occlude. Interestingly, my hands became acutely sensitive to feeling the reduction of blood flow and the restoration of it as well through changes in pulses. You may have heard about other techniques in rehabilitation that do use tourniquets, blood pressure cuffs, and bands to restrict blood flow during exercise with the intention of increasing muscle mass and strength. This method requires vetting from the medical community, as patients are not only being occluded by these devices but are exercising while wearing one.

My methodology and intention are totally different. I use my hands (and belts occasionally) to partially block blood vessels with a necessary blood-borne washout step afterward. The intention is to promote tissue recovery and not necessarily muscle strength.

With lots of repetition and practice, I devised a full body curriculum to train practitioners to use their hands to create partial blood flow occlusions to treat musculoskeletal tissue injuries after an injury has occurred. I call this method Ischemic Conditioning Techniques, or ICT. Ischemic means to restrict blood supply to tissues. Conditioning means to train. Techniques are a methodology.

Let me give you a real-life example of where we’ve used Ischemic Conditioning successfully. My patient Jane Doe came in with swollen, discolored and painful knees from Lyme Disease. She was treated for three sessions over one and a half weeks, during which I partially occluded her femoral artery at the thigh, using my hands, and again at the femoral artery closer to the knee. In the photo below you can see her improvement after occluding her three times for 3 minutes with 2-minute washout (or reperfusion) phases in between. She also managed to get a tan once she felt better and started walking outside in shorts.

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Before
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After

There are several other examples where ischemic conditioning has been successful. We’ve treated tennis elbow, or lateral epicondylitis, by partially occluding the radial artery in the forearm taking as little as one session to improve patients’ pain and function. We’ve also used this technique to treat orofacial/jaw pain such as Temporomandibular Joint Dysfunction or TMD. If you place your fingers in front of the tragus, which is that small pointed projection you feel at the front of your ear, you may feel the pulse of the superficial temporal artery. (If you can’t feel it, don’t worry; it’s a very subtle pulse.) While you are feeling it, let me tell you what we would do as practitioners. We would press slightly off the artery, never on the artery, and slide our fingers forward to create tension across the artery (towards the nose). And we would hold that spot from 30 seconds to 5 minutes. We may even do this with our finger inside the mouth to increase the compression. When we release the occlusion the practitioner and/or the patient may feel the blood and warmth return. Imagine our success with NYC clenchers! So far what I have described are treatments that we employ when an injury exists. Call it a form of post-injury conditioning or ischemic post-conditioning. That is what we do in my practice.

However, this begs the question, does ischemic pre-injury conditioning as a treatment exist? Let’s call it ischemic pre-conditioning. Pre-conditioning of tissues is where this whole story begins. It all started in heart research. Let me remind you that when you obstruct blood flow to the heart, this is what causes a heart attack. But what some gutsy researchers did in 1986 is occluded blood vessels to the heart as a form of treatment for a future planned heart attack in anesthetized dogs. What they found was quite remarkable. Providing brief and transient blood flow occlusions with restoration phases in between decreased tissue injury by 75% when compared to the control.

Other organs became areas of focus through the 90s and 2000s. Not only the heart, but also the brain, the digestive tract, kidneys, lungs, liver and skeletal tissue were showing promise of protection and repair with Ischemic preconditioning and post-conditioning. But could researchers find a safer methodology? It’s not easy to repeatedly clamp a coronary artery in a clinical setting, is it? Much less find willing participants. In 2002, researchers found that similar heart protection could occur by occluding the brachial artery, the artery found in your upper arm. Other studies soon followed demonstrating that the femoral artery, the artery I used to post-condition my Lyme Patient, also demonstrated protective effects at remote/distant organs. Yes, briefly and transiently choking blood vessels in the thigh or upper arm could protect and treat the remote organ such as the heart or the brain. You did not need to cut the patient open and block the blood flow internally. Simply using tourniquets, blood pressure cuffs and maybe even one’s hands, as I was seeing in my own clinic on the arm or leg was much more clinically feasible. This came to be called Remote Ischemic Conditioning.

Taking this idea of clinical applicability one step further, researchers began to look at whether full occlusion was necessary to produce the local and remote effects as tourniquets/clamps/blood pressure cuffs also have some risks of use. It turns out that reducing the intensity of occlusion and making it partial could also create an optimal response — but the blood borne washout, or reperfusion, was a critical step. Finally, increasing the dosing schedule or performing chronic ischemic conditioning showed a dose-dependent response. The more often we could perform this technique daily prior to or after an injury the better the effect. So, you may be wondering how does this all really work? How does brief repeated bouts of occlusion elicit protect a remote organ and do so before the injury? The critical washout phase, that I keep referring to, the same blood borne washout that occurs when I use my belt and my hands on a patient, is key to the method.

Once the arteries are stressed, or blocked, during an occlusion, the arterial walls themselves release anti-inflammatory molecules that accumulate in the area of the occlusion. Once the occlusion is released, the molecules themselves get redistributed through the circulatory system and the whole-body benefits. Also choking off an artery is stressful, and the body recognizes the stress. The body begins to prepare itself for a future stressful event, just how a vaccine works.

So how do we predict a future stressful situation in the body, to know who to target for preconditioning as a treatment? Do we have to be psychic? I can think of 2 examples. The example that affects my field is the total hip and total knee replacement patients. “Pre-ops” are sessions where health care practitioners prepare a patient for a future surgery with exercises and information. Why couldn’t ischemic preconditioning help here, too? Currently there are several studies that have shown how preconditioning a total knee replacement before the procedure can reduce the impact of injury by increasing the response to inflammation. Ischemic conditioning and the pre-op for Elective total knee replacement and total hip replacement could work well together.

Who else undergoes a predictive stressful event, maybe in their brain?

Recently, Traumatic Brain Injury has become another area of focus in the field of Ischemic preconditioning, specifically Chronic Traumatic Encephalopathy, or CTE. Elite athletes such as pro football players, boxers, mixed martial artists, hockey players and soccer players, as well as the military, are among the healthiest subjects at risk of accumulating tremendous organ damage. To date, there is no single effective treatment to reduce the effects of CTE in humans.

The National Institutes of Health has sponsored two neuropathological groups who are taking on the great challenge of figuring out diagnostic features of CTE. Currently, an elevation of the infamous Tau protein, which creates specific formations called neurofibrillary tangles, are considered the hallmark traits of CTE. Unfortunately, the subjects have to be dead for it to be diagnosed. The NIH’s goal is to identify imaging tools that can be used to detect CTE in living beings which may take years to develop. And time is ticking.

Ischemic preconditioning studies are already demonstrating promise as safe technique in treating traumatic brain injuries, but further investigation is needed. Applying these brief choke holds as a method could potentially be the panacea needed as we struggle to define diagnostic criteria for CTE in the living. And because those who study brain trauma say that it is the accumulation of benign nontraumatic blows, rather than one strong forceful blow, that can cause CTE in athletes, there is hope that treatment can begin before these injuries occur, using ischemic conditioning to physiologically prime the athletes for impact. I am not attempting to tamper with return to play rules as the rules are clearly established by the Centers for Disease Control and Prevention. Good sportsmanship, protective gear and regulations are still critical to injury-free play. I am simply trying to bring some hope and optimism to those playing football and other contact sports.

How about you? Do you have any predictive stressful events that you can foresee? Are you planning to sit at a desk hunched over a computer? Taking another HIIT class soon or playing a game of soccer in a rec league? Many different people of all ages are suffering from injury and impacting our healthcare system. Using brief, repetitive chokeholds with washout phases in between can help treat a problem if it exists and prevent one if it looms. Ischemic Conditioning may be the medicine we all need.

So, who wants to get choked?

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