Manual Medicine Through Occlusion: Healing with your Hands, Fingers, Elbows, Thumbs…

Vinita Chandra Mody, Founder of Stroma Physical Therapy and ICT by Stroma™

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Can you imagine the ability to elicit healing mechanisms that improve tissue damage and functional outcomes through a manual therapy technique? By briefly occluding the arterial supply of tissues at specific points throughout the body, we can protect and promote the integrity of the tissues using the body’s own natural mechanistic defenses. This method of occlusion is termed Ischemic Conditioning (IC).

Over the past 30 years, medical research has shown and proven that occluding blood flow using IC can improve tissue damage by 30–60% in many tissue types. Murry et al. (1986) first demonstrated in an animal model that occluding the Circumflex Coronary Artery using four 5-minute bouts of occlusion with 5-minute reperfusion phases in between (also known as Ischemic/Reperfusion cycles or I/R cycles) as an intervention just prior to a lethal ischemic dose of the same artery, reduced the zone of risk of Myocardial Infarction (MI) by 75%. This seminal research demonstrated the intriguing concept of Pre-Conditioning (Pre-C) where an ischemic intervention can be provided prior to a lethal ischemic event and, ironically, mitigate tissue damage in the target organ. Soon, other researchers began exploring the curious nature of this effect, the physiological mechanisms at play, and similar results were seen in other organ tissues, including the brain, liver, pancreas, digestive tract, skin, and musculoskeletal tissues. Additionally, the mechanisms also worked when the intervention was applied during and after the lethal ischemic event, known as Per-Conditioning (Per-C) and Post-Conditioning (Post-C), respectively. With the evolution of a Per-C and Post-C model, the method could be used as a form of treatment and not just prevention of a high-risk population. In conjunction with this research, there was a spatial evolution for the method and it was discovered that applying occlusion at a remote site, called Remote Ischemic Conditioning (RIC), also demonstrated similar effects. Applying an ischemic intervention at any major arterial branch throughout the body, distant from the target organ, still confers protection from ischemic injury. Ren et al. (2009) showed in a murine model that applying ipsilateral Post-C femoral artery I/R cycles after a Middle Cerebral Arterial (MCA) ischemic stroke demonstrated improvements in brain damage by 43%-67%.

IC has also demonstrated positive effects in orthopedics by reducing the impact of injury and by enhancing sports performance. Murphy et al. (2010) looked at the effects of Pre-C on gene expression of skeletal tissue of patients undergoing a Total Knee Replacement (TKR). They found that there was a protective genomic response which increased defense against oxidative stress and improved pro-survival functions for the Pre-C group who underwent 3 I/R cycles of 5 mins just prior to surgery when compared to the control. Bailey et al. (2012) demonstrated that preconditioning using bilateral leg occlusion increased 5-km time trial running performance in healthy individuals and attenuated a rise in blood lactate concentrations at a given workload during a submaximal incremental running test. In a related topic, Zhao. et al (2018) compared the effects of chronic long-term doses of RIC to regular exercise and concluded that chronic RIC-mediated beneficial effects similar to exercise-related favorable effects and could have widespread health benefits for those that are unable to exercise due to injury or disease.

What does this mean for rehabilitation specialists?

A general clinical consensus regarding IC exists that there is consistent evidence among diverse models and species that brief I/R cycles applied in local or remote tissues confers cytoprotection against tissue damage. With this consensus, a manual therapy technique targeted to elicit similar mechanistic effects as IC is plausible and, perhaps even more effective than the methods used in traditional IC models. Traditional methods have used tourniquets, clamps or cuffs, which have inherent risks of neural damage and poor patient compliance due to the discomfort with the methodology. Manual therapists can provide similar occlusive effects at arteries throughout the body by using specific hand placement when treating patients more safely and just as effectively. Arming rehabilitation specialists with a heightened awareness of vascular supply through a sophisticated method that mimics Ischemic Conditioning, stands not only to improve one’s senses when treating patients but also allows for improved patient outcomes and tissue healing in areas such as orthopedics, sports injuries, neurology, cardiology and wound care.
An Ischemic Conditioning (IC) manual therapy technique exclusively for rehabilitation specialists has the potential to be used as a:

  • Method to manually dose patients locally and/or remotely which can be embedded into current manual treatment approaches
  • Preconditioning method for biological protection and enhancement in high-risk injury populations such as elite athletes, high-risk cardiac and stroke patients
  • Postconditioning method for the treatment of musculoskeletal injuries and other organ injuries such as MI, stroke, Traumatic Brain Injury (TBI), burns and other forms of ischemic injuries in the body
  • Method to chronically dose patients in a variety of population settings, as rehabilitation specialists have opportunities for repetitive long-term interactions with patients

References:
Bailey, T.G., Jones, H., Gregson, W., Atkinson, G., Cable, N., Thijssen, D. (2012). Effect of Ischemic Preconditioning on Lactate Accumulation and Running Performance. Med. Sci. Sports Exercise. Vol. 44, №11, pp. 2084–2089.
Murphy, T., Walsh, P., Doran, P., Mulhall, K. (2010). Transcriptional responses in the adaptation toischaemia-reperfusion injury: a study of the effect of ischaemic preconditioning in total knee arthroplasty patients. Journal of Translational Medicine. Vol. 8, №1, pp. 1.
Murry, C. E., Jennings, R. B., & Reimer, K. A. (1986). Preconditioning with ischemia: A delay of lethal cell injury in ischemic myocardium. Circulation. 74(5), 1124–1136.
Ren, C., Yan, Z., Wei, D., Gao, X., Chen, X., & Zhao, H. (2009). Limb remote ischemic postconditioning protects against focal ischemia in rats. Brain Research. 1288, 88–94.
Zhao, W., Li, S., Ren, C., Meng, R., Ji, X. (2018). Chronic Remote Ischemic Conditioning May Mimic Regular Exercise: Perspective from Clinical Studies. Aging Dis. Feb; Vol. 9(1), pp. 165–171.

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