Name: Vascular Occlusion Training for Inclusion Body Myositis: A Novel Therapeutic Approach (Video) | JoVE Journal
Uploaded: 2010-06-05T17:00:00.000+00:00
Duration: 9 min 1 s
Description: Explore vascular occlusion training for Inclusion Body Myositis using resistance exercise with blood flow restriction. This method safely improves muscle strength and function in IBM patients without increasing inflammation.

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5 minutes

We would like to thank Mr. Julio Maia for participating in this video and Mr. Joel S. Torres for reviewing the manuscript. Bruno Gualano is supported by Conselho Nacional de Pesquisa e Tecnologia.

1. Determination of full vascular occlusion pressure
<ol>
 <li>In order to determine the blood pressure of vascular occlusion, in mmHg, a vascular Doppler is used</li>
 <li>The patient lies in a supine position while a customized blood pressure cuff (180mm length x 80mm width) is fixed on his thigh.</li>
 <li>After detection of the tibial artery location, the Doppler's probe is then placed over the determined spot in the patient's leg.</li>
 <li>A sound signal is generated by the Doppler machine as it captures the artery pulse.</li>
 <li>The customized blood pressure cuff is then inflated until it interrupts the ascultatory pulse of the tibial artery.</li>
 <li>The pressure required for full vascular occlusion is registered for future use during training.</li>
 <li>For safety reasons, arterial blood pressure is also monitored.</li>
</ol>
2. Resistance training with vascular occlusion
<ol>
	<li>A brief warm-up on a treadmill (5 min walk at a comfortable pace) is recommended prior to exercise</li>
	<li>The patient is then positioned on the strength training equipment. A conventional leg press machine is used</li>
	<li>Two pressure cuffs are now positioned near the inguinal fold region on each thigh and inflated to the correspondent training pressure (50% of full vascular occlusion pressure).</li>
	<li>At this time, it is important to keep the manometers facing forward, for fine tuning of the appropriate pressure.</li>
	<li>The patient performs 3 sets of 15 repetitions, with 30 seconds rest periods between sets.</li>
	<li>Note that training pressure is maintained during the whole exercise session, including resting intervals.</li>
	<li>A conventional leg extension machine is also part of our exercise program. The same protocol is used on this equipment, and again, occlusion pressure is kept constant at all times.</li>
	<li>The last exercise is the half squat. A chair may be used for safety reasons, since the impaired strength ability of the IBM patient. Blood flow occlusion procedure follows the same pattern as the previous exercises</li>
	<li>Training intensity is adjusted according to the gradual increase in strength so the patient would be able to perform no more than 15 repetitions. We recommend that training sessions are monitored by at least two investigators, each one controlling the occlusion pressure on each leg.</li>
</ol>

<ol><li>Needha, M., Mastaglia, F. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Inclusion+body+myositis%3A+current+pathogenetic+concepts+and+diagnostic+and+therapeutic+approaches%5BTitle%5D)+AND+%22Lancet+Neurol%22%5BJournal%5D)">Inclusion body myositis: current pathogenetic concepts and diagnostic and therapeutic approaches.</a> Lancet Neurol. 6, 620-631 (2007).</li>
<li>de Salles Painelli, V., Gualano, B., Artioli, G. G., de Sa Pinto, A. L., Bonfa, E., Lancha Junior, A. H., Lima, F. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+possible+role+of+physical+exercise+on+the+treatment+of+idiopathic+inflammatory+myopathies%5BTitle%5D)+AND+%22Autoimmun.+Rev%22%5BJournal%5D)">The possible role of physical exercise on the treatment of idiopathic inflammatory myopathies.</a> Autoimmun. Rev. 8, 355-359 (2009).</li>
<li>Spector, S. A., Lemmer, J. T., Koffman, B. M., Fleisher, T. A., Feuerstein, I. M., Hurley, B. F., Dalakas, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Safety+and+efficacy+of+strength+training+in+patients+with+sporadic+inclusion+body+myositis%5BTitle%5D)+AND+%22Muscle+Nerve%22%5BJournal%5D)">Safety and efficacy of strength training in patients with sporadic inclusion body myositis.</a> Muscle Nerve. 20, 1242-1248 (1997).</li>
<li>Gualano, B., Neves, M. Jr, Lima, F. R., de Sá Pinto, A. L., Laurentino, G., Borges, C., Baptista, L., Artioli, G. G., Aoki, M. S., Moriscot, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Training+with+Vascular+Occlusion+in+Inclusion+BodyMyositis%3A+A+Case+Study%5BTitle%5D)+AND+%22Med.+Sci.+Sports+Exerc%22%5BJournal%5D)">Training with Vascular Occlusion in Inclusion BodyMyositis: A Case Study.</a> Med. Sci. Sports Exerc. , Forthcoming Forthcoming.</li>
<li>Takarada, Y., Takazawa, H., Sato, Y., Takebayashi, S., Tanaka, Y., Ishii, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effects+of+resistance+exercise+combined+with+moderate+vascular+occlusion+on+muscular+function+in+humans%5BTitle%5D)+AND+%22J.+Appl.+Physiol%22%5BJournal%5D)">Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans.</a> J. Appl. Physiol. 88, 2097-2106 (2000).</li>
</ol>

We presented a novel, and likely the first, non pharmacological therapeutic tool able to counteract the muscle atrophy and decline of strength that usually occurs in patients with IBM under conventional treatment. Resistance training with vascular occlusion is a relatively novel training method, but results are very encouraging. We have found that after a 12-wk training program, an IBM patient's leg press one-repetition maximum, balance and mobility function, and thigh cross-sectional area increased 15.9%, 60%, and 4.7%,...

<table><tbody><tr><td>Vascular Doppler</td><td></td><td></td><td></td></tr><tr><td>Treadmill (optional)</td><td></td><td></td><td></td></tr><tr><td>Two customized tourniquets cuffs with pressure manometers</td><td></td><td></td><td></td></tr><tr><td>Conventional blood pressure cuff</td><td></td><td></td><td></td></tr><tr><td>Leg extension machine</td><td></td><td></td><td></td></tr><tr><td>Leg press machine</td><td></td><td></td><td></td></tr><tr><td>Ankle weights</td><td></td><td></td><td></td></tr></tbody></table>

vascular occlusion training for inclusion body myositis: a novel therapeutic approach

Vascular Occlusion Training for Inclusion Body Myositis: A Novel Therapeutic Approach

Inclusion body myositis (IBM) is a rare idiopathic inflammatory myopathy. It is known to produces remarkable muscle weakness and to greatly compromise function and quality of life. Moreover, clinical practice suggests that, unlike other inflammatory myopathies, the majority of IBM patients are not responsive to treatment with immunosuppressive or immunomodulatory drugs to counteract disease progression1. Additionally, conventional resistance training programs have been proven ineffective in restoring muscle function and muscle mass in these patients2,3. Nevertheless, we have recently observed that restricting muscle blood flow using tourniquet cuffs in association with moderate intensity resistance training in an IBM patient produced a significant gain in muscle mass and function, along with substantial benefits in quality of life4. Thus, a new non-pharmacological approach for IBM patients has been proposed. Herein, we describe the details of a proposed protocol for vascular occlusion associated with a resistance training program for this population.

The present article presents the details pertaining to the application of resistance training associated to vascular occlusion in IBM patients.

Inclusion body myositis (IBM) is a rare idiopathic inflammatory myopathy. It is known to produces remarkable muscle weakness and to greatly compromise ...

Inclusion body Myo or IBM is a rare inflammatory myopathy occurring at approximately 15 people per million, and it usually affects people at mid age and beyond. The pathogen is of this acquired myopathy is still unknown, but some studies have reviewed histological evidence of inflammation in the affected muscle. The major feature of this disease is a remarkable muscular atrophy leading to proximal and distal weakness.Evidence-based IBM treatment is lacking largely due to a very low prevalence of this disease. The clinical practice suggests that most patients are not responsible to treatment with immunosuppressive drugs until few years ago. Physicians have contraindicated physical exercise to patients with inflammatory myopathies because they believe that it could increase inflammation in the affected muscles.These recommendations have changed after a few recent studies suggesting that physical exercise is safe for these patients. Therefore, low intensity physical training has been prescribed for patient with stable disease in order to improve muscle function. However, low intensity exercise does not seem affected to improve muscle hypertrophy and strength.Instead, high intensity exercise is required to achieve these goals since high intensity exercise may increase the inflammatory response. The ideal type of exercise intervention for IBM patients should increase muscle strength and cross-sectional area while minimizing exercise intensity. A new approach to exercise training has been suggested recently.In this regard, it has been observed that restricting muscle blood flow using tourniquet cuts during moderating test exercise, produce a greater benefits as compared to high intense exercise training. These findings have been demonstrating athletes, the frail, elderly, and inpatients undergoing rehabilitation after surgery. The clinic complication of this intervention may be of particular interest to IBM patients, even though the mechanisms by which vascular occlusion affects muscle mass and strains remaining clear following, we are going to introduce you to the details of the use of vascular occlusion training protocol.The patient lies in a supine position while a customized blood pressure cuff is fixed on his thigh. The tibial artery location is detected. A vascular dopper is used in order to determine the blood pressure for full vascular occlusion.The Doppler probe is placed over the determined spot in the patient's leg. A sound signal is generated by the Doppler machine as it captures the arterial pulse. The customized blood pressure cuff is then inflated until it interrupts the exclusatory pulse of the tibial artery.The pressure required for full vascular occlusion is registered for future use during training.Wow.Wow. Wow, wow, wow, wow. The patient is submitted to a brief warmup on a treadmill.Two pressure cuffs are positioned near the inguinal fold region on both sides and inflated to the training pressure. In our study involving IM patients, the training pressure protocol was established as 50%of the full vascular occlusion pressure. The conventional leg press machine is used.The patient performs three sets of 15 repetition maximum. He takes a 32nd rest between sets. The cuffs pressure is maintained during the whole session, including intervals leg extension.Exercise is the next step in our program. The same protocol is used on this exercise. The occlusion pressure is again, kept constant.The last exercise is the half squat. A chair is used for safety reasons since the impaired strength ability of the IBN patient blood flow occlusion follows the same pattern as the previous exercises. Training intensity was adjusted according to the gradual increase in the patient's strength.In order to maintain exercise volume within a 15 repetition maximum, we recommend that training sessions are monitored by at least two physical trainers, each one controlling the occlusion pressure on each leg. Resistance exercise training with vascular occlusion is a relatively novel training method, but results are very encouraging. There is a growing body of evidence indicating the safety of short-term training with cuff occlusion.Moreover, it has recently been reported that except for acute muscle pain, no adverse effects are observed when using this exercise method. In fact, we have employed the previously suggested exercise program with very interesting results in an IBM patient thigh, cross-sectional area, and all the SF 36 subscales. A quality of life inventory indicated significant patient progress.

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Explore vascular occlusion training for Inclusion Body Myositis using resistance exercise with blood flow restriction. This method safely improves muscle strength and function in IBM patients without increasing inflammation.

Vascular Occlusion Training for Inclusion Body Myositis: A Novel Therapeutic Approach

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