Info Spot: Past Issues

Controlled Whole Body Vibration in the Treatment of Low Back Pain

Introduction

In Australia, if one is to believe the popular press and web site advertising relating to the fitness industry, the application of controlled whole body vibration (cWBV) technology, whereby controlled vibrations are applied to either the resting or exercising human body, has now literally “taken the world by storm”. It is further alleged that some high profile football clubs, and probably other sporting organisations, own and use these devices “behind closed doors”.

I think that it must actually be a “storm in a teacup”, because if one actually visits fitness centres, visits gym equipment suppliers, or talks to fitness instructors, few know much about it, and some have never even heard of these devices!

A quite small number of well-informed physiotherapists are aware of it, and some are even using such a device to assist with the rehabilitation of various musculoskeletal disorders and injuries.

Some research, and design and development facilities such as universities and various space programs including NASA are seriously investigation the potential of these devices. But by and large, their safety and efficacy (especially with regards to some of the “colourful” fitness benefit claims) are yet to be determined.

Some of the cWBV potential applications are in relation to:-

• Fitness/sport industry
• Elderly
• Microgravity
• Rehabilitation – knee reconstruction/low back pain
• Specific medical conditions – diabetes/chronic fatigue syndrome/fibromyalgia syndrome/Parkinson’s disease/stroke/cerebral palsy

Despite very large numbers of research articles and studies that have been published in medical and paramedical journals, it seems that there has been only one study 1 presented (in 2002), quite a small randomised control trial, investigating the possible benefit of repeated short sessions of cWBV on those with chronic low back pain.

Controlled whole body vibration will have a place in the world (and beyond!), but that place is yet to be determined.

 

What is Controlled Whole Body Vibration?

The human body is constantly interacting with the external environment, experiencing various externally applied forces. Some of these forces will be constant and smooth in nature, while others will involve sudden impacts (or jarring), or continuous but unsteady (vibrating type) forces. Most of the forces will induce vibrations and oscillations within the tissues of the body 2. The body relies on a range of structures (the various tissues and joints) and mechanisms (eg. muscle contraction/changes in posture) to regulate the transmission of impact shocks and vibrations throughout the body.

Irregular and random vibration “exercising” machines could be devised, generating white noise like vibration, but, to date, this has not been done.

Controlled Whole Body Vibration (cWBV) is the utilisation of a controlled mechanical device, usually a type of platform upon which to stand, that oscillates rhythmically with simple harmonic motion. The intent is that the plate vibrates, with small and controlled displacement, generally in a vertical direction, and transmits such vibrations or oscillations through the feet and lower limbs of the user, to the “whole body”. The device is used for only short sessions, usually no more that about 7-10mins at a time 3,4. In part, these short exposure times are to reduce muscle fatigue and to avoid any possible long term side effects associated with prolonged vibration exposure.

It is supposed that this controlled whole body vibration will induce various “changes” to the body’s homeostasis, such that “favourable outcomes” will be achieved. These outcomes could be either transient or more long lasting, and may be achieved immediately or within a short space of time, or otherwise might only develop following many repeated cWBV sessions.

Other vibrating devices exist, such as small, light weight, hand held appliances that can be applied to very specific sites. There are vibrating dumbbells that are held with the more specific intent of transmitting vibration directly to the upper limbs, shoulder girdle, head and neck, and upper spine. Additionally, vibrating cable devices intend to apply a controlled vibrating load to gym type equipment such that aerobic exercises may be performed simultaneous to the loaded limb being vibrated.

cwb

Galileo Up-X Dumbbell

Most cWBV devices have various controls or settings. The degree of vertical displacement may be mechanically adjustable (usually to not more than 13 or 14mm), and may be further adjustable by the width of the foot spacing. Close together foot spacing reduces the vertical displacement and vice-a-versa. Further, there is usually an ability to ‘dial up’ a particular vibration frequency – by as much as 0 to 60Hz (cycles per sec) in some machines.

Two other variables that may be controlled are the duration spent performing a session on the vibrating plate, and the user weight. Some researchers advocate applying external loads to the body (eg. to waist or shoulders) in order to better achieve some desired outcome3.

cwb usage

Use of a controlled whole body vibrating device.
 

Can Controlled Whole Body Vibration be useful for the treatment of low back pain?

There is an obvious paucity of good scientific data regarding cWBV as a potential treatment for low back pain.

A number of “older” studies 5,6 report on the application of fairly small devices operating at relatively high frequencies (100Hz or more) directly onto or around areas of localised pain. It is most likely that the demonstrated benefits of this technique are, at least in part, attributable to the modulation (via the activation of large diameter afferents) of signal transmission in small diameter afferents by a ‘gating’ phenomenon occurring within the spinal cord (ie. a central effect). There may well be peripheral anti-nociceptive mechanisms going on as well.

To date, the only published study involving cWBV’s effect on low back pain is that by Rittweger, et al 1 in 2002. This was a randomised control study involving (only) 50 recruited volunteers with chronic low back pain and devoid of specific spine diseases (local newspaper recruitment, mean age 52yrs, pain history 13yrs). The baseline, pre-entry fitness level of participants was not documented, but during the 12 week study, participants were asked not to engage in any other fitness or training program, nor any other therapy (including pain medication) for their back pain. The 50 were equally randomised into 2 groups that would either engage in the cWBV exercise activity or an isodynamic lumbar extension exercise. The exercise program was certainly not onerous, with only 18 exercise units (each unit only about 7 mins duration, plus some additional warm-up time) being performed by both groups within the 12 week study period.

The cWBV machine employed was the Galileo 2000, set at a vibration frequency of 18Hz and an amplitude of 6mm (=12mm peak-to-peak). Participants engaged in the cWBV exercise group stood on the machine with knees slightly flexed and usually with hands on hips (the wearing of shoes or type of soles was not documented). The actual “exercises” performed on the vibrating plate were a series of basic pelvic and spinal movements. External loads (up to 30% body weight) were progressively added to the shoulders through the 12 weeks.

Pain on a visual analogue scale (VAS – “hidden” 0 to 10) was the primary outcome measure. Secondary measures included pain-related limitation in everyday life, maximum isometric lumbar extension torque, and the “tendency to depression”. These measurements were apparently recorded at each weekly visit over the 12 week study, and some measurements also recorded 6 months after program completion.

In both groups there was a significant decrease in pain sensation (by VAS). A 6 month post-treatment measurement was unfortunately not presented in the results.

Similarly, in both groups there was a significant decrease in pain-related limitation immediately after and at 6 months after program completion.

The lumbar extension group did measurably better with regards to their depression scores at 6 months after completion, whereas the cWBV exercise group made little change.

Interestingly, following program completion, both groups had increased their lumbar extension torque, but the gain was much more pronounced in the lumbar extension exercise group.

 cwb chart

So, overall, the results of this single, small, relatively recent randomised control study do suggest that both lumbar extension exercises and cWBV exercise can, in the short term, relieve pain and pain-related limitation in everyday life for those with chronic low back pain.

 An interesting and perhaps important corollary is that the degree of improvement of lumbar extension strength is not proportional to the degree of pain relief achieved. Indeed, these two may not be associated in any way other than by coincidence.

Reasons for the apparent reduction in perceived pain with repeated short bursts of cWBV over a number of weeks are not yet known, but the reason(s) are likely to be complex, inter-related, and possibly different for different individuals.

Altered neuromuscular controls, connective tissue changes, muscle strength alteration, hormonal changes, increase in nitric oxide levels, circulatory changes, brain and spinal cord changes, and nociception changes could all play some role.

It seems that impaired postural stability is related to deficits in motor control and coordination, and is at least one factor associated with chronic low back pain7 , and this can be reversed or improved.

galilleo2

Galileo 2000

A recent small study (25 young healthy participants) by Fontana, et al also utilised a Galileo 2000 machine set at 18Hz for a single 5 min treatment session. It
was demonstrated that lumbopelvic proprioception (determined by repositioning the pelvis to a criterion position) is significantly improved by cWBV. As pointed out by Fontana, et al, to treat patients with low back pain effectively, proprioception training is usually considered to be an important element of the rehabilitation exercise program.

I consider it possible that cWBV may be assisting with the neuromuscular “fine tuning” of both pro-gravity and anti-gravity muscle groups simultaneously, such that the repositioning (and joint protecting) ability is enhanced. In those with low back pain there may be intermittent and considerable mismatch between the opposing muscle groups, such that any improvement in this mismatch will help to stabilise and protect the lumbopelvic region, thus reducing pain and dysfunction.

 

References

1.         Rittweger J, Just K, Kautzsch K, Reeg P, Felsenberg D. Treatment of chronic lower back pain with lumbar extension and whole body vibration exercise: a randomised controlled trial. Spine 2002;27(17):1829-34.

2.         Cardinale M, Wakeling J. Whole body vibration exercise: are vibrations good for you? Br J Sports Med  2005;39(9):585-9.

3.         Rittweger J, Ehrig J, Just K, Mutschelknauss M, Kirsch K, Felsenberg D. Oxygen uptake in whole body exercise: Influence of vibration frequency, amplitude and external load. Int J Sports Med 2002;23:428-32.

4.         Gusi N, Raimundo A, Leal A. Low-frequency vibratory exercise reduces the risk of bone fracture more than walking: a randomized controlled trial. BMC Musculoskeletal Disorders 2006;7:92

5.         Lundeberg T. Long-term results of vibratory stimulation as a pain relieving measure for chronic pain. Pain 1984;20(1):13-23.

6.         Sherer C, Clelland J, O’Sullivan P, Doleys D, Canan B. The effect of two sites of high frequency vibration on cutaneous pain threshold. Pain 1986;25:133-8.

7.         Luoto S, Aalto H, Taimela S, Hurri H, Pyykkö I, Alaranta H. One-footed and externally disturbed two-footed posture control in patients with chronic low back pain and healthy control subjects. A controlled study with follow-up. Spine 1998; 23(19):2081-9.

8.         Fontana T, Richardson C, Stanton W. The effect of weight-bearing exercise with low frequency, whole body vibration on lumbosacral proprioception: a pilot study on normal subjects. Aust J Physiother 2005;51(4):259-63.

 

Prolotherapy

written 9th Mar, 2008

Introduction.

Prolotherapy is a safe medical treatment technique that can be used to help treat various musculoskeletal disorders and pain conditions. It can be particularly useful when other ‘traditional methods’ have failed, or if surgery appears to be the “only” remaining (though perhaps undesired) treatment. Note however, prolotherapy can certainly be used as ‘first line’ treatment for rapid healing of more acute injuries and sprains.
The word “prolotherapy” derives from two words – ‘proliferation’ (=to increase in quantity) and ‘therapy’ (=to treat or cure).
Prolotherapy involves a series of periodic injections, often at about weekly intervals. The substance injected is a sterile ‘proliferant’ solution. In Australia, this proliferant solution is generally a special mixture of saline, glucose and local anaesthetic. The strength and the quantity of solution used are adjusted to suit the particular individual condition and stage of treatment. As glucose is not a drug in the true sense of the word, it could be considered that prolotherapy is, in fact, a “natural” treatment.
Overseas, different proliferant solutions may be utilised, though most will include glucose to some extent. A proliferant mixture of glucose, glycerine and phenol has been fairly popular. More recently, a proliferating solution utilising the patients own blood has been experimented with.

History.

Hippocrates was, two and a half thousand years ago, able to stabilise the damaged anterior shoulder capsule of Spartan spear throwers by the insertion of searing needles. Thus they were able to continue with their important and valued warrior duties.

In the 1830’s intentional scarring (“sclerotherapy”) was utilised to help repair hernias. Various sclerosing (or scarring) methods have been used extensively (even now) to treat varicose veins.
Earl Gedney (1937), an osteopath from Philadelphia, USA, was the first to introduce injection treatment to help heal damaged, stretched or “relaxed” ligaments and fascial tissue structures. This treatment was still referred to as sclerotherapy until George Hackett, in the mid-1950, studied and organised the injection technique which is now known as prolotherapy.

A Theory of Prolotherapy?

Weakened ligaments and tendons around joints are believed to be a common contributor to chronic joint pain. Without strong ligaments to secure them together, the joints become unstable, like a tent with loose guy ropes. The muscles (and other tissues) have to compensate for these weakened ligaments. Prolotherapy injections aim to strengthen these weak ligaments by rejuvenating the healing process. This occurs by causing a small amount of controlled, localised and specific inflammation. The inflammation then stimulates the body to strengthen the weakened ligaments with strong fibres called collagen. Strengthening of these ligaments leads to a reduction in pain and disability. The inflammation is triggered by the mild trauma caused by the needles and to some further extent by the proliferant solution that is injected. When glucose is injected directly into joints, such as the knee or hip, it may also encourage the regeneration of damaged cartilage.

Effectiveness of Prolotherapy?

A number of clinical trials have been done to test the effectiveness of prolotherapy. A relatively recent study was performed by the University of Queensland, which investigated prolotherapy in the treatment of chronic low back pain. One hundred and ten patients with low back pain duration for an average of 14 years were treated. Despite having such long lasting pain, the following responses occurred in these patients:-
·        At six months, 50% had less than half of their original pain.
·        At twelve months, 40% had less than half of their original pain and 75% felt their pain was less than their original pain
·        At 12 months the average reduction in pain was 40%
The figures for reductions in disability are very similar for those for reductions in pain.
(Reference: Yelland MJ, et al. Prolotherapy injections, saline injections, and exercises for chronic low back pain: a randomised trial. Spine 2004; 29(1): 9-16.)
One trial from the USA on prolotherapy for knee arthritis showed significant reduction in pain after prolotherapy. The results were as good or better than those achieved with anti-inflammatory tablets or glucosamine, but gave better improvements in flexibility than these treatments. Similar results to these were found in a similar trial for hand arthritis performed by the same clinic in the USA.

Individual Assessment for Prolotherapy.

Because prolotherapy aims to treat the cause of the pain, it has the potential to offer much longer lasting relief than some other treatments.
Before treatment is commenced, a medical assessment is done to decide if your particular problem is suitable for prolotherapy. This involves giving a history and undergoing a physical examination, and sometimes having an X-ray, scan and/or blood test. Prolotherapy is often helpful for pain that is affected by movement of the painful part, or by sustained postures, eg. prolonged standing or sitting.
Note that it is important that any other medical condition (eg. diabetes, hypertension, asthma, etc.) are reasonably well controlled during your prolotherapy treatment. Your normal GP should be able to help with this.
There are a number of conditions that may not respond well to prolotherapy. These include:
·        Certain types of arthritis where inflammation is very prominent such as rheumatoid arthritis, gout, and very advanced osteoarthritis.
·        Pain coming from pinched nerves rather than ligaments. Treatments other than prolotherapy may be more suitable.
·        Pain coming from discs in the back or neck. This type of pain is hard to distinguish from ligament pain and sometimes may only be diagnosed by a process of elimination when prolotherapy fails to help.
·        Fibromyalgia, a condition with very widespread tissue pain, and marked body fatigue.
Further, if you have already had surgery to the painful area, you may require more than the average number of treatments to get a response from prolotherapy.
If your pain problem is found to be suitable for prolotherapy, and you meet some qualifying medical criteria, you may be offered this treatment. Before commencing treatment, you should be aware that early benefits from prolotherapy may not be noticed until you have had several treatments – enough to allow sufficient strengthening of the ligaments. Therefore it is unwise to commence unless you think you are prepared to have at least four treatments. You are free to cease the prolotherapy treatment at any time.
Your response to the treatment (often by way of a simple pain and disability assessment) will be regularly reviewed.

The Prolotherapy Procedure.

To achieve ligament strengthening in a controlled way that has lasting results, the injections need to be given on several occasions, typically six times for the low back, spine, head and neck and four times for the knee, hip and shoulder. Injections are typically spaced by one or two weeks, but it does not seem to matter if they are given less frequently than this to suit your needs or the doctor’s schedule.
No injection treatment is totally pain free, but a lot can be done to reduce the pain of injections. Before injecting the ligaments, the skin overlying the ligaments is usually numbed with a bleb of local anaesthetic. Although these blebs sting like an ant bite, they reduce the overall level of discomfort with this treatment, and may even make the treatment work better. Taking a painkiller at least an hour before each treatment is also helpful. Entonox (“laughing gas”) is available – but you will probably need someone to drive you home afterwards. Keeping your mind off the pain by talking to the doctor about something interesting during the injections is very helpful. A heat pack is often applied to the treated area for about 10 minutes after the injections to sooth any discomfort that may occur.
The injections themselves do not make you drowsy, so you should be able to drive home after each treatment, as long as any painkiller you have taken does not make you drowsy. Occasionally you may feel a little dizzy from the local anaesthetic, but this usually passes within a short time of having the injections. Caution! – some people may feel quite faint following any needle (or minor surgical procedure)!
It may be wise, however, to consider someone drive you home after the first few injections sessions.
Because an aim of treatment is tissue healing and strengthening, it is suggested that prolotherapy may be aided by vitamin and mineral supplements. These include vitamin C, zinc and manganese (not magnesium). These should be taken for at least three months from the commencement of treatment. A convenient way to take this is by purchasing several products:
          Vitamin C – 500mg tablets, one tablet twice daily
          Zinc (15-30 mg/d) and Manganese (10-20 mg/d)
 If you need extra pain relief during the treatment period, paracetamol, dextropropoxyphene, tramadol or codeine may be used. Brand names for these medications include Panadol, Panamax, Codalgin, Panadeine, Panadeine Forte, Digesic, Capadex, Paradex, Zydol and Tramal. If at all possible, no aspirin or other anti-inflammatory drugs (such as Nurofen, Brufen, Voltaren, Feldene, Naprosyn, Mobic or Celebrex) should be used for pain relief as they will reduce the inflammatory process that is part of the treatment.
Ideally, prolotherapy is just part of a whole treatment programme, and use of other treatments is usually encouraged. Such treatments include:-
·        General exercise to improve fitness. These include walking, swimming and most gym programmes. Staying active or increasing activity is a very important part of the recovery process with prolotherapy.
·        Specific strengthening exercises such as back stabilising exercises, hydrotherapy and Pilates exercises are usually helpful alongside prolotherapy. Physiotherapists are excellent resources for these programmes.
·        Rehabilitation programmes to aid return to work.
·        Diet to help control other co-existing medical conditions. For example, avoiding gluten if you have Coeliac disease, as this condition often reduces your absorption of important vitamins and minerals.
·        Useful medications such as:- antidepressants to help improve pain thresholds; most painkillers; and glucosamine (1500mg/d) with chondroitin (1200mg/d).
[However the anti inflammatory medications described above should be avoided unless they are absolutely required for other joints not being treated with prolotherapy.]
·        Physical therapies such as massage, manipulation and mobilisation.
·        Behavioural therapies designed to give you strategies for coping with the pain and disability (eg. relaxation, imagery, pacing your activities and focussing on activities rather than pain) are all important in improving your pain threshold and everyday functioning.
After completing the initial course of four to six injections you will usually be asked to return about six weeks later. At this visits, your condition will be reassessed. Some patients have a low or minimal response to the initial course of prolotherapy. In these cases, several additional stronger injections may prove beneficial. Other aspects of your treatment programme will also be reviewed at the follow up visit.

Possible Side Effects of Prolotherapy.

Side effects are minimised by using careful injection techniques, however minor side effects are still common. The main side effects of prolotherapy injections are a mild to moderate flare in the pain and stiffness after the injections. It is temporary and usually well controlled with simple pain medications or local heat. In the low back this occurs in about 80% of patients at some time during treatment and may persist for a few days. It is a result of the minor needle trauma and the inflammation deliberately caused by the injections. It is less frequent later in the series of injections and is very rarely bad enough for patients to want to stop treatment. In the University of Queensland study on prolotherapy for low back pain, 95% of people who started treatment completed the full course of six treatments.
Uncommon side effects of prolotherapy for low back problems include sharp leg pains due to irritation of nerves to the leg and headaches associated with head and neck treatments. Most headaches which occur following prolotherapy are due to muscle contraction in the head or neck or are not related to the prolotherapy. With neck problems, irritation of nerves to the arms occasionally causes sharp pains in the arms.   All of these side effects usually last no more than a few days and have no lasting effects.
Occasionally the vitamin and mineral supplements cause nausea and diarrhoea, but this is easily remedied by stopping them, changing brands or adjusting the dose.