Vibration Exercise Therapy

It’s been some time since my last blog. I had the unfortunate task of undergoing meniscal surgery and trying to get back on my feet. It’s amusing how we doctors are the worst patients out there. I can’t remember the number of times being yelled at for not resting enough by my surgeon, chiropractor and therapist! However, there were some positives that came out of it, and that was right before my surgery. A few months ago, I had reinjured my knee and ended up with a very swollen knee with limited range of motion. That’s why I had decided to go for the procedure. At the time of surgery, my surgeon was amazed that I recovered full range of motion and my strength was still there. That’s one reason why I was able to get back on my feet quicker than most. This was all due to doing an effective prehabilitation program. Whenever I talk to other doctors, I start to realise that prehabilitation is not something that everyone does, although the results for your patients will be that much better.

Prehabilitation is not only defined as exercises to develop areas of the body to prevent future injuries, but also ability to maximize strength, flexibility and mobility in people prior to surgery in order to increase functional outcomes after surgery. This is starting to become more and more important in this time and age. People that are showing up at surgery are more sedentary, obese, and have a constellation of health conditions that increases the risk of morbidity and delays recovery following surgery. This is a major reason to begin getting your patients into as best of shape as possible prior to the surgery. The importance of this can’t be underestimated. Research is already showing that prehabilitation leads to better outcomes after surgery.

Prehabilitation is not as difficult to do as one may think. Setting up a small room for various exercise equipment is a good start if you don’t have any. Start off with something simple as bands and a gym ball and work your way to more equipment as interest grows. Marketing prehabilitation to your patients and the public is also important to increase awareness. Since it’s not a service most people know of, education is a key component of making this successful. Another angle to take with prehabilitation is preventing injuries from occurring in the first place. This is popular among sports trainers to prevent injuries in their athletes. But why stop at athletes? Talking about the benefits of prehabilitation is also important for workplace injuries. Back schools have been around for awhile, but there’s also the ability to address other conditions, such as carpal tunnel, knee pain, headaches, etc. By promoting a preventative practice, there will be an increased awareness of your practice in the community. So next time your patient goes for surgery, take advantage of the situation. I’m certainly glad I did.

What technologies are the most effective in sports rehabilitation and performance? This is the question that was posed to me at the Florida Chiropractic Association convention in Kissimmee over the weekend. There were many different technologies and techniques out there on the trade floor show, so it can become quite overwhelming to any of us in what we need to put in our practice. I was at the tradeshow demonstrating vibration therapy, and since it’s one of the fastest growing modalities out there in the Chiropractic field, it was natural to get these type of questions. Before we jump on board with the latest and greatest, the answer doesn’t lie in the product, but in a simple principle that has been used in sports performance. If we go through the principle first, we can then look at products on the market and see what will fit us the best:

Everything works, and nothing works all the time

Alwyn Cosgrove, a prominent personal trainer, made a good point with this. The principle is simple. If we subject our body to the same stimuli all the time, our body will get used to it and further improvements are minimized. You can see that with some of the gym rats. They will tell you they have been working out for a year and haven’t seen any gains in strength or muscle tone. The problem is they stick to one weight training program and the body eventually plateaus. If you provide different intensities, frequencies and weights to their program, the body experiences something new. This keeps it guessing and gains are continued. For a sports rehabilitation practice, this means that you must be active in progressing someone from simple exercises to something more complex. Not only that, but keep the body guessing by throwing in different tools. If you are using a rocker board for balance and proprioception, progress to a rocker board, or simply progress to functional lunges. Simply put, don’t subject your patients to the same type of exercise all the time. That’s why having as many different tools in your arsenal will lead to better outcomes.

Another chiropractor asked me about vibration training and whether it’s superior to other modalities out there. If we look at the above principal, it’s not the vibration device that makes your program superior to others. It’s HOW you use it. Placing someone on it at the right stage of injury, rehabilitation or performance enhancement is crucial. You have to also align the right exercises with the right goals. You won’t get explosive strength with an athlete if all they do are calf raises on it! That athlete will need to add additional weight and also do plyometric training off it. If an athlete is undergoing rehabilitation following an Achilles strain, gentle static calf raises may be the most effective thing to do.

So when you decide to purchase a piece of equipment that promises unbelievable results for your patients, first ask yourself who you are going to be using it for. Also ask questions regarding the product on how it can be used in different stages of injury. There shouldn’t be a cookbook approach to using it, but basic principles you can follow when developing your own unique programs.

Myth: Vibration exercise therapy is something new.

Fact: Vibration, in various forms, has been around for years. Local vibration has been used with the spinal cord population to fatigue muscles and decrease spasticity. Other forms of local vibration have been used to break up scar tissue adhesions, increase blood flow to the area and increase local mobility. As Chiropractors, we have been using localized vibration for years as an integral part of our practice. Vibration exercise therapy is just a novel alternative to generate global effects of vibration as part of an exercise program.

Myth: Whole body vibration has adverse effects similar to occupational whole body vibration.

Fact: Occupational vibration effects is determined by amount of dose of vibration per day and the frequency of that vibration. Vibration exercise therapy utilizes frequencies that are in the safe range. For example, frequencies of less than 20 HZ represents the resonance frequencies of the internal organs. This is why truck vibration contributed to so many low back problems. However, vibration exercise frequencies don’t go into this range. In addition, occupational vibration exposure is cumulative over time with several hours a day of dosage to produce any significant adverse effects. Vibration exercise therapy takes only 15 minutes per day, three times per week.

Myth: Vibration therapy is limited to athletic people that can handle the stress of vibration exercise.

Fact: Initially, vibration exercise therapy has been used by high level athletes to give them that extra edge in competition. However, more and more hospitals, therapy and chiropractic centers are starting to use vibration exercise therapy to increase function and decrease pain. New research is showing the positive effects that vibration therapy is having for the senior population, in addition to people that are compromised with any host of health issues. It’s shifting from the high level athlete to the individual that is unable to engage in conventional exercise due to physical limitations or conditions.

Myth: There is no research to support vibration exercise

Fact: Actually, more and more research is coming out every month in peer reviewed journals showing the positive effects of vibration therapy. In addition, research is being conducted at various North American universities, medical colleges and chiropractic colleges. The positive benefits seen in clinical practice is increasing the interest of the research community.

Myth: All vibration machines are the same.

Fact: As with any therapeutic modality, it is important to do your research into assessing which machine is the right one for you. Safety is extremely important, in addition to understanding that you are getting a consistent dose of exercise every time. Smaller, cheaper machines may not care about limiting lateral motion, which increases shearing forces on the joints. The primary point is that you get what you pay for. It’s important to assess how you will be using it in your practice, who you will be using it on and whether you require a high commercial use for high volume use or something smaller for occasional use.

Treating back pain with whole body vibration is both effective and time efficient for the doctor. However, it’s sometimes confusing to hear the words ‘whole body vibration’ and ‘back treatment’ in the same sentence! As Chiropractors, we are all well aware of the adverse effects of whole body vibration on back pain. However, new research is showing that when vibration is applied within specific safe frequencies, it has positive benefits on back pain. Since applications of vibration exercise with low back pain is the most requested topic I get, let’s go over the current literature and introduce some rehabilitation concepts that can be applied with vibration exercise.

It’s surprising how much new research is coming out for vibration therapy. Just five years ago, I would be hard pressed to see an article appear in a peer reviewed journal every few months. Currently, new research is being published in such journals as Spine, Stroke, American Journal of Clinical Rehabilitation, to name a few. It appears the focus is slowly shifting towards health benefits as opposed to the initial research in sports performance, although there’s significant research going on in that also.

Here’s a summary of 2 interesting articles about low back pain and vibration therapy that we can discuss:
Rittweger J, Just K, Kauthzsch K, Reeg P, Felsenberg D. Spine 2002: Treatment of chronic lower back pain with lumbar extension and whole-body vibration exercise: 27; 1829 – 1834.

Findings: This was a randomized controlled trial that showed comparable results of reduction in pain sensation and pain-related disability when comparing back extension exercises to vibration therapy. The study also cites that poor lumbar muscle force is probably not the exclusive cause of chronic lower back pain. It is thought that vibration exercise may be activating muscles via reflexes.

In practice, we tend to see a lot of back pain patients. Our take on vibration exercise is that there is an increased proprioceptive effect due to the instability of the platform. This may be activating the deep muscles of the low back. Prior to vibration therapy, we would utilize rocker and wobble boards, based upon treating muscular imbalances through some of the methods taught by Janda. We found that vibration therapy tends to achieve similar results but in less time. Not only are we getting muscle activation, but increased strength gains in the lower extremities.

Belavy DL, Hides JA, Wilson SJ, Stanton W, Dimeo FC, Rittweger J, Felsenberg J, Richardson CA. Spine 2008. Resistive simulated weightbearing exercise with whole body vibration reduces lumbar spine deconditioning in bed – rest. 33: 121 – 131.

Findings: The resistive vibration exercise countermeasures reduced, but did not entirely prevent, multifidus muscle atrophy and passive spinal tissue deconditioning during bed-rest.

This is an interesting study and shows the importance of providing early rehabilitation for anyone with low back pain. It’s already been shown that after an attack of low back pain, there is atrophy of the multifidus muscle. Even after the back pain is gone, a group that did no exercise was still seen to have atrophy. Hence, the importance of exercise cannot be overstated. This study is reinforcing the positive effects of exercise. What makes vibration therapy so unique is that you can utilize it for patients that are unable to engage in conventional therapy either due to decreased mobility or increased pain. When I get an acute low back patient, or a chronic patient with limited mobility and pain avoidance behaviour, starting off their rehab program is as simple as lying down next to the vibration platform and putting two feet on it. Distal stimulation allows activation of the muscles in addition to increased circulation. In this situation, I use vibration therapy as an ‘early adoption of exercise.’ Achieving early strength and flexibility gains is crucial to progress the patient into a more functional program. We have found that vibration therapy allows us to begin this process early enough so that the patient does not fall into sedentary habits.

Choosing the right vibration platform is not as easy as one might think. Over the last few weeks, I’ve had a lot of fellow chiropractors ask about which vibration platform I recommend for their practice. The answer really depends on several factors, and not all include specifics on the platform itself. The following are some things to look at when considering a vibration platform for your office:

First thing to note is the amount of space you have available. Some chiropractors have rehabilitation space while others may only have limited space in their treatment rooms. Both locations are effective. We have seen chiropractors place a vibration platform in a treatment room and utilized it as a modality. Others have placed several in their rehabilitation area and utilized it as a modality or something that can be utilized post discharge from chiropractor care. Platform sizes vary in size and can get to taking up as much as 10 square feet of space (includes vibration platform area AND exercise area).

On the other side of the coin, one has to be aware that a larger platform size will give you more flexibility in the types of exercises you can provide your patients. Remember that patients are not just going to stand and do squats. They should have the ability to do lunges, push ups, or lie their extremities on the platform to receive mobilization or deep tissue massage. We have patients with Multiple Sclerosis doing walking patterns to help with proper gait and balance, so size of the platform is an important consideration, especially if you have special populations that you are treating.

Ask about the company’s training and support. Since vibration exercise therapy may be something new for some, it’s essential that you get the support to answer any questions regarding protocols. There’s always the simple exercises, charts, posters and videos that one gets in the mail, but ensure that follow up support is there.

Price. Price seems to be an issue for a lot of chiropractors, and since this technology is steadily being adopted, there are many different companies out there trying to pitch on price. Don’t let price be the factor in your buying decision. I’ve been to an office that used a relatively cheap machine. However, that machine didn’t last long once the doctor started putting their overweight or athletic patients on it. There are machines on the market place that capitalize on the success of vibration therapy but when you look into it, their quality, durability and reliability comes into question. Only way to compare this is to jump on a treadmill that you see in your local gym, and then buy one at a discount store and try to use that at home. Always remember that you are placing patients on these machines and not fit and healthy people. The quality is critical.

Quality is not only critical for your patients, but also for your bottom line. If you are buying for your practice, always ensure that you ask for ‘commercial use’ devices. These devices are meant to be used in a high volume environment, day in and day out.

Ask about translation forces. This basically means a platform’s direction of vibration should be as close to vertical as possible. Any horizontal translation forces leads to shearing forces on the joints and should be avoided. Remember that we are treating patients with health conditions. Therefore minimizing shearing forces is critical.

For those looking at purchasing, make sure you do your research and feel comfortable with the company you are dealing with. The more information you have and the more support you get from the company, the better outcomes you will get with your patients.

In order to appreciate the benefits vibration exercise therapy can have on your patients, it’s important to know the underlying mechanism behind how it works. Today, we’ll discuss the science behind vibration exercise, thereby getting a better appreciation of the physiological effects that it will have on your patients.

Biomechanical Muscle Stimulation

Vibration exercise can come in many forms, from hand held devices to large platforms. I think it’s a bit of a misnomer calling it ‘vibration’. A better analogy would be that of Electrical Muscle Stimulation. With EMS, the goal is to create muscle contractions involuntarily. However, you are limited to the muscles that are directly associated with the motor units that are in contact with the stimulation pads. In addition, this is a passive form of therapy. If we called vibration exercise ‘Biomechanical Muscle Stimulation’, then it would be a bit clearer to most clinicians on what it does. Vibration exercise therapy is more of an active form of therapy, allowing an individual to progress in various exercise positions from static to dynamic.

The Tonic Vibration Stretch Reflex:

Vibration exercise basically works through the stretch reflex. This is the same stretch reflex that is initiated when we tap a patient over the knee with a reflex hammer. There is a strong involuntary contraction that occurs, leading to contraction of the quadriceps muscle. We all remember doing this over and over again in first year class on diagnostic testing. The vibration platform works in the same way. Take for example, someone being placed in a squat position on a vibration platform. The platform will drop a few mm, leading to a quick stretch of the muscles. As a response, there will be a strong involuntary muscle contraction that occurs in the quadriceps muscle. Now consider that the platform can drop up and down 50 times per second. That leads to 50 muscle contractions per second, and up to 3000 contractions within 1 minute. Since it is involuntary, a lot of patients that are unable to engage in conventional strength training exercises can now have an option that will allow their muscles to get the work load it requires.

Neurological Adaptation:

I’ve always had people ask how it’s possible to gain strength when all a person does is stand on a platform in a static position for as little as 2 minutes total vibration time. It almost comes across as an ideal pitch on a late night infomercial! However, let’s take a look at how strength gains are achieved with conventional training first. Everyone that has taken time off from weight training and then begins again, will notice something startling within the first 4 to 6 weeks of training. Every day you go to the gym, you are pleasantly surprised on how much you can increase your lifting capacity. It seems like you’ll be able to lift 500 pounds in no time. However, after the initial exhilaration, we all tend to plateau. This first blast of increased strength does not come from increasing the size of our muscle fibres through hypertrophy. This basically comes from increasing the amount of muscles that are recruited for that particular exercise. This is called neurological adaptation. However, we tend to plateau and then have to rely on increasing strength through hypertrophy. Vibration exercise therapy is based on increasing strength through neurological adaptation. Since the muscle contractions are involuntary, a greater number of muscle fibres are recruited than with conventional training. There is a great advantage to this. In a rehabilitation setting, we aren’t trying to make someone super human or work towards becoming Mr. Universe. Our goal is to increase strength and stabilize joints as quickly as possible. With vibration exercise, you’ll be able to make those initial strength gains quicker, thereby progressing the patient faster through their rehabilitation stages.

Force = Mass X Acceleration:

Anyone that weight trains knows that in order to increase strength, one has to consistently continue to increase the amount of weight they are lifting in order to see strength gains and muscle hypertrophy. Therefore, the FORCE generated is based upon increasing the MASS of the object one is lifting.
As we already can see, vibration exercise is based upon the acceleration of the platform, dropping up and down a certain number of times at a certain distance. Therefore, vibration exercise increases the force on the muscles through the ACCELERATION of the platform instead. However, add resistance bands, hand weights, or weighted vests to your patients, and you‘ll get added benefit from the increase in mass also.

In essence, this should give you a simplified explanation of the mechanisms behind vibration exercise therapy. Once these are known, it’s easier to understand the many benefits that are achieved when applying it to your patient population.

The other day, I met a fellow Chiropractor, and as always, the topic turned towards discussing the latest innovations in technology and the direction Chiropractic was headed. We discussed all the latest innovations that were available, from decompression to laser therapy. We discussed the changing landscape of health care, with ever increasing competition not only from other health care professionals, but even from fitness clubs and personal trainers that entered the rehabilitation field. When he asked me about my practice, I mentioned that apart from Chiropractic care, I provided whole body vibration exercise therapy. The doctor fired off about a million questions after that. Evidently, he heard that vibration therapy was highly effective for Chiropractic patients and more and more Chiropractors were utilizing it. However, there was a general lack of information available for Chiropractors on its applications and specifics regarding its implementation within a practice.

A lack of information on this new and exciting technology has led to the formation of this blog. This blog will provide regular information on vibration therapy, from protocols to the latest research. In addition, we will also focus on how to effectively implement it into a Chiropractic practice. Backed by over 40 years of research, whole body vibration exercise was initially focused on the fitness and athletic enhancement fields. However, its effectiveness quickly crossed into the health care field, and is now being used in hospitals, physical therapy, and Chiropractic offices. Research is currently being conducted at various universities, hospitals and Chiropractic colleges also. It’s an exciting new field that promises to provide the Chiropractor with another effective tool to help their patients, in addition to expanding practice opportunities. As we continue to expand on the blog, comments and questions are more than welcome. I am sure there will be a lot of discussion on this and it’s applications. In the end, the more informed we are the more effective we can become in the care of our patients.