Evidence-based physical therapy devices like percussion massage are becoming a must for DC practices
I have had more and more patients asking me about handheld devices that release muscle tension and body aches over the last few years, along with vibrating rollers and spheres to help them relax and stretch. Could these be good for them to purchase? My answer is “Yes!”
Over the last couple of years we’ve seen professional athletes, weekend warriors and general consumers embrace vibration percussion technology. The NFL, NBA, MLB, PGA Tour and UFC all brought on an “official recovery technology partner,” increasing player access to these modalities, looking to help prevent injuries and promote the athletes’ longevity. With the increased accessibility of this type of technology also come questions.
What’s the science and how do these tools fit into an evidence-based practice?
Percussion massage devices allow the user to loosen muscle and fascia, increase range of motion and flexibility, and decrease soreness and stiffness. I utilize my staff members to provide percussion massage in my office for patients who like massage and want a slightly more intense, focused approach. Percussion massage blends extremely well with other manual therapies or can be a stand-alone therapy. Many patients are buying professional-grade devices and doing it themselves at home, which allows them to target muscle “knots,” aches and pains, and maintain the therapy as long and as often as they want.
Not only do percussion massagers come in handheld machines, but we all now have access to vibrating foam rollers, spheres, and even neoprene wraps that combine vibration with heat to alleviate pain and relax muscles. Having these tools in my practice has given me new ways to treat, and simply put, patients love them, which is always a good thing.
What do handheld percussion and vibration devices do other than oscillate?
Vibration effects include:
- Increased metabolism
- Increased ROM
- Improved vascularization
- Release of trigger points
- Reduction of fascia densification, scar tissue and calcifications
Possible side effects:
- Pressure sensitivity
Conditions that can benefit from vibration therapy:
- Arthritis (degenerative joint disease)
- Back or disc pain
- Muscle, ligament and tendon injuries
- Sprains and strains
- Post-surgical patients
- Soft tissue trauma
Vibration is particularly helpful for cumulative trauma injuries such as:
- Carpal Tunnel Syndrome
- Cubital Tunnel Syndrome
- Epicondylitis ulnar/radial, epicondylosis
- Myofascial pain syndromes
- Peripheral nerve entrapment
- Thoracic outlet syndrome
- De Quervain’s tenosynovitis
- Musculoskeletal disorders (RSI)
- Chronic tendinosis
- Calcification (e.g. rotator cuff)
- Bursitis (trochanter, shoulder, knee, etc.)
- Runner’s knee
- Achilles tendon pain
- Plantar fasciitis
- Shin splint
These tools are not painful yet reveal tender and sore spots. In my opinion they can be as beneficial as a hands-on deep tissue massage.
Key effects of percussion massage therapy:
Percussion massage therapy helps to remix water into possible dehydrated areas of metabolically active tissues of the body, including muscle cells, organ cells, blood cells and immune cells. Percussion massage certainly influences the superficial fascia, which has rich autonomic innervation that sends information to the prevertebral ganglia. This innervation controls thermo-regulation, lymph drainage, and metabolism of the subcutaneous adipose tissue (Stecco).
The deep fascia envelops various muscles and connects them, forming various compartments in the body. This layer of fascia gives proprioceptive information, creates motor unit activation and aids peripheral motor coordination. Palpation of fascia that may be related to pain areas will feel dense and have a lack of gliding.
As you become skilled using handheld percussion massage devices, they will become an extension of your hand and you can feel the lack of glide or densification of tissues through the device. You will be able to palpate taut fibers and tight muscles while communicating with the patient about the pain level and if there is referred pain from a spot. Lack of fascial gliding is one of the most diagnostic indicators that percussion massage may be needed.
Percussion and vibration tools along with heat therapy (TECAR (Transfer of Electricity–Capacitive and Resistive), laser), mechanical cupping devices, and other devices such as extracorporal pulse wave therapy and the use of pain relief topicals can regain softness in the fascia and muscles, so they contract and release better to increase local cellular metabolism and range of motion.
Immobilization causes increased muscle connective tissue thickening (Slimani 2012) and aging itself creates stiffer epimysial fascia (Gao 2008). Percussion massage will help loosen contracted and shortened muscles.
In this regard and through our understanding of reciprocal inhibition it can stimulate weak, flaccid muscles. Using a percussion massager while putting patients in a gentle stretch position or asking them to do a repeated motion provides stimulation to both the muscles and connective tissues that surround and support the muscles and many other parts of the body (vascular and lymph vessels, tendons, joints), which helps keep these tissues elastic.
Percussion massage increases the circulation of blood and flow of lymph. The stimulation of nerve receptors causes the blood vessels to dilate, which also facilitates blood flow. The direct mechanical effect of rhythmical pressure and movement used in percussion massage can dramatically increase the rate of blood flow. I talk to my patients about this type of peristalsis movement of the fluid and this seems to help them visualize the benefit of the treatment.
Most lymph nodes are located near organs or major joints of the body. All ducts join in the upper chest and empty into the left jugular vein prior to returning to the heart. Trauma, infection, autoimmune reaction (RA), or heat can cause edema and inflammation.
If excess fluids (intra and extracellular fluids, exudates, proteins) become trapped or stagnant they will put pressure on touch receptors. Increased pressure in the superficial layers and lack of skin movement inhibit lymphatic collectors, increasing edema. When lymphatic circulation slows down, the regeneration of cells becomes less effective. This condition allows toxins and proteins to accumulate around the cells, causing hypoxia (lack of cellular oxygenation), and tissue regeneration is diminished. Hypoxia is a painful condition and is helped by the increased vascularization that percussion massagers stimulate.
Reducing fascia densification, scar tissue and calcifications
Muscle spindles, the chief proprioceptive cells affecting our muscles, are not in the muscle, but in the fascia surrounding the muscle and its muscle bundles.
If you have scar tissue from old injuries or densification from prolonged and poor posture (sitting slumped over) you need to make the dense tissue softer and more pliable. Percussion massager therapy can help do that. The surfaces underneath the skin should slide and glide. If everything is stuck together, and it doesn’t slide and glide, it needs to be treated.
A principal component of synovial fluid and loose connective tissue is hyaluronic acid (HA). It’s located in every tissue of the body, between sublayers of aponeurosis, superficial fascia, deep fascia, epimysium, perimysium, etc.
With overuse and tissue trauma, we can get resultant inflammation that causes overproduction of HA, leading to molecular fragmentation and degradation. In time, the granulated particles form a sticky, concentrated dehydrated gel, which may decrease fluidity, resulting in a binding or “gluing” of myofascial layers. Percussion massage can prevent and restore “adhesive” gliding of the fascia over the muscle. Further, densified hyaluronic acid prevents normal mechano-reception (Stecco).
Restricted fascia may temporarily respond to stimulation, but require continuous stimulation over time.
Altered spindle feedback results in altered stimulation to the muscles, resulting in altered function.
Fascial alteration could alter afferent information to the central nervous system, causing incorrect motor unit functioning and, over time, pain in the corresponding portion of the joint maintaining dysfunction – even in the absence of pain.
One example is when that “old ankle sprain” loses its ability to report signals due to persistent densified fascia; and the muscle supply to the ankle area can become deficient, resulting in repeated strain to the area and eventual compensatory hyper- or hypo-function to the knee, pelvis, hip or back. The knee or back pain patient may need the fascia (proprioception) of the ankle to be treated.
Percussion massage decreases densification of the fascia and improves gliding effects, which improves motor behavior, which the brain likes because the brain exists to help us move, which helps relieve pain. Fibrosis is similar to the process of scarring and these areas need to be released by some type of scar release therapy. Densification of tissues that I find in the majority of pain in chronic low-back patients, shoulder pain, calf muscle tightness, plantar fasciitis, tennis elbow, hip pain, and non-healing sports injuries do better with percussion massage coupled with cyclical stretching more than continuous stretching for fascial pain relief.
Many studies including these in the International Journal of Sports Physical Therapy and the Journal of Bodywork and Movement Therapy conclude that self-myofascial release:
- Increases mobility and joint range of motion;
- Reduces post-workout soreness and DOMS (delayed onset muscle soreness);
- Allows for greater workout performance in future workouts;
- May lead to improved vascular function and parasympathetic nervous system function.
After utilizing a percussion massager or vibration in a few treatments I think you will see how it acts as an analgesic. The explanation can be that percussion and vibration lead to depletion of substance P (neuropeptide/neurotransmitter) out of its storing vesicles. Substance P plays a central role as a pain mediator and growth factor. This molecular mechanism explains the long-lasting analgesic effect of the oscillating waves.
Substance P has been shown to dilate blood vessels, stimulate neovascularization and contribute to new bone formation. Percussion massage waves likely stimulate the angiogenesis-related growth factors including eNOS (endothelial nitric oxide synthase), VEGF (vessel endothelial growth factor) and PCNA (proliferating cell nuclear antigen). This promotes neovascularization that improves blood supply and increases cell proliferation and tissue regeneration to repair tendon or bone tissues.
The waves created by percussion massage act to overstimulate the small nerve fibers to block an increase in pain stimuli and therefore intensify the analgesic effect, and I would go back to the Melzak and Wall Gate Control Theory to explain that.
A host of benefits for patient pain
The benefits of using a “percussion massager” include: increased circulation, reduced pain, faster rehabilitation from injury, increased lymphatic flow, breakup of muscular scar tissue and densified tissue, reduced lactic acid buildup, tissue regeneration, soft and active tissue release, and stimulation of proprioceptive functions.
You can enhance your practice with percussion massage therapy to stimulate deep-muscle tissue and concentrate on general or local muscle spasms. Deep, rapid, short-duration percussion and vibration are the key to the elimination of many patients’ pain, and I am looking forward to seeing how these tools continue to develop.
JEFFREY TUCKER, DC, is the current president of the ACA Rehab Council. He writes for Hyperice, practices in West Los Angeles, Calif., and can be reached at DrJeffreyTucker.com.