By O. Bouimer, LMT, CMMP, (Los Angeles, USA)
Dr. E. Gubsky (Republic of Belarus)
In Part I of this article (Science of Massage Institute » GOOD VIBRATIONS. PART I. Clinical Effects Of Vibration MassageScience of Massage Institute » GOOD VIBRATIONS. PART I. Clinical Effects Of Vibration Massage) we reviewed some theoretical aspects of vibration’s effect on the human body and examined the impacts of vibratory stimuli on tissues and organs. To summarize: every therapist who practices the clinical aspects of massage therapy must employ manual and/or electric vibration as an integrative part of treatment.
Application of vibration stimuli greatly assists in the treatment process by desensitizing the Central Nervous System (CNS) (Whitsel et al., 2000) as well as soft tissues (Leung et al, 2005) in the affected area, enhancing circulation and resetting the receptors in the skeletal muscles. Desensitization is a treatment outcome when the peripheral receptors (peripheral desensitization) and/or CNS (central desensitization) stop reacting to any sensory stimulation (e.g., from hyperactive touch receptors or nociceptors, etc.).
To achieve this, the therapists must understand the clinical application of vibration, do it correctly, and base treatment on the clinical data.
We express gratitude to the Science Of Massage Institute for letting us use scientific data on the application of Vibration Massage gained from Medical Massage Volume I by Dr. Ross Turchaninov as well as SOMI’s Medical Massage seminars.
Vibration can be conducted both manually and with the aid of electric vibration devices. Prof. Kreymer (1987) recommends electrical vibration while other authors (Bortfeild et al., 1979) recommend manual vibration, especially for the treatment of patients with Cerebral Palsy.
Both electric vibration and manual vibration have their advantages and disadvantages. Electric vibration is a very powerful way to deliver vibratory stimuli; it is easy to conduct, and it has distant therapeutic effects (e.g., in cases of visceral disorders). At the same time, electric vibration does not have such a detailed and delicate approach to the tissue as does manual vibration. Also, manual vibration can be combined with other massage techniques like friction, for mutual enhancement. However, manual vibration demands a lot of energy from the practitioner; it does not have distant therapeutic effects and it is unable to deliver vibration with the necessary therapeutic frequency (60-120Hz). Thus, electric vibration has more therapeutic value, but it is frequently overlooked by practitioners. Let’s review the basic requirements for the clinical application of electric vibration.
TYPE OF VIBRATION
We need to separate all vibration machines into two groups which have their own application rules:
1. Machines that produce true vibration
These massagers are used in clinical cases when the therapist needs quick and stable desensitization of the peripheral receptors in the affected area as well as the patient’s sensory cortex. It is a critical component of successful application of Trigger Point Therapy. Also, true vibration prepares muscle spindle receptors for re-setting and engages the Golgi tendon organ receptors. It also helps patients recovering from peripheral neuralgias and arterial vasoconstriction (e.g., Burger’s Disease)
2. Machines that produce vibration as a result of percussion
In the clinical setting these machines are used in cases of muscle atrophy, or flaccid palsy after stroke. They are also an important part of sports massage. Percussion vibration eventually desensitizes the sensory cortex, but more superficially than true vibration. It also exposes soft tissues to an unnecessary vibratory overload. However, the main clinical benefit of percussion vibration is the stimulating impact on sensory and motor cortex.
Thus, in the ideal scenario, the therapist should have both machines at his or her disposal and use them appropriately. It is a mistake to use machines that produce percussion vibration on spastic muscles, inflamed spinal or peripheral nerves or in cases of Cerebral Palsy. Of course, the therapist won’t harm the patient, but vibration therapy will become less efficient and many clinical outcomes in medical massage depend on a treatment’s efficiency.
CONTACT AREA
For the best clinical results, the contact area of the massager must be at least 2 cm wide (approximately 1 inch). In such a case the therapist achieves better results by the so-called spatial summation of vibratory stimuli (Forta et al., 2012) which desensitizes the patients’ sensory cortex quicker.
Spatial summation is the summing of electric potentials generated by peripheral receptors from neighboring areas of the body. Spatial summation from any peripheral receptors including Pacinian corpuscles depends on their density of distribution in stimulated areas. For example, upper (or proximal) parts of the extremities, compared to the lower (or distal parts) have larger density of Pacinian corpuscles and this fact greatly affects the brain’s perception of sensory stimuli especially the sense of vibration (Sherrick et al., 1990). This finding has an important clinical outcome: therapists need less time for the application of vibratory stimulation to achieve desired results on the lower parts of extremities compared to the upper parts.
The contact area must be moderately firm, but not hard. If the contact area is made from hard plastic the therapist should use a folded towel between contact area and soft tissues.
FREQUENCY
The specification of the device must show the range of frequency within the 60-120Hz (Bensmaïa et al, 2005; Hollins et al., 2005). Low-frequency true vibration primarily activates Meissner corpuscles and Merkel receptors (which are touch and pressure receptors) which exhibit slower and more superficial peripheral and central desensitization while higher-frequency, true vibration activates Pacinian corpuscles, which we discussed in the Part I, as main highway of peripheral and central inhibition.
Thus, the treatment may start with low frequency vibration and after first 30 sec of its application the therapist should switch to high-frequency produced by the same machine. In cases of causalgia (i.e., severe, sometimes burning pain, caused by direct trauma of the peripheral nerve) only low frequency vibration can be used until the affected nerve shows clear signs of recovery.
RULES OF CLINICAL APPLICATION
Electric and manual vibration share the same principles of clinical application which were summarized by Birach (1985). The author’s recommendations are still widely used, and it underlines three main features of vibration application: mode of application (static and mobile), regime of application (constant and interruptive), and level of application (deep and superficial).
MODE OF APPLICATION
1. Static Vibration
During application of vibration in a static regime, the practitioner places the contact area of the hand or massager on the targeted area and starts vibration. The hand or massager does not move throughout the massaged area. Static mode has the largest peripheral and central desensitization effects (Bensmaïa et al., 2005).
Pacinian corpuscles are rapidly adapted peripheral receptors. If the therapist applies the massager to the soft tissues the Pacinian corpuscles are immediately activated, and they send a powerful flow of sensory stimuli to the patient’s CNS. This flow overrides activity of all other peripheral receptors: mechanoreceptors, temperature receptors, including nociceptors (i.e., receptors which work with the pain analyzing system) triggering peripheral and central desensitization.
After 15-20 seconds of tissue exposure to static vibration, the Pacinian corpuscles adopt and stop to elicit an ascending sensory flow, but already achieved desensitization of the spinal cord and sensory cortex is still strong enough to prevent any new sensory stimuli, including the activity of nociceptors, to form motor response in the CNS (Bensmaïa et al., 2005). Thus, the therapist triggers peripheral and central desensitization, which creates the perfect setting for Trigger Point Therapy, forceful stretching of the shoulder in cases of Frozen Shoulder, or application of the Periostal Massage in cases Tennis Elbow etc.
Let’s say that the therapist now moves massager back and forth along the entire segment using vibration in mobile mode. Every time the therapist brings the machine back to the area where he or she was just seconds ago the Pacinian corpuscles there are going to consider this vibration as completely new stimuli since they immediately recovered normal activation threshold and as soon as the massager was moved out (Griffin 1990).
If Pacinian corpuscles are activated again and again by a therapist applying vibration in mobile mode along the segment, the Pacinian corpuscles can’t trigger deep and efficient desensitization since they are going to be constantly reactivated.
2. Mobile Vibration
During the application of mobile vibration massage, the practitioner places the contact area of the hand or massager on the targeted area, starts vibration and moves along or across the massaged segment, constantly maintaining contact with the skin. Lubricant may be used in mobile vibration. What happens during mobile vibration was discussed above.
When is mobile vibration used? If the Medical Massage protocol controls the pain analyzing system and the patient is on the way to recovery the therapist should switch to mobile vibration to stimulate and reset the patient’s sensory and motor cortex as well as other peripheral receptors. Another example is the application of mobile vibration along the pathway of the peripheral nerve as long as there is no previous direct trauma to it. Finally, mobile vibration should be used in cases of muscle atrophy, flaccid palsy, hypertension, abdominal application for gastroparesis or constipation etc.
REGIME OF APPLICATION
1. Constant Vibration
During constant vibration, the practitioner uses manual or electric vibration in the massaged area for a period of time, usually 2-3 minutes. This technique has a powerful inhibitory effect and to achieve this, the vibration must be applied for at least one minute without changing position or the angle of application. Basically, it is similar to the concept of static vibration but in the application of the constant vibration the angle application is a critical factor which determines the difference between these two. The application of ischemic compression during Trigger Point Therapy requires detection of the ‘entrance’ into the trigger point. The concept of constant vibration under a detected angle is a very important factor in successful Trigger Point Therapy.
2. Interruptive Vibration
During interruptive vibration, the practitioner applies and withdraws manual or electric vibratory stimuli. Every time the hand or massager is reapplied to the skin, the Pacinian corpuscles are activated and a new wave of action potentials are generated. Thus, interruptive vibration massage is a stimulating technique.
The practitioner has to apply vibration for 5 seconds, lift the massager and re-apply it again. Interruptive vibration can be combined with Mobile mode of application for 2-3 minutes. It has a stimulating impact on the tissues and CNS.
LEVEL OF APPLICATION
1. Deep Vibration
To apply deep vibration, the therapist should increase pressure on the contact area with the hand or massager. As it was shown by Wall and Crowly-Dillan (1960) the combination of static vibration and pressure is the best way to control the patient’s pain analyzing system.
In the case of manual vibration, the closer the practitioner’s hand is to a 90 degree angle to the surface of the body, the deeper the vibration is achieved. This technique is a helpful tool for stimulating peripheral receptors which are deeply located (periosteum, ligaments).
2. Superficial Vibration
Superficial manual vibration is applied by the whole hand or with the fingers laying flat on the skin. In the case of superficial electric vibration, be sure to support the massager so that its weight is not a factor. Superficial vibration activates receptors which are mostly located in the skin and fascia.
DURATION OF APPLICATION
The duration of application in the area of a single reflex zone should not exceed 2-3 minutes. If the patient has two reflex zones, the practitioner should spend at least 2 minutes on each zone.
In clinical practice, all these techniques may be combined, even during the same application. For example, to prepare the quadratus lumborum muscle for Trigger Point Therapy, the practitioner should use static, constant, deep vibration to remove protective muscular tension and to block the pain analyzing system. In the same area, after the patient exhibits stable clinical improvements, the practitioner should add mobile, interruptive, superficial vibration to maintain reflex vasodilation.
APPLICATION OF VIBRATION AS A RESULT OF PERCUSSION
For the application of vibration percussion the therapist should use exactly the same rules and parameters we discussed above. However, the niche for the clinical application of percussion vibration is narrower. As mentioned above, percussion vibration is an irreplaceable tool to activate sensory and motor cortex which is used in cases of muscle atrophy, insufficient innervation of soft tissues or in cases of arterial vasoconstriction. The same massager can be effectively used on healthy athletes as preparation for competition or during competition. The therapist should switch to true vibration while working on the athlete following the competition or training.
APPLICATION OF MANUAL VIBRATION
Manual vibration is the most physically demanding technique of medical massage. It has to be done in the proper way to reduce the practitioner’s fatigue and to prevent hand and finger trauma. The patient’s muscles should be relaxed as much as possible.
As soon as the correct combination of vibration is chosen, start vibration in the massaged area. Relax the whole arm and apply vibration waves from the shoulder, down to the forearm, and finally to the hand or finger(s). Do not generate vibration by the hand only; it will quickly exhaust the therapist.
REFERENCES
Bensmaïa S.J., Leung Y.Y, Hsiao S.S., Johnson K.O. Vibratory Adaptation of Cutaneous Mechanoreceptive Afferents. J Neurophysiol. 2005 Nov; 94(5): 3023–3036.
Birach, A. Health through the Hands: Massage of Reflex Zones. Minsk, 1985.
Bortfield, S.A., Gorodetskaya, G.F., Rogoleva, E.I.: Point Massage for Treatment of Cerebral Palsy Syndrome. “Medicina”, Moscow, 1979.
Forta, N. G., Griffin, M. J. and Morioka, M. Vibrotactile difference thresholds: Effects of vibration frequency, vibration magnitude, contact area, and body location. Somatosensory and Motor Research. 2012, 29, 1, p. 28-37.
Griffin M.J. Handbook of Human Vibration. Academic Press, London 1990
Hollins M., Goble A.K., Whitsel B.L, Tommerdahl, M. Time course and action spectrum of vibrotactile adaptation. Somatosens Mot Res 1990;7(2):205-21.
Kreymer, A.Y.: Vibration Massage at Diseases of the Nervous System. “Tomsk University”, Tomsk, 1987.
Leung YY, Bensmaïa SJ, Hsaio SS, and Johnson KO. Time-course of vibratory adaptation and recovery in cutaneous mechanoreceptive afferents. J Neurophysiol 94: 3038–3046, 2005
Sherrick C.E., Cholewiak R.W., Collins A.A. The localization of low- and high-frequency vibrotactile stimuli. The Journal of the Acoustical Society of America, 01 Jul 1990, 88(1):169-179
Wall, P.D., Crowly-Dillon, J .R.: Pain, Itch and Vibration. A.MA. Arch. Neurol., 2: 19-29, 1960
Whitsel BL, Kelly EF, Delemos KA, Xu M, and Quibrera PM. Stability of rapidly adapting afferent entrainment vs responsivity. Somatosens Mot Res 17: 13–31, 2000
Oleg Bouimer, LMT, graduated from State Institute of Physical Education in Ukraine in 1985. Currently he has an extensive private practice in Los Angeles. Among his clients are celebrities, famous politicians and sports stars. The NBA, NHL and NFL widely recognize Oleg and the system of Russian Sports Massage. He teaches nationwide and has founded a Medical and Sports Massage Club in Los Angeles. Oleg is author of many articles in American and European professional journals. His main educational website: www.russiansportsmassage.com
Dr. Evgeny Gubsky graduated from the Belorussian State Medical University. He has been a general medicine and massage therapy practitioner for over ten years. Dr. Gubsky is an active blogger and educator specializing in the rehabilitation of injured athletes using massage therapy and other clinical tools. He is the creator of the Massage Solutions website, which gives therapists all tools required to incorporate electric vibration into their practice:
https://massagesolutions.net/
Category: Medical Massage
Tags: 2021 Issue #2