CURRENT RESEARCH
How ARPwave Therapy Utilizes Dual Electrical Signals to Increase Blood Flow
Emerging evidence has demonstrated that electrical stimulation can increase blood flow through changes in vessel size and increasing the blood flow velocity. A recent study demonstrated that electrical stimulation delivers at a contractile level, known as exercise level stimulation, increases blood by increasing vessel size.
By Vincent De Bono, DC CSCS
Electrical stimulation for increased blood flow
Emerging evidence has demonstrated that electrical stimulation can increase blood flow through changes in vessel size and an increased blood flow velocity. A recent study showed that electrical stimulation delivered at a contractile level, referred to as exercise level stimulation, enhances blood flow by enlarging vessel size. Conversely, electrical signals provided solely at a sensory stimulus level, known as sensory stimulation, improve blood flow velocity without altering vessel size. This increase in blood flow velocity, despite no changes in vessel size, seems to be mediated by a modification in sympathetic tone, leading to increased muscle tension and enhanced venous return.
Dual signals effect both changes in vessel size and increased velocity of blood flow
ARPwave Therapy uniquely influences blood flow through two distinct mechanisms. The primary signal induces sustained muscle contractions at rates as high as high as 1000 contractions per second, leading to vessel dilation and enhanced blood flow driven by the oxygen requirements of the active muscles. Complementing this, the background signal operates at a sub-sensory level, enhancing blood flow velocity without causing vessel dilation by stimulating increased sympathetic tone. This dual-action not only aids in venous return and mitigates edema but also fosters an environment conducive to healing through improved blood flow velocity.
Unique capability to improve healing
The ARPwave system's ability to provide an initial primary exercise level stimulation followed by a secondary sub-sensory background signal offers a distinct advantage in therapeutic applications. Initially, the primary exercise signal promotes vasodilation, facilitating increased blood flow to targeted areas. Once this initial phase is complete, the option to switch to the background signal allows for enhanced venous return without the continued vasodilatory effects. This method not only supports improved healing by promoting circulation but also plays a crucial role in edema reduction. By optimizing blood flow dynamics, the use of ARPwave techniques can thus contribute to the overall efficacy of rehabilitation and recovery processes.
[1] Jin HK, Hwang TY, Cho SH. Effect of Electrical Stimulation on Blood Flow Velocity and Vessel Size. Open Med (Wars). 2017;12:5-11. Published 2017 Mar 6. doi:10.1515/med-2017-0002
[2] Jin HK, Hwang TY, Cho SH. Effect of Electrical Stimulation on Blood Flow Velocity and Vessel Size. Open Med (Wars). 2017;12:5-11. Published 2017 Mar 6. doi:10.1515/med-2017-0002
ARP , The R-C Circuit And Arthrogenic Muscle Inhibition
The ability to perform a smooth and coordinated body movement is accomplished through an eloquent feedback loop based through the muscle spindle fibers. Injuries to the musculo-skeletal system, particularly injuries to joints, can distribute this feedback loop leading to dysfunctional movement patterns and muscle weakness through inhibition.
By Vincent De Bono, DC CSCS
The process of achieving fluid and coordinated body movement hinges on an intricate feedback loop established by muscle spindle fibers. When the musculoskeletal system sustains injuries, especially to the joints, this feedback mechanism can be disrupted. Such disruptions often result in maladaptive movement patterns and muscle weakness due to inhibition, making it crucial to address these injuries effectively to restore proper function and movement dynamics.
THE ALPHA-GAMMA FEEDBACK LOOP
The alpha-gamma feedback loop is a crucial mechanism in the regulation of muscle contraction. Extrafusal fibers, the primary component of skeletal muscles, are responsible for generating force and movement. These fibers are innervated by alpha motor neurons; their activation leads to muscular contraction.
In parallel with extrafusal fibers are intrafusal fibers, or muscle spindles, which have a predominantly sensory role. These intrafusal fibers detect changes in muscle length and respond to stretch. When a muscle is stretched, such as during the initial phase of lifting a heavy weight, the intrafusal fibers activate, sending signals that lead to the contraction of the extrafusal fibers. This reflexive response serves to counteract the tension imposed by the new load.
However, it is important to note that as the extrafusal fibers shorten during contraction, the intrafusal fibers may become slack. This slackness can lead to a loss of sensory feedback since muscle spindles respond primarily to stretch. To mitigate this, intrafusal fibers are also contractile and are innervated by gamma motor neurons. The simultaneous activation of alpha motor neurons (to contract extrafusal fibers) and gamma motor neurons (to contract intrafusal fibers) facilitates continuous feedback and maintains sensitivity throughout the contraction phase.
Additionally, the alpha motor neuron pool receives direct sensory input from Ia afferent fibers originating in the muscle spindles. This excitatory input from Ia afferents is essential for achieving full muscle activation, ensuring that the muscle can respond effectively to the various demands placed upon it. This integration of motor and sensory pathways exemplifies the intricate nature of muscle control and coordination within the alpha-gamma feedback loop.
HOW DOES THIS EFFECT CLINICAL PRACTICE?
In clinical practice, it is crucial to acknowledge the interplay between joint injuries or pathologies and the resultant neurological inhibition of surrounding muscles. This understanding underscores the importance of addressing not only the physical aspect of an injury but also the underlying neurological mechanisms at play.
For instance, in cases of osteoarthritis of the knee, the impairment of Ia afferent feedback due to γ-loop dysfunction necessitates a more comprehensive approach to rehabilitation. Traditional methods may focus on strengthening exercises, but without addressing the inhibition of the quadriceps resulting from compromised sensory outputs, these efforts may be insufficient.
To achieve optimal outcomes, practitioners should incorporate strategies that aim to restore normal sensory feedback and enhance muscle activation. Techniques such as kinesiology taping and myofascial release may assist in facilitating proper neuromuscular function and improving proprioceptive input.
Ultimately, rehabilitation practices that integrate an understanding of neurological inhibition and employ targeted interventions may lead to more effective management of joint injuries. This holistic approach not only promotes recovery but also reduces the risk of further complications related to muscle weakness and atrophy.
REHABILITATION
ARP plays a vital role in the rehabilitation of arthritic or injured joints. The ARPwave Black generates a stimulus through a resistance-capacitance (RC) circuit, producing a smoother waveform. This capacitance allows for energy storage and gradual discharge between cycles, similar to how a light bulb continues to glow briefly after being turned off. Neurons also function as biological RC circuits, storing and releasing charges in a similar manner, which permits a prolonged transmission of impulses.
The resistance in this model is influenced by the number of ion channels that open during impulse transmission. More open ion channels lead to reduced resistance and increased conductance of the nerve. Neurological inhibition, specifically γ-loop dysfunction, may result from increased resistance in the 1a fibers, possibly due to fewer ion channels opening when transmitting impulses.
The ARP Neuro device generates impulses in a waveform that mirrors natural neuronal activity but operates at an accelerated frequency of 500 contractions per second. This high rate response seems to effectively restore feedback from the 1a fibers, as evidenced by the enhanced contraction strength observed after ARP Neuro therapy. This approach highlights the importance of aligning rehabilitation techniques with the underlying mechanisms of neural function for improved patient outcomes.
This may be a result of the ARP stimulus opening additional ion channels in the 1a neuron, which decreases resistance and increases the conductance of signals to the alpha-motor neuron pool. In summary, the ARP Neuro stimulus appears to reverse γ-loop dysfunction, an essential factor in addressing arthrogenic muscle inhibition. By overcoming arthrogenic muscle inhibition resulting from joint injury, appropriate loading and biomechanics of the affected joint can be restored, leading to improved long-term outcomes.
ARPwave
The emerging evidence on the profound effect of neuromuscular electrical stimulation (NEMS) combined with active movements on overcoming muscle inhibition from joint injury warrants a re-examination of NEMS by physical medicine practitioners. As research advances, our understanding of NEMS technology also evolves. Today's units, such as the ARPwave Balck, are capable of delivering up to 1000 contractions per second. This level of stimulation mimics the body's natural processes but at a significantly accelerated rate. Such advancements can potentially lead to dramatic improvements in long-term outcomes for patients dealing with joint injuries. Integrating NEMS into therapeutic practices may enhance rehabilitation strategies, facilitating quicker recovery and improved muscle function.
References:
Lepley AS, Lepley LK. Mechanisms of Arthrogenic Muscle Inhibition. J Sport Rehabil. 2021 Sep 1;31(6):707-716. doi: 10.1123/jsr.2020-0479. PMID: 34470911.
Konishi Y, Yoshii R, Ingersoll CD. Gamma Loop Dysfunction as a Possible Neurophysiological Mechanism of Arthrogenic Muscle Inhibition: A Narrative Review of the Literature. J Sport Rehabil. 2022 Jan 25;31(6):736-741. doi: 10.1123/jsr.2021-0232. PMID: 35078149.
Pietrosimone B, Lepley AS, Kuenze C, Harkey MS, Hart JM, Blackburn JT, Norte G. Arthrogenic Muscle Inhibition Following Anterior Cruciate Ligament Injury. J Sport Rehabil. 2022 Feb 14;31(6):694-706. doi: 10.1123/jsr.2021-0128. PMID: 35168201.
Rice DA, McNair PJ, Lewis GN. Mechanisms of quadriceps muscle weakness in knee joint osteoarthritis: the effects of prolonged vibration on torque and muscle activation in osteoarthritic and healthy control subjects. Arthritis Res Ther. 2011;13(5):R151. doi: 10.1186/ar3467. Epub 2011 Sep 20. PMID: 21933392; PMCID: PMC3308081.
Hagbarth KE, Kunesch EJ, Nordin M, Schmidt R, Wallin EU: Gamma loop contributing to maximal voluntary contractions in man. J Physiol. 1986, 380: 575-591.
Dabrowski KM, Castaño DJ, Tartar JL. Basic neuron model electrical equivalent circuit: an undergraduate laboratory exercise. J Undergrad Neurosci Educ. 2013;12(1):A49-A52. Published 2013 Oct 15.
New Muscle Discovered - Tensor of the Vastus Intermedius
To date, the TVI has been attributed to the VL. Indeed, the affiliation of the TVI to the VL is confirmed by the close relationship of the two muscle heads in the proximal aspect. However, the course and function of the TVI and its neurovascular supply suggest that it is aligned more with the VI than the VL. Yet, when the nerves supplying the quadriceps femoris are viewed as a whole, the TVI should be considered together with the VL and the lateral portion of the VI as a func- tional unit. All three lamellar muscles are closely related and are supplied by the same deep lateral divi- sion of the femoral nerve.
The quadriceps femoris is traditionally described as a muscle group composed of the rectus femoris and the three vasti. However, clinical experience and investigations of anatomical specimens are not consistent with the text- book description. We have found a second tensor-like muscle between the vastus lateralis (VL) and the vastus intermedius (VI), hereafter named the tensor VI (TVI). The aim of this study was to clarify whether this intervening muscle was a variation of the VL or the VI, or a separate head of the exten- sor apparatus. Twenty-six cadaveric lower limbs were investigated. The architecture of the quadriceps femoris was examined with special attention to innervation and vascularization patterns. All muscle components were traced from origin to insertion and their affiliations were determined. A TVI was found in all dissections. It was supplied by independent muscular and vascular branches of the femoral nerve and lateral circumflex femoral artery. Further distally, the TVI combined with an aponeurosis merging separately into the quadriceps tendon and inserting on the medial aspect of the patella.
Motus Comment - in examining the course of this newly discovered muscle one may wonder if it plays a role in lateral tracking disorders of the patella - comments are welcome on this hypothesis.
Treating the Lateral Raphe to Improve Contraction of the Transverse Abdominus
Purpose: Recent evidence suggested the significance of integrity of the tension balance of the muscle-
fascia corset system in spinal stability, particularly the posterior musculofascial junction which is adja-
cent to dorsal located paraspinal muscles joining each other at lateral raphe (LR). The purpose of this
study was to compare the contraction of the transversus abdominis (TrA) at both anterior and posterior
musculofascial muscle-fascia junctions in patients with low back pain (LBP) and asymptomatic partici-
pants before and immediately after a sustained manual pressure to LR.
Methods: The present observational cohort study used a single-instance, test-retest design. The outcome
variables included the resting thickness (Tr), the thickness during contraction (Tc), change in thickness
(DT), sliding of musculofascial junction (DX), muscle length at rest (L) and displacement pattern (DD) of
the TrA using ultrasonography. Vertical tolerable pressure at the LR was applied manual for 1 min. Tr, Tc,
DT, and DX were analyzed by three-way ANOVA (musculofascial junction sites*group* pre-post manual
release). DL and DD were analyzed by two-way ANOVA (group* pre-post manual release).
Results: Participants with LBP revealed less Tc, DT and DX at both sites (p < 0.005). After myofascial
release, LBP group demonstrated a positive DD of the musculofascial junctions at both end (p < 0.001).
Nevertheless, both groups increased the DT and DX at both sites (p < 0.001 and 0.001, respectively).
Conclusion: The result indicated immediately effect of sustained manual pressure on musculofascial
junction of TrA and supported the concept that the possible imbalanced tension of the myofascia corset
of TrA in patients with LBP.
Myofascial release of the Lateral Raphe is a technique that we have recently incorporated into out Level 1 Motus course, we have found the technique to be very useful in establishing core stability for the lumbar spine through activation of the TA. We also cover the importance of the co-contraction of the lumbar erectors and the rectus abdominus, as well as the areas of densification that should be assessed between the external oblique, internal oblique and TA. All of these are critical comments in ensuring the proper stabilization of the lumbar spine.
This article demonstrates the changes in the contractability of the TA by manual pressure techniques on the lateral raphe through diagnostic ultrasound imaging.
Current Review of Hamstring Injuries
In spite of all the research and additional under- standing of hamstring muscle injures over the past 20–30 years, we have not reduced the incidence of first-time injuries and the recurrence rate is still extremely high. While research published over the past couple of years has led to an increased under- standing of these challenging injuries, we still have a long way to go in the management of hamstring muscle injuries.
Despite increased knowledge of hamstring muscle injuries, the incidence has not diminished. We now know that not all hamstring injuries are the same and that certain types of injuries require prolonged rehabilitation and return to play. The slow stretch type of injury and injuries involving the central tendon both require longer times to return to play. A number of factors have been proposed as being indicators of time taken to return to play, but the evidence for these is conflicting. Recurrence rates remain high and it is now thought that strength deficits may be an important factor. Strengthening exercise should be performed with the hamstrings in a lengthened position. There is conflicting evidence regarding the efficacy of platelet-rich plasma injection in the treatment of hamstring injuries so at this stage we cannot advise their use. Various tests have been proposed as predictors of hamstring injury and the use of the Nordboard is an interesting addition to the testing process. Prevention of these injuries is the ultimate aim and there is increasing evidence that Nordic hamstring exercises are effective in reducing the incidence.
Manual Manipulation Effective for Leg Pain due to SI Joint Dysfunction
Abstract:
Purpose: The sacroiliac joint (SIJ) may be a cause of sciatica. The aim of this study was to assess which treatment is successful for SIJ-related back and leg pain.
Methods: Using a single-blinded randomized trial, we assessed the short-term therapeutic efficacy of physiotherapy, manual therapy, and intra-articular injection with local corticosteroids in the SIJ in 51 patients with SIJ-related leg pain. The effect of the treatment was evaluated after 6 and 12 weeks.
Results: Of the 51 patients, 25 (56 %) were successfully treated. Physiotherapy was successful in 3 out of 15 patients (20 %), manual therapy in 13 of the 18 (72 %), and intra-articular injection in 9 of 18 (50 %) patients (p = 0.01). Manual therapy had a significantly better success rate than physiotherapy (p = 0.003).
Conclusion: In this small single-blinded prospective study, manual therapy appeared to be the choice of treatment for patients with SIJ-related leg pain. A second choice of treatment to be considered is an intra-articular injection.
Researchers Find Missing Link Between the Brain and Immune System
Implications profound for neurological diseases from autism to Alzheimer’s to multiple sclerosis.
In a stunning discovery that overturns decades of textbook teaching, researchers at the University of Virginia School of Medicine have determined that the brain is directly connected to the immune system by vessels previously thought not to exist. That such vessels could have escaped detection when the lymphatic system has been so thoroughly mapped throughout the body is surprising on its own, but the true significance of the discovery lies in the effects it could have on the study and treatment of neurological diseases ranging from autism to Alzheimer’s disease to multiple sclerosis.
“Instead of asking, ‘How do we study the immune response of the brain?’ ‘Why do multiple sclerosis patients have the immune attacks?’ now we can approach this mechanistically. Because the brain is like every other tissue connected to the peripheral immune system through meningeal lymphatic vessels,” said Jonathan Kipnis, PhD, professor in the UVA Department of Neuroscience and director of UVA’s Center for Brain Immunology and Glia (BIG). “It changes entirely the way we perceive the neuro-immune interaction. We always perceived it before as something esoteric that can’t be studied. But now we can ask mechanistic questions.”
“We believe that for every neurological disease that has an immune component to it, these vessels may play a major role,” Kipnis said. “Hard to imagine that these vessels would not be involved in a [neurological] disease with an immune component.”
Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders?
Discussion: Increasing evidence reveals structural and functional changes within the Central Nervous System (CNS) of people with chronic MSD that appear to play a prominent role in the pathophysiology of these disorders. These neuroplastic changes are reflective of adaptive neurophysiological processes occurring as the result of altered afferent stimuli including nociceptive and neuropathic transmission to spinal, subcortical and cortical areas with MSD that are initially beneficial but may persist in a chronic state, may be part and parcel in the pathophysiology of the condition and the development and maintenance of chronic signs and symptoms. Neuroplastic changes within different areas of the CNS may help to explain the transition from acute to chronic conditions, sensory-motor findings, perceptual disturbances, why some individuals continue to experience pain when no structural cause can be discerned, and why some fail to respond to conservative interventions in subjects with chronic MSD. We argue that a change in paradigm is necessary that integrates CNS changes associated with chronic MSD and that these findings are highly relevant for the design and implementation of rehabilitative interventions for this population.
Summary: Recent findings suggest that a change in model and approach is required in the rehabilitation of chronic MSD that integrate the findings of neuroplastic changes across the CNS and are targeted by rehabilitative interventions. Effects of current interventions may be mediated through peripheral and central changes but may not specifically address all underlying neuroplastic changes in the CNS potentially associated with chronic MSD. Novel approaches to address these neuroplastic changes show promise and require further investigation to improve efficacy of currents approaches.
Musculoskeletal rehabilitative care and research have traditionally been guided by a structural pathology paradigm and directed their resources towards the structural, functional, and biological abnormalities located locally within the musculoskeletal system to understand and treat Musculoskeletal Disorders (MSD). However the structural pathology model does not adequately explain many of the clinical and experimental findings in subjects with chronic MSD and, more importantly, treatment guided by this paradigm fails to effectively treat many of these conditions.
Cellular mechanotransduction: putting all the pieces together again
Analysis of cellular mechanotransduction, the mechanism by which cells convert mechanical signals into biochemical responses, has focused on identification of critical mechanosensitive molecules and cellular components. Stretch-activated ion channels, caveolae, integrins, cadherins, growth factor receptors, myosin motors, cytoskeletal filaments, nuclei, extracellular matrix, and numerous other structures and signaling molecules have all been shown to contribute to the mechanotransduction response. However, little is known about how these different molecules function within the structural context of living cells, tissues, and organs to produce the orchestrated cellular behaviors required for mechanosensation, embryogenesis, and physiological control. Recent work from a wide range of fields reveals that organ, tissue, and cell anatomy are as important for mechanotransduction as individual mechanosensitive proteins and that our bodies use structural hierarchies (systems within systems) composed of interconnected networks that span from the macroscale to the nanoscale in order to focus stresses on specific mechanotransducer molecules. The presence of isometric tension (prestress) at all levels of these multiscale networks ensures that various molecular scale mechanochemical transduction mechanisms proceed simultaneously and produce a concerted response. Future research in this area will therefore require analysis, understanding, and modeling of tensionally integrated (tensegrity) systems of mechanochemical control
This is one of the articles that changed the way we thought about how sensory input and mechanical stimuli effected the underlying tissue. Mechanotransduction processes offer great insight on how manual therapy effects the underlying physiology of the body.
Neuronal hyperexcitability in the dorsal horn after painful facet joint injury
Excessive cervical facet capsular ligament stretch has been implicated as a cause of whiplashassociated disorders following rear-end impacts, but the pathophysiological mechanisms that produce chronic pain in these cases remain unclear. Using a rat model of C6/C7 cervical facet joint capsule stretch that produces sustained mechanical hyperalgesia, the presence of neuronal hyperexcitability was characterized 7 days after joint loading.
Emerging research illustrating the concept that a possible mechanism of chronic pain in patient may be due to central sensitization after an injury. This article examines the role of central sensitization following injury to the facet joint capsule in cases of whiplash.