Good vibrations: whole-body vibration therapy

I recently started using a whole-body vibration platform daily and in just a couple of weeks I have experienced impressive improvements in low back pain and leg muscle control. I think that, used carefully, there is real potential for whole-body vibration to help people with arthrofibrosis. It’s important to note that I’m not suggesting whole-body vibration is a cure, but rather a therapy that can help to maintain health for those unable to exercise, and which might perhaps tip the balance towards healthy healing for some. But evidence is lacking, because despite thousands of papers on whole-body vibration therapy, there isn’t research about its application in arthrofibrosis. Manufacturers recommend that patients wait for 6 to 8 weeks after an operation before using whole-body vibration, and there are contraindications (no-go conditions) I’ll mention below.

A range of devices deliver mechanical vibration therapy, including handheld devices like massage “guns”, vibrating weights and wearable devices. Whole-body vibration differs from these, because the entire body experiences the effects of vibration as the user stands on the vibrating platform, providing important additional systemic effects [1]. However, handheld massage guns have a role to play for increasing blood and lymphatic flow in targeted muscles and I find one especially useful for the quadriceps.

Figure 1: A Hypervibe side-alternating platform, published with permission. Note the “softened”, slightly bent knees. The user would normally face the stand.

Whole-body vibration is a form of passive exercise in which the machine does the work and stimulates muscles [2] and nerves, inducing reflexive (involuntary) muscle contractions [3] and providing exercise-like benefits [4]. It has been widely used to increase muscle strength and control in various groups, including older people and elite athletes, and there is increasing interest whole-body vibration for treating musculoskeletal (muscle and bone) conditions [5] and in neuro-rehabilitation (damaged nerves and pain) [6]. Research indicates it can reduce the symptoms of a range of diseases including osteoarthritis, patellofemoral pain [7], diabetic neuropathy [8], osteoporosis, muscle loss in the elderly, low-back pain and chronic pain [5].

If you have knee arthrofibrosis you’ll likely be familiar with the common symptoms of muscle loss, abnormal nerve functioning and pain [9]. After major surgery like an ACL reconstruction there is a significant reduction in muscle control and function [10]. Nerves are damaged and inflamed, and abnormal nerve signaling reduces awareness of knee position and movement (poor proprioception) [10]. And, while you probably won’t be aware of it, surgery and scar tissue create tissue hypoxia (a lack of oxygen) that can adversely affect muscles and joints. Hypoxia is one of the factors that creates powerful feedback effects, activating myofibroblasts (the cells that make fibrosis and scar tissue) and creating yet more hypoxia [9], and I believe that addressing this is an important aspect of arthrofibrosis therapy.

Whole-body vibration appears to be able to address many arthrofibrosis symptoms, with benefits including reduced pain, increased blood flow and improved proprioception and tissue recovery, in addition to improving balance [11, 12].

But, as mentioned, we don’t yet know which arthrofibrosis patients will find whole-body vibration helpful, and it takes time and consistent use, probably over several months, for the full benefits to be felt. Since reducing hypoxia is one of the important ways that whole-body vibration can potentially assist in treating arthrofibrosis, daily home use may provide better results compared to less frequent use in a clinic. Whole-body vibration has the potential to improve or restore blood flow in people with reduced peripheral (limb) circulation, including people with musculoskeletal injuries and in diabetes [12]. Long-term use appears to support muscle tissue oxygenation during exercise and reduces arterial stiffness, reducing blood pressure [12].

There is also evidence that whole-body vibration can reduce blood markers of inflammation [1], increase flexibility and reduce muscle stiffness, so long as vibration is not excessive [13]. In addition, it seems that there are benefits for bone [12] and cartilage health for people who are unable to bear weight normally [14]. And a recent study in people with central nervous system injury found that vibration reduced a gene associated with muscle atrophy while increasing the transcription of genes associated with muscle growth [15].

Exercises

There is sound evidence that short duration (1-minute bouts) of low intensity whole-body vibration can have positive effects [4] for a wide range of people by providing a positive mechanical stimulus [16]. Squats and upper body exercises are commonly performed on the vibration platform [17] and the Hypervibe comes with a handy booklet outlining these. However, when using any type of exercise therapy, it’s essential to adapt protocols to the individual and their specific requirements [1]. The forces generated by whole-body vibration are potentially harmful in certain situations [17], and what works for healthy young people likely isn’t beneficial for arthrofibrosis—a “first, do no harm” approach is recommended.

I believe it’s very unwise for anybody with active, painful knee arthrofibrosis to attempt squats or lunges on a whole-body vibration platform.

This is an important point to understand. In knee arthrofibrosis the Hoffa’s fat pad typically becomes fibrotic, swollen and easily pinched between the bones of the knee while bending under load (see Hoffa’s fat pad). If treated with care early on the fat pad can heal, and avoiding squats, lunges and steps becomes essential for an extended period (many months). There may be some knees that won’t tolerate standing on a whole-body vibration platform due to the location of fibrosis, and some knees won’t straighten enough to take load while standing. In these situations, sitting on a chair placed next to the vibration platform, with feet placed on it during vibration, may provide benefits. Users can also sit directly on the platform with feet off it.

I personally like the “little and often” approach to whole-body vibration. I use a side-alternating platform (Hypervibe G10) at low amplitude (close foot placement at marked “L”) and 20Hz. I use a softened stance (knees very slightly bent) and looking ahead (not down). There is more information about settings and posture below. I begin each day with three 1-minute bouts with 1 minute rest intervals between each bout. I’m gradually building in additional 1-minute bouts, which is particularly useful after sitting for a period. I don’t go above low amplitude (estimated 2.5 to 3.5mm) and I avoid 15Hz, because like others, 15Hz makes me feel uncomfortable due to body resonances [18]. I use the elastic cords supplied with the device to gently exercise my arms, but I don’t perform leg exercises. Moving the hips and using a posterior pelvic tilt (pushing the hips backwards) helps to strengthen core back muscles [19]. I experience pleasant effects immediately after stopping vibration, my legs feel relaxed and slightly tingly, perhaps from the increased blood flow.

How it works

The role of physiotherapy (physical therapy) is to use tailored mechanical forces generated by physical stimuli (such as exercise) to repair tissues [20]. However, many people are restricted in their ability to load-bear and exercise, so finding novel ways to safely introduce mechanical forces are needed [20]. Even astronauts suffer from bone loss and muscle atrophy [21], despite exercising in space, from the lack gravity acting on their bodies. To address this, the German Aerospace Agency and NASA conducted research in the early 2000’s with Galileo side-alternating platforms.

This research triggered a surge in popularity for whole-body vibration, but this early adoption led to many misunderstandings, the sale of poorly designed machines, and unrealistic expectations of weight loss. Fortunately, there is now a considerable amount of data that supports the use of whole-body vibration as a therapy. Whole-body vibration causes rapid changes in muscle and tendon length, stretching and releasing tissues in a cyclical manner [16] as the body absorbs the energy from the platform. This sends a reflex signal to the spine and is thought to trigger a “tonic vibration reflex” that generates periodic muscle contraction and relaxation [8, 11].

This cyclic stretch provides a healthy mechanical signal that stimulates nerves [16] and increases muscle activity and metabolism [12].

Whole-body vibration and stretch-reflex cycles induce reflex muscle activation in both relaxed and active muscles, even while seated off the vibrating platform, with feet placed on it [22]. However, several studies suggest that taking non-steroidal anti-inflammatory drugs (NSAIDs) before loading (exercise or vibration therapy) can negatively impact the desired cellular responses, including muscle and bone building [20, 23, 24].

Types of machines

Many cheap machines currently available are likely to be ineffective due to their very low intensity or produce high accelerations that may be too aggressive for people with arthrofibrosis. So, it’s important to know the upper and lower limits of amplitude and frequency that a machine can perform at.

Whole-body vibration therapy works by accelerating the body upwards, then gravity returns it to baseline in alternating phases [16] that are rapidly repeated. Two types of whole-body vibration machines are available. Linear, or synchronous, machines transfer upwards movement to both feet equally at the same time (see diagram below). The second type of platform is side alternating (also called rotational and pivoting). This type of platform lifts one foot while the other foot is lowered [16], alternatively tilting the pelvis and mimicking the movements of walking and running [12].

On side-alternating platforms the amplitude increases with distance from the central axis (middle of the platform) – that is, a wider foot position results in a higher amplitude [12]. The low, medium and high amplitude foot placements are usually marked on the platform. The tilting movement of side-alternating platforms has been found to stimulate muscle and tendon groups in the lower legs and feet more at a given amplitude and frequency, and to be significantly more effective at increasing neuromuscular activation of the leg muscles, compared to linear platforms [2]. Side-alternating machines have also been reported to activate back muscles and increase peripheral blood flow more effectively compared to linear machines, especially at lower vibration frequencies from 10Hz to 25Hz [3, 12].

Other downsides of linear platforms are the transmission of stronger, undesirable vibration to the head [16] and, with the exception of Power Plate, fixed amplitude that restricts therapeutic use. However, although my personal preference is for side-alternating platforms, some linear platforms with the appropriate design can also provide benefits, but you do need to check the specifications. A quick guide to the g’s produced at various settings is provided below in the table. Another type of whole-body vibration platform combines linear and side-alternating movements, but these are more expensive and do not appear to provide benefits over side-alternating or linear vibration [25]. Research on horizontal vibration failed to show increases in lower body muscle activation [25].

Vibration Protocol

As with any therapy, it’s important to know the safe and effective dose and tailor it to the individual’s disease status [12]. The dose in this case is the training load, and this is determined by the intensity (machine settings) and volume (number of sets and set duration) [26] as well as how frequently whole-body vibration is performed [1]. This is a little technical, but don’t worry if you don’t understand the details. It is however important to understand that more is not necessarily better - the correct vibration settings should be used for a short duration to obtain the desired outcome, and careful consideration needs to be given to the vibration intensity [27].

Vibration intensity (acceleration) is measured in multiples of Earth’s gravitational force (g) and is a function of the vibration amplitude and frequency [26]. One “g” is the amount of load we experience during standing. During normal walking and navigating steps, we experience between 2 to 4.5g at different phases of the stride. Intensities of 1g (about 12Hz at 3.6mm) or higher have been associated with improved bone health [27], but 2g (about 17Hz at 3.6mm) may provide additional benefits, since intensities below 1.8g on a side-alternative platform (the threshold is higher for a linear platform) have little effect on muscle activity [25].

• Frequency of oscillations is the number of times the platform moves up, down and back per second, and is measured in Hertz (Hz).

• Amplitude is the distance the platform moves from full up to full down and is measured in mm. Low amplitudes (around 2 to 4mm) are probably wise in arthrofibrosis therapy and for people with a prosthesis - but research is lacking.

It’s important to note that vibration intensity increases with the square of frequency, so doubling the frequency will quadruple the vibration intensity. But intensity rises in a direct way with amplitude, so doubling the amplitude doubles the vibration intensity. In any case, both vibration amplitude and frequency have a large effect on the response of muscles [12], and reducing the frequency or amplitude reduces the loading on the legs [27]. High frequencies can induce pain, and low frequencies are considered safer [28]. Too large an amplitude can potentially cause tissue damage - tolerance will vary with the individual, but amplitudes up to 4mm are often used [12].

I believe that people with arthrofibrosis would be wise to start carefully and slowly, with low amplitude (2 to 4mm) and frequencies around 10Hz, slowly increasing the frequency as tolerated, to a maximum of 20Hz.

The intensity of the vibration settings is often increased slowly over a period of several months duration [17]. There may be some additional benefits to frequencies at, or above, 20Hz if tolerated, since type IIa muscle fibres, which are used primarily for movements like walking, contract at 20Hz and above [29] and neuromuscular responses increase as the settings increase [2]. Researchers often use frequencies between 5 and 35Hz but the age and health of the subject should determine the protocol [12]. While it’s thought that 20Hz is superior to lower frequencies for strengthening muscles [19], I personally found 22Hz (at 3.5mm) too intense during the first couple of weeks of use. Special caution is wise in the presence of severe patellar tendinopathy.

Research suggests that 30Hz and above increases the levels of inflammatory cytokines (biological signalling proteins) IL-1β and IL-6 in healthy people [1].

These cytokines are implicated in fibrosis [9] and increases in their levels should probably be avoided by people with active, painful arthrofibrosis. Very aggressive settings (high amplitude plus high frequency) can impose loads (acceleration) up to 50g [27], which are likely to be damaging. However, there are many contradictory papers but many don’t report the amplitude used, an essential aspect of the protocol [30] that, together with frequency, determines cellular responses and behaviour [21]. Most meta-analytical reviews are inconclusive and confounded by misunderstandings of vibration settings, varying bout, session and study durations, incomplete reporting [30] as well as different types of machines.

Whole-body vibration platform protocols with a maximum duration of 1-minute per bout, with 1-minute rest periods between bouts, are frequently specified and are thought to reduce injury risk compared to longer bouts of continuous vibration [17].

It is well established that workplace exposure to overly intense vibration for prolonged periods is associated with harms [4, 16] and hence there are workplace guidelines to manage vibration exposure. Although various animal and cell models have been used to study the effects of vibration, many use aggressive or long-duration protocols that are not recommended for people. I feel that the results of animal research should be interpreted with caution since animals have double the number of legs and very different limb biomechanics that could alter the biological effects. There are similar problems with cell culture research.

Posture

If you try whole-body vibration, you’ll notice that small changes in posture affect how much vibration is transmitted to the upper body and head. If you move your weight forwards onto the balls of your feet and toes there will be very little head vibration, but your ankles and calf muscles will be activated more strongly [16]. When activation of the knee extensor muscles is the aim, a normal, mid-foot stance is suggested [2]. You can feel the vibration in different muscle groups by placing your hands on them.

Slight flexion of the knees while standing on the platform stretches the quadriceps muscles and increases the positive response to vibration [31].

The knees dampen acceleration and reduce vibrations at higher areas of the body [27]. The parts of the body that are closer to the platform absorb the most energy [12]. Socks, but not shoes, are usually recommended, but shoes should be worn by people with diabetes or other foot conditions where ulceration is a risk [12]. It’s advisable to lightly hold onto the platform stand, or something else if the device doesn’t have a stand, to prevent falls until strength and balance have improved. Looking forwards (not downwards) is recommended [19] to reduce head vibration.

Contraindications (no-go) for whole-body vibration

If you have a joint replacement that is problematic it’s a good idea to have scans to rule out fractures and a loose prosthesis before starting whole-body vibration, and these are typically prescribed early in the treatment pathway. There are a number of diseases and conditions that are thought to be contraindications for whole-body vibration, based on theory. These include having a pacemaker, epilepsy, deep vein thrombosis and current blood clots, pregnancy, severe retinopathy (eye disease), recent fractures or orthopaedic implants (such as a total knee replacement) and cancer [32]. However, it seems that many oncologists consider whole-body vibration an appropriate therapy in a range of cancers, but not for bone cancer [33]. Please consult your doctor before starting whole-body vibration.

Whole-body vibration has provided significant health benefits for me already, I feel stronger and I’m excited to see the results in the longer term. Please share your experiences with whole-body vibration in the comments section below or our IAA Group.

Table 1. Here is a quick guide to working out how many g’s a machine can provide. Frequencies (Hz) are in the blue column, and g’s resulting from various amplitudes (top row) are given in the body of the table.

Hz	3.6 mm (L)	6mm (M)	8mm (H)
10	0.7	1.2	1.6
11	0.9	1.5	1.9
12	1.1	1.7	2.3
13	1.2	2.0	2.7
14	1.4	2.4	3.2
15	1.6	2.7	3.6
16	1.9	3.1	4.1
17	2.1	3.5	4.7
18	2.4	3.9	5.2
19	2.6	4.3	5.8
20	2.9	4.8	6.4
21	3.2	5.3	7.1
22	3.5	5.8	7.8
23	3.9	6.3	8.5
24	4.2	6.9	9.3
25	4.6	7.5	10.1
26	4.9	8.1	10.9
27	5.3	8.7	11.7
28	5.7	9.4	12.6
29	6.2	10.1	13.5
30	6.6	10.8	14.5

The IAA has no affiliation or association with Hypervibe.

References

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