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Commentary: The spine and vibration: whole lotta shaking going on
The Spine Journal 13 (2013) 437–438
Commentary
Commentary: The spine and vibration: whole lotta shaking going on James B. Talmage, MD, BSca,b,* b
a Occupational Medicine, Meharry Medical College, Nashville, TN, USA Occupational Health Center, 315 N. Washington Ave., Suite 165, Cookeville, TN 38501, USA
Received 31 January 2013; accepted 8 February 2013
COMMENTARY ON: Holguin N, Martin JT, Elliott DM, Judex S. Low-intensity vibrations partially maintain intervertebral disc mechanics and spinal muscle area during deconditioning. Spine J 2013;13:428–36 (in this issue)
In this issue of The Spine Journal, Holguin et al. [1] report on a biomechanics study in which rats subjected to deconditioning by preventing lower limb weightbearing had 15 minutes a day of vibration exposure. The exposure helped to decrease the negative effects of non-weight bearing on the rat lumbar discs. Readers may ponder the vibration paradox. Workers exposed to whole body vibration through motor vehicles or trains frequently have physicians opine and testify that the vibration exposure injured the workers’ spines, and workers’ compensation systems and Federal Employers Liability Act juries frequently accept this assertion. However, the recent systematic review by Bible et al. [2] failed to find any evidence to support the concept that vibration injures the spine. The best study is in identical twin pairs highly discordant for driving by Battie et al. [3], who report no evidence of injury. Although vibration is alleged, without good evidence, to cause spinal injury, the paradox is the present use of whole body vibration to treat spinal disorders. A ‘‘Google search’’ of whole body vibration and low back pain on January 31, 2013 resulted in 1,160,000 ‘‘hits,’’ with most of the first few hundred from web sites advocating vibration as a therapy. Wolff’s law says bone responds to the stresses placed on it, and yet, reviews of vibration platform therapy for the DOI of original article: 10.1016/j.spinee.2013.01.046. FDA device/drug status: Not approved (Vibration platforms). Author disclosures: JBT: Royalties: American Medical Association (B); Consulting: Reed Group, Ltd (C); Speaking/Teaching Arrangements: ACOEM (B), SEAK (B); Trips/Travel: ACOEM (B), AADEP (B), AAOS (B). The disclosure key can be found on the Table of Contents and at www. TheSpineJournalOnline.com. * Corresponding author. Occupational Health Center, 315 N. Washington Ave., Suite 165, Cookeville, TN 38501, USA. Tel.: (931) 526-1604; fax: (931) 526-7378. E-mail address: [email protected] (J.B. Talmage) 1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.02.004
treatment of osteoporosis [4,5] have not been able to show effectiveness, perhaps because the vibration doses used have been subtherapeutic or because the studies are too short (osteoporosis takes a long time to develop). In human volunteers undergoing prolonged bed rest, vibration has been shown to help prevent the negative effects of bed rest on lumbar muscles [6] and discs, [6,7] although the addition of vibration to exercise appeared to have little additional benefit for spine muscles when compared with exercise alone [8]. A randomized controlled trial with 50 nonspecific low back pain patients with the intervention group treated with 24 sessions of vibration [9] reported statistically significant improvement in the clinically important outcomes of back pain, Oswestry, and Roland Morris questionnaires, yet the improvements were below the minimal clinically important difference [10] for each of these outcome measures. Physicians are more comfortable recommending treatments for patients if the treatment has both the evidence of efficacy in human studies and in experimental animal models. Humans are difficult to study, in that investigators have to try to quantitate and statistically control for confounders or hope randomization controls the confounders for them. Experimental studies (rats in the lab) let investigators control for confounders. Thus studies such as Holguin et al. [1] are looked to for evidence of efficacy, mechanism of efficacy, and to help perhaps define the dose to be used in human studies. The biomechanical properties tested and discussed in this study will send clinician-readers to biomechanics textbooks or cause these readers to skip the ‘‘methods’’ section and jump to the ‘‘conclusions’’ section. The authors’ previous studies (referenced in the article) showed that vibration exposure to the hind limb of immobilized rats mitigated somewhat the loss of disc glycosaminoglycan content and the disc height. Ninety hertz was
438
J.B. Talmage / The Spine Journal 13 (2013) 437–438
more effective than 45 Hz vibration, so 90 Hz was used in this study. This is a higher frequency of vibration than was used in some previous human studies [6,7] and is above the frequency (10–50 Hz) of vibration generated in humans by normal lower limb muscle activity [11,12]. The authors clearly disclose the commercial interest (patent) of one author, which is a potential source of bias, but with human studies showing similar benefits, commercial bias is unlikely to have affected this study’s results. With the Google search showing over one million sites discussing vibration and back pain, using vibration platforms to treat back pain patients without Food and Drug Administration device approval is yet another example of technology being introduced before the basic science and clinical studies have provided the evidence of safety and effectiveness to justify the treatment. Holguin et al. are to be commended for helping provide the evidence. For the time being as evidence of the therapeutic benefit of vibration accumulates, it is at least time for physicians to stop attributing back pain in workers to vibration exposure on the job. References [1] Holguin N, Martin JT, Elliott DM, Judex S. Low-intensity vibrations partially maintain intervertebral disc mechanics and spinal muscle area during deconditioning. Spine J 2013;13:428–36.
[2] Bible JE, Choemprayong S, O’Neill KR, et al. Whole body vibration: is there a causal relationship to specific imaging findings of the spine? Spine 2012;37:E1348–55. [3] Battie MC, Videman T, Gibbons LE, et al. Occupational driving and lumbar disc degeneration: a case control study. Lancet 2002;360: 1369–74. [4] Merriman H, Jackson K. The effects of whole-body vibration training in aging adults: a systematic review. J Geriatr Phys Ther 2009;32: 134–45. [5] Wysocki A, Butler M, Shamliyan T, et al. Whole-body vibration therapy for osteoporosis: state of the science. Ann Intern Med 2011;155:680–6. [6] Belavy DL, Hides JA, Wilson SJ, et al. Resistive simulated weightbearing exercise with whole body vibration reduces lumbar spine deconditioning in bed rest. Spine 2008;33:E121–31. [7] Holguin N, Muir J, Rubin C, Judex S. Short applications of very low-magnitude vibrations attenuate expansion of the intervertebral disc during extended bed rest. Spine J 2009;9:470–7. [8] Belavy DL, Armbrecht G, Gast U, et al. Countermeasures against lumbar spine deconditioning in prolonged bed rest: resistive exercise with and without whole body vibration. J Appl Physiol 2010;109: 1801–11. [9] del Pozo-Cruz B, Hernandez Mocholi MA, Adsuar JC, et al. Effects of whole body vibration therapy on main outcome measures for chronic non-specific low back pain: a single blind randomized controlled trial. J Rehabil Med 2011;43:689–94. [10] Carragee EJ, Cheng I. Minimum acceptable outcomes after lumbar spinal fusion. Spine J 2010;10:313–20. [11] Cardinale M, Wakeling JM. Whole body vibration exercise: are vibrations good for you? Br J Sports Med 2005;39:585–9. [12] Wakeling JM, Nigg BM. Soft tissue vibrations in the quadriceps measured with skin mounted transducers. J Biomech 2001;34: 539–43.
Commentary
Commentary: The spine and vibration: whole lotta shaking going on James B. Talmage, MD, BSca,b,* b
a Occupational Medicine, Meharry Medical College, Nashville, TN, USA Occupational Health Center, 315 N. Washington Ave., Suite 165, Cookeville, TN 38501, USA
Received 31 January 2013; accepted 8 February 2013
COMMENTARY ON: Holguin N, Martin JT, Elliott DM, Judex S. Low-intensity vibrations partially maintain intervertebral disc mechanics and spinal muscle area during deconditioning. Spine J 2013;13:428–36 (in this issue)
In this issue of The Spine Journal, Holguin et al. [1] report on a biomechanics study in which rats subjected to deconditioning by preventing lower limb weightbearing had 15 minutes a day of vibration exposure. The exposure helped to decrease the negative effects of non-weight bearing on the rat lumbar discs. Readers may ponder the vibration paradox. Workers exposed to whole body vibration through motor vehicles or trains frequently have physicians opine and testify that the vibration exposure injured the workers’ spines, and workers’ compensation systems and Federal Employers Liability Act juries frequently accept this assertion. However, the recent systematic review by Bible et al. [2] failed to find any evidence to support the concept that vibration injures the spine. The best study is in identical twin pairs highly discordant for driving by Battie et al. [3], who report no evidence of injury. Although vibration is alleged, without good evidence, to cause spinal injury, the paradox is the present use of whole body vibration to treat spinal disorders. A ‘‘Google search’’ of whole body vibration and low back pain on January 31, 2013 resulted in 1,160,000 ‘‘hits,’’ with most of the first few hundred from web sites advocating vibration as a therapy. Wolff’s law says bone responds to the stresses placed on it, and yet, reviews of vibration platform therapy for the DOI of original article: 10.1016/j.spinee.2013.01.046. FDA device/drug status: Not approved (Vibration platforms). Author disclosures: JBT: Royalties: American Medical Association (B); Consulting: Reed Group, Ltd (C); Speaking/Teaching Arrangements: ACOEM (B), SEAK (B); Trips/Travel: ACOEM (B), AADEP (B), AAOS (B). The disclosure key can be found on the Table of Contents and at www. TheSpineJournalOnline.com. * Corresponding author. Occupational Health Center, 315 N. Washington Ave., Suite 165, Cookeville, TN 38501, USA. Tel.: (931) 526-1604; fax: (931) 526-7378. E-mail address: [email protected] (J.B. Talmage) 1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.02.004
treatment of osteoporosis [4,5] have not been able to show effectiveness, perhaps because the vibration doses used have been subtherapeutic or because the studies are too short (osteoporosis takes a long time to develop). In human volunteers undergoing prolonged bed rest, vibration has been shown to help prevent the negative effects of bed rest on lumbar muscles [6] and discs, [6,7] although the addition of vibration to exercise appeared to have little additional benefit for spine muscles when compared with exercise alone [8]. A randomized controlled trial with 50 nonspecific low back pain patients with the intervention group treated with 24 sessions of vibration [9] reported statistically significant improvement in the clinically important outcomes of back pain, Oswestry, and Roland Morris questionnaires, yet the improvements were below the minimal clinically important difference [10] for each of these outcome measures. Physicians are more comfortable recommending treatments for patients if the treatment has both the evidence of efficacy in human studies and in experimental animal models. Humans are difficult to study, in that investigators have to try to quantitate and statistically control for confounders or hope randomization controls the confounders for them. Experimental studies (rats in the lab) let investigators control for confounders. Thus studies such as Holguin et al. [1] are looked to for evidence of efficacy, mechanism of efficacy, and to help perhaps define the dose to be used in human studies. The biomechanical properties tested and discussed in this study will send clinician-readers to biomechanics textbooks or cause these readers to skip the ‘‘methods’’ section and jump to the ‘‘conclusions’’ section. The authors’ previous studies (referenced in the article) showed that vibration exposure to the hind limb of immobilized rats mitigated somewhat the loss of disc glycosaminoglycan content and the disc height. Ninety hertz was
438
J.B. Talmage / The Spine Journal 13 (2013) 437–438
more effective than 45 Hz vibration, so 90 Hz was used in this study. This is a higher frequency of vibration than was used in some previous human studies [6,7] and is above the frequency (10–50 Hz) of vibration generated in humans by normal lower limb muscle activity [11,12]. The authors clearly disclose the commercial interest (patent) of one author, which is a potential source of bias, but with human studies showing similar benefits, commercial bias is unlikely to have affected this study’s results. With the Google search showing over one million sites discussing vibration and back pain, using vibration platforms to treat back pain patients without Food and Drug Administration device approval is yet another example of technology being introduced before the basic science and clinical studies have provided the evidence of safety and effectiveness to justify the treatment. Holguin et al. are to be commended for helping provide the evidence. For the time being as evidence of the therapeutic benefit of vibration accumulates, it is at least time for physicians to stop attributing back pain in workers to vibration exposure on the job. References [1] Holguin N, Martin JT, Elliott DM, Judex S. Low-intensity vibrations partially maintain intervertebral disc mechanics and spinal muscle area during deconditioning. Spine J 2013;13:428–36.
[2] Bible JE, Choemprayong S, O’Neill KR, et al. Whole body vibration: is there a causal relationship to specific imaging findings of the spine? Spine 2012;37:E1348–55. [3] Battie MC, Videman T, Gibbons LE, et al. Occupational driving and lumbar disc degeneration: a case control study. Lancet 2002;360: 1369–74. [4] Merriman H, Jackson K. The effects of whole-body vibration training in aging adults: a systematic review. J Geriatr Phys Ther 2009;32: 134–45. [5] Wysocki A, Butler M, Shamliyan T, et al. Whole-body vibration therapy for osteoporosis: state of the science. Ann Intern Med 2011;155:680–6. [6] Belavy DL, Hides JA, Wilson SJ, et al. Resistive simulated weightbearing exercise with whole body vibration reduces lumbar spine deconditioning in bed rest. Spine 2008;33:E121–31. [7] Holguin N, Muir J, Rubin C, Judex S. Short applications of very low-magnitude vibrations attenuate expansion of the intervertebral disc during extended bed rest. Spine J 2009;9:470–7. [8] Belavy DL, Armbrecht G, Gast U, et al. Countermeasures against lumbar spine deconditioning in prolonged bed rest: resistive exercise with and without whole body vibration. J Appl Physiol 2010;109: 1801–11. [9] del Pozo-Cruz B, Hernandez Mocholi MA, Adsuar JC, et al. Effects of whole body vibration therapy on main outcome measures for chronic non-specific low back pain: a single blind randomized controlled trial. J Rehabil Med 2011;43:689–94. [10] Carragee EJ, Cheng I. Minimum acceptable outcomes after lumbar spinal fusion. Spine J 2010;10:313–20. [11] Cardinale M, Wakeling JM. Whole body vibration exercise: are vibrations good for you? Br J Sports Med 2005;39:585–9. [12] Wakeling JM, Nigg BM. Soft tissue vibrations in the quadriceps measured with skin mounted transducers. J Biomech 2001;34: 539–43.