A Handheld Quantifiable Soft Tissue Manipulation Device for Tracking Real-Time Dispersive Force-Motion Patterns to Characterize Manual Therapy Treatment.

OBJECTIVE: Low back pain (LBP) is one of the leading neuromusculoskeletal (NMSK) problems around the globe. Soft Tissue Manipulation (STM) is a force-based, non-invasive intervention used to clinically address NMSK pain conditions. Current STM practice standards are mostly subjective, suggesting an urgent need for quantitative metrics. This research aims at developing a handheld, portable smart medical device for tracking real-time dispersive force-motions to characterize manual therapy treatments as Quantifiable Soft Tissue Manipulation (QSTM). METHODS: The device includes two 3D load-cells to quantify compressive and planar-shear forces, coupled with a 6 degrees-of-freedom IMU sensor for acquiring volitionally adapted therapeutic motions while scanning and mobilizing myofascial restrictions over larger areas of the body. These force-motions characterize QSTM with treatment parameters (targeted force, application angle, rate, direction, motion pattern, time) as a part of post-processing on a PC software (Q-Ware©). A human case study was conducted to treat LBP as proof-of-concept for the device's clinical usability. RESULTS: External validation of treatment parameters reported adequate device precision required for clinical use. The case study findings revealed identifiable therapeutic force-motion patterns within treatments indicating subject's elevated force-endurance with self-reported pain reduction. CONCLUSION: QSTM metrics may enable study of STM dosing for optimized pain reduction and functional outcomes using documentable manual therapy. Clinical trials will further determine its reliability and comparison to conventional STM. SIGNIFICANCE: This medical device technology not only advances the state-of-the-art manual therapy with precision rehabilitation but also augments practice with reproducibility to examine neurobiological responses of individualized STM prescriptions for NMSK pathology.

Soft Tissue Manipulation May Attenuate Inflammation, Modulate Pain, and Improve Gait in Conscious Rodents With Induced Low Back Pain.

INTRODUCTION: Low back pain (LBP) is common in warfighters. Noninvasive interventions are necessary to expedite return-to-function. Soft tissue manipulation, for example, massage, is a method used to treat LBP. Instrument-assisted soft tissue manipulation (IASTM) uses a rigid device to mobilize the tissue. This study explored the effects of IASTM on pain, function, and biomarkers. METHODS: Sprague-Dawley rats (n = 44) were randomized to groups (n = 6/grp): (A) cage control; (B) 3 days (3d) postinjury (inj), untreated; (C) 3d inj, < 30-minute post-IASTM treatment; (D) 3d inj, 2 hours (2h) post-IASTM; (E) 14 days (14d) inj, untreated; (F) 14d inj, < 30-minute post-IASTM; and (G) 14d inj, 2h post-IASTM. Researchers induced unilateral LBP in Sprague-Dawley rats using complete Freund's adjuvant injection. Conscious rodents received IASTM for 5 min/session once at 3 days or 3×/week × 2weeks (6× total) over 14 days. Biomarker plasma levels were determined in all groups, while behavioral outcomes were assessed in two groups, D and G, at three time points: before injury, pre-, and post-IASTM treatment. Circulating mesenchymal stem cell levels were assessed using flow cytometry and cytokine plasma levels assayed. RESULTS: The back pressure pain threshold (PPT) lowered bilaterally at 3 days postinjury (P < .05), suggesting increased pain sensitivity. IASTM treatment lowered PPT more on the injured side (15.8%; P < 0.05). At 14 days, back PPT remained lower but similar side to side. At 3 days, paw PPT increased 34.6% in the contralateral rear limb following treatment (P < .01). Grip strength did not vary significantly. Gait coupling patterns improved significantly (P < .05). Circulating mesenchymal stem cell levels altered significantly postinjury but not with treatment. Neuropeptide Y plasma levels increased significantly at 3 days, 2h post-IASTM (53.2%) (P < .05). Interleukin-6 and tumor necrosis factor-alpha did not vary significantly. At 14 days, regulated on activation, normal T cell expressed and secreted decreased significantly <30-minute post-IASTM (96.1%, P < .002), while IL-10 trended upward at 2h (53.1%; P = .86). CONCLUSIONS: LBP increased pain sensitivity and diminished function. IASTM treatment increased pain sensitization acutely in the back but significantly reduced pain sensitivity in the contralateral rear paw. Findings suggest IASTM may positively influence pain modulation and inflammation while improving gait patterns. Soft tissue manipulation may be beneficial as a conservative treatment option for LBP.

Mechanical stimulation of human dermal fibroblasts regulates pro-inflammatory cytokines: potential insight into soft tissue manual therapies.

OBJECTIVE: Soft tissue manual therapies are commonly utilized by osteopathic physicians, chiropractors, physical therapists and massage therapists. These techniques are predicated on subjecting tissues to biophysical mechanical stimulation but the cellular and molecular mechanism(s) mediating these effects are poorly understood. Previous studies established an in vitro model system for examining mechanical stimulation of dermal fibroblasts and established that cyclical strain, intended to mimic overuse injury, induces secretion of numerous pro-inflammatory cytokines. Moreover, mechanical strain intended to mimic soft tissue manual therapy reduces strain-induced secretion of pro-inflammatory cytokines. Here, we sought to partially confirm and extend these reports and provide independent corroboration of prior results. RESULTS: Using cultures of primary human dermal fibroblasts, we confirm cyclical mechanical strain increases levels of IL-6 and adding long-duration stretch, intended to mimic therapeutic soft tissue stimulation, after cyclical strain results in lower IL-6 levels. We also extend the prior work, reporting that long-duration stretch results in lower levels of IL-8. Although there are important limitations to this experimental model, these findings provide supportive evidence that therapeutic soft tissue stimulation may reduce levels of pro-inflammatory cytokines. Future work is required to address these open questions and advance the mechanistic understanding of therapeutic soft tissue stimulation.

Whole-Body Vibration Training Increases Stem/Progenitor Cell Circulation Levels and May Attenuate Inflammation.

INTRODUCTION: Whole-body vibration training (WBVT) may benefit individuals with difficulty participating in physical exercise. The objective was to explore the effects of WBVT on circulating stem/progenitor cell (CPC) and cytokine levels. METHODS: Healthy male subjects each performed three activities randomly on separate days: (1) standing platform vibration, (2) repetitive leg squat exercise; and (3) in combination. Pre- and post-activity blood samples were drawn. Cell populations were characterized using flow cytometry. Biomarkers were analyzed using enzyme-linked immunosorbent assays. RESULTS: CPC levels increased significantly 21% with exercise alone (1465 ± 202-1770 ± 221 cells/mL; P = 0.017) and 33% with vibration alone in younger participants (1918 ± 341-2559 ± 496; P = 0.02). Angiogenic CPCs increased 39% during combined activity in younger (633 ± 128-882 ± 181; P = 0.05). Non-angiogenic CPCs increased 42% with vibration alone in younger (1181 ± 222-1677 ± 342; P = 0.04), but 32% with exercise alone in older participants (801 ± 251-1053 ± 325; P = 0.05). With vibration alone, anti-inflammatory cytokine interleukin-10 increased significantly (P < 0.03), although inflammatory interleukin-6 decreased (P = 0.056); tumor necrosis factor-alpha (P < 0.01) and vascular endothelial growth factor levels increased (P < 0.005), which are synergistically pro-angiogenic. CONCLUSIONS: WBVT may have positive vascular and anti-inflammatory effects. WBVT could augment or serve as an exercise surrogate in warfighters and others who cannot fully participate in exercise programs, having important implications in military health.

Taking the Next Steps in Regenerative Rehabilitation: Establishment of a New Interdisciplinary Field.

The growing field of regenerative rehabilitation has great potential to improve clinical outcomes for individuals with disabilities. However, the science to elucidate the specific biological underpinnings of regenerative rehabilitation-based approaches is still in its infancy and critical questions regarding clinical translation and implementation still exist. In a recent roundtable discussion from International Consortium for Regenerative Rehabilitation stakeholders, key challenges to progress in the field were identified. The goal of this article is to summarize those discussions and to initiate a broader discussion among clinicians and scientists across the fields of regenerative medicine and rehabilitation science to ultimately progress regenerative rehabilitation from an emerging field to an established interdisciplinary one. Strategies and case studies from consortium institutions-including interdisciplinary research centers, formalized courses, degree programs, international symposia, and collaborative grants-are presented. We propose that these strategic directions have the potential to engage and train clinical practitioners and basic scientists, transform clinical practice, and, ultimately, optimize patient outcomes.

Dysfunctional stem and progenitor cells impair fracture healing with age.

Successful fracture healing requires the simultaneous regeneration of both the bone and vasculature; mesenchymal stem cells (MSCs) are directed to replace the bone tissue, while endothelial progenitor cells (EPCs) form the new vasculature that supplies blood to the fracture site. In the elderly, the healing process is slowed, partly due to decreased regenerative function of these stem and progenitor cells. MSCs from older individuals are impaired with regard to cell number, proliferative capacity, ability to migrate, and osteochondrogenic differentiation potential. The proliferation, migration and function of EPCs are also compromised with advanced age. Although the reasons for cellular dysfunction with age are complex and multidimensional, reduced expression of growth factors, accumulation of oxidative damage from reactive oxygen species, and altered signaling of the Sirtuin-1 pathway are contributing factors to aging at the cellular level of both MSCs and EPCs. Because of these geriatric-specific issues, effective treatment for fracture repair may require new therapeutic techniques to restore cellular function. Some suggested directions for potential treatments include cellular therapies, pharmacological agents, treatments targeting age-related molecular mechanisms, and physical therapeutics. Advanced age is the primary risk factor for a fracture, due to the low bone mass and inferior bone quality associated with aging; a better understanding of the dysfunctional behavior of the aging cell will provide a foundation for new treatments to decrease healing time and reduce the development of complications during the extended recovery from fracture healing in the elderly.

Conference Report: 6th Annual International Symposium on Regenerative Rehabilitation.

The 6th International Symposium on Regenerative Rehabilitation, hosted by the Alliance for Regenerative Rehabilitation Research and Training (AR3T), included a preconference meeting of institutional representatives of the International Consortium of Regenerative Rehabilitation, keynote talks from distinguished scientists, platform and poster presentations from experts and trainees, panel discussions and postconference workshops. The following priorities were identified: increasing rigor in basic, preclinical and clinical studies, especially the use of better controls; developing better outcome measures for preclinical and clinical trials; focusing on developing more tissue-based interventions versus cell-based interventions; including regenerative rehabilitation in curricula of professional programs like occupational and physical therapy; and developing better instruments to quantify rehabilitative interventions.

Understanding Mechanobiology: Physical Therapists as a Force in Mechanotherapy and Musculoskeletal Regenerative Rehabilitation.

Achieving functional restoration of diseased or injured tissues is the ultimate goal of both regenerative medicine approaches and physical therapy interventions. Proper integration and healing of the surrogate cells, tissues, or organs introduced using regenerative medicine techniques are often dependent on the co-introduction of therapeutic physical stimuli. Thus, regenerative rehabilitation represents a collaborative approach whereby rehabilitation specialists, basic scientists, physicians, and surgeons work closely to enhance tissue restoration by creating tailored rehabilitation treatments. One of the primary treatment regimens that physical therapists use to promote tissue healing is the introduction of mechanical forces, or mechanotherapies. These mechanotherapies in regenerative rehabilitation activate specific biological responses in musculoskeletal tissues to enhance the integration, healing, and restorative capacity of implanted cells, tissues, or synthetic scaffolds. To become future leaders in the field of regenerative rehabilitation, physical therapists must understand the principles of mechanobiology and how mechanotherapies augment tissue responses. This perspective article provides an overview of mechanotherapy and discusses how mechanical signals are transmitted at the tissue, cellular, and molecular levels. The synergistic effects of physical interventions and pharmacological agents also are discussed. The goals are to highlight the critical importance of mechanical signals on biological tissue healing and to emphasize the need for collaboration within the field of regenerative rehabilitation. As this field continues to emerge, physical therapists are poised to provide a critical contribution by integrating mechanotherapies with regenerative medicine to restore musculoskeletal function.

Instrument-assisted cross fiber massage increases tissue perfusion and alters microvascular morphology in the vicinity of healing knee ligaments.

BACKGROUND: Ligament injuries are common clinical problems for which there are few established interventions. Instrument-assisted cross fiber massage (IACFM) was recently shown to accelerate the restoration of biomechanical properties in injured rodent knee medial collateral ligaments (MCL). The current study aimed to investigate the influence of IACFM on regional perfusion and vascularity in the vicinity of healing rodent knee MCL injuries. METHODS: Bilateral knee MCL injuries were induced in female Sprague-Dawley rats. Commencing 1 week post-injury, 1 minute of IACFM was introduced unilaterally 3 times/week for 3 weeks. The contralateral injured MCL served as an internal control. Regional tissue perfusion was assessed in vivo throughout healing using laser Doppler imaging, whereas regional microvascular morphology was assessed ex vivo via micro-computed tomography of vessels filled with contrast. RESULTS: IACFM had no effect on tissue perfusion when assessed immediately, or at 5, 10, 15 or 20 min following intervention (all p > 0.05). However, IACFM-treated hindlimbs had enhanced tissue perfusion when assessed 1 day following the 4th and 9th (last) treatment sessions (all p < 0.05). IACFM-treated hindlimbs also had greater perfusion when assessed 1 wk following the final treatment session (32 days post-injury) (p < 0.05). Subsequent investigation of microvascular morphology found IACFM to increase the proportion of arteriole-sized blood vessels (5.9 to <41.2 µm) in the tibial third of the ligament (p < 0.05). CONCLUSIONS: These findings suggest IACFM alters regional perfusion and vascularity in the vicinity of healing rodent knee MCL injuries. This effect may contribute to the beneficial effect of IACFM observed on the recovery of knee ligament biomechanical properties following injury.

Instrument-assisted cross-fiber massage accelerates knee ligament healing.

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To investigate the effects of instrument-assisted cross-fiber massage (IACFM) on tissue-level healing of knee medial collateral ligament (MCL) injuries. BACKGROUND: Ligament injuries are common and significant clinical problems for which there are few established interventions. IACFM represents an intervention that may mediate tissue-level healing following ligament injury. METHODS: Bilateral knee MCL injuries were created in 51 rodents, while 7 rodents were maintained as ligament-intact, control animals. IACFM was commenced 1 week following injury and introduced 3 sessions per week for 1 minute per session. IACFM was introduced unilaterally (IACFM-treated), with the contralateral, injured MCL serving as an internal control (nontreated). Thirty-one injured animals received 9 ACFM treatments, while the remaining 20 injured animals received 30 treatments. Ligament biomechanical properties and morphology were assessed at either 4 or 12 weeks postinjury. RESULTS: IACFM-treated ligaments were 43.1% stronger (P<.05), 39.7% stiffer (P<.01), and could absorb 57.1% more energy before failure (P<.05) than contralateral, injured, nontreated ligaments at 4 weeks postinjury. On histological and scanning electron microscopy assessment, IACFM-treated ligaments appeared to have improved collagen fiber bundle formation and orientation within the scar region than nontreated ligaments. There were minimal differences between IACFM-treated and contralateral, nontreated ligaments at 12 weeks postinjury, although IACFM-treated ligaments were 15.4% stiffer (P<.05). CONCLUSION: IACFM-accelerated ligament healing, possibly via favorable effects on collagen formation and organization, but had minimal effect on the final outcome of healing. These findings are clinically interesting, as there are few established interventions for ligament injuries, and IACFM is a simple and practical therapy technique. J Orthop Sports Phys Ther 2009;39(7):506-514, Epub 24 February 2009. doi:10.2519/jospt.2009.2997.

A pilot study comparing two manual therapy interventions for carpal tunnel syndrome.

OBJECTIVE: The purpose of this study was to determine the clinical efficacy of manual therapy interventions for relieving the signs and symptoms of carpal tunnel syndrome (CTS) by comparing 2 forms of manual therapy techniques: Graston Instrument-assisted soft tissue mobilization (GISTM) and STM administered with the clinician hands. METHODS: The study was a prospective comparative research design in the setting of a research laboratory. Volunteers were recruited with symptoms suggestive of CTS based upon a phone interview and confirmed by electrodiagnostic study findings, symptom characteristics, and physical examination findings during an initial screening visit. Eligible patients with CTS were randomly allocated to receive either GISTM or STM. Interventions were, on average, twice a week for 4 weeks and once a week for 2 additional weeks. Outcome measures included (1) sensory and motor nerve conduction evaluations of the median nerve; (2) subjective pain evaluations of the hand using visual analog scales and Katz hand diagrams; (3) self-reported ratings of symptom severity and functional status; and (4) clinical assessments of sensory and motor functions of the hand via physical examination procedures. Parametric and nonparametric statistics compared treated CTS hand and control hand and between the treatment interventions, across time (baseline, immediate post, and at 3 months' follow-up). RESULTS: After both manual therapy interventions, there were improvements to nerve conduction latencies, wrist strength, and wrist motion. The improvements detected by our subjective evaluations of the signs and symptoms of CTS and patient satisfaction with the treatment outcomes provided additional evidence for the clinical efficacy of these 2 manual therapies for CTS. The improvements were maintained at 3 months for both treatment interventions. Data from the control hand did not change across measurement time points. CONCLUSIONS: Although the clinical improvements were not different between the 2 manual therapy techniques, which were compared prospectively, the data substantiated the clinical efficacy of conservative treatment options for mild to moderate CTS.