Clinical Rehabilitation 2009; 23: 771–781 Vibration therapy in multiple sclerosis: a pilot studyexploring its effects on tone, muscle force, sensationand functional performance F Schyns Revive MS Support, MS Therapy Centre, Glasgow, L Paul Nursing and Health Care–Faculty of Medicine, University ofGlasgow, K Finlay Wishaw General Hospital, NHS Lanarkshire, C Ferguson Department of Statistics, University of Glasgow andE Noble Gartnavel General Hospital, NHS Greater Glasgow & Clyde – North, Glasgow, UK Received 23rd June 2008; returned for revisions 5th December 2008; revised manuscript accepted 6th December 2008.
Objective: To examine the effectiveness of whole body vibration (WBV) on tone,muscle force, sensation and functional performance in people with multiple sclerosis.
Design: A randomized cross-over pilot study.
Setting: Revive MS Support Therapy Centre. Glasgow, UK.
Subjects: Sixteen people with multiple sclerosis were randomly allocated to one oftwo groups.
Intervention: Group 1 received four weeks of whole body vibration plus exercisethree times per week, two weeks of no intervention and then four weeks of exercisealone three times per week. Group 2 were given the two treatment interventions inthe reverse order to group 1.
Main measures: Ten-metre walk, Timed Up and Go Test, Modified Ashworth Scale,Multiple Sclerosis Spasticity Scale (MSSS-88), lower limb muscle force, NottinghamSensory Assessment and Multiple Sclerosis Impact Scale (MSIS-29) were usedbefore and after intervention.
Results: The exercise programme had positive effects on muscle force and well-being, but there was insufficient evidence that the addition of whole body vibrationprovided any further benefit. The Modified Ashworth Scale was generally unaffectedby either intervention, although, for each group, results from the MSSS-88 showedwhole body vibration and exercises reduced muscle spasms (P ¼ 0.02). Althoughresults for the 10-m walk and Timed Up and Go Test improved, this did not reachstatistical significance (P ¼ 0.56; P ¼ 0.70, respectively). For most subjects sensationwas unaffected by whole body vibration.
Conclusion: Exercise may be beneficial to those with multiple sclerosis, but there islimited evidence that the addition of whole body vibration provides any additionalimprovements. Further larger scale studies into the effects of whole body vibration inpeople with multiple sclerosis are essential.
Address for correspondence: Franc¸oise Schyns, Support, Unit 16 Chapel Street Industrial Estate, GlasgowG20 9BQ, UK. e-mail: [email protected] ß SAGE Publications 2009Los Angeles, London, New Delhi and Singapore neurological conditions, although sparse, suggestsoptimism. Ahlborg et al.12 showed that an eight-week programme of whole body vibration training Exercise therapy is considered to be a key had positive effects on muscle tone and strength compared with resistance exercise in children with people with multiple sclerosis, but the evidence cerebral palsy. Proprioception of the affected to support its use is relatively poor. A recent lower limb improved in people with stroke after Cochrane systematic review1 exploring the effects of exercise for people with multiple sclerosis Schuhfried et al.14 studied the effect of whole showed that exercises have beneficial effects on body vibration at low frequency on 12 people with multiple sclerosis. In the intervention group, activities (transfer, balance and walking) and on subjects received vibration (applied without any mood, without any evidence of detrimental effects.
exercises) in five series of 1 minute each with 1-minute break in between. In the placebo group, particular exercise programmes, included within subjects received transcutaneous electrical nerve the review, were more effective in improving or stimulation (TENS) in a similar fashion. After one week of intervention, the results showed a Whole body vibration has been around for over significant improvement in balance, as measured 30 years and has been used by cosmonauts to by posturography and also in functional scores, as delay muscle atrophy and loss of bone density.
measured by a timed up and go test. These results Research on whole body vibration training as a suggest that whole body vibration had a positive method of muscle strengthening has been investi- influence on mobility and postural control.
gated mainly on healthy subjects.2–8 Whole body Thus overall there is limited evidence to support vibration involves subjects performing static or the use of whole body vibration for people with dynamic movements on a vibrating platform.
neurological conditions, in particular multiple The vibrations generated by the engine of the sclerosis. However, people with multiple sclerosis platform are transmitted to the person standing, are increasingly buying relatively expensive vibra- sitting or lying on the machine. Whole body tion machines despite the lack of evidence.
vibration can be delivered in two main ways: by The aim of this pilot study, therefore, was to vertical displacements of the whole platform or by establish whether whole body vibration training side alternating whole body vibration, which combined with exercises was more beneficial operates like a seesaw.9 Physiologically the vertical to people with multiple sclerosis than exercise vibrations generate acceleration forces working on the body, causing the muscles to lengthen andthus triggering the stretch reflex.9 This effect onthe neuromusculature (muscle spindles and the alpha-motoneurons) increases the synchronizationof the motor units when combined with a voluntary muscle contraction.10 As a result, greater muscle strength can be achieved compared balanced design was used for a sample of 16 to conventional training.11 In the side alternating people with multiple sclerosis randomly allocated systems, the seesaw-like displacement of the to one of two groups (group 1 or group 2).
platform is reported to mimic human gait, in Subjects were randomized by the physiotherapist which one foot moves upwards and the other involved with the treatments drawing a number one downwards. These systems offer larger from an envelope to allocate each subject to a amplitudes of oscillations but a lower frequency group: number 1 for group 1 and number 2 for range than platforms generating pure vertical group 2. Each group then consisted of eight The current research to support the use of whole For group 1, the protocol consisted of four body vibration in the rehabilitation of people with weeks of a set exercise programme performed with whole body vibration, three times per week, Subjects were recruited via flyers within Revive Thereafter, subjects received a further four-week MS Support and at local community leisure period of the same exercises but without whole centres around Glasgow. To establish eligibility, body vibration, three times per week. The recruited subjects undertook a screening process subjects in group 2 had exercise without whole to ascertain that they had a confirmed diagnosis body vibration for four weeks first, and then of multiple sclerosis, a disability level between 1 rest for two weeks and then four weeks of and 6 on the Hauser Ambulation Index15 and had exercise and whole body vibration (Figure 1).
at least one of the following symptoms based on Selected outcome measures were taken before previous clinical assessment: abnormal muscle and after each four-week period of exercise and tone, lower limb weakness, altered sensation and/or proprioception. In group 1, there were initial assessment of baseline n = 16 Flowchart of the experimental protocol.
five females and three males, with five subjects having bilateral leg symptoms. In group 2, there The isometric force output of seven muscle were seven females and one male and four subjects groups was tested with a hand-held dynamometer: had bilateral symptoms. The mean age was 45.8 hip flexors, hip extensors, hip abductors, hip addu- years (SD 8.4) and 49.5 years (SD 6.14) for groups ctors, quadriceps, hamstrings and ankle dorsi- 1 and 2 respectively. The duration of multiple flexors. The hand-held dynamometer was used to sclerosis from diagnosis varied from 10 months record the peak force exerted during maximum to 23 years (mean 6.7 years) in group 1 and 3.5 voluntary isometric contraction using the ‘make to 18 years in group 2 (mean 11.8 years).
test’.18 Where patients exhibit clinically weak mus- Participants were asked to stabilize their medi- cles, such as patients with neuromuscular disorders, cations, especially antispasmodic drugs, for the the hand-held dynamometer provides a reliable and duration of the study. Subjects were excluded accurate means of assessing muscle strength.19 An from the study if they were receiving ongoing phy- average of two measures for each muscle group of siotherapy or were keen to continue attending the affected lower limb(s) was recorded.
other types of exercise class, were receiving com-plementary therapy (e.g. acupuncture, reflexology,and aromatherapy), had previous or current use of whole body vibration, or presented with any con- As there is no specific scale to measure sensory traindications of whole body vibration such as impairment in multiple sclerosis the Nottingham tumour, pacemaker, pregnancy, epilepsy, severe Sensory Assessment,20 a scale for assessing sensory pain, active infection or dizziness.
impairment in stroke patients, was used. The sub-jects’ tactile sensation to light touch, pinprick,pressure, temperature and proprioception was assessed at the knee, ankle and foot of the affected The outcome measures were taken before and after each four-week exercise period and restperiod (Figure 1). All measures were performed by a physiotherapist who was not involved in the Walking performance was tested using the 10-m training procedure and who was blind to the walk test.21 This is simple, quick and inexpensive, relatively reliable and responsive and has estab-lished face validity.22 The subjects were instructedto walk a standardized 10 m distance at their ‘own pace’, using their walking aid if necessary. The Tone was assessed with the Modified Ashworth 10-m walk was undertaken twice and the average Scale.16 The four muscle groups most commonly affected by multiple sclerosis were measured: hip Balance in basic mobility movements was evalu- adductors, quadriceps, hamstrings and gastroc- ated with the Timed Up and Go Test,23 a reliable nemius. Only the affected lower limb(s) were and valid test for quantifying functional mobi- lity.23–25 Participants sat on a standard chair The Multiple Sclerosis Spasticity Scale 88 with arms and were instructed to get up and (MSSS-88)17 was used to measure the subjects’ walk at a comfortable and safe pace to a line on perception of the impact of abnormal tone on the floor 3 m away, turn around, return to the their multiple sclerosis. The MSSS-88 is a ques- chair and sit down again. The time required to tionnaire that quantifies the impact of spasticity in six clinically relevant areas: three spasticity-specific symptoms (muscle stiffness, pain andmuscle spasms) and three areas of physical func- tioning (ADL, walking, body movements), emo- tional health and social functioning.
(MSIS-29)26 was used to measure the participants’ health-related quality of life. The MSIS-29 is a This again was followed by a two-week rest measure of the physical and psychological impact period. For group 2, the order of treatment was of multiple sclerosis from the patients’ perspective reversed (i.e. four weeks of exercise alone, two and consists of a 29-item questionnaire (20 items weeks rest and then four weeks of exercise with for physical construct and 9 items for psychologi- cal construct). It shows good variability, smallfloor and ceiling effects, high internal consistencyand high test–retest reliability.26 Prior to starting the study ethical approval was granted by the Research Committee of Glasgow participants were asked to report any effect on Support. A courtesy letter was sent to all subjects’ their symptoms. The purpose of this was to high- GPs. All subjects received written information light potential subjective changes which may not about the study and were made aware that they have been picked up by the chosen outcome could withdraw from the study at any time with- The whole body vibration was delivered via a vibrating platform (VibroGym International BV, The Netherlands). On this device vertical vibra- tions can be delivered at a frequency of 30, 40 or interaction was performed on the continuous 50 Hz and the amplitude of the vibrations can be chosen between low (2 mm) and high (4 mm). As the literature base was limited the frequency and Test). This allowed comparison of the data for amplitude of the vibrations, as well as the duration both groups and investigated whether the order of exercises, were chosen according to the manu- of interventions had any effect, and if there was facturers’ recommendations for stretching and any carryover effect from each intervention strengthening exercise (i.e. 40 Hz, low amplitude respectively. Provided there was no evidence of carryover or order effects the data were combined In group 1, the subjects performed a series of and a Wilcoxon signed ranks test was carried out exercises with vibrations three times a week for on the difference between change following whole four weeks. Each session consisted of a warm-up body vibration and exercise and change following massage of the quadriceps, hamstrings and exercise alone. Medians and non-parametric tests gastrocnemius muscles delivered by the vibrating were considered as a result of the small sample size plate. Each muscle group was treated for 60 and where interactions were identified differences seconds at 50 Hz. Following the warm-up, subjects performed 10 different strengthening and stretch- Categorical tests such as McNemar’s test were ing exercises for the lower limbs with vibration considered for the variables Modified Ashworth frequency of 40 Hz, and for 30 seconds. Each session ended with a cool-down massage similar However, the sample sizes were too small to to the warm-up. After a two-week rest period, obtain meaningful results with even exact versions the same protocol of exercises, this time without of the test and hence descriptive analyses are the vibration, was performed three times weekly presented here to illustrate the frequency and per- for another four weeks. In this case, the warm- centage of subjects with a decrease in score, no up and cool-down consisted of 3 minutes of slow change in score and an increase in score following passive movements on a motorized cycling machine.
for exercise alone compared with whole bodyvibration and exercise.
Each of the eight components of the MSSS-88 Of the 16 subjects who were recruited and agreed was analysed. For MSSS-88 pain, there was a to participate nine had multiple sclerosis affecting both lower limbs whereas seven subjects had a more unilateral presentation. Of the 16 subjects, considered separately. For group 1, there was a four failed to complete the study; for one subject statistically significant difference between the the whole body vibration aggravated a pre-existing results before and after whole body vibration knee condition and the other three subjects with- (P ¼ 0.036). However, for group 2, there was no drew as they found coming to the therapy centre significant difference. For MSSS-88 spasm, there three times a week unfeasible. Thus 12 subjects was no evidence of order or carryover effects and Although the study was of a cross-over design, combined and analysed using a Wilcoxon signed statistical analysis revealed that there was little ranks test. This produced a P-value of 0.02 with a evidence of a group or interaction effect for any 95% confidence interval (CI) of 2.00, 14.50, which of the outcome measures (except MSSS-88).
highlights that a greater reduction in score was Therefore, while appreciating that this may be a result of the small sample size in some cases, the exercise compared to exercise alone.
effect of whole body vibration and exercise was For the remainder of the MSSS-88 components compared with that of exercise alone regardless (ADL, social functioning, stiffness, gait, body of the order the interventions occurred. In addi- movement and emotional health) no statistically tion, statistical results are presented for right and left affected limbs separately. However, descriptiveresults Nottingham Sensory Assessment are presentedfor all limbs affected by multiple sclerosis as a result of small sample sizes for categorical data From Table 3 it appears that both interventions analysis. Thus, although there were 12 subjects, increased the subjects’ walking speed as evidenced due to the bilateral presentation of some subjects by a faster 10-m walk time, however the difference data for 18 limbs from group 1 and 21 limbs from between performance with vibration and exercise, and exercise alone was not statistically significant(P ¼ 0.561). A similar pattern was observed withthe results of the Timed Up and Go Test(P ¼ 0.720). There was insufficient evidence that including whole body vibration within the exercise The results for maximum muscle force produced programme improved these functional outcomes for each of the seven muscle groups tested suggest for people with multiple sclerosis over that of that there was a trend towards an improved ability exercise alone. The confidence intervals for the to generate muscle force especially following results of both outcome measures are relatively whole body vibration and exercise (Table 1).
wide mainly due to two subjects with a higher Although there appeared to be a trend, this differ- level of disability (i.e. score of 6 on the Hauser ence did not reach statistical significance.
Index) and thus a relatively poor functional abilitycompared to the remainder of the subjects.
Although the results were variable, for most subjects the Modified Ashworth Scale score For most subjects, sensation was unaffected by remained unchanged following each of the inter- either intervention in that there was no change in ventions (Table 2). Tone tended to increase more the scores recorded (Table 4). For each of the five Maximum muscle force produced for each of the seven muscle groups Values are median difference (before minus after) [interquartile range of difference] for each intervention. P-values and 95%confidence intervals (CI) for the difference between change (before minus after) in muscle force (N) following whole bodyvibration and exercise and change in muscle force following exercises were computed using a Wilcoxon signed ranks test.
Left n ¼ 8, right n ¼ 10.
WBV, whole body vibration.
Frequency and percentage of subjects with a decrease, no change or increase in Modified Ashworth Score following each intervention Results for 10-m walk and Timed Up and Go Test Values are median difference (before minus after) [interquartile range of difference] for each intervention.
P-values and 95% confidence intervals (CI) for the difference between change (before minus after) infunctional measures following WBV and exercise and change in functional measures following exercisewere computed using a Wilcoxon signed ranks test (n ¼ 12).
WBV, whole body vibration; TUG, Timed Up and Go Test.
sensations assessed the number of subjects with increased scores (i.e. improved sensation) was higher for exercise alone than for exercise com- Frequency and percentage of subjects with a decrease, no change or increase in the Nottingham Sensory Assessment scores following each intervention Increase in score represents improved sensation. Maximum score of 6 represents intact sensation for all exceptproprioception where the maximum score is 9.
WBV, whole body vibration.
Results for the Multiple Sclerosis Impact Scale For Multiple Sclerosis Impact Scale physical and psychological, median difference (before minus after) [interquartile range ofdifference] for each intervention. P-values and 95% confidence intervals (CI) for the difference between change (before minusafter) in scores following whole body vibration and exercise and change in scores following exercise were computed using aWilcoxon signed ranks test (n ¼ 10).
WBV, whole body vibration.
psychological constructs within the MSIS-29 immediately after the session and improved questionnaire (Table 5). However the difference statistically significant in either case (psychologicalor physical), suggesting that whole body vibration had no added value in terms of the results.
The results of this study suggest that exercise per-formed three times a week for four weeksimproved muscle force output, functional ability and general well-being in people with multiple Subjective comments given by participants were sclerosis. The addition of whole body vibration supportive of both vibration and exercise, and to the exercise programme provided some added exercise alone. The comments made by subjects benefit to exercise alone in terms of reducing muscle spasm. In addition there was a trend the following: improved sleeping, more energy towards a greater increase in muscle force genera- during the day, and improved and brighter tion with the addition of whole body vibration.
Exercise, with or without whole body vibration, by subjects while receiving whole body vibration appeared to have had no effect on sensation or following statements: reduction in foot cramps at The MSSS-88 yielded several interesting find- night, improved ability to feel the ground ings. It appeared that whole body vibration and exercise decreased muscle spasms as well as the impact on subjects’ functional level.28 In a pre- pain associated with those spasms to a greater vious study on cerebral palsy,12 the 6-minute extent than exercise alone. Potential physiological walk test and the Timed Up and Go Test did explanations for these findings have not been not change significantly following either whole explored as previous studies have concentrated body vibration or resistance training. However in on the effects of whole body vibration on muscle that study, subjects did not exercise on the vibrat- ing platform and thus it appears that for func- An increase in the maximum force generated tional improvement vibration alone may not be from each of the seven muscle groups tested was sufficient. In the study of whole body vibration observed for both interventions (whole body for people with multiple sclerosis,14 the results of the Timed Up and Go Test were better for the Although the results failed to reach statistical sig- whole body vibration group compared with the nificance, they revealed a trend for greater placebo immediately after the intervention, and improvement in muscle force production following this was maintained one week later. However, whole body vibration and exercise compared to Schuhfried et al.14 used different treatment param- exercise alone. Although there is some literature eters to the ones used in the present study: they on the effect of whole body vibration in healthy used a low frequency (1 Hz), which was increased subjects, only one study has investigated the as tolerated, and 3 mm amplitude compared to the effects of whole body vibration on muscle strength parameters in the present study of 40 Hz and in those with neurological problems.12 Ahlborg amplitude of 2 mm. In addition, no exercises et al.12 showed an increase in quadriceps strength were performed concurrently with the whole following whole body vibration in subjects with body vibration and their control group did not cerebral palsy. The present study is the first to receive whole body vibration. In summary, consider the effect of whole body vibration on muscle force in people with multiple sclerosis. In body vibration appears to provide little added healthy subjects, numerous studies have demon- benefit over exercise alone, it may be that the use strated the potential of whole body vibration of whole body vibration has benefits compared to training to induce strength gains in the knee exten- no intervention at all for people with multiple sor muscles and jump performance.5–8 In a recent systematic review on strength training effects of Although subjective comments suggested that whole body vibration27 the five studies with sensation was improved following whole body strong experimental designs found that whole vibration, the results of the Nottingham Sensory body vibration did not have additional value to Assessment found that for the majority of subjects the effect of the concomitant exercises performed sensation was unaffected by either intervention.
on the vibrating platform. The review also high- It is reported that vibration stimuli can have the lighted a significant methodological flaw in some following effects: stimulation of the pressure studies where the control group did not perform receptors on the sole of the foot, stimulation of similar training exercises to the whole body vibra- the proprioceptors, increased blood flow and trig- tion group. The exercises were the same for both ger of reflexes.29,30 Although outwith the scope of interventions in the present study and the result the present study a more sensitive outcome mea- was a trend towards a greater increase in muscle sure such as Quantitative Sensory Testing (QST) force with whole body vibration and exercise.
would provide objective results to examine the Both interventions – whole body vibration and potential effect of whole body vibration on the exercise and exercise alone – improved function as sensory system in people with multiple sclerosis.
measured by the 10-m walk and the Timed Up and Finally, well-being improved after both inter- Go Test. However, there was insufficient evidence ventions, but there was insufficient evidence of that whole body vibration had added benefit over added benefit from the whole body vibration.
exercise alone. In both interventions, the exercises This corroborates results of a systematic review performed were static and it is possible that more on exercises and multiple sclerosis2 that reported that exercise, regardless of the type, has a strong positive effect on the physical and psychological One subject was unable to complete the study as the whole body vibration appeared to exacerbate a  With the exception of a reduction in muscle pre-existing knee condition, unrelated to her mul- tiple sclerosis. The three other subjects who with- that the addition of whole body vibration to drew from the study did so because they found the exercise programme provided any added attending the centre three days a week impossible.
Throughout the course of the study, none of the  Whole body vibration did not appear to have subjects reported any significant deterioration in a detrimental effect on multiple sclerosis.
symptoms. Thus although the effects of whole  Further, larger trials are warranted.
body vibration in multiple sclerosis have notbeen completely elucidated in this study, it does seem that whole body vibration caused few adverse effects in this sample of people with multi-ple sclerosis.
This study was designed as a pilot study and therefore the main limitation was obviously the FS and EN initiated the study. FS, EN and LP small sample size thus trends and minor differ- acquired funding. FS managed the project, FS and ences observed may have been due to chance. A KF undertook the recruitment and treatment/ larger sample would increase statistical power and assessment. CF provided statistical support and allow more formal statistical procedures to be undertook statistical analysis. FS and LP wrote applied in the case of categorical data. Further the draft manuscript. FS, LP and CF revised the research to determine the optimum parameters manuscript and with KF and EN gave approval of for the application of whole body vibration for the final version submitted. FS takes responsibility people with neurological conditions is required.
for the accuracy and honesty of the report and the A recent review on the use of vibration training highlighted that the differences in vibrationtraining methodologies affect the short- and long-term effect on neuromuscular performance.
The vibration characteristics (vibration amplitude, Multiple Sclerosis Trust of Great Britain and the frequency and vertical versus side-alternating) as School of Health and Social Care of Glasgow well as the exercise protocols (type of exercises, intensity, and dosage) are complex methodological Rafferty, School of Health and Social Care, aspects to consider as they may greatly influence Glasgow Caledonian University for technical sup- the potential benefits obtained with vibration port and Frank Jamieson, University of Glasgow, training. Further larger scale studies into the for his assistance with statistical analysis.
effects of whole body vibration in people withmultiple sclerosis, and indeed other neurologicalconditions, are essential.
Exercise may be beneficial to those with multi- ple sclerosis, but there is limited evidence thatincluding whole body vibration provides any addi- Rietberg MB, Brooks D, Uitdehaag BMJ,Kwakkel G. Exercise therapy for multiple sclerosis tional improvements. Whole body vibration, using (Review). The Cochrane Library 2005, Issue 4.
the parameters used in this study, did not appear Chichester, John Wiley & Sons, Ltd.
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Bohannon RW, Smith MB. Inter-rater reliability of Torvinen S, Kannus P, Sieva¨nen H et al. Effect a modified Ashworth scale of muscle spasticity.
Hobart JC, Riazi A, Thompson AJ et al. (2006) randomized controlled study. J Bone Miner Res Getting the measure of spasticity in multiple sclerosis: the Multiple Sclerosis Spasticity Scale Delecluse C, Roelants M, Verschueren S. Strength (MSSS-88). Brain 2006; 129: 224–34.
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