Biomechanical Stimulation Therapy-An Efficacious Method for Facial Scleroderma with Reduced Oral Aperture

C l i n M e d International Library Citation: Berg W, Tarner IH, Riemekasten G, Müller-Ladner U, Lange U (2016) Biomechanical Stimulation Therapy An Efficacious Method for Facial Scleroderma with Reduced Oral Aperture. J Rheum Dis Treat 2:030 Received: December 21, 2015: Accepted: January 23, 2016: Published: January 26, 2016 Copyright: © 2016 Berg W, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Biomechanical Stimulation Therapy An Efficacious Method for Facial Scleroderma with Reduced Oral Aperture Walter Berg1, Ingo H Tarner2, Gabriela Riemekasten3, Ulf Müller-Ladner2 and Uwe Lange2*


Introduction
Systemic sclerosis (SSc) is a chronic, severe connective tissue disorder characterized by a microangiopathy and excess deposition of connective tissue matrix in the skin and internal organs [1][2][3].Skin involvement is the most conspicuous manifestation of SSc, and based on its extent two distinct disease subsets are recognized, diffuse cutaneous (dcSSc) and limited cutaneous systemic sclerosis (lcSSc), with lcSSc affecting only the distal extremities and the face and dcSSc also affecting the proximal extremities and the trunk [1,4,5].

ISSN: 2469-5726
Berg et al.J Rheum Dis Treat 2016, 2:030 blinded to the treatment group.Oral aperture was measured as mean interlabial distance (in millimeters) based on three measurements per patient using a micro-caliper.Between each measurement, the patients were asked to close their mouth and re-open as wide as possible.As a control-group, the interlabial distance was measured in 20 healthy, age-matched individuals.In addition, patients were asked at the end of the 3-week treatment period about subjective changes of their facial skin according to the corresponding item (delta-skin) of the European Scleroderma Study Group activity score [9].Data were tested for normal distribution using normal Q-Q plots and the Shapiro-Wilk test.Due to a lack of normal distribution, statistical analysis included the Wilcoxon test for evaluation of the changes of oral aperture before and after therapy in either group and the Mann-Whitney U test for analysis of the differences between the two treatment groups.A p-value < 0.01 was considered as statistically significant.The study's alpha-level was 0.05.All analyses were done using R for Windows 2.14.

Results
All patients reported that their facial skin felt softer and less tense after completion of BMS therapy, without any adverse effects or increased pain during the treatment.Ten patients (35.7%) reported that during BMS there was an extremely pleasant, soothing sensation of warmth in the treated facial skin areas.

Discussion
Efficacy of physical therapy in SSc has been suggested by clinical Thursdays whereas the others were treated on Mondays, Wednesdays and Fridays.
The hand-held BMS unit, which has a fixed amplitude of 4 mm, was set to a vibrating frequency ranging between 23 and 28 Hz as described by Klyscz et al. [6] and was applied to the perioral, sternocleidomastoid muscle and maxillary regions using a dynamic technique of circular movements (Figure 1).By choosing different frequencies, it is possible to obtain different therapeutic effects.The lower frequency range of ≥ 23 Hz improves muscular perfusion and has a pronounced anti-lymphedematous effect [6].Frequencies of around 28 Hz mediate an analgesic effect [7,8].During the course of BMS therapy no other treatment was applied.
All patients were examined prior to BMS treatment and after completion of the treatment period by a study physician who was studies [10,11] and positive effects in daily practice.Established physical therapy methods are manual lymphatic drainage, connective tissue massage, carbon dioxide baths, mobilization treatment, and proprioceptive neuromuscular facilitation (PNF) therapy.
In the spectrum of physical therapy, biomechanical stimulation therapy (BMS) is a novel physiotherapy method for SSc [6].Application of BMS causes tissue structures to vibrate visibly along the longitudinal axis at frequencies between 23-28 Hz.Thus far, the exact mechanisms of the biologic effects of BMS are not completely understood.BMS has been shown to improve joint mobility in healthy subjects and SSc patients and to reduce muscular tone and tissue edema [6,12] without any signs of adverse effects.Furthermore, pain was ameliorated noticeably about 10 -15 seconds after initiation of treatment and resulted in a pleasant sensation of warmth in study groups exposed to similar vibration therapies [7,8,13].A possible explanation for this vibration-induced improvement in flexibility and mobility in terms of a neurophysiological phenomenon could be that the tissue vibration results in a stimulation of the Golgi tendon organs leading to an inhibition of muscle contractions followed by muscle relaxation [14].
The present study shows that regular BMS application for three weeks results in a significant improvement of oral aperture in facial scleroderma without causing any adverse effects.Furthermore, comparison between two treatment regimens with different intensities of BMS application reveals a significant superiority of intensive BMS with 30 minutes of treatment applied five times per week.The achieved increase in oral aperture of 5.6 mm can be of critical importance for allowing oral access with a spoon when eating, a tooth brush for oral hygiene or a dental instrument.In addition, 36% of patients experienced the treatment to be very pleasing and soothing and all patients felt an amelioration of skin tension, the importance of which cannot be overestimated, particularly regarding facial skin.Thus, taken all benefits together, BMS therapy substantially improves the patients' quality of life.Of note, application of this treatment method can be learned by patients relatively easily after detailed instruction by an experienced physiotherapist.Thus, BMS is suitable for convenient, daily self-application by SSc patients.We conclude that BMS is an effective, easy-to-use and safe technique which should be used as part of a multimodal therapy in SSc patients on a regular basis.Our pilot study provides the basis for further studies which should compare BMS to other physical therapy modalities such as active exercise, connective tissue massage and ultrasound in order to further confirm its efficacy and to develop optimal combination strategies.

Key messages
• Facial scleroderma and reduced oral aperture represent significant impairment in the quality of life in patients with SSc.
• Thus far, there is no effective, evidence-based treatment option for impaired oral aperture.
• Biomechanical stimulation therapy is a highly effective, safe, easyto-use and low-cost treatment option that provides significant improvement of oral aperture and relief of facial skin tension in patients with SSc.

Figure 1 :Figure 2 :
Figure 1: Dynamic BMS application technique.The hand-held device is applied to the lower face and the neck in gentle, rotating movements starting in the perioral area underneath the lower lip (A) and continuing from there to the right sternocleidomastoid muscle area (B), the right mandibular area (C), and onward to the perioral area above the upper lip, the left mandibular area, the left sternocleidomastoid muscle area and back to the perioral area underneath the lower lip.This large circle was repeated several times during each treatment session.