Introduction
This study undertaken at LVIADS was passed by the appointed Human Ethics Committee. In 1989 Norman Thomas and David Seiver demonstrated that repetitive Audio-Visual (AVE) Brain Wave Entrainment (BWE) and TENS achieved rapid and effective relaxation of the masticatory musculature (Figure 1,2) [1].
More recently NuCalm using only audio BWE duplicated the effects of AVE treatments raising the question how BWE compared with electroneutral stimulation TENS Figure 3,4 used in neuromuscular dentistry of CMD patients (Craniomandibular dysfunctional) who might find flashing visual images of AVE and electrical TENS stressful. It has been claimed that TENS reduces the voltage amplitude of painful masticatory musculature by relaxation. In 1981 Stulen and DeLuca observed that although the change in electromyogram (EMG) voltage amplitude is dependent upon conduction velocity it is a second order effect and requires confirmation by correlation with frequency analysis. Thomas NR (1986 and 1990) then showed by Fourier spectral analysis of masseter electromyogram that ultra-low frequency transcutaneous electrostimulation (TENS) of cranial motor nerves V and VII at the pre auricular mastoid notch was actually found to relax rather than fatigue the masticatory musculature resulting in the addition of scan 18 spectral analysis to the Myotronics protocol [2].
Figure 5 presents a graph of the sine wave of EMG Myotrajectories from a classical text. Fourier analysis of sine wave is depicted where Hz (m. sec)/uVx100 calculus is plotted along Y (volts) and X (degrees) axes. For a given phase dv of the sine wave signal corresponds to a unique minimum frequency called the instantaneous frequency Hz is given if dt is diminishing small which is true for mandibular movement TENS stimulation The TENS procedure was used to derive a muscularly relaxed occlusal registration (bite) from which a Craniomandibular Orthotic (CMO) is constructed and worn 24/7 Figure 6-10. When signs and symptoms of TMD are resolved or alleviated to maximal medical improvement definitive treatment was followed either by phase 1 Coronoplasty 2 Full mouth fixed reconstruction or 3 Orthodontics performed dependent on severity of the occlusal change. This treatment was followed by an increasing cadre of neuromuscular dentists at ICCMO and at Las Vegas Institute of Advanced Dental Studies where Norman Thomas served as Director of Neuromuscular Research under the leadership of Dr W.G Dickerson.
In [3] and Kleinberg I (2008) published a position paper 'Establishment of a temporomandibular treatment affects reduction of TMD symptoms in 313 patients' in Journal. Cranio- Mandibular Practice 25(2)104-115).
Despite the publication criticism continued by [4] in the Journal of the American Dental Association JADA 143:351- 62 who stated that neuromuscular dentists only utilize EMG voltages. [5] Published a rebuttal that Myotronics Kinesiography does include amplitude and spectral analysis. [5] and Oliver S also rightly pointed out that TMD Temporomandibular Disorder is a broad term of conditions and which no single testing device or procedure can exclusively diagnose. Al-Saleh, et al. had obfuscated their logic by citing Okeson "the absolute association between muscular pain and high EMG amplitude must be considered in combination with the EMG frequency both of which are dependent on the degree of muscle fatigue". We will show here that scan 18 simply confirms what was evident in the actual EMG records comparing the habitual and relaxed muscle trajectories. For these reasons this study of the effects of NuCalm and TENS on both EMG amplitude and frequency will be followed throughout. In this connection one cannot over emphasize the importance of understanding the concept of application of trigonometric data of physiological relaxation of the masticatory muscles.
It has been pointed out above that recently NuCalm using only audio BWE has duplicated the effects of AVE treatments and both continue to be in vogue particularly in those patients who find the electrical TENS stimulation stressful. Furthermore no adverse effects of brain entrainment by audio or visual entrainment to date have neither been observed in general or in the potentially pregnant patient. Of course in muscle relaxation by TENS should not be undertaken in cases of known pregnancy in keeping with FDA regulations. We should therefore critically consider the significance of calculus of amplitude and frequency in this study of muscle relaxation by TENS and NuCalm BWE.
NuCalm Methodology
Males and females in total 12 subjects (10 completions) were assessed for baseline resting EMG amplitudes and frequencies of the bilateral masseter and temporal muscles on three sequential days. This establishes control levels for normalization in percentage EMG amplitude voltages and frequency. It was found that the subjects who were treated in the supine condition should be kept warm with blankets to reduce problematic postural changes and environmental cooling. The supine findings were seen to compare well with the upright posture results normally obtained in NM treatment using TENS.
In the NuCalm treated subjects two tablets of amino acid supplements including neurotransmitters GABA and 5HTP were orally administered with Theanine relaxant from green tea all of which are known to pass the blood brain barrier when given sublingually. Centro electrical stimulation was applied behind the auricle along known acupuncture stimulation. Neuroacoustic brain entrainment at 10Hz was applied binaurally via earphones and ostensibly consists of relaxing music with hidden entrainment beats in each auditory channel. Light blocking glasses were worn throughout the process. Surface EMGs (SEMGs) were recorded from alcohol cleansed skin over the masticatory and facial muscles at 0, 5, 10, 30, 40, 50 and 60 minutes. All ten subjects were recorded by bipolar electrodes placed at controlled interelectrode intervals by standard Myotronics electrodes The three studies included rest alone, TENS alone, NuCalm alone and NuCalm and TENS together.
Figure 5 presents a graph of the sine wave of EMG Myotrajectories from a classical text. Fourier analysis of sine wave is depicted where Hz (m. sec)/uV calculus is plotted along Y (volts) and X (degrees) axes. For a given phase dv of the sine wave signal corresponds to a unique minimum frequency called the instantaneous frequency Hz is given if dt is diminishing small which is true for mandibular movement TENS stimulation The Myotrajectories for a given phase and trajectory angles further depicted in scans 4/5 (of jaw movements) and scan 18 which directly calculate masticatory muscle EMGs and frequency in the Myotronics program to which the trigonometric tables of sine, cosine and tan apply. With reference to the calculus property of unit circle where the radius is by definition 1 it will be seen that it is necessary to convert 1/t from decimal milliseconds (time) to cycles per second (Hz) for frequency and the EMG microvolts (uV) recorded. Thus Hz/Volts is frequency per volt as demonstrated in Thomas NR (1999) Anth. ICCMO (1999): vol V 159-170. The caption of Figure 5 states that "For a given phase, dv vs dt of the sine wave signal corresponds to a unique minimum frequency called the instantaneous frequency if dt is diminishingly small" Figure 8 is a kinesiograph (K7 version) scan 4/5 pre and post TENS scans of the sagittal and frontal view of jaw motion from physiological rest to the occlusal plane of a patient in an upright posture. On the left side of the figure is the pre and post treatment scans of the myotrajectory from clinical rest and physiological rest. The TENS evoked jaw motion extends from physiological rest to the centric occlusal plane (CO) and compared with the patient's voluntary pre-existing habitual jaw motion from aberrant clinical rest in sweep mode. On the right the data is represented in nonsweep mode. The pre TENS habitual closures post TENS pulses are overwritten on the right trace and correspond to the pulses shown on the left side in the sweep mode. For mathematical ease the reader may assume that in this scan 4/5 the vertical scale represents the amplitude in microvolts while the horizontal scale is in hundreds of Hz in scan 18 due to the fact that the scans are similar triangles to the unit triangle of the sine wave. Thus Figure 8 scan 4/5 compares the habitual trajectory of 56 degrees for a Pre TENS un- relaxed patient while relaxed myotrajectory is 63 degrees representing the post TENS condition of mandible downwards and forward of the clinical occlusion that requires relaxation because of presenting pain and abnormal mandibular motion. The scan 4/5 gives a tan of 1.5 (actual 1.4826) for the habitual trajectory with sine of .8290 and cosine of .5592 which from the trigonometric table is 56 degrees while that for the relaxed myotrajectory gives a tan of 2.03 (actual 1.9626 for a relaxed trajectory with sine of .8910 and cosine .4540 which from the trigonometric table is close to 63degrees Thus Scan 4/5 for the habitual and relaxed myotrajectories provide pre relaxed and post TENS relaxed conditions. For a TMD patient habitual and relaxed myotrajectories for the pre and post TENS conditions are shown as the scan 18 data of 56 and 63 degrees respectively Figure 9 6.67/3.4=1.962=tan63degrees relaxed frequency of 6.67X100=667Hz 3.60/2.4=1.48=tan56degrees habitual trajectories with frequency of 3.60x100 =360Hz calculated from the trig tables Figure 10.
Thus given any two of the parameters of frequency, voltage, angle of trajectory and time taken from physiological rest to CO in decimals of milliseconds it is possible to provide the calculation of the degree of fatigue or of relaxation produced by the treatment within scientific error of measurement from the kinesiograph Figure 9 is the scan 18 derived from a Fourier analysis of the same data exhibited in scan 4/5 and shows how voltage and frequency for the various states or sample points of relaxation are coordinate with each other.
Finally if the habitual trajectory is accompanied by signs and symptoms then it is most important that the calculated myotrajectory angle be larger than the initial or habitual trajectory angle so that the trajectories should not cross or interact. This is because when the trajectories cross the treated myotrajectory assumes the voltage and frequency of the pre-existing trajectory and can thus be a source of continuing symptoms and signs of the original condition including postural anomaly and obstructive sleep apnea with all the accompanying co- morbidities. But it is imperative that one understands that the frequency is a first order resultant of fatigue and relaxation and the voltage is a second order effect as the above calculations show. A priori consideration is that frequency is a primary resultant of changes in velocity of conduction of the muscle while the voltages are action potentials.
Figure 11 is an example of the NuCalm derived post NuCalm resting EMG scan 9 (amplitude in volts) of a subject resting in the supine state for 30 minutes. The resting voltage is 4.1uV which increases with light tooth contact (Rest CO) to 9.8uV (Figure 12). Both data indicate rest which requires confirmation by accompanying frequency analysis. The increased voltage on light occlusal contact is the raison d'etre why bite correction is necessary.
Figure 11 reveals an amazing reduction in uV with NuCalm in just 5 minutes and concurs with the AVE findings of [1]. Figure 12 shows the EMG data for subject 1 in light centric occlusion (CO) indicating that the habitual occlusion ideally requires coronoplasty or other phase of treatment mentioned above.
Figure 13 provides another example of the remarkable muscle relaxation by NuCalm by just 20minutes relaxation and so it continues for all ten subjects.
Figure 14,15,16 give the mean EMG voltages compared with the baselines for NuCalm alone, TENS alone and NuCalm and TENS together over 60 minutes treatment. Figure 17 is a table comparing the change in per cent frequency (Hz cycles per second) per amplitude voltages for 60 minutes treatment by NuCalm+TENS treatment. The comparison of relaxing effects of the different modalities in the table shown in Figure 17 clearly indicate that Nu Calm is superior relaxant to TENS alone and that NuCalm and TENS improves relaxation best.
Clearly the relaxation procedures of NuCalm alone and TENS alone are seen to represent different physiological mechanisms of muscle relaxation. NuCalm relaxes muscle via brain wave entrainment whereas TENS relaxation occurs via antidromic hyperpolarization of midbrain motor efferents demonstrated in Figure 18,19 developed from findings of [6,7]. TENS motor V nerve increases the inhibitory 1a afferents from muscle spindles of the H wave allowing the direct M action potential to the masticatory muscle to become facilitated as a relaxation phenomenon [7,8]. Figure 20,21 is a summary graph of the effects of NuCalm alone, TENS alone and NuCalm+ TENS relaxation on frequency of masseter EMG over time. While NuCalm plus TENS continues to be the best methodology to relax the musculature when assessed by voltage amperes uV. But the graphs are nonlinear. Figure 22 shows that all frequencies are equivalent to tans of angles which are linear to trigonometrical points.
Conclusion
The positive effect of NuCalm versus TENS is very clear when combining frequency and voltage. TENS appears a lesser procedure when voltage alone is followed but when combined with the first order of fatigue which is frequency the effect of TENS is more positive. While so called neuromuscular dentists know from following a patient that a TENS orthotic is effective one readily sees why those who oppose the technique only see voltage amplitude and erroneously remain unconvinced by the data including sensitivity, specificity and reliability because when calculated from frequency Hz/uV they are all linear falling along trigonometrical points.
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