By: Jim Poole, President and CE0
It had been correctly pointed out by F.B Stulen and C De Luca (1981) in Biomedical Engineering Vol BME 28:515-‐523 that although the change in amplitude is used as an empirical measure of muscle fatigue it is a second order effect and requires confirmation by frequency analysis. Despite criticisms of the Myotronics procedure by Al-‐Saleh MA et al (2012) in the Journal of the American Dental Association JADA 143:351-‐62 that neuromuscular dentists only utilize EMG voltages Thomas N.R together with Jenkins D published a rebuttal in a following JADA where it was explained that Myotronic K7 Kinesiograph does include spectral analysis in the form of scan 18. It will also be shown below that the trajectories in the commonly applied scan 4/5 display horizontal and vertical coordinates of the frequency and amplitude of the electromyograms (EMGs) respectively. Neuromuscular dentists routinely use these coordinates in the right angle triangle of Scan 4/5 to develop a treatment plan on the degree of departure exhibited in the myotrajectory relative to the habitual trajectory from physiological rest to the occlusal plane (CO) essential to deducing the correct construction bite of the proposed CMO in strict concordance to the Pythagorean Principle. The latter states that the square on the hypotenuse (trajectory) equals the sum of the squares on the other two sides. Furthermore those sides of the right angle triangle constitute the sines, cosines and tans of the respective angles that are published in the well-‐known trigonometric tables utilized in calculus. Thus Al Saleh et al were eminently incorrect in denouncing specificity, sensitivity, reliability and predictability of the kinesiograph. And even though some neuromuscular dentists may not have been aware of the inclusion of frequency in their occlusal registrations they most certainly form the jaw trajectories and their depictions in Scan 4/5 which will be described below. In 1988 Norman Thomas and David Seiver revealed that repetitive brain wave audiovisual (AVE) brain wave entrainment (BWE) achieved rapid and effective relaxation of the masticatory musculature (Thomas N.R and Seiver D The Fourth European Congress Oxford Hypnosis 239-‐ 245 eds Waxman D, Pedersen, Wilkie D and Mellette P).
Recently NuCalm using only audio BWE has duplicated these effects of AVE treatments and both continue to be in vogue, particularly in those patients who find the electrical stimulation stressful.
Protocol and Calculation of amplitude (uV), frequency (Hz) and time (t) quotient ratios of the stress and relaxed data:
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 amplitudes and voltages .The subjects were treated in the supine condition with blankets to reduce problematic postural changes and environmental cooling. The supine findings will be seen to compare well with the upright posture results normally obtained in NM treatment. 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 administered sublingually.Centro electrical stimulation (CES) was applied behind the auricle along known acupuncture meridian. Neuroacoustic entrainment at 10Hz was applied binaurally via earphones and ostensibly consists of relaxing music with hidden entrainment differential 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 TENS alone NuCalm alone and NuCalm and TENS together.
Figure 1 presents a graph of the sine wave of alternating EMG current along Y and X axes further depicted in scans 4/5 and 18. and hence to which the trigonometric tables of sine, cosine and tan apply with reference to the property of a unit circle and unit triangle. It will be seen that it is necessary to convert 1/t decimal milliseconds to cycles per second (Hz) for frequency and microvolts (uV) to V (volts) Thus Hz/Volts is frequency in decimals of a millisecond 1×10-‐4 divided by volts (1/millionth of a volt) 1×10-‐6 which converts to Hzx102/uV i.e. Hz/uV as pointed out in Anth. ICCMO Thomas N.R. (1999): vol V 159-‐170.
The caption at the bottom of Figure 1 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” as indeed it is referred to as decimals of a millisecond 1×10-‐4
Figure 2 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 post treatment myotrajectory scan traces of the TENS evoked jaw motion extending from physiological rest to the centric occlusal plane (CO) and compared with the patient’s voluntary preexisting habitual jaw motion from aberrant clinical rest in sweep mode. On the right the data is represented in non-‐sweep mode. The 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 scan 4/5 the vertical scale represents the amplitude in microvolts while the horizontal scale is in hundreds of Hz.
Thus in Figure 1 scan 4/5 it may be seen that the trajectory angles are ratios of the sample points in scan 4/5 : 2.8, 3.4 and 3.6 mm (vertical) for the sample points 2, 1 and 3 respectively shown in red and represent frequencies of 517, 667 and 738Hz respectively as calculated from scan 18 (Figure 3) and are the data of trajectory angles of 61,63 and 64 degrees respectively: 5.17/2.8=1.846=tan61degrees 6.67/3.4=1.962=tan63degrees 7.38/3.6=2.05=tan64degrees 3.6/2.4=1.48=tan56degrees habitual trajectory.
Thus given any two of the parameters of frequency, voltage, angle of trajectory and time taken from physiological rest to CO which is in decimals of milliseconds it is possible to provide the calculation of the degree of fatigue or of relaxation produced by the treatment.
Figure 3 is a scan 18 of the same data exhibited in the scan 4/5 and shows how voltage and frequency for the various states or sample points of relaxation are coordinated. Since the K7 scans are coordinates of the data points and will give the other data points simply by using the trigonometric tables.
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 4 is an example of an 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 tooth contact (Rest CO) to 9.6uV. Both data indicate continuing fatigue which ideally requires confirmation by frequency analysis. This increased voltage is the raison d’être why bite correction is thought to be necessary.
Figure 5 reveals an amazing reduction in uV with Nucalm in just 5 minutes and concurs with the AVE findings of Thomas and Seiver (1988).
Figs 6, 7 and 8 give the mean amplitude voltages compared with the baselines for NuCalm , TENS and Nucalm and TENS together. Figure 9 is a table comparing the change in per cent voltages over the 60 minutes. The evidence clearly indicates that Nu Calm is superior to TENS and NuCalm and TENS .It is noted that there is a falloff in stress reduction at sixty minutes which was also observed in Thomas and Seiver (1988) and likely due to a cooling effect of all treatments on muscle function.
Figure 10 is a graph of the changes in voltage over the 60 minutes. Again it is evident that NuCalm is superior to the other treatments despite the fall off at 60 minutes.
Figure 11 is a table of the combined results of voltage and frequency and the graph of the results in Figure 12 exhibit improved linearity and continued relaxation. The 2.88Hz marker at 60 minutes is equivalent to a myotrajectory 71 degree which is phenomenal and no doubt also due to the effect of the supine posture which suggests that this may be improved further by combining with facial warming and postural decompression.
Figure 13 compares the results of TENS and NuCalm using Voltage alone, frequency alone and frequency /voltage ratios.
Conclusion: The positive effect of NuCalm alone over TENS and NuCalm plus TENS is clear even given the small number of subjects. Though there is a falloff in the data at 60minutes which agrees with Thomas and Siever (1988) and apparently due to cooling effect on the muscles which induces an increase in muscle tone due to a ‘shivering’ reflex, “The Relationship between Muscle Temperature, MUAP Conduction Velocity and the Amplitude and Frequency Components of the Surface EMG During Isometric Contractions” (J. Petrovsky and M. Laymon (2005) Basic Appl. Myol 15 (2): 61-‐74. While neuromuscular dentists know that the TENS orthotic is effective treatment for OSA and TMD the critics by those who erroneously believe that NM treatment only includes voltage amplitude studies negates their charge against using CMO treatment based on relaxation as a failure to establish sensitivity and specificity. Stress reduction decreases sympathetic action on skin vessels with resulting cooling of the muscle belly .Improvements in neuromuscular treatment by warming the facial and neck skin is increasingly used to positive effect by neuromuscular dentists in combination with postural decompression.