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Electromagnetic Biology and Medicine

ISSN: 1536-8378 (Print) 1536-8386 (Online) Journal homepage: https://www.tandfonline.com/loi/iebm20

Acute effects of capacitive and resistive electric


transfer (CRet) on the Achilles tendon

Tsubasa Bito, Yuto Tashiro, Yusuke Suzuki, Yuu Kajiwara, Hala Zeidan,
Mirei Kawagoe, Takuya Sonoda, Yasuaki Nakayama, Yuki Yokota, Kanako
Shimoura, Masataka Tatsumi, Kengo Nakai, Yuichi Nishida, Soyoka Yoshimi,
Tadao Tsuboyama & Tomoki Aoyama

To cite this article: Tsubasa Bito, Yuto Tashiro, Yusuke Suzuki, Yuu Kajiwara, Hala Zeidan,
Mirei Kawagoe, Takuya Sonoda, Yasuaki Nakayama, Yuki Yokota, Kanako Shimoura, Masataka
Tatsumi, Kengo Nakai, Yuichi Nishida, Soyoka Yoshimi, Tadao Tsuboyama & Tomoki Aoyama
(2019): Acute effects of capacitive and resistive electric transfer (CRet) on the Achilles tendon,
Electromagnetic Biology and Medicine, DOI: 10.1080/15368378.2019.1567525

To link to this article: https://doi.org/10.1080/15368378.2019.1567525

Published online: 19 Jan 2019.

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ELECTROMAGNETIC BIOLOGY AND MEDICINE
https://doi.org/10.1080/15368378.2019.1567525

Acute effects of capacitive and resistive electric transfer (CRet) on the Achilles
tendon
Tsubasa Bito, Yuto Tashiro, Yusuke Suzuki, Yuu Kajiwara, Hala Zeidan, Mirei Kawagoe, Takuya Sonoda,
Yasuaki Nakayama, Yuki Yokota, Kanako Shimoura, Masataka Tatsumi, Kengo Nakai, Yuichi Nishida,
Soyoka Yoshimi, Tadao Tsuboyama, and Tomoki Aoyama
Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Sakyo-ku, Japan

ABSTRACT ARTICLE HISTORY


This study aimed to investigate the acute effects of capacitive and resistive electric transfer (CRet) on Received 6 June 2018
Achilles tendon elongation during muscle contraction, as well as the circulation in the peritendinous Accepted 2 December 2018
region. Sixteen healthy men participated in this study. All 16 participants underwent 2 interventions: KEYWORDS
(1) CRet trial and (2) CRet without power (sham trial). Tendon elongation was measured four times. Electrophysical agents;
Using near-infrared spectroscopy, the blood circulation (volume of total-hemoglobin (Hb), oxygenated blood circulation; tendon
hemoglobin (oxy-Hb), and deoxygenated hemoglobin (deoxy-Hb)) was measured for 5 min before the elongation; thermal agent;
intervention and for 30 min after the intervention. The differences between the measurements Achilles tendon
obtained before and after intervention were compared between the two interventions. The changes
in tendon elongation and deoxy-Hb were not significantly different between the interventions. Total-
and oxy-Hb were significantly increased in the CRet trial compared with the sham trial. In addition, the
increases in total-Hb and oxy-Hb lasted for 30 min after the CRet intervention (CRet vs. sham: oxy-Hb:
F = 8.063, p = 0.001, total-Hb: F = 4.564, p = 0.011). In conclusion, CRet significantly improved blood
circulation in the peritendinous region.

Introduction that vascular supply is one of the important factors to treat


tendon tissue. It has been reported that the application of
Tendon disorders often occur in many sports. Achilles
heat led to improved blood flow and oxygen saturation in
tendinopathy represents one of the most frequently occur-
the Achilles tendon (Kubo and Ikebukuro, 2012; Kubo
ring ankle and foot overuse injuries (Li and Hua, 2016).
et al., 2008). Thus, thermal agents may be an effective
The effects of various treatments on the Achilles tendon,
method of treating tendon disorders.
including eccentric exercise, deep friction massage, tendon
Recently, capacitive and resistive electric transfer
mobilization, and therapy using physical agents such as
(CRet), a diathermic process, has been developed. CRet
ultrasound, low-level laser therapy and shockwave therapy,
is a non-invasive electro-thermal therapy, which delivers
have been investigated (Li and Hua, 2016). However, the
electric currents of 448 kHz within the radiofrequency
gold standard treatment for Achilles tendinopathy has not
(RF) range. Energy passes between the active and inactive
yet been determined. Vascular supply is one factor that is
electrodes, thus generating heat in the human body. CRet
reported to have an effect on tendon tissue repair
is a more effective thermal agent than hot packs for
(Richards, 1980). When the blood supply was disturbed
improving circulation, oxygenation, and flexibility of the
in the Achilles tendon of a rabbit, the following changes
muscles (Tashiro et al., 2017; Yokota et al., 2017).
were observed: the bonded fascicles of the rabbit’s tendon
Additionally, CRet decreases pain in patients with tendon
that are normally enclosed separated and the tenocytes
disorders (Wiegerinck et al., 2013). Although there are
dropped out of the interfascicular spaces. The strands of
some studies on the effects of CRet on muscle, the effect of
collagen became acellular and fragmented. Moreover,
CRet on tendons is unclear. Therefore, the main aim of
changes observed in chronic degenerative tendon disorders
this study was to investigate the circulatory changes in
were shown to be the same as those that occur when the
a peritendinous region after a CRet intervention. We also
blood supply to the rabbit’s Achilles tendon is disturbed
focused on changes in tendon elongation during muscle
(Fenwick et al., 2002; Macnab, 1973). This demonstrates
contraction after the intervention. We hypothesized that

CONTACT Tsubasa Bito bitoh.tsubasa.82x@st.kyoto-u.ac.jp Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine,
Kyoto University, 53 Kawahara-cho Shogoin, Sakyo-ku, Kyoto 606-8507, Japan
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iebm.
© 2019 Taylor & Francis Group, LLC
2 T. BITO ET AL.

CRet would improve the circulation but would not a polyamide coating that acts as a dielectric medium,
change tendon elongation because CRet is known to insulating its metallic body from the skin surface,
improve circulation to the muscles. Heat alone has not allowing it to generate external heat near the skin.
been associated with changes in tendon elongation in The RES electrode is uncoated. The RF energy goes
studies using rat tail tendons (Lehmann et al., 1979; directly through the body into the inactive electrode,
Yokota et al., 2017). and therefore, it generates heat in deeper parts of the
body. The subjects were exposed to the intervention
applied to the Achilles tendon for 15 min in a prone
Materials and methods position (5 min in CAP using the electrode with
Subjects a diameter of 55 mm, 5 min in RES using the elec-
trode with a diameter of 55 mm, and 5 min in RES
Sixteen healthy male adults participated in this study. using the electrode with a diameter of 35 mm). We
We excluded subjects with orthopedic or neural disor- selected this intervention time (5 min in CAP and
ders of the right lower limbs. In addition, subjects with 10 min in RES) based on a previous study so that the
contraindications to CRet were excluded, e.g. deep vein effect of the CRet intervention on hemoglobin satura-
thrombosis, hypoesthesia, damaged skin, and an tion and tissue temperature would be revealed
implanted pacemaker. This study was approved by the (Tashiro et al., 2017). The active electrode was con-
ethical committee. Participants received sufficient oral tinually moved in a circular motion on the skin of
and written explanations of the purpose and methods the right posterior lower leg and Achilles tendon,
of this study and provided informed consent. while the inactive electrode was placed under the
We calculated the sample size needed for a two-way right thigh. A manufacturer-supplied conductive
analysis of variance (ANOVA) with repeated measures cream was used as a coupling medium between the
(effect size = 0.40, α error = 0.05, power = 0.8, number active electrode and the skin surface during the inter-
of groups = 2, number of measurements = 7) using vention. The subjects’ perceptions of the CRet inten-
G power 3.1 software (Heinrich Heine University, sity were defined as 6 or 7 on a subjective analogue
Dusseldorf, Germany). The result showed that 16 subjects scale, which was an 11-point, self-reported thermal
were needed. sensation scale (0: no thermal sensing, 6–7: comfor-
table thermal sensing, 10: worst possible thermal
Design sensing). The duration and intensity of the CRet
trial were based on the manufacturer’s recommended
This was a feasibility study performed to investigate the method for safe performance that was considered the
effects of CRet. All participants experienced two inter- most effective without causing the subject discomfort
ventions: (1) a CRet trial and (2) a CRet trial without or pain (Kumaran and Watson, 2015). The sham trial
power (a sham trial). The order of the interventions was unpowered for CRet but was otherwise per-
was randomized and they were conducted at least 24 h formed using the same methods and conditions as
apart. The interventions and measurements were based those in the CRet trial.
on interventions applied to the right lower leg and
Achilles tendon.
Measurements
Tendon elongation
Intervention
A 5–13 MHz linear-array B-mode ultrasound (US)
The Indiba® activ Pro Recovery HCR902 (Indiba probe (EUP-L74M, Hitachi Aloka Medical, Tokyo,
S. A., Barcelona, Spain) was used for the CRet inter- Japan,) was used to measure displacement of the myo-
vention. The interventions in this study followed the tendinous junction (MTJ) of the medial head of the
method of Yokota et al. (2017). CRet operates at gastrocnemius muscle which represented Achilles ten-
a frequency of 448 kHz. Two rigid circular metallic don elongation. Kubo et al. used a 7.5 MHz wave
electrodes with diameters of 35 and 55 mm were frequency to measure the tendon, so the same wave
used as active electrodes, while a large flexible rec- frequency was used in this study (Kubo et al., 2005).
tangular metallic plate (measuring The US probe was placed in the sagittal plane over the
200 mm × 260 mm) was used as the inactive elec- distal medial portion of the gastrocnemius to obtain the
trode. This method provides RF energy in two modes origin of the MTJ of the Achilles tendon. The US probe
in the active electrodes: capacitive (CAP) and resis- was secured using a bandage to prevent movement
tive (RES) modes. The CAP electrode has during the measurements (Figure 1).
ELECTROMAGNETIC BIOLOGY AND MEDICINE 3

Circulation
The circulation was measured in the peritendinous
region using near-infrared spectroscopy (NIRS) on an
OMEGAMONITOR BOM-L1 TR W (Omegawave Co.,
Ltd., Tokyo, Japan) as in previous studies (Boushel
et al., 2000). The peritendinous region was defined as
area around the distal MTJ of the medial gastrocnemius
including the Achilles tendon, skin, and other soft
tissue.
This device’s two photo detectors absorb three wave-
lengths of light (780, 810, 830 nm) from a light source.
The absorbance is analyzed using a modified version of
the Lambert–Beer law, which indicates the hemoglobin
(Hb) content as measured by the photo detectors. The 2
Figure 1. The setting of each probe.
photo detectors were placed 15 and 30 mm away from
NIRS probe: near-infrared spectroscopy probe; US probe: ultra-
sound probe. the light source, with the distance between the 2 detec-
tors reflecting the measurement depth. The circulation
at around 15 mm below the skin surface was measured
in this study. Kubo et al. (2008) reported that the depth
Subjects were seated on a Biodex System 4 isokinetic
of the Achilles tendon from the skin was 2.2 mm at its
dynamometer (Biodex Medical Systems Inc., Shirley. NY)
superficial surface and 7.8 mm at its deep surface.
with their hip flexed to 90º, the right knee extended, the
Because of this, we concluded that we could measure
right ankle in neutral, and the left knee and ankle in
the peritendinous region circulation, including the
relaxed positions. The right lateral malleolus was aligned
Achilles tendon tissue, using NIRS. The circulatory
with the axis of rotation of the dynamometer and the foot
measurement indices included oxygenated (oxy-),
was secured to the foot plate to prevent heel movement
deoxygenated (deoxy-), and total (total-) Hb concentra-
during muscle contraction. In addition, the thorax, hips,
tions. The total-Hb was defined as the sum of the oxy-
and right thigh were secured with straps to prevent dis-
Hb and deoxy-Hb. The NIRS probe was taped in series
placement. Having referred to the method of A. J. Bayliss
in the distal of the US probe. Because the US probe was
et al. (2016), the subjects were asked to perform incre-
set on the skin above the MTJ, the distal US probe was
mental plantar flexion contractions of 25%, 50%, 75%,
considered to be located on the skin above the Achilles
and 100% of maximal isometric force, with the subjects
tendon. One therapist consistently placed the NIRS
monitoring their contraction force on a display. They held
probes on the subjects.
the contraction for 5 s before relaxing, then for 5 s before
proceeding to the next level. Only before the intervention,
they were given one warm-up trial with two measure-
Procedures
ments of the maximal isometric plantar flexion force to
define the maximal voluntary contraction (MVC), which The procedural methods in this study were based on
was followed by the actual data collection trial. The higher a previous study by Yokota et al. (2017). The duration of
result was defined as the MVC. The MVC measurement the experiment was 50 min in total, divided as follows:
was conducted in the first experiment (CRet or sham 5 min before the intervention (rest), the 15-min interven-
intervention) but not in the second experiment (sham tion, and 30 min after the intervention (rest). Tendon
or CRet intervention). In the latter experiment, the sub- elongation and circulation were measured 5 min before
jects performed contractions based on the value of MVC and 30 min after the intervention and were recorded as
obtained the former experiment. In the data collection follows: tendon elongation before (T1), immediately after
trial, US images were taken as the subjects performed each (T2), 15 min after (T5), and 30 min after (T8); circulation
contraction. During the contraction, a therapist manually data for 5 min before the intervention (I1), and at 5-min
fixed the US probe to avoid its movement. We defined intervals for 30 min after the intervention (I2-I7). The
tendon elongation as its displacement from the point of average of the 5-min intervals was also recorded.
the MTJ at rest to the point of the MTJ at 100% of MVC. NIRS was used to measure the changes in Hb at I1, and
The displacement of the MTJ as seen in the US images MVC measurement was conducted at only T1 (only the
were calculated using Image J software (National Institute first experiment for each of the subjects). The T1 mea-
of Health, Bethesda, Maryland, USA). surement was obtained before the intervention in both the
4 T. BITO ET AL.

Figure 2. Experimental procedure.

CRet and sham trials. The interventions for the CRet or Table 1. Changes in tendon elongation after each intervention.
sham trials were then conducted for 15 min. After the CRet trial Sham trial ANOVA
interventions, T2, T5, and T8 measurements were T1 0 0 n.s.
T2 −1.03 ± 4.12 −1.04 ± 3.56
obtained. The NIRS measurement was performed con- T5 −0.57 ± 2.37 −2.07 ± 3.16
tinuously for 30 min after the interventions, which is T8 −0.53 ± 3.55 −1.41 ± 4.03
represented by I2-I7 (Figure 2). Unit: mm (mean ± standard deviation);
n.s.: not significant;
CRet: capacitive and resistive electric transfer. The chronological changes in
tendon elongation in the CRet and sham trials. There is no interaction in
tendon elongation.
Statistical analysis
For each measured index, the change (Δ) from the Changes in blood circulation
initial value was calculated and compared at each
The changes in total-, oxy-, and deoxy-Hb of the peri-
time point after the intervention to clarify the dura-
tendinous region are shown in Figure 3. There was
tion of effect of each intervention. A two-way analy-
a significant interaction between the Δoxy-Hb
sis of variance (ANOVA) was used to investigate the
(F = 8.063, p < 0.01) and the Δtotal-Hb (F = 4.564,
interactions. The two-way ANOVA with 2 × 4
p < 0.05) (Table 2). The Δdeoxy-Hb did not differ
repeats was used to measure the changes in tendon
significantly between the interventions (Table 2). The
elongation. The changes in each Hb index were ana-
Sidak post hoc test showed that Δoxy-Hb and Δtotal-
lyzed using two-way ANOVA with 2 × 7 repeats.
Hb were significantly higher in the CRet trial than in
When an interaction was shown, a Sidak post hoc
the sham trial for I2 and I7 (oxy-Hb: I2-7 p < 0.01,
multiple comparison test was conducted to reveal the
total-Hb: I2, I4-7 p < 0.05, I3 p < 0.01).
differences in the interventions and the differences
between two interventions. The statistical analysis
was performed using SPSS version 20.0 (IBM Corp., Discussion
Armonk, NY), with a significance threshold of 0.05.
We investigated the effects of CRet on Achilles tendon
elongation and peritendinous blood circulation. Our
main findings indicated that the total-Hb and oxy-Hb
Results significantly increased after the CRet intervention, and
this effect lasted for 30 min after the intervention;
Changes in tendon elongation
however, the deoxy-Hb did not change. This shows
There was no significant difference in the Δelongations that the changes in total-Hb were attributed to the
between any two trials and within each trial (Table 1). increase in oxy-Hb. An increase in oxy-Hb meant that

Figure 3. Changes in blood circulation.


ELECTROMAGNETIC BIOLOGY AND MEDICINE 5

Table 2. Changes in blood circulation after each intervention. studies, these responses are associated with the direct
CRet trial Sham trial ANOVA reflex activation of vascular smooth muscle through
Oxy-Hb I1 0 0 F = 8.063 skin thermoreceptors, suppression of the sympathetic
I2 0.73 ± 0.73** 0.06 ± 0.52
I3 0.80 ± 0.79** 0.01 ± 0.53 nervous system via indirect activation of local spinal
I4 0.72 ± 0.75** 0.05 ± 0.52 reflexes, and increases in the release of inflammatory
I5 0.57 ± 0.66** −0.09 ± 0.51
I6 0.60 ± 0.60** −0.03 ± 0.51 chemical mediators such as nitric oxide, histamine, and
I7 0.53 ± 0.58** −0.01 ± 0.56 prostaglandins (Crockford et al., 1962; Kellogg et al.,
Deoxy-Hb I1 0 0 n.s.
I2 0.15 ± 0.49 0.09 ± 0.36 1999; Minson et al., 2001).
I3 0.11 ± 0.54 −0.01 ± 0.34 Despite its relatively avascular appearance, the ten-
I4 0.05 ± 0.45 0.05 ± 0.40
I5 0.12 ± 0.45 0.06 ± 0.40 don relies on oxygen more than other tissues in the
I6 0.09 ± 0.41 −0.06 ± 0.37
I7 0.02 ± 0.40 −0.05 ± 0.34
joints, such as cartilage, and it requires enhancement of
Total-Hb I1 0 0 F = 4.564. the circulation during its repair process (Liang et al.,
I2 0.87 ± 1.1* 0.14 ± 0.77
I3 0.9 ± 1.19** −0.01 ± 0.76 2012). The circulation is the main factor involved in
I4 0.76 ± 1.08* 0.10 ± 0.73 oxygenation of the cells. Furthermore, oxygen is
I5 0.68 ± 0.95* −0.02 ± 0.76
I6 0.68 ± 0.81* −0.08 ± 0.73 required for almost every step of the healing process
I7 0.55 ± 0.78* −0.06 ± 0.76 since hypoxia and ischemia delay wound healing, can
Unit: µmol/l (mean ± standard deviation); **p < 0.01 CRet trial vs. sham lead to pain, and prevent normal collagen synthesis
trial; *p < 0.05 CRet trial vs. sham trial; n.s.: not significant;
CRet: capacitive and resistive electric transfer; (Fenwick et al., 2002; Guo and Dipietro, 2010;
Oxy-Hb: oxygenated hemoglobin; Schreml et al., 2010; Uitto and Prockop, 1974). In
Deoxy-Hb: deoxygenated hemoglobin;
Hb: hemoglobin. The chronological changes in Oxy-Hb, Deoxy-Hb, and
clinical research, it has been reported that CRet is
Total-Hb in the CRet and sham trials are shown. There are interactions effective in reducing pain in patients with tendon dis-
between Oxy-Hb and Total Hb. From I2 to I7, Oxy-Hb and Total-Hb levels orders (Costantino et al., 2005; Wiegerinck et al., 2013).
were significantry higher in the CRet trial than in the sham trial.
Transfer of energy capacitive and resistive therapy was
one of the methods in which CRet was used in patients
there was an increase in the freshly oxygenated blood with Achilles tendonitis (twelve 30-min sessions,
supply (Karasuno et al., 2005). Some previous studies divided into 15 min using the CAP method, 15 min
reported that other thermal agents increased tendon using the RES method; the method was applied in
blood flow (Kubo and Ikebukuro, 2012; Kubo et al., a continuous manner using medium power). All
2010). One study demonstrated that a 10-min hot pack patients reported benefits from the intervention. Pain,
application increased tendon blood flow and the effect which was evaluated using the visual analogue scale
lasted for 20 min after the intervention (Kubo et al., score, was significantly reduced (Costantino et al.,
2010). Another study of the thermal effects of infrared 2005). Therefore, the findings that CRet increased the
rays showed that a 20-min intervention improved ten- peritendinous circulation, and particularly increases
don circulation, and the effect lasted for 30 min after oxy-Hb, demonstrates that CRet can be a useful agent
the intervention (Kubo and Ikebukuro, 2012). In addi- in the treatment of tendon disorders.
tion, it was shown that CRet improved the superficial On the other hand, tendon elongation did not
and deep tissue temperatures, circulations, and oxyge- change after the CRet intervention. Hot water immer-
nations of the muscles more than the application of hot sion has no effect on the mechanical properties of the
packs (Tashiro et al., 2017; Yokota et al., 2017). The human tendon (Kubo et al., 2005). In addition,
results in this imply that CRet exerts an effect that is according to previous findings in animal models, the
equal to or greater than those of thermal agents for application of heat alone did not contribute to the
improving tendon circulation. elongation of rat tail tendons (Lehmann et al., 1979).
CRet is a thermal agent. The intervention method in In this study, CRet alone had no effect on tendon
this study was the same as in previous studies that extensibility immediately after the interventions, simi-
showed that CRet exerted thermal effects (Tashiro lar to the previous studies. However, the combination
et al., 2017; Yokota et al., 2017). Thus, the increases of the application of heat and stretching did affect
in total- and oxy-Hb were considered to have resulted tendon extensibility in the previous study (Lehmann
from the thermal effects of CRet. Based on the changes et al., 1979). CRet can be used during stretching,
in the muscle circulation that occurred during the massage, or exercise. Therefore, the combination of
application of heat (Sekins et al., 1984), it is likely that CRet with other methodologies should be investigated
circulatory improvement could have resulted from in the future. In particular, the effect of using CRet
vasodilatation and increased capillary permeability simultaneously with other approaches should be
(Sekins et al., 1984). In addition, according to previous clarified.
6 T. BITO ET AL.

This study had three limitations. First, the tissue tem- Karasuno, H., Morozumi, K., Fujiwara, T., Goh, A., et al.
peratures were not measured, so the thermal effects on the (2005). Changes in intramuscular blood volume induced
Achilles tendons is unclear. Second, we used NIRS to mea- by continuous shortwave diathermy. J. Phys. Ther. Sci.
17:71–79. doi:10.1589/jpts.17.71
sure the circulation, which included the circulation to the Kellogg, D. L., Liu, Y., Kosiba, I. F., O’Donnell, D. (1999).
skin, muscle, and other connective tissues. Thus, the circu- Role of nitric oxide in the vascular effects of local warming
lation to the tendon alone remains unknown. Third, we did of the skin in humans. J. Appl. Physiol. (1985)
not compare CRet to other thermal agents, so whether CRet 86:1185–1190. doi:10.1152/jappl.1999.86.4.1185
is more useful than other agents in the treatment of tendon Kubo, K., Ikebukuro, T. (2012). Blood circulation of patellar
and achilles tendons during contractions and heating.
disorders is unclear. Despite these limitations, to the best of
Med. Sci. Sports Exerc. 44:2111–2117. doi:10.1249/
our knowledge, this is the first experimental study to inves- MSS.0b013e31825fa82e
tigate the effects of CRet on tendons, and its usefulness in Kubo, K., Ikebukuro, T., Tsunoda, N., Kanehisa, H. (2008).
the treatment of tendon injuries. Noninvasive measures of blood volume and oxygen satura-
tion of human Achilles tendon by red laser lights. Acta.
Physiol. (Oxf) 193:257–264. doi:10.1111/j.1748-
Conclusion 1716.2008.01849.x
Kubo, K., Kanehisa, H., Fukunaga, T. (2005). Effects of cold
CRet improved blood circulation of the Achilles tendon and hot water immersion on the mechanical properties of
without causing tendon elongation. Therefore, CRet human muscle and tendon in vivo. Clin. Biomech. (Bristol,
may be recommended as a treatment for Achilles ten- Avon) 20:291–300. doi:10.1016/j.clinbiomech.2004.11.005
Kubo, K., Yajima, H., Takayama, M., Ikebukuro, T., et al.
don injuries.
(2010). Effects of acupuncture and heating on blood
volume and oxygen saturation of human Achilles tendon
in vivo. Eur. J. Appl. Physiol. 109:545–550. doi:10.1007/
Acknowledgments s00421-010-1368-z
The authors thank all the subjects who volunteered to participate Kumaran, B., Watson, T. (2015). Thermal build-up, decay
in the study and those who collaborated with data collection. and retention responses to local therapeutic application of
448 kHz capacitive resistive monopolar radiofrequency:
A prospective randomised crossover study in healthy
adults. Int. J. Hyperthermia 31:883–895. doi:10.3109/
Disclosure statement 02656736.2015.1092172
This study was not funded by the funder listed in Open Funder Lehmann, J. F., Masock, A. J., Warren, C. G., Koblanski, J. N.
Registry. We conducted this study together with INDIBA- (1979). Effect of therapeutic temperatures on tendon
JAPAN Co., Ltd. However the industry funder had no role extensibility. Arch. Phys. Med. Rehabil. 51:481–487.
in the study design, data collection and data analysis or in the Li, H. Y., Hua, Y. H. (2016). Achilles tendinopathy: Current
preparation of this manuscript. concepts about the basic science and clinical treatments.
Biomed. Res. Int. 2016:6492597. doi:10.1155/2016/
6492597
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