Journal of Acupunctureand Tuina Science.2004, Vol.2, No. 2
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Non-operative Therapy for Prolapsed Lumbar Intervertebral Discs ZHANG Jia-fu(~ ~ ~ ), CHENWen-hua(1~~ ~) Department of Tuina, ShanghaiMunicipalFirst People's Hospital,Shanghai,China,200080 ~j--~-: !Q~ : ~ ' ~ - ~ - ~ ' ; - L - i ~ , ~ - f ~ / ~ . t ~ C ~ r . ~ ,
L~.~s
~ : : t ~ - 165 l'~,])~;f~l'~.t~
Abstract Objective: To analyze the short-term and long-term effects of non-operative therapy in the treatment of prolapsed lumbar intervertebral discs. Methods: One hundred and sixty-five subjects were randomized in single-blind method into traction group (A), Tuina group (B), and Tuina and exercise group (C); after 2 courses of treatment, the short-term effects were evaluated. Moreover, 102 cases with significant short-term effects were randomized in single-blind method into exercise group (D) and control group (E). The relapse rates in the two groups were survey one year after treatment; and the lumbar functions were assessed respectively six months and twelve months after treatment. Results: Groups B and C had obviously better effects than group A (~=8.359, P<0.01); the relapse rate after one year was strikingly lower in group D than group E (~=12.631, P<0.01). Conclusion: Tuina plus functional exercise is an effective method in the prevention and treatment of prolapsed lumbar intervertebral discs. Key Words Intervertebral disk Displacement; Tuina; Massage: Traction short-term effects of prolapsed lumbar intervertebral disc treated by non-operative therapy were studied, but little work has done to assess their long-term effects. This article aims to explore the effects of traction, massage, and massage plus functional exercise in the prevention and treatment of prolapsed lumbar intervertebral disc.
Clinical Data
ZHANG Jia-fu, junior consultant doctor, member of ShanghaiTuinaAcademy. With the change of life style, the occurrence of lower back and leg pain increases. Andersson l~] argued that 70%-80% people experienccd lumbago, 5%-10% people had to leave their work for more than 7 days. Most of the patients with prolapsed lumbar intervertcbral disc were well treated with non-operative therapies [2]. The
1. Diagnostic criteria According to Shanghai Diagnostic and Treatment Convention [br TCM Disease TM. 2. Including criteria a. Those with diagnostic criteria. b. Those scoring 0-23. The scoring table [4] of lumbar function was presented in table 1. c. Those between ages 20-60. d. Those did not receive any treatment. e. Those willing to participate in this study.
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Journal of Acupuncture and Tuina Science. 2004, Vo[. 2, No. 2
Table 1. Scoring table of lumbar function
Item Lumbago Subjective symptom (0-9 points)
Clinical sign (0-10 points) Daily movement (0-12 points)
Pain and/or nnmbness in lower limb Walking capacity Raising test of straight leg Scoliosis and tenderness Sensation Myodynamia Reflex Easy: 2 points; difficult: I point; extremely difficult: 0
Score No: 3 points: occasional and mild: 2 points; mild or occasionally serious: I point; severe: 0 No: 3 points; occasional and mild: 2 points; mild or occasionally serious: 1 point; severe: 0 Normal: 3 points: over 500 m: 2 points; within 500 m: I point; within 100 m: 0 Normal: 2 points; 30" -70 ~ : 1 point; <30 ~ : 0 No: 2 points; no bending bnt mild tenderness: I point; both: 0 Normal: 2 points; mild disturbance: I point; striking disturbance: 0 Grade V : 2 points; grade IV: 1 point; grade 0-111:0 Normal: 2 points; diminished: I point; disappearance: 0 Turning-over during sleep, standing, washing face, bending forward, I h-sitting, holding heavy objects
Note: The highest score is 31 4. Subject This study was done from October 2000 to October 2003. One hundred and sixty-five outpatients were randomized in single-blind method into traction group (Group A), Tuina group (Group B) and Tuina plus exercise group (Group C), 55 cases in each group (Table 2).
After first-stage treatment, o f the 165 cases, 102 cases got significant effects. These 102 cases were than randomized in single-blind method into exercise group (Group D) and control group (Group E), 51 cases in each group (Table 2), and the score o f lumbar function were 25.87+5.13 and 25.67+4.98 in Group D and Group E, respectively.
Table 2. The general data of the subject
Group
n
A B C D E
55 55 55 51 51
Sex............ A gc(Yem_)......................... D!.tr_9__ti_~.......................................................................Prolap__se.__ddi:s_c. . . . M 32 31 31 30 29
F 23 24 24 21 22
Range 20-60 20-60 20-60 20-60 20-60
Average 40.9+10.5 41.2+10.8 42.1+_10.5 39.4_+10.1 39.5-+10.2
Range Average(Month) 10d-15 y 6.8+2.3 7d-13 y 6.9+2.3 4d-12 y 6.8_+.2.4 7d-12y 6.7_+2.2 10 d-12 y 6.7-+2.2
Treatment Methods
1. G r o u p A Domestic TF-4 computerized traction bed was employed. The traction was performed when patients were on their back. The weight of traction began with half the body weight, and then gradually increased till it reached the body weight. The traction was given 20 minutes each time, once a day, and a total of 20 treatments were given. 2. Group B
Treatment principle was to relax tendon and unblock collaterals, activate blood and dissipate blood stasis, loosen adhesion, and remedy displacement. The treatment methods include waist rolling and posterior stretching manipulation, pressing and regulating manipulation, modified lumbar pulling manipulation,
L_,_3 I 2 I I I
L3q 2 2 I 1 I
L4-5 23 22 21 21 20
Ls -St 19 2(I 22 2(1 21
L4_sandL5-SI 10 9 10 8 8
prone posterior stretching manipulation, and forced leg raising manipulation. They were introduced as follows. Waist rolling and posterior stretching manipulation: The patient took a prone position, tile practitioner rolled his/her waist. When the muscles relaxed, the waist was passively made to stretch backwards. Pressing and regulating manipulation: The patient took a prone position, with a pad on the abdomen. The practitioner put one hand on the transverse process opposite the diseased vertebra, and the other hand on the transverse process of upper vertebra o f the diseased one, pressing to regulate the vertebra. Modified lumbar pulling manipulation: In general, the lumbar vcrtebrae were pulled bilaterally. Take the right-side pulling manipulation as an example: The patient took a side position, with the left leg upper and flexed at about 90 ~ right leg lower and straightened, and waist relaxing. The practitioner stood facing the patient, with the right-side elbow on the medial iliac crest and the
Journal of Acupuncture and Tuina Science. 2004, Vol. 2, No. 2
other hand on the shoulder. Move the waist in a small range in the same direction first, and then shake the waist in opposite direction. When the waist rotates to a certain degree, a "clicking" sound would be heard, which indicated the successful manipulation. If no "clicking" sound was heard, but the practitioner's finger felt the movement of the posterior joint, this also indicated the successful manipulation. Prone posterior stretching manipulation: The patient took a prone position, and the practitioner sat on thc patient's waist and lifted the patient's lcgs upward. Forced leg raising manipulation: The patient took a supine position, and the practitioner stood on the affected side, with his ribs against the patient's thigh. Meanwhile, the practitioner's one hand grasped the patient's heel and the other pulled the toes to raise the straightened leg. Balancing manipulation: The patient took a prone position, and the practitioner rolled the patient's waist, hip and leg to the heel. Afterwards, the patient took a side position, and the patient rolled acupoint Juliao (GB 29) and the lateral side of thigh. Finally, the patient took a supine position, and the practitioner rolled the anterior side of the thigh and leg and the back of the foot based on the individual condition. The treatment was given once a day, twenty minutes each treatment, and a total of twenty treatments were given. 3. Group C Besides above Tuina techniques, the patients in this group were instructed to do some functional exercises for the lumbar and abdominal muscles. They were prcsented as follows. Supine leg raising exercise: The patient took a supine position, with flexed hip joint and straightened knee joint, alternately lifting and dropping the legs eight times, and then lifting and dropping the legs eight times at the same time. Supine holding knee exercise: The patient took a supine position, with two knees flexed and separated, and holding and pulling the knees eight times towards the chest as near as possible. Throwing-out exercise: The patient took a supine position, relaxing the whole body, making lumbar vertebrae lie on bed as possible, lifting abdomen and hip, to make the pelvis backwards; or support the body with head, elbows and hips, throwing out the chest and abdomen; or support the body with head, elbows and
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hcels, throwing out the chest and abdomen as possible, five seconds each time and eight times each exercise. Sit-ups exercise: The patient took a supine position and place the knees near bed as possible as he can, lifting arms at 90 ~, do sit-ups eight times. Prone lifting leg exercise: The patient took a prone position, altcmately lifting and dropping the legs eight times, and then lifting and dropping the legs at the same times. Prone lifting head cxcrcise: The patient took a prone position, putting fingers together and placing them behind the nape, expanding the chest and lifting the head, eight times. Swallow-touching water exercise: The patient took a prone position, relaxing the whole body, making the abdomen lie on the bed, lifting the hands and legs at the same time; or alternately lifting the contralateral arms and lcgs, cight times. Side lifting leg exercise: The patient took a side position, straightening the upper leg and lifting it eight times; then he took the other side position and repeated the exercise eight times. After all the exercises were finished, took a supine position and relax the whole body, taking an abdominal breathing five minutes. The use of above eight exercises depended upon the individual conditions, three times a day. The exercise was done twenty to thirty minutes before sleeping. 4. Group D In this group, the patients were told to protect their waists and instructed to do lumbar and abdominal muscle cxercises. The methods were introduced in group C. 5. Group E The patients were told to protect their waists, and not instructed to do lumbar and abdominal exercises.
Therapeutic Outcomes 1. Criteria for therapeutic effects The therapeutic effects were assessed according to Shanghai Diagnostic and Treatment Convention for TCM Disease. [31 Cure: Pain of the waist and leg disappears; straightened leg raises above 70 ~ ; the patient can do normal work. hnprovelncnt: Pain of waist and leg is eased and the waist movement improves. Failure: Symptoms and signs improve little.
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Journal of Acupuncture and Tuina Science. 2004, Vol. 2, No. 2
4. T r e a t m e n t results 2. A s s e s s m e n t o f l u m b a r f u n c t i o n
The score of lumbar function was determined in the light of scoring table of lumbar function I31. Calculate the improvement rate to assess the therapeutic effects. Improvement rate is the number obtained from quotient that the score margin after treatment and before treatment was divided by the score margin normal score and score before treatment. Cure: Improvement rate ) 95%; Marked effect: Improvement rate >60%; Effectiveness: Improvement rate between 25% and 60%; Failure: Improvement rate: <25%. (1) Hort-term effects: The average score and number of treatment before and after treatment. (2) Long-term effects: The lumbar functions respectively six and twelve months after treatment. 3. Statistical m e t h o d s
All the data were statistically analyzed by SPSS 10. 0 software, t test for quantitative data, Chi square test for qualitative data. The data were expressed in x +_s, the test standard ct=0.05.
The severity of prolapsed lumbar intervertebral disc in groups A, B and C. See table 3. The scores of groups A, B and C before and after treatment. See table 4 The short-term effects in groups A, B and C see table 5. The long-term effects in groups D and E were presented in table 6. Table 3. Prolapsed lumbar intervertebral disc in groups A, B and C
Group
n
A B C
55 55 55
Severity Mild 20 12 12
Modemte 24 20 24
Seve~ I1 13 11
Table 4. Comparison of scores before and after treatment in groups A, B and C
Group A B C
(x :t:~-,point)
n Score beforet~atment 55 12.78• 55 12.75_+1.65 55 12.79_+1.67
Scoreaftertreatment 17.87_+7.51 u 25.71_+4.95 ~)2) 25.73• ~2)3)
Notes: I) in comparisonwith the scores before treatment, P<0.01; 2) in comparison with group A, P<0.01; 3) in comparison with group C, P>0.05.
Table 5. Comparison of short-term effects in groups A, B and C
Group A B C
n 55 55 55
Cure 12 19 20
Markedeffects 12 20 19
Effectiveness 19 II 12
Failure 12 5 4
Markedeffectiverate 43.6% 70.9% 70.9%
Times of treatment 20-+0 12.29_+3.5I I 1.09_+4.35
Table 6. Comparison of long-term effects in groups D and E (x +s, point)
Group D E
n 51 51
After treatment 25.67+4.98 25.87_+5.13
6 m after treatment 28.49_+5.51 22.13_+3.75
Table 5 showed that there was no difference in the marked effective rate of short-term effects between group B and group C, but there was a difference in the number of treatment between the two groups (t=2.424, P<0.05). However, the marked effective rates were obviously higher in groups B and C than in group A (;(2=8.359, P<0.01 ). Within one year, the relapse rate in group D was obviously lower than that in group E (X2= 12.631, P<0.01); but there was no difference in the relapse rate within six months between group D and group E (X-'=3.047, P>0.05); in group D, the scores of lumbar functions six
12 m after treatment 28.74_+5.37 19.21_+3.79
Relapse rate 7.8% 37.2%
months and twelve months after treatment were significantly higher than those instantly after treatment (t=2.712, 2.994, P<0.01). In group E, the scores of lumbar function 6 months and 12 months after treatment were obviously lower than those instantly after treatment, with great differences (t--4.203, 7.457, P<0.01); nevcrtheless, there was no difference in the score of lumbar function between six months and twelve months after treatment (,'=0.232, P>0.05). In group E, the scores 6 months and 12 months after treatment were significantly difference (t=-3.911, P<0.01). The scores 6 months and 12 months after treatment in group D were
Journal of Acupuncture and Tuina Science. 2004, Vol. 2, No. 2 significantly higher than that in group E (t:6.815, 10.355, P<0.01) Discussion Prolapsed lumbar intervertebral disc is a condition in which the external force breaks the fiber rings on the basis of degenerative lumbar intervertebral discs and the prolapsed nucleus pulposus compressing the nerve roots, leading to aseptic inflammation and ensuing symptoms and signs such as pain in the lower back and leg. The intrinsic cause of degenerative lumbar intervertebral disc is long-term improper body posture, and its direct cause is trauma or fatigue, while its predisposing cause is cold invasion and sneezing, etc. Majorities o f patients with prolapsed lumbar intervertebral disc could be treated with non-operative therapy, but its recurrence rate was higher I-~l. It is now imperative to decide upon how to choose the non-operative therapy and how to reduce its relapse rate. In this study, the patients were randomly assigned in single-blind method into group A, group B and group C, and the short-tema effects and long-term effects in these three groups were observed. Comparison of the short-term effects in .these three groups showed that Tuina plus functional exercise had better effects than simple either Tuina or functional exercise whether in the marked effective rate or in the average number of treatment. Tuina treatment can promote the local blood circulation, dilate capillary vessels, quicken micro-venous return, accelerate the absorption of inflammatory agents, correct small joint displacement, remove the compression of prolapsed nucleus pulposus on nerve roots. Meanwhile, Tuina can also stimulate brain stem or pituitary through sensory nerves Io release endorphin, which can act on the opium receptors of the second and third glial layers of posterior angles of spine, regulate the harmful afferent impulses of C nerve fibers, as a result to ease pain. Moreover, the functional exercise plays a vital role in stabilizing spine colunm and balancing lumbar vertebraeI5I. In the protection of waist, people are become more and more aware of the correct posture of the body. Improper posture disturbs the balance o f muscle and skeletal systems. Long-term improper posture can gradually increase the muscle movement, eventually decrease the blood flow supply to the muscles, leading to
9 37 9 insufficiency of blood and oxygen in the local muscles and further accumulation of inflammatory products, giving rise to inflammatory reactions. Joints and tendons can stabilize the erect spine, but the body weight or asymmetric loading easily displace the spinal vertebrae. Functional exercise has a significant preventing function in reducing the relapse rate of prolapsed discs. The relapse rate one year after treatment was obviously lower in group D than in group E. There was no striking difference in the score of lumbar function in group D and group E immediately after treatment, but six months and twelve months after treatment, the score in group D increased evidently, suggesting that functional exercise can not only prevent the relapse of lumbar prolapse, but also improve the lumbar functions. In group E, the score of lumbar function six months and twelve months after treatment obviously decreased in comparison with those immediately after treatment, indicating that if the patients with prolapsed lumbar intervertebral disc do not do some functional exercises to stabilize spine column and balance lumbar vertebrae, the lumbar function may decline and the prolapse may relapse more. References
&g~ K, 2002, 6( 14): 2034. t|E Cheng-qi, DING Ming-fu. Rehabilitative Treatment of Non-specific Lumbago. Journal of Chinese Clinical rehabilitation, 2002, 6( 14): 2034. [2]Hsieh CY, Adams AH, Tobis J, et al. Effectiveness of four Conservative Treatments for Subacute Low Back Pain. Spine 2002, 27(I I): 1142-1149. ~ th r162 1998:274. Shanghai Municipal Health Bureau. Shanghai Diagnostic and Treatment Convention for TCM Disease. Shanghai: Publishing house of Shanghai University of Traditional Chinese Medicine, 1998: 274. [4].@,.fft.l~. ~'Pfg--:~)]~;ffi-Jh~g-b~..~7~-;L-. Bb[~.~fiJ. [F,.~,-~,,~., 1998, 13(5): 214-215. YU Wei-hao. Introduction to a Method of Lumbar Function Assessment. Journal of Chinese Rehabilitation medicine, 1998, 13(5): 214-215. 2003, 23(5): 303-307. HUANG Qiang-min, Alva. A., AIf. T. Electric Activityof Back and Abdominal Muscles When Trunk Laterally Bending and its Physiological Effects on Stabilizing Spine Column. All-China Journal of Orthopaedics, 2003, 23(5): 303-3079 Translator: XIAO Yuan-chun ( '~i~ )