Liu Zhen-huan, Cen Li-ting

Nanhai Maternity and Children’s Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine

Effect of Tuina on Neurodevelopment in Premature Infants with Brain Injury

Liu Zhen-huan, Cen Li-ting

Nanhai Maternity and Children’s Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine

Objective: To investigate the effect of tuina on promoting neurodevelopment of premature infants with brain injury.

Methods: A total of 82 cases who met the inclusion criteria were randomized into an intervention group and a control group. In addition to early conventional intervention (Chinese medicinal bath therapy and physical training), specific tuina manipulations (aims to unblock the Governor Vessel, refresh the brain, benefit the kidney and strengthen the spleen) were combined in the intervention group, whereas comforting touch in the control group. The rehabilitation assessments were then made prior to treatment and three months after the treatment using Gross Motor Function Measure (GMFM), Bayley Scales of Infant Development-Ⅱ(BSID-Ⅱ) and Gesell Developmental Schedules (GDS) based Developmental Quotient (DQ).

Results: The DQ in all GDS areas and scores of GMFM A and B dimensions were significantly increased in both groups after the treatment (P＜0.01). The DQ and population mean of GMFM B dimension in the intervention group were higher than those in the control group, showing statistical differences (P＜0.05). However, in terms of Mental Development Index (MDI) and Physical Development Index (PDI) in both groups, there were no statistical differences before and after treatments.

Conclusion: Both methods combined with conventional early intervention can help to improve the mental and motor development of infants with brain injury. However, the specific tuina manipulations have been proved more effective in improving the infants’ gross motor function, particularly the “sitting” item.

Brain Injury; Tuina; Massage; Premature Birth

Thanks to the dramatic advance in maternity and ICU technology for neonates, more and more premature infants now survive. However, an increased incidence in brain injury among these infants becomes a growing problem. Based on the research findings, premature infants with brain injury often suffer from neurodevelopmental sequelae, causing disabilities in varying degrees in 10.0%-20.0% of the premature birth survivors[1]. Actually, as the leading risk factor of cerebral palsy, premature birth (infants) accounts for 40.4% of the total cerebral palsy cases[2]. The survey in 30 000 children aged from 1 to 6 years old in seven provinces in 1997 showed that 29.1% of premature infants developed cerebral palsy, which was 25.2 times of the term infant[3]. As a result, early diagnoses of brain injury in premature infants and active interventions have great significance to reduce the rate of disability and benefit their prognosis.

1 Clinical Data

1.1 Diagnostic criteria

The diagnosis of brain injury in premature infants is based on thePractical Pediatrics[4]and relevant literature[5].

Infants with a gestational age ≤37 weeks; at least one of the following neuroimaging biomarkers: periventricular hemorrhage-intraventricular hemorrhage (PVHIVH), periventricular leukomalacia (PVL), intraparenchymal infarction/hemorrhage, and intraparenchymal edema and/or cytotoxic brain edema; simultaneously, Resistance Index (RI) ＞0.75 or ＜0.55 by cranial Doppler ultrasound can help to confirm the diagnosis; presence of neurological deficits; and exclusion of brain injuries due to infection, electrolyte disturbances and congenital metabolic diseases.

1.2 Inclusion criteria

Those who met the above criteria; corrected gestational age of 3-6 months; absence of major conditions involving liver, kidney, heart, hematopoietic and endocrine system; exclusion of congenital anomalies such as inherited metabolic diseases and developmental malformation of the brain; the infants’guardians willing to sign the informed consent forms.

1.3 Exclusion criteria

Those who failed to meet the diagnostic or inclusion criteria; refused to participate in the trial, unwilling to cooperate or making follow-up impossible; presence of severe complications; presence of serious skin lesion; those who were receiving acupuncture or medication treatment.

1.4 Random method

According to the simple random method in theClinical Study Methodology on Integrative Chinese and WesternMedicine, referred to the random digits table to generate random numbers and then arrange these numbers in sequence. Subjects with a number whose last digit was odd were allocated into the intervention group, whereas those with a number whose last digit was even or “0” into the control group. Then filled in the random allocation sheets and placed these sheets into opaque envelopes. Subjects who met the inclusion criteria were asked to open the corresponding envelop and follow the instructions on the sheet.

1.5 Statistical treatment

The SPSS 16.0 version software was used for statistical analysis, a descriptive analysis for general material distribution, mean and absolute frequency of research subjects, Chi-square test for grouped data and numeration data comparison andt-test for the measurement data.

1.6 General material

A total of 82 infants (41 in each group) were recruited from the Departments of Pediatric Neurological Rehabilitation, Neonates and Child Care, Nanhai Maternity and Children’s Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine between December 2010 and December 2011.

As shown in table 1, there were no statistical differences in gender, months after birth and gestational age between the two groups (P＞0.05). Before intervention, there were no statistical differencs (P＞0.05) in Developmental Quotients (DQs) in all Gesell Developmental Schedules (GDS) areas, scores of Gross Motor Function Measure (GMFM) A and B dimensions and Mental Development Index (MDI)/ Physical Development Index (PDI) distributions, indicating that the two groups are comparable.

The clinical procedures in the two groups are illustrated in Fig.1.

Table 1. Inter-group comparison of general material ()

Table 1. Inter-group comparison of general material ()

GroupsnGender (case) BoysGirls Age (month) Gestation age (week) Intervention 4120 21 3.26±1.04 34.34±2.36 Control 4126 15 3.34±1.15 33.41±2.84

Fig.1 Flow chart of clinical procedures in the two groups

2 Treatment Methods

2.1 Intervention group

2.1.1 Tuina

Tui-Pushing the Governor Vessel: Tui-Push the Governor Vessel 5-7 times, starting from Changqiang (GV 1). An-Press and Rou-Knead Changqiang (GV 1),Yaoshu (GV 2), Yaoyangguan (GV 3), Mingmen (GV 4), Xuanshu (GV 5), Jizhong (GV 6), Zhongshu (GV 7), Jinsuo (GV 8), Zhiyang (GV 9), Lingtai (GV 10), Shendao (GV 11), Shenzhu (GV 12), Taodao (GV 13), Dazhui (GV 14), Fengfu (GV 16) and Baihui (GV 20), (Fig.2).

Fig.2 Tui-Pushing the Governor Vessel

Digital An-Pressing acupoints: Apply digital An-Pressing to Shenting (GV 24), Benshen (GB 13), Baihui (GV 20), Sishencong (EX-HN 1) and Yamen (GV 15), 5-10 times for each acupoint (Fig.3).

Fig.3 Digital An-Pressing the acupoints on the head

Nie-Pinching the spine: Lift and pinch the skin along the spine (Governor Vessel) and bilateral lines of the Bladder Meridian, repeat 3-5 times (Fig.4).

Bu-Reinforcing Shenjing: Tui-Push the pad of the little finger in straight motion (eccentric) with the doctor’s thumb for 50-100 times (Fig.5).

Bu-Reinforcing Pijing: Rou-Knead the pad of the thumb in a circular motion with doctor’s thumb for 50-100 times (Fig.6).

Bu-Reinforcing Weijing: Rou-Knead the proximal knuckle of the thumb in a circular motion with doctor’s thumb for 50-100 times (Fig.7).

Rou-Kneading Zusanli (ST 36): Rou-Knead Zusanli (ST 36) on both sides, 50-100 times for each side (Fig.8).

Fig.4 Nie-Pinching the spine

Fig.5 Bu-Reinforcing Shenjing

Fig.6 Bu-Reinforcing Pijing

Rou-Kneading Yongquan (KI 1): Rou-Knead Yongquan (KI 1) on both sides, 50-100 times for each side (Fig.9).

The above tuina therapy was conducted once every day, 25-40 min for each treatment; 30–day treatments made up a course.

2.1.2 Chinese medicinal bath (hydrotherapy)

Decoct 30 g ofNiu Xi(Radix Achyranthis Bidentatae), 40 g ofChi Shao(Radix Paeoniae Rubra), 30 g ofSang Zhi(Ramulus Mori), 60 g ofShen Jin Cao(Herba Lycopodii) and 60 g ofTou Gu Cao(Caulis Impatientis) into 3 000-6 000 mL of medicinal bathcream. Place the cream into the hydrotherapy pool (water temperature: 36℃-38℃). Then slowly put the infants (with life jacket) into the water, allowing the infants to move 10-15 min in water. This was conducted once every day.

Fig.7 Bu-Reinforcing Weijing

Fig.8 Rou-Kneading Zusanli (ST 36)

Fig. 9 Rou-Kneading Yongquan (KI 1)

2.1.3 Physical training (PT)

Bobath handling technique was mainly used to improve normal motor sense and pattern through reflex inhibition of abnormal posture and movement.

Inhibition and reflex inhibition are the processes of intervention that reduce dysfunctional muscle tone and break up abnormal excessive spasm.

Facilitation is a key technique to improve the normal patterns of posture and movement, break up abnormal signals, intensify normal signals and thus make the normal movement possible.

Tactile stimulation (e.g., tapping) is compression or weight-bearing/resistance exercise to increase muscle tone and inhibit involuntary movements.

The above training and exercise were conducted 20-40 min each time, 1-2 times a day.

2.2 Control group

2.2.1 Infant massage (touch)

The infant massage (touch) methods are based on the Johnson & Johnson Guide to Infant Touch approved and recommended by the Chinese Nursing Association.

Face: First apply a small amount of mild baby oil or cream. Starting from the center of the forehead, push out to the sides using doctor’s thumbs, making a smiling shape. Repeat this on the eyebrow, eye socket, philtrum and chin.

Chest: Place hands over the baby’s costal margins, move doctor’s right hand up to the baby’s right shoulder and then return to the normal position. Repeat this with doctor’s left hand.

Hands: First drop the baby’s hands. Grasp the baby’s arm with one hand; gently squeeze the upper arm down to the wrist with the other hand. Then massage the wrist. Repeat this on the other hand. Hold the baby’s arm with doctor’s hands, making up-down twisting. Then slightly rub wrist and hand (from the palm to fingers) using doctor’s thumb.

Tummy: Massage the baby’s belly in a clockwise direction. Massage the belly from doctor’s left to right using doctor’s finger tip (it is possible that you may feel air bubble moving beneath doctor’s fingers). Try the “I LOVE YOU” experience, that is making a single downward stroke “I” with doctor’s right hand on baby’s left belly (doctor’s right), then making an upside down“L” going from doctor’s left to right and finally making an rainbow shape (an upside-down “U”) going from the doctor’s left to right. At the same time, tell the baby “I LOVE YOU” to pass the doctor’s love and care.

Leg: Massage the baby’s thigh, knee, and lower leg. Gently squeeze from the thigh to the ankles. Then massage the ankles and feet. After this, hold the baby’s lower leg, making an up-down paddling and rubbing the ankle and sole. Massage from the heel to the toes using doctor’s thumb (but make sure not to harm the ankle).

Back: First place hands over the baby’s back. Massage from the neck down to muscles bilaterally along the spine using the finger tips. Repeat this from the neck to the lower part of the spine.

The above touch was conducted once every day, 25-40 min each time and 30-day treatments make up a course.

2.2.2 Chinese medicinal bath

This is the same as in the intervention group.

2.2.3 PT

This is the same as in the intervention group.

Infants in both groups were treated successively for 30 d (a course of treatment). This trial consisted of 3 courses of treatment.

3 Outcomes and Analysis

3.1 Observation indexes

Rehabilitation assessment was performed on infants in two groups before and after treatments. They included Gross Motor Function Measure (GMFM), Bayley Scales of Infant Development-Ⅱ (BSID-Ⅱ) and Developmental Quotient (DQ) according to Gesell Developmental Schedules (GDS).

3.2 Research findings

3.2.1 Comparison of after-treatment DQ between the two groups

After an early intervention, the DQ in all GDS areas in both groups were significantly improved (P＜0.01). Except for a statistical significance in DQ in GMFM motor area between two groups (P＜0.05), there were no statistical differences in DQ in the other four areas between the two groups (table 2).

3.2.2. Comparison of infants’ after-treatment gross motor function between the two groups

After an early intervention, the scores of A and B GMFM dimensions in both groups were significantly increased (P＜0.01). The score of B GMFM dimension in the intervention group was significantly higher than that in the control group (P＜0.05). There was no statistical difference in the A dimension score between the two groups (table 3).

Table 2．Comparison of DQ in all GDS areas before and after treatment in two groups ()

Table 2．Comparison of DQ in all GDS areas before and after treatment in two groups ()

Note: Compared with the before-treatment result of the same group, 1)P＜0.01; compared with the after-treatment result of the control group, 2)P＜0.05

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Table 3. Comparison of all GMFM dimensions before and after treatment between the two groups (, point)

Table 3. Comparison of all GMFM dimensions before and after treatment between the two groups (, point)

Note: Compared with the before-treatment result of the same group, 1)P＜0.01; compared with the after-treatment result of the control group, 2)P＜0.05

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3.2.3 Comparison of infants’ MDI and PDI after treatment

After treatment, the MDI and PDI in the intervention group were higher than those of the control group, but the inter-group differences were not statistically significant (table 4).

Table 4. Comparison of after-treatment MDI and PDI between the two groups (case)

4 Discussion

In Chinese medicine, the brain injury in premature infants falls under the category of “fetal timidity” or“fetal weakness”. It is closely associated with the intra-uterine growth and development. The brain, spleen and kidney are mainly involved in this condition. The pathomechanism can be explained as deficiency of the kidney (essence and yang) and spleen (qi) leading to malnourishment of the brain. The treatment principles are therefore to refresh the brain and strengthen the spleen. The specific tuina manipulations in this paper aim to fortify the Governor Vessel (also known as the“sea of yang meridians”) and supplement yang by Tui-Pushing and Nie-Pinching the spine, thusrefreshing the brain (also known as sea of marrow). This, coupled with Bu-Reinforcing Pijing, Weijing, Shenjing, Rou-Kneading Zusanli (ST 36) and Yongquan (KI 1), can tonify the congenital base (kidney) and strengthen the acquired base (spleen) and benefit musculoskeletal system.

Research findings have shown that in addition to conventional intervention, both methods can improve the mental and physical development of premature infants. However, specific tuina manipulations can obtain better effect in improving the gross motor function, particularly the sitting posture. There were no statistical differences in terms of fine movement, language and mental development. This indicated that specific tuina manipulations could improve the sitting function in a short period of time; but, there were no statistical differences in holding the head up and rolling when compared with infant massage (touch). An ability to sit up depends on spinal extension, spinal extending to the L3level, and a fully mature head-control capability[6]. It is evident that spinal extension is a key to sitting position. The specific tuina manipulations on the Governor Vessel and the Bladder, Spleen and Kidney Meridians can improve the circulation of qi and blood on the back. In addition, lifting and pinching the corresponding Back-Shu points of the Zang-fu organs can stimulate and regulate the internal organs[7-8]. Digital An-Pressing the points on the head can refresh the brain and benefit mental development[9-10]. Infant massage (touch), on the other hand, is a process of applying mild gentle massage to the entire body skin. As a result, it was as not good as specific tuina manipulations in promoting the gross motor development, especially the sitting ability.

Since language in children often develops after 9 months and prospers at 2-3 years old, this trial does not show significant effect on language development. The fine movements are mainly linked to the flexibility of hands, especially the thumb and index finger. There is no special massage on the fingers and tendons in both methods. Massage on both hands should therefore be included in future early intervention study, particularly in study on pediatric tuina. This can promote the fine movement development and also regulate the infants’constitution.

This clinical trial has proven that in addition to conventional intervention, both specific tuina manipulations and infant massage can promote the infants’ mental and physical developments; the former shows a better effect in improving the premature infants’ gross motor function and sitting posture. The two methods share a similar effect on infants’ mental, language and fine movement development.

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Translator: Han Chou-ping

Received Date: September 20, 2012

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the specific tuina manipulations, Chinese medicinal bath and physical trainings.

Author: Liu Zhen-huan, M.D., professor, chief physician and doctorial supervisor

E-mail: lzh1958424@163.com