Guo Qing, Wang Hai-qin, Hua Yu, Ji Quan, Li Ying

Community Health Service Center, Huajing Township, Xuhui District, Shanghai, Shanghai 200231, China

Therapeutic Efficacy Observation on Combining Acupuncture, Tuina and Functional Exercise for Transverse Process Syndrome of the Third Lumbar Vertebra

Guo Qing, Wang Hai-qin, Hua Yu, Ji Quan, Li Ying

Community Health Service Center, Huajing Township, Xuhui District, Shanghai, Shanghai 200231, China

Objective: To observe the clinical effect of combining acupuncture, tuina and functional exercise for transverse process syndrome of the third lumbar vertebra.

Methods: A total of 90 cases were randomly allocated into an observation group and a medication group. The 48 cases in the observation group were treated with acupuncture, tuina and functional exercise, whereas the 42 cases in the medication group were treated with Ibuprofen sustained release capsules. Before and after treatment, the short-form McGill pain questionnaire (SF-MPQ) was employed to observe the changes in pain rating index (PRI), visual analogue scale (VAS) and present pain intensity (PPI). In addition, therapeutic efficacies were compared between two groups.

Results: The total effective rate in the observation group was 97.9%, versus 61.9% in the medication group, showing a statistical difference (P＜0.05). After treatment, there were statistical differences between the two groups in sensory PRI score, affective PRI score, total PRI score, VAS score and PPI score (P＜0.05); and there were also statistical differences between two groups in clinical sign scoring (P＜0.05). After 4 and 8 weeks of treatment, there was a statistical difference between the two groups in relapse rate (P＜0.05).

Conclusion: Combining acupuncture, tuina and functional exercise can obtain better effects and has a lower relapse rate than Ibuprofen sustained release capsules for transverse process syndrome of the third lumbar vertebra.

Low Back Pain; Acupuncture-moxibustion Therapy; Tuina; Massage; Exercise Therapy

Transverse process syndrome of the third lumbar vertebra often results from acute injury, strain and/or external contraction of wind, cold and dampness. It can manifest as aseptic inflammation, adhesion, degeneration and thickening of the transverse process. Clinically it is characterized by pain in the low back and buttock due to compression to the local spinal nerve. This condition most commonly affects young and middle-aged laborers and is seen more in men than women[1-3]. We’ve treated 48 cases with acupuncture, tuina and functional exercise over the past 4 years and compared with 42 cases treated with Ibuprofen sustained release capsules. The results are now summarized as follows.

1 Clinical Materials

1.1 Diagnostic criteria

This was made according to the diagnostic basis for transverse process syndrome of the third lumbar vertebra stipulated in theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[4]: Having a history of lumbar sprain, chronic strain or cold attacking the waist; young and middle aged laborers; low back pain on one side that can be aggravated by bending the waist, getting up in the morning and after sitting upright, and the pain can radiate down to the knee; tenderness of the transverse process of the third lumbar vertebra is positive and coupled with palpable hard ropy lump; and overgrowth, hypertrophy or left-right asymmetrical transverse process of the third lumbar vertebra confirmed by X-ray.

1.2 Inclusion criteria

Men and women in any age that met the above diagnostic criteria; and those who were willing to participate in this trial and signed the informed consent.

1.3 Exclusion criteria

Those with low back and leg pain due to hyperostosis, tumor or intervertebral disc disorder; having mental disorders or complications of life-endangering primary conditions such as cardio-cerebrovascular diseases and liver or kidney deficiency; women during pregnancy or lactation; and those receiving other therapies concurrently that may affect the efficacy evaluation.

1.4 Termination and rejection criteria

Those who failed to stick with the treatment; those who failed to follow the treatment protocol; and those who experienced severe complications or deterioration during the treatment.

1.5 General data

The 90 cases with transverse process syndrome of the third lumbar vertebra who met the inclusion criteria were all treated in Acupuncture and Tuina Departments of our hospital between June 2008 and June 2012. They were allocated into an observation group and a medication group by the random digits table. There were no statistical differences in gender, age and duration between two groups (P＞0.05), indicating that the two groups were comparable (table 1).

Table 1. Between-group comparison of general data

2 Treatment Methods

2.1 Observation group

2.1.1 Tuina

Local relaxation: After the patient took a prone position, the doctor stood on one side of the patient. First, applied 3-5 min of gentle Gun-Rolling, An-Pressing and Rou-Kneading manipulations to the surrounding area of the transverse process of the third lumbar vertebra. Concurrently, applied digital An-Pressing to Shenshu (BL 23) and Dachangshu (BL 25) until the patient felt soreness and distension. This aimed to relieve the muscle tension and spasm (Fig.1).

Fig.1 Gun-Rolling manipulation

Tanbo-Plucking, Cuo-Twisting and Rou-Kneading manipulation: Applied Tanbo-Plucking manipulation to the tip of the transverse process of the third lumbar vertebra perpendicular with the ropy lump (Fig. 2) using the thumbs. It is advisable to gradually increase the force to make it soft but penetrating. At the same time, combined Cuo-Twisting and Rou-Kneading to relieve spasm, alleviate pain and separate adhesion[5].

Fig.2 Tanbo-Plucking manipulation

Gun-Rolling and Rou-Kneading the affected lower limb: Applied 3-5 times of Gun-Rolling and Rou-Kneading to the buttock, posterior and lateral aspect of the thigh and lateral aspect of the lower leg. Concurrently, applied digital An-Pressing to Huantiao (GB 30), Zhibian (BL 54), Weizhong (BL 40) and Chengshan (BL 57) to relax sinews, circulate blood and resolve stasis.

Finishing manipulation: Applied 3-5 times of Gun-Rolling and Rou-Kneading to both sides of the Bladder Meridian to relax muscles. Then combined with passive extension of the low back and finally Ca-Rubbing both sides of the Bladder Meridian longitudinally and lumbosacral region transversely until a heat sensation was felt (Fig.3).

Fig.3 Ca-Rubbing manipulation

2.1.2 Acupuncture and moxibustion treatment

Acupuncture: Triple needling therapy[6]was adopted. After the patient took a prone position, the doctor stood on one side of the patient. Sterilized the local skin and found the transverse process of the third lumbar vertebra via digital pressure; then, inserted a filiform needle of 0.3 mm in diameter and 50-70 mm in length at 3-4 cm lateral to the spine, forming an angle of 80° between the needle body and skin. The first needle was inserted in the middle towards the apex of the transverse process, making the needle tip to touch the osseous tissue. Another two needles were then inserted 1 cm and 2 cm respectively away from the first needle. After arrival of qi, applied mountain-burning technique [9 times of fast pressing and slow lifting or rotating in either 3 layers (superficial, intermediate and deep) or 2 layers (superficial and deep)] to all three needles until the appearance of local warm-heat sensation.

Moxibustion: Upon the warm-heat sensation of the needles, inserted the needles to the deep layer. Placed a 3 cm-long moxa cone over the needle handles, ignited and replaced 3 times. Then withdrew the needles and closed the needle holes[7].

Both acupuncture and tuina were conducted once a day, 10 times constituted a course of treatment and the therapeutic effect was observed after two courses of treatment.

2.1.3 Functional exercise

Five- or three-point support: Took a supine position and used 5 points (both feet, both elbows and head ) or 3 points (both feet and head) to lift the waist, back, buttocks and lower limb out of the bed. Maintained the posture until the patient felt tired and then returned to a supine position (Fig.4 and Fig.5). Each exercise was repeated for approximately 10 min, once in the morning and once in the evening.

Fig.5 Three-point support

Swallow-flying in a prone position: Took a prone position and placed upper limbs behind the back; then, tried to lift the head, chest and legs out of the bed to make the body to form a reversed arc. Maintained the posture until the patient felt tired (Fig.6). Each exercise was repeated for approximately 10 min, once in the morning and once in the evening.

Fig.6 Swallow-flying in a prone position

Kouji-Tapping the waist and back: Sat upright and made a hollow fist with the left hand. Tapped the left-side waist from top to bottom for 10 min using the left fist; then, conducted 5-min massage or Cuo-Twisting and Rou-Kneading on the waist with the left palm (Fig.7). After this, repeated the same procedure using the right hand. This exercise wasconducted once in the morning and once in the evening.

Fig.7 Kouji-Tapping manipulation

2.2 Medication group

Patients in the medication group were treated with Ibuprofen sustained release capsules (manufactured by Sino-American Tianjin Smith Kline & French Laboratories Ltd.), 300 mg for each dose, 2 doses a day and 10 d constituted one course of treatment. The therapeutic effect was observed after 2 courses of treatment.

3 Therapeutic Effect Observation

3.1 Observation indexes

3.1.1 Scoring of clinical symptoms

The short-form McGill pain questionnaire (SF-MPQ) was used to evaluate the low back pain before and after treatment. This included scoring of pain rating index (PRI), visual analogue scale (VAS) and present pain intensity (PPI). Individual patients were asked to select an item that best reflects their pain and sign for confirmation. Then professional statistical analysts calculated the scores. Higher scores mean more severe pain.

3.1.2 Scoring of clinical signs

This was mainly based on clinical examination. Total scores were calculated according to the numbers of tenderness spots, tenderness-inducing intensity, activity of the low back and leg, localized skin temperature, skin color and swelling severity. The whole calculation process was conducted by professionals who were not involved in the clinical treatment and had been trained for fair and objective scoring before the study.

3.2 Therapeutic efficacy criteria

This was based on theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicinefor the transverse process syndrome of the third lumbar vertebra[4].

Recovery: Absence of low back pain coupled with functional recovery.

Improvement: Alleviation of low back pain coupled with recovery of basic activities; however soreness, pain or discomfort occurs after fatigue.

Failure: Limited activity and no substantial alleviation of low back pain.

3.3 Statistical method

After an Epidata entry, the SPSS 13.0 version software was used for statistical analysis, () for expression of measurement data andt-test for inter-group significance comparison. A statistical significance is indicated by the statementP＜0.05.

3.4 Treatment results

3.4.1 Comparison of clinical effects

The total effective rate in the observation group was 97.9%, versus 61.9% in the medication group, showing a statistical difference (P＜0.05) and indicating a better effect in the observation than that in the medication group (table 2).

Table 2. Between-group comparison of clinical effects (case)

3.4.2 Comparison of SF-MPQ scoring

Before treatment, there was no between-group statistical difference (P＞0.05) in SF-MPQ score. After treatment, SF-MPQ scores in both groups were reduced (P＜0.05); and the reduction in the observation group was more significant than that in the medication group (P＜0.05), indicating a better effect of pain alleviation in the observation group than that in the control group (table 3).

3.4.3 Comparison of clinical sign scoring

Before treatment, there was no between-group statistical difference (P＞0.05) in clinical sign scoring. After treatment, clinical sign scores in both groups were markedly reduced (P＜0.05); and there was statistical significance in before-after differences between the two groups (P＜0.05), indicating a better improvement in clinical sign in the observation group than that in the control group (table 4).

3.4.4. Between-group comparison of relapse rates

The follow-up of patients with effectiveness showed that the relapse rates after 4 and 8 weeks were 2.1% and 4.3% in the observation group respectively, versus 61.5% and 84.6% in the medication group, indicating a statistical difference (P＜0.05) and a lower relapse rate in the observation group (table 5).

Table 3. Between-group comparison of SF-MPQ scoring before and after treatment ()

Table 3. Between-group comparison of SF-MPQ scoring before and after treatment ()

Note: Compared with the intra-group result before treatment, 1)P＜0.05; compared with the medication group, 2)P＜0.05

GroupsnTime Sensory PRI score (point) Affective PRI score (point) Total PRI score (point) VAS score (cm) PPI score (point) Observation 48 Before treatment After treatment Medication 42 Before treatment After treatment 16.25±3.14 9.56±1.561)2)15.96±3.06 13.46±1.841)6.56±1.26 3.40±0.941)2)6.62±1.19 4.54±1.361)22.02±2.24 12.38±1.581)2)21.93±2.19 17.32±1.571)5.40±1.29 2.38±0.981)2)5.43±1.31 4.38±1.12 3.12±0.68 1.54±0.491)2)3.24±0.69 2.69±0.56

Table 4. Between-group comparison of clinical sign scoring before and after treatment (, point)

Table 4. Between-group comparison of clinical sign scoring before and after treatment (, point)

Note: Compared with the medication group, 1)P＜0.05

O b s e r v a t i o n 4 8 8 . 2 4 ± 1 . 4 5 3 . 1 5 ± 0 . 9 7 4 . 7 2 ± 1 . 3 41)M e d i c a t i o n 4 2 7 . 9 8 ± 1 . 6 9 5 . 2 0 ± 1 . 4 8 2 . 5 2 ± 0 . 7 6

Table 5. Between-group comparison of relapse rates in patients with effectiveness (case)

4 Discussion

The transverse process syndrome of the third lumbar vertebra falls under the category of low back pain and Bi-Impediment syndrome in traditional Chinese medicine. It mainly results from acute or chronic injury. Contributing factors may include psoas strain, obstructed flow of meridian qi and external contraction of wind, cold and dampness. These factors can lead to stagnation of qi and blood and subsequently pain. We treated this condition with acupuncture, tuina and functional exercise. Tuina manipulations can warm the kidney, dissipate cold, disperse yang-qi, circulate blood and resolve stasis. Directly exerted on local points, these manipulations help to dredge Bladder Meridian of Foot Taiyang and restore yang-qi to warm the psoas. The force from Tanbo-Plucking and An-Pressing manipulations can penetrate deep into the soft tissue, speeding up the blood circulation in the affected area and thus helping with the absorption of stagnant blood. Functional exercise can strengthen the waist and back muscles to prevent further progression of the lumbar injury and facilitate functional recovery. Triple needling therapy is particularly effective for Bi-Impediment pain in a small but deep area[8]. The mountain-burning fire technique coupled with warm needling moxibustion[9-10]can warm meridians, resolve dampness, dissipate cold and absorb stasis. Combined acupuncture, tuina and functional exercise can obtain a lower relapse rate and significantly better effect than Ibuprofen sustained release capsules alone. Consequently, it is an effective therapy for transverse process syndrome of the third lumbar vertebra.

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Translator: Han Chou-ping

R246.2

A

Date: June 15, 2013

Author: Quo Qing, attending physician.

E-mail: xintianw@163.com