1 Pain Management, the First Hospital of Hunan University of Chinese Medicine, Changsha 410007, China

2 Nanwan People’s Hospital of Longgang District, Shenzhen City, Shenzhen 518112, China

CLINICAL STUDY

Clinical Observation on Comprehensive Treatment on Cutaneous Region for Low Back Pain

Zhao Feng, Liu Shu-tian

1 Pain Management, the First Hospital of Hunan University of Chinese Medicine, Changsha 410007, China

2 Nanwan People’s Hospital of Longgang District, Shenzhen City, Shenzhen 518112, China

Author: Zhao Feng, master degree candidate, attending physician.

E-mail: zhaolefeng1977@163.com

Objective: To observe the clinical effects of comprehensive treatment on cutaneous region for low back pain.

Methods: One hundred and twenty outpatients with low back pain who met the diagnostic criteria were randomly divided into a cutaneous region group or a medication group, 60 cases in each group. The cases in the cutaneous region group were treated by Nie-pinching up the skin of the lumbosacral region, cupping and acupuncture. Those in the medication group were treated by oral administration of Celecoxib capsule. The visual analogue scale (VAS) and Oswestry disability index (ODI) were used to assess the therapeutic effects.

Results: After treatment, the VAS scores of both groups were different from those before treatment, showing statistical significances (allP＜0.01). The D-valuse of VAS scores of both groups were different from those before treatment, showing statistical significances (allP＜0.01). The D-value of OID scores in the cutaneous region group was significantly different from that in the medication group (P＜0.01). After treatment, the total effective rate was 91.7% in the cutaneous region group versus 76.7% in the medication group, there was a significant difference in comparing the clinical effect (P＜0.01).

Conclusion: Both comprehensive treatment on the cutaneous region and Celecoxib capsule can obviously relieve low back pain. But comprehensive treatment on the cutaneous region is better than Celecoxib capsule in the therapeutic effects.

Cutaneous Region; Cupping Therapy; Acupuncture Therapy; Tuina; Massage; Pinching Manipulation; Low Back Pain

Low back pain (LBP) refers to pain in the low back, lumbosacral region and buttocks[1]. To date, its etiology and pathogenesis are still unknown, which brings lots of difficulties for the treatment. The cutaneous region is a component part of the meridian system, and is the site on the body surface to reflect functional activities of the meridians, which is also where the meridian qi spreads[2]. Stimulation to the cutaneous region is a therapeutic method in which the cutaneous region is used as the operation site to process different stimulation for producing the therapeutic effects[3]. Stimulation to the cutaneous region is an external therapy for safe and effective treatment of low back pain. Under the circumstance of unknown pathogenesis, stimulation to the cutaneous region is a comparatively ideal option. We treated low back pain by stimulating the cutaneous region in comparison with the medication therapy, in order to explore the function of this therapy for low back pain. Now, the report is given as follows.

1 Clinical Materials

1.1 Diagnostic criteria[4]

Persistent pain between the twelfth rib and inferior gluteal sulcus at the back, accompanied or not accompanied by radiating pain on the posterior side of the thigh (not over the knee joint); chief complaints of tenderness and (or) muscular spasm in the painful area and above; in addition to the vertebral rotation of the lumbar vertebrae, stenosis, separation and asymmetry of the small joint clearance in X-ray film, no other positive findings in imaging examination, exclusion of low back pain induced by other system by experimental and imaging examinations.

1.2 Inclusion criteria

Those in conformity with the above diagnostic criteria of low back pain; at the age between 20 and 70 years old (including 20 and 70 years old), able to cooperate with the treatment actively; without application of other therapeutic methods or analgesic agents of traditional Chinese medicine and/or Western medicine at least two weeks before treatment; without severe functional disturbance of the internal organs; without drug allergy; nonpregnant and non-lactating women; without other severe diseases, such as cancer, cerebral stroke and mental disorder.

1.3 Exclusion criteria

Those not in conformity with the above diagnostic criteria; complicated with hepatic and renal diseases, blood diseases, tumors, and diseases in the circulatory system, cardio-cerebrovascular diseases, and diseases in the autoimmune system, with abnormal functions in the bladder and rectum; those with extreme weakness, unconsciousness and unable to explain the subjective discomfort symptoms; those with mental disorders.

1.4 Statistical analysis

Statistical analysis was processed by SPSS 10.0 version statistical software. The measurement data were expressed by using mean ± standard deviationThe comparison within the group was processed by pairedt-test, and the comparison between the two groups was processed by using independent samplet-test. The counting data were processed by Chi-square test and rank sum test.

1.5 General data

Totally 120 cases of low back pain were included from the Pain Physiotherapy Department in our hospital, from May of 2013 to September of 2013, without contraindication of physiotherapeutic treatment. The patients were divided into a cutaneous region group or a medication group by the random digits. By the statistical management of the gender, age, duration, and scores of visual analogous scale (VAS) and Oswestry disability index (ODI) of the patients in the two groups, the differences were not statistically significant, indicating that the two groups were comparable (Table 1).

Table 1. Comparison of general data between the two groups

2 Methods

2.1 Cutaneous region group

2.1.1 Nie-pinching up the skin

After the patient took a prone position and fully exposed the low back and sacral region, the doctor Nie-pinched up the skin to turn and move with the two hands, till the skin of the lumbosacral region became slightly red and warm, for about 3-5 min each time (Figure 1).

2.1.2 Flash cupping

After the manipulation of Nie-pinching up the skin, moderate-size cup was used for flash cupping on the lumbosacral region, without retaining the cup, for about 3-5 min each time.

Figure 1. Nie-pinching up the skin

2.1.3 Superficial acupuncture

Acupoint: Ashi points.

Operation: After the tenderness was detected on the lumbosacral region and routine disinfection, the filiform needles of 0.35 mm in diameter and 25 mm in length were used to puncture for 0.2-0.5 mm superficially, without the needling sensation. The needle was retained for 20 min.

The above treatment was given once every other day. Six sessions made one course (11 d).

2.2 Medication group

The patients in the medication group were treated by oral administration of Celecoxib capsule, 0.2 g each time, twice a day. If low back pain disappeared continuously for three days, medication was stopped. The longest duration was 12 d.

The patients in the two groups were told to have good rest and keep warm during the treatment.

3 Assessment of Therapeutic Effects

3.1 Indexes of assessment

3.1.1 VAS score

VAS scores ≤3 points stood for mild pain; 3-7 points for moderate pain, and ＞7 points for severe pain.

3.1.2 ODI score

Pain severity, activity of daily living (ADL) and general health states were assessed in all patients before and after the treatment. ODI included 10 parts totally. The first part was related to pain. The rest parts were related to the behavior of daily life. In every part, there were six questions of progressive levels, with the integral index from 0-5. The total maximum integral index was 50. The higher the integral index, the severer limitation of the ADL and social life.

3.2 Criteria of therapeutic effects

In accordance with the VAS score-reducing rate, the therapeutic effects were assessed.

VAS score-reducing rate＝(VAS score before treatment － VAS score after treatment) ÷ VAS score before treatment × 100%.

Remarkable effect: VAS score-reducing rate≥80%.

Improvement: VAS score-reducing rate ＞20%, but＜80%.

Failure: VAS score-reducing rate ≤20%.

3.3 Results

3.3.1 Comparison of VAS and ODI scores between the two groups

Before treatment, there were no statistical differences in VAS and ODI scores between the two groups. After treatment, there were statistical differences in VAS and ODI scores (P＜0.01), indicating that the two therapies were effective to LBP. There were statistically significant differences in the D-value of before and after treatment between the two groups (P＜0.01), indicating that the therapeutic effect was better in the cutaneous region group than that in the medication group (Table 2).

3.3.2 Comparison of therapeutic effect between the two groups

The total effective rate was 91.7% in the cutaneous region group and 76.7% in the medication group. The difference of the total effective rate between the two groups was statistically significant (P＜0.01), indicating that the therapeutic effect was better in the cutaneous region group than that in the medication group (Table 3).

Table 2. Comparison of VAS and ODI scores before and after treatment between two groups (point)

Table 2. Comparison of VAS and ODI scores before and after treatment between two groups (point)

Note: Compared with the same group before the treatment, 1) P＜0.01; compared with the medication group, 2) P＜0.01

Table 3. Comparison of therapeutic effect between the two groups (case)

4 Discussion

LBP refers to pain or discomfort in the lumbosacral region, not accompanied by radiating pain in the lower limb. It is a symptom or a syndrome, but not name a disease. Over 50% LBP of the initial attack can be spontaneously cured within 4-8 weeks, but the recurrent rate is as high as 85%[5]. In the whole life, people will be disturbed by LBP more or less. It can be relieved by rest in majority of the people, and only 25%-30% of the patients would seek medical treatment[6]. LBP is characterized by pain in the low back and leg as well as functional limitation, and long-term duration will lead to low working capacity and depression. Therefore, it is significant to explore the effective therapy for LBP. Because the etiology of this disease is unknown, there is no specific therapeutic method for its etiology. The anti-inflammatory and analgesic agents and various external therapies are commonly used. The adverse reactions from medications, such as disturbance of the gastrointestinal functions, are gradually acknowledged. Therefore, more and more LBP patients turn to acupuncture and tuina[7-9].

VAS and ODI scores are the domestic and international acknowledged methods to assess pain. VAS mainly focuses on pain level of self sensation. ODI is mainly to reflect the general health state[10-11].

The cutaneous region is situated in the outmost layer, a subsidiary part of the meridian system, linking with qi and blood of the meridians, it is also a defending barrier of the organism and plays a role in protecting the body, resisting the external pathogens and reflecting diseases and symptoms. By treating the cutaneous region, it can regulate the functions of Zang-fu organs and treat LBP. Celecoxib capsule used in this study is an anti-inflammatory agent commonly used to treat low back pain, to play an analgesic role by reducing the algogenic substance in the local pain. However, the stimulation to the cutaneous region can produce mechanical stimulation and warming effect to the skin, cause congestion in the local skin, promote the blood capillary expansion, strengthen the blood circulation, enhance metabolism and activity of tissue cells by traction, adhesion and acupuncture, and also can reflectively adjust the exciting and inhibitory process of the cerebral cortex, so as to generally enhance the tolerance of the body to pain, and additionally can also induce a series of nerve-endocrine reaction by stimulating the multiple system of the nerves, skin glands, and muscles[12-17], so as to enable the patients to increase their activity, excite their spirit, improve sleep and elevate their general functions.

From the theory on the cutaneous region, three types of commonly used skin-stimulating therapeutic methods of Nie-pinching up the skin, flash cupping and superficial acupuncture are selected in this study. The results showed that after treatment, VAS and ODI scores obviously decreased, and the reducing degree was more obvious in the cutaneous region group than in the medication group, indicating that stimulation to the cutaneous region has better therapeutic effect for LBP, better than Celecoxib capsule in analgesic effect, easy in operation, absent in adverse reaction, and needs to be popularized clinically.

Conflict of Interest

The authors declared that there was no conflict of interest in this article.

Acknowledgments

This work was supported by the Key Project of Scientific Research Plan of State Administration of Traditional Chinese Medicine of Hunan Province (No. 2010008).

Statement of Informed Consent

Informed consent was obtained from all individual participants included in this study.

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Translator: Huang Guo-qi

R246.2

: A

Date: February 10, 2014