Department of Acupuncture, Tuina and Traumatology, Shanghai No.6 People’s Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China

CLINICAL STUDY

Clinical Study on Treatment of Cervical Spondylotic Radiculopathy by Electroacupuncture plus Tuina

Zhu Wei-min, Wu Yao-chi, Zhang Jun-feng, Li Shi-sheng

Department of Acupuncture, Tuina and Traumatology, Shanghai No.6 People’s Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China

Author: Zhu Wei-min, bachelor, associate chief physician

Objective: To observe the clinical effects of electroacupuncture (EA)plus tuina for cervical spondylotic radiculopathy.

Methods: One hundred and twenty cases with cervical spondylotic radiculopathy were divided randomly by the digital table into the observation group and control group. The patients in an observation group were treated by EA plus tuina techniques. The patients in the control group were treated by simple tuina techniques.

Results: The total effective rate was 91.7% in the observation group and 78.3% in the control group. The effective rates in the two groups were statistically different (P＜0.05).

Conclusion: EA plus tuina therapy is better than simple tuina therapy in the treatment of cervical spondylotic radiculopathy.

Acupuncture Therapy; Electroacupuncture; Tuina; Massage; Spondylosis; Neck Pain; Radiculopathy

Cervical spondylosis refers to the corresponding symptoms and signs induced by involvement of the adjacent tissues (nerve root, spinal cord, vertebral artery, sympathetic nerve) due to degenerative change of the cervical intervertebral disc and its secondary degenerative change of the intervertebral joints. According to investigation, the incidence rate is about 10% in the population over 30 years old, about 25% in the population over 40-50 years old, and over 50% in the population over 50-70 years old. Due to the change of life styles in recent years, the incidence age of this disease tends to be younger[1]. Cervical spondylotic radiculopathy is a most common type in cervical spondylosis, accounting for 50%-70% of patients with cervical spondylosis[2]. Acupuncture and tuina therapy are commonly used conservative therapies for cervical spondylotic radiculopathy and is also affirmative in therapeutic effects. In this study, clinical effects of electroacupuncture (EA) plus tuina treatment for cervical spondylotic radiculopathy were observed.

1 Clinical Materials

1.1 Diagnostic criteria

The diagnosis was processed in reference to theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[3]and the criteria of diagnosis and classification of the cervical spondylopsis, established at the Second Seminar on Cervical Spondylopsis in 1992[4], neck pain accompanied by radiating pain in the upper limbs as themain symptoms; aggravated pain in backward extension of the neck; decreased sensation at the skin segment distribution of the compressed nerve root, abnormal tendon reflexes, muscular atrophy, muscular weakness, limited neck mobility; positive in the brachial plexus traction test and vertex-knocking text; vertebral bone hyperplasia, obvious hyperplasia of Luschka joints, narrowing of the intervertebal space, and diminishing of the intervertebral foramen indicated by cervical X-ray examination; bulge or protrusion of the intervertebral disc, postvertebral neoplasm and narrowing of nerve root canal seen in CT or MRI.

1.2 Inclusion criteria

Those in conformity with the above diagnostic criteria; at the age of 20-60 years old; clear consciousness, able to cope with the collection of clinical data; voluntarily joined the clinical trial, and signed informed consent was included.

1.3 Exclusion criteria

Those with other types of cervical spondylopsis; those with indications for surgery; those without clinical symptoms of cervical spondylopsis and only abnormality in image findings; those with pain in the upper limb mainly caused by non-cervical lesions (thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome, cubital tunnel syndrome, frozen shoulder, myotenositis of biceps tendon, etc); those with bone tuberculosis, osteoporosis and vertebral fusion indicated by X-ray; those with pregnancy or complicated with other serious diseases; those with mental disorders; those unable to follow this observation; and those unable to be judged in the therapeutic effects and with incomplete information.

1.4 Statistical methods

All data were processed by using the SPSS 18.0 software. The comparison of the rates was processed by Chi-square test. The accounting data were expressed as mean ± standard deviationPairedt-test was used for intra-group comparison. The comparison between the groups was analyzed byt-test.P＜0.05 indicated a statistically significant difference.

1.5 General data

One hundred and twenty cases with cervical spondylotic radiculopathy, hospitalized between February of 2011 and April of 2013 in our hospital, were selected and divided randomly into two groups by the random digital table. There were 60 cases in the observation group, including 36 males and 24 females, with the age from 22 to 60 years old, at the average age of (46.80±5.74) years old, and the duration from 1 d to 15 years, at the average duration of (18.40±2.61) months. There were 60 cases in the control group, including 34 males and 26 females, with the age from 23 to 60 years old, at the average age of (48.00±5.85) years old, and the duration from 1 d to 18 years, at the average duration of (19.70±2.74) months. By statistical management, the differences of gender, age and duration between the two groups were not statistically significant (P＞0.05), and the two groups were comparable.

2 Therapeutic Methods

2.1 Observation group

2.1.1 EA treatment

Major points: Dazhui (GV 14), Dazhu (BL 11), cervical Jiaji (EX-B 2) points and Houxi (SI 3).

Adjunct points: Hegu (LI 4) was added for wind, cold and damp pattern; Geshu (BL 17) for pattern of qi stagnation and blood deficiency; Fenglong (ST 40) for pattern of obstruction of collaterals by phlegm and dampness; Sanyinjiao (SP 6) for pattern of insufficiency of the liver and kidney; Zusanli (ST 36) for pattern of deficiency of qi and blood.

Operation: The points were located according to theNomenclature and Location of Acupuncture Points[5]. First, after the skin of the acupoints was cleaned routinely with 75% alcohol cotton ball, the disposable stainless filiform needles of 0.30 mm in diameter and 25-40 mm in length were selected and inserted for 0.5-1.2 cun according to the anatomy of the acupoints. After the arrival of the needling sensation, the needles were twisted for 2 min by even reinforcing-reducing technique and the patients were demanded to have a numb sensation in the local area. In puncturing Houxi (SI 3), the needle was penetrated toward Hegu (LI 4). Then, Dazhui (GV 14) and Dazhu (BL 11) as one group and cervical Jiaji (EX-B 2) points as another group were connected with G6805-II EA apparatus for continuous 20 min, with continuous wave, 40 Hz frequency and 2 mA current intensity.

2.1.2 Tuina treatment

Tuina treatment was given by the therapeutic principles and methods for cervical spondylotic radiculopathy[6-7].

The soft tissues were relaxed by An-pressing and Rou-kneading, Na-grasping and Rou-kneading, and Gun-rolling manipulations. The patient took a sitting position and the practitioner stood behind the patient’s side. First, the neck muscles and area lateral to the spinuous processes were Rou-kneaded (Figure 1), then the muscles of the neck and shoulder were Na-grasped and Rou-kneaded (Figure 2), and then the muscles of the neck and back were Gun-rolled and Rou-kneaded (Figure 3). Finally, tender spots of the spinuous processes were An-pressed and Tanbo-plucked. The relaxing method lasted for 10-12 min.

Figure 1. An-pressing and Rou-kneading

Figure 2. Na-grasping and Rou-kneading

Figure 3. Gun-rolling and Rou-kneading

The Duanti-lifting method in an upright sitting position: After the patient took an upright sitting position, the practitioner held the patient’s jaw by the two sides or occipital part and jaw with the two hands respectively, to pull upward forcefully or bend forward and extend backward, with the two thumbs pressing on Fengchi (GB 20) continuously for about 5 min (Figure 4).

The rotating reduction at fixed points in a sitting position: After the patient took an upright sitting position, the practitioner stood behind the patient, and located the position of the deviated spinuous process with the thumb, and then pulled the patient’s head and chest close to the chest of the practitioner. Then the practitioner pressed and held up against the right side of the deviated spinuous process with the thumb of the left hand, with the rest four fingers adhered to the left side of the neck, and asked the patient to bend the neck forward. The practitioner flexed the right elbow joint and held the patient’s jaw with the forearm and elbow fossa, and guided the patient to rotate the neck toward the sick side while giving a vertically pulling and extending force on the patient’s neck. When the muscles of the patient’s neck were relaxed, under the coordination of the practitioner’s manual operation, the practitioner first lifted and upheld the hand holding the patient’s jaw, and suddenly increased the rotation amplitude of the neck, with the thumb of the left hand pushing the articular process upward and outward for immediate reduction (Figure 5).

Figure 4. Tuanti-lifting method

Figure 5. Rotating reduction at fixed points

EA and tuina treatments were given once every day. Ten sessions made one course. Five-day rest was given between two courses. After two courses, the therapeutic effects were observed.

2.2 Control group

The patients in the control group were only given the same tuina treatments as those in the observation group. Tuina manipulations and courses were as same as those in the observation group.

3 Observation of Therapeutic Effects

3.1 Observed indexes

The changes of the integral in the symptoms and signs after the treatment were observed. The detailed integral criteria were as follows.

3.1.1 Pain of the neck and shoulder

0 point: No pain.

1-3 points: Mild pain, still able to do normal activity.

4-6 points: Moderate pain, unable to work, but able to manage the daily living.

7-9 points: Severe pain, unable to manage the daily living.

10 points: Serious and intolerable pain.

3.1.2 Neck tenderness

0 point: No pain.

3 points: Mild tenderness, painful sensation by pressure.

6 points: Moderate tenderness, painful sensation by pressure, accompanied by suffering expression (frowning, etc.)

9 points: Severe tenderness, painful sensation by pressure, accompanied by withdrawal of the joint (dodging away).

3.1.3 Numbness of the upper limb

0 point: No numbness.

1 point: Occasional numbness, quickly relieved.

2 points: Intermittent numbness, mostly appeared during the sleep or in the morning, able to be relieved.

3 points: Continuous numb sensation, unable to be relieved.

3.1.4 Cervical activity

0 point: Lateral flexion, forward flexion and backward bending of the neck ≥40°, lateral rotation of the neck ≥75°.

1 point: Lateral flexion, forward flexion and backward bending of the neck 30°-39°, lateral rotation of the neck 60°-74°.

2 points: Lateral flexion, forward flexion and backward bending of the neck 20°-29°, lateral rotation of the neck 45°-59°.

3 points: Lateral flexion, forward flexion and backward bending of the neck ＜20°, lateral rotation of the neck ＜45°.

3.1.5 Sensory disturbance of the upper limb

0 point: No sensory disturbance in the upper limb.

1 point: Slight decrease in the sensation of the upper limb.

2 points: Obvious decrease in the sensation of the upper limb.

3.1.6 Myodynamia of the upper limb

0 point: Normal myodyanamia in the upper limb (Grade V).

1 point: Slight decrease of the myodynamia in the upper limb (Grade IV).

2 points: Obvious decrease of the myodynamia in the upper limb (Grade 0-III).

3.1.7 Tendon reflexes

0 point: No obvious abnormality in the tendon reflexes.

1 point: Decreased tendon reflexes.

2 points: Disappeared tendon reflexes.

3.1.8 Brachial plexus traction test

0 point: Negative in brachial plexus traction test.

2 points: Positive in brachial plexus traction test.

3.1.9 Intervertebral foramen compression test

0 point: Negative in intervertebral foramen compression test.

2 points: Positive in intervertebral foramen compression test.

According to the above scoring criteria, the symptoms and signs before and after the treatment were assessed to calculate the total scores. The highest score was 35 points, and lowest score was 0 point, the higher the scores, the more obvious the functional disturbance. The therapeutic effects were assessed by the integral-decreasing rate.

The integral-decreasing rate ＝ (Total scores of the symptoms and signs before treatment － Total scores of the symptoms and signs after treatment) ÷ Total scores of the symptoms and signs before treatment × 100%.

3.2 Criteria of therapeutic effects

The therapeutic effects were assessed in reference to theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[3], in combination with the criteria of the therapeutic effects on cervical spondylopsis of Sampath P, et al[8]. The therapeutic effects were assessed by the improvement of the patient’s symptoms and signs, the restoration of the ability in the work, daily living, and the integral-decreasing rate.

Clinical cure: The original symptoms and signs disappeared, with normal myodynamia and normal restoration of the functions in the neck and limb, able to join the normal labor and work, and with the integral-decreasing rate ≥95%.

Remarkable effect: The original symptoms and signs were obviously relieved, with normal myodynamia and normal restoration of the functions inthe neck and limb, able to join the light labor and work, and with the integral-decreasing rate ≥70%, but ＜95%.

Effect: The original symptoms and signs were obviously relieved, and the pain in the neck, shoulder and back was reduced. The functions of the limbs were improved, and the integral-decreasing rate≥30%, but ＜70%.

Failure: No change in the original symptoms and signs, the integral decreasing rate ＜30%.

3.3 Therapeutic results

3.3.1 Comparison of the clinical effects

After two-course treatment, the total effective rate was obviously higher in the observation group than that in the control group. The difference of the total effective rate between the two groups was statistically significant (P＜0.05), indicating that the therapeutic effects were better in the observation group than that in the control group (Table 1).

Table 1. Comparison of therapeutic effects between the two groups (case)

3.3.2 Comparison of symptom and sign scores

Inter-group comparison, the scores of the symptoms and signs between the two groups were not statistically different before treatment (P＞0.05), but the scores were statistically different after treatment (P＜0.01). Intra-group comparison, the scores of the symptoms and signs dropped significantly in both groups after treatment (P＜0.01), indicating that both the therapeutic methods are effective in treating cervical spondylotic radiculopathy, but the therapeutic effect was obviously better in the observation group than that in the control group (Table 2).

Table 2. Comparison of VAS scores before and after treatment (point)

Table 2. Comparison of VAS scores before and after treatment (point)

Note: Intra-group comparison with before treatment, 1) P＜0.01; compared with the control group, 2) P＜0.01

4 Discussion

In accordance with clinical manifestations of cervical spondylopsis, it can be attributed to the scope of Bi-impediment syndrome and vertigo in traditional Chinese medicine. The therapeutic measures mainly include surgical and non-surgical. As for non-surgical therapy, currently the comparatively consistent viewpoint in the medical field, especially in traditional Chinese medicine field, is to treat this disease with the non-drug therapy of acupuncture and tuina predominantly[9].

Tuina therapy has the precise effect for Bi-impediment syndrome and painful diseases. It has been found out in the modern studies that the Gun-rolling, Rou-kneading, Tui-pushing, Mo-rubbing, Tanbo-plucking not only can relax the spasmodic muscles but also can enhance the excitement of the muscles in the areas of the pathological changes, promote metabolism of the local tissues, reduce whole blood hematocrit and blood viscosity, improve microcirculation, promote the metabolism of inflammatory reactive matter, reduce the stimulation to the neural stem, posterior branch of the spinal nerve, dorsal root ganglion, and vertebral sinus nerve, so as to perform an anti-inflammatory and analgesic effect[10]. The rotating technique can suddenly pull and relax the high muscular tension by lifting and pulling actions, so as to restore the abnormal muscular tension and relieve spasm of the neck muscles. At the same time, it can relax adhesions, correct joint disorders, eliminate the synovial incarceration, improve local microcirculation, and reduce the strain of the intervertebral disc and stress relaxation rate, promote the absorption of inflammation, restore the cervical curvature, so as to correct the vicious cycle of the imbalance between the dynamic property and static property of the cervical vertebra, and establish the virtuous circle, beneficial to the rehabilitation of cervical spondylotic radiculopathy[11].

EA has the effects to promote the analgesic ability, promote circulation of qi and blood and regulate the muscular tension mainly by stimulating the acupoints via the filiform needles with the impulse current. EA can promote the acceleration of the local blood circulation, relieve spasm and edema of the tissues, relieve nerve root compression, improve blood circulation and tissue nutrition of the muscles, relieve inflammation around the involved nerve root, increase metabolism, so as to have the damaged muscles restored at maximum. EA can also promote the release of endomorphin (EM), enkephalin (ENK) and dynorphin (DYN) in the endogenous opioid peptide. They respectively produce the analgesic effects by integrating with the corresponding endogenous opioid peptides acceptors[12].

It has been indicated by modern experimental electrophysiological studies that the analgesic effectby EA on the Governor Vessel may mainly result from exciting downstream inhibition to control and influence the transmission of pain impulses inside the spinal cord. And it has been proven by the neurochemical studies that EA on the Governor Vessel can enhance the levels of 5-hydroxytryptamine (HT) and its metabolites (5-hydroxy indole acetic acid) in the brainstem and caudate nucleus, and the serotonin neurons play important roles in acupuncture analgesia. Therefore, it is believed that the analgesic effect of EA on the Governor Vessel may be related to the stimulation of metabolism of the serotonin neurons in the brain[13].

The sites of Jiaji (EX-B 2) points are the extended and overlapped areas of meridian qi from the Bladder Meridian. Over here, Jiaji (EX-B 2) points link and communicate with the Governor Vessel and the Bladder Meridian, and have the effects to regulate and control the two meridians. Therefore, EA on Jiaji (EX-B 2) points can regulate the integrative effect of the two meridians[14-15].

In summary, the therapeutic effects are precise in the treatment of cervical spondylotic radiculopathy by tuina techniques. However, combining EA and tuina techniques can produce a better therapeutic effect. This comprehensive method is simple, safe, and easy to operate, and thus has a high clinical value in the non-surgical treatment of cervical spondylotic radiculopathy.

Conflict of Interest

There is no conflict of interest in this article.

Acknowledgments

Thank for the support of Project from the Major and Special Funds of Shanghai Science and Technology Commission (No.10DZ1950700); Lu’s Acupuncture Inheritance Study of Shanghai Schools of Traditional Chinese Medicine (No. 201204).

Statement of Informed Consent

All the parents signed the informed consent.

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Translator:Huang Guo-qi

Wu Yao-chi, chief physician, professor, doctoral tutor.

E-mail: wuyaochi@online.sh.cn

R246.2

: A

Date:October 15, 2013