Zhai Bingsheng (翟炳生)

Orthopedics Department, Beijing Tong Ren Tang Hospital of Traditional Chinese Medicine, Beijing 100051, China

ABSTRACT OBJECTIVE: To explore the curative effects of warming needle moxibustion combined with manipulation massage on cervical spondylotic vertebral arteriopathy and its influence on the cerebral blood flow and cervical vertebra function. METHODS: A total of 84 patients with cervical spondylotic vertebral arteriopathy admitted to our hospital from February 2016 to June 2017 were selected, and all patients were divided into an observation group (n=42) and a control group (n=42) according to the random number table method. The patients in the control group were given conventional western treatment, and the patients in the observation group were treated with warming needle moxibustion combined with manipulation massage on the basis of the control group. After 4 weeks of treatment, the changes of main clinical symptoms (vertigo, headache, neck and shoulder pain, tinnitus), cervical function (clinical symptoms, clinical examination, daily life action) and cerebral blood flow parameters (average blood flow velocity of left vertebral artery,right vertebral artery and basilar artery) of the 2 groups were observed, and the clinical efficacy of the 2 groups were statistically analyzed. RESULTS: The scores of vertigo, headache, neck and shoulder pain and tinnitus in the 2 groups were all significantly lower than before treatment (P ＜ 0.05), and the clinical symptom scores in the observation group were significantly lower after treatment (P ＜ 0.05); After treatment, the scores of clinical symptoms, clinical examination and daily life action in the 2 groups were significantly higher than those before treatment (P ＜ 0.05), and the increase of cervical vertebral function score in the observation group was better than that in the control group (P ＜ 0.05); The mean blood flow velocity of the left vertebral artery, right vertebral artery and the basilar artery in the 2 groups after treatment were significantly higher than before treatment (P ＜ 0.05), and the increase of the above cerebral blood flow parameters in the observation group were higher than the control group (P ＜ 0.05). The total effective rate was 92.9% in the observation group and 76.2% in the control group after treatment, and the difference between the 2 groups was statistically significant(P ＜ 0.05). CONCLUSION: Warming needle moxibustion combined with manipulation massage can quickly relieve the clinical symptoms of patients with cervical spondylotic vertebral arteriopathy, improve the cervical function and cerebral blood flow parameters, increase the vertebrobasilar artery blood flow, and promote the recovery of the disease.

KEYWORDS: Cervical spondylotic vertebral arteriopathy; Warming needle moxibustion; Manipulation massage;Cerebral blood flow parameters; Cervical spine function

Cervical spondylotic vertebral arteriopathy(CSA) refers to vertebral artery curvature, spasm or compression due to cervical degenerative changes and cervical biomechanical imbalance, which leads to insufficient blood supply to the vertebral-basilar artery and changes of cerebral blood flow parameters, the main clinical features of the syndrome. This disease is one of the common types of cervical spondylosis, the incidence rate of about 20%-30% of cervical spondylosis, second only to nerve root type cervical spondylosis. The main symptoms of CSA are vertigo during the onset period,and the symptoms aggravate when the neck flexes or extends backward. In addition, some patients are also accompanied by varying degrees of neck and shoulder pain, blurred vision, visual rotation, nausea, tinnitus,headache and other symptoms, seriously affecting the normal work and life of patients[2]. At present, Western medicine treatment of CSA is mainly divided into surgical treatment and conservative treatment. The risk of conservative treatment is relatively small, but the treatment period is longer, and the individual efficacy is different. Although surgical treatment can quickly alleviate clinical symptoms, its strict indications, high risk, more postoperative complications, make it more difficult to be accepted by patients[3]. Traditional Chinese medicine has a long history and abundant experience in treating orthopedic diseases, of which acupuncture and massage are widely used in the clinical treatment of CSA because of their advantages of simple operation, safety,reliability and exact curative effect. The combination of the two can quickly dredge meridians and promote the movement of Qi and blood, thus improve the blood supply of the vertebral-basilar artery and promote the healing of the disease. In this study, a randomized controlled clinical study was conducted to evaluate the effect of warming needle moxibustion combined with manipulation massage on the clinical efficacy of CSA patients through the main clinical symptoms score, cervical vertebral function score and cerebral blood flow parameters. The report is as follows.

CLINICAL DATA

General data

A total of 84 patients with CSA admitted to our hospital from February 2016 to June 2017 were selected.

The diagnosis of western medicine meets the requirements of the "Summary of the 3rd National Symposium on Cervical Spondylopathy" on CSA[4]:Vertebral artery color ultrasonography indicated distortion or localized stenosis of the second vertebral artery; X-ray indicated instability of the uncinate vertebral joint or accompanied by hyperostosis; the cervical rotation test showed positive; vertigo was the main symptom, which may be accompanied by a certain degree of tinnitus,blurred vision, nausea, neck and shoulder pain, insomnia and other symptoms; most of the patients have a history of chronic strain. TCM syndrome differentiation is in line with the "Guidelines for Clinical Research of New Drugs in Traditional Chinese Medicine" on the deficiency of Qi and blood syndrome[5], of which the main symptoms conclude: vertigo, aggravated by fatigue, headache, neck pain;

Secondary symptoms include: palpitations, tinnitus,shortness of breath, night Frequent nocturnal urination;tongue and pulse manifestation: dull tongue, white and greasy tongue coating, deep and thready pulse.The patients were 30-70 years old, and the course of disease was5 years. No treatment was used in the past 1 week. All patients were informed about the contents of this clinical trial and signed the informed consent.Excluding vertigo caused by otogenic, ocular, brainderived, neuro-functional, traumatic, and intracranial tumors, hematological patients with hemorrhagic tendency, patients with spinal injury or spinal cord injury,congenital spinal stenosis, osteomyelitis, osteoarticular tuberculosis and senile osteoporosis, major organ dysfunction, pregnant and lactating women, psychiatric patients, poor treatment compliance. The enrolled patients were randomly divided into 2 groups: observation group consisted of 42 patients, totally 18 males and 24 females;aged 32-68 (57.2±3.7) years old; and the course of disease was 2-14 (6.0±1.1) months. Control group consisted of 42 patients, totally 17 males and 25 females;aged 33-666 (58.2±3.5) years; the course of disease was 2-13 (5.8±1.0) months. There was no significant difference in the general clinical data between the 2 groups (P ＞ 0.05).

Treatment methods

(1) Observation group: On the basis of conventional treatment of Western medicine, warming needle moxibustion combined with manipulation massage were given. Warming needle moxibustion treatment: Acupoints were Baihui (GV20), Fengchi (GB20) (bilateral) and corresponding Jiaji (EX-B2) of diseased vertebral body.Needle were Huayu brand stainless steel disposable acupuncture needle (production from Suzhou Huatuo Medical Instruments, specifications: 0.32mm×25mm,0.32mm×50mm), conventional disinfection at the acupuncture point, Baihui (GV20): perpendicular insertion of 0.3 inch, Fengfu (GV16): oblique insertion toward the nose tip of 0.5-0.8 inches, Jiaji(EX-B2): perpendicular insertion of 0.3 inch 0.3 to 0.5 inch. The moxa strip was cut into a cylinder with a length and diameter of 1.5cm,insert it into the needle handle of Baihui (GV20), Fengfu(GV16) and Jiaji (EX-B2) and ignited. The moxa strip is about 4-5cm away from the skin, and the hard paper is placed underneath to protect skin from scald, 1 section of moxa strip is 1 moxa-cone, continuous 2 moxa-cone.Manipulation massage treatment: the patient takes the seat, the doctor stands behind the patient, first relax the upper back and neck and shoulder by rolling method for 5 minutes, then press, knead, pinch, and grasp the neck. After the neck muscles are completely relaxed, the patient's head turns to the leftmost side and flexes to the maximum extent until the fixed feeling is reached. The doctor holds the patient's lower jaw with his left hand,the rear occipital with the right hand, and pulls up the head quickly under the traction. After hearing one or more sounds, doctor rotates the head to the right side and finally ends the manipulation massage by patting and splitting. Warming needle moxibustion and manipulation massage are treated for 2 weeks as a course of treatment and a total of 2 courses are needed (2) Control group:routine treatment with western medicine was given,oral Betahistine mesylate tablets (Guangdong Shixin Pharmaceutical Co., Ltd., national medicine quasi-word is H20100025, specification: 6mg), 6mg / time, 3 times / d,continuous 4 weeks; oral eperisone hydrochloride tablets(Qingdao Guohai Bio-Pharmaceutical Co., Ltd., national medicine quasi-word is H20010657, specification: 50mg),50mg / time, 3 times / d, for 4 weeks. After 4 weeks of treatment, the clinical efficacy in 2 groups was evaluated.

Observation index

X-ray, TCD examination did not reach the above efficacy criteria. Cure + Markedly effective + Effective = Total effective. ② Major clinical symptom scores: According to the literature[5], the four main clinical symptoms of vertigo, headache, neck and shoulder pain and tinnitus were scored before and after treatment. The scores were 0-3 points according to the severity of symptoms. The higher the score is, the more severe the symptoms are. ③Comprehensive evaluation of cervical vertebra function:Assessment Scale for Cervical Syndrome (ASCS)was used to evaluate the cervical function before and after treatment[7], including clinical symptoms, clinical examination, daily life action, among which Clinical symptoms refer to neck, shoulder and back pain, upper limb numbness or pain, vertigo, headache, and active pain; clinical examination refers to brachial plexus pull test, crowding and/or intervertebral foramen crush test,tenderness, sensory disorder, cervical hyperextension test,Hoffman sign, muscle strength grading; Daily life action refers to neck activity and turning over during sleep. The higher the score, the stronger the cervical spine function.④ Cerebral blood flow parameters detection: the average blood flow velocity of the left and right vertebral artery and basilar artery before and after treatment was examined by transcranial Doppler ultrasound tester.

Statistical methods

Statistical analysis was performed using SSPS 22.0 statistical software. Measurement data were expressed as, and t-test was used for comparison. Enumeration data is represented by n (%), andtest was used for comparison. P ＜ 0.05 was considered statistically significant.

RESULTS

Comparison of clinical efficacy after treatment between the 2 groups

After treatment, the total effective rate of the observation group was 92.9%, which was significantly higher than that of the control group (76.2%). The difference was statistically significant (P ＜ 0.05). See Table 1.

Table 1. Comparison of clinical effects between the 2 groups after treatment (%)

Table 2. Comparison of main clinical symptom scores before and after treatment in the 2 groups (x-±S, score)

Table 3. Comparisons of comprehensive scores of cervical vertebra function before and after treatment in the 2 groups (x-±S, score)

Table 4. Comparison of mean blood flow velocity of vertebral artery and basilar artery before and after treatment in the 2 groups (x-±S, cm/s)

Comparison of the main clinical symptom scores before and after treatment in the 2 groups

There was no significant difference in the scores of vertigo, headache, neck and shoulder pain and tinnitus between the 2 groups before treatment (P ＞ 0.05).After treatment, the scores of vertigo, headache, neck and shoulder pain and tinnitus in the 2 groups were significantly reduced (P ＜ 0.05), the degree of reduction in the observation group was more significant, and the difference between the 2 groups was statistically significant (P ＜ 0.05). See Table 2.

Comparisons of comprehensive scores of cervical vertebra function before and after treatment in the 2 groups

There was no significant difference in clinical symptoms, clinical examination and daily life action scores between the 2 groups before treatment(P ＞ 0.05). After treatment, the scores of clinical symptoms, clinical examination and daily life action in the 2 groups were significantly higher than those before treatment (P ＜ 0.05), and the increase were more obvious in the observation group. The difference between the 2 groups was statistically significant (P ＜ 0.05). See Table 3.

Comparison of mean blood flow velocity of vertebral artery and basilar artery before and after treatment in the 2 groups

There was no significant difference in the mean blood flow velocity of the left vertebral artery, the right vertebral artery and the basilar artery between the 2 groups before treatment (P ＞ 0.05); After treatment, the mean blood flow velocity of the left vertebral artery,the right vertebral artery and the basilar artery in the 2 groups were significantly increased (P ＜ 0.05), and the increase was more obvious in the observation group. The difference between groups was statistically significant(P ＜ 0.05). See Table 4.

DISCUSSION

In recent years, with the acceleration of life rhythm and changes of lifestyle, computers and air conditioners have been widely use. In addition to the lack of sports and the aging of the population, the incidence of cervical spondyloses has significantly increase, and the age of onset is becoming younger and younger, which had made it become a common and frequently-occurring disease in the clinic[8]. CSA is one of the common types of cervical spondylosis, mainly refers to the main clinical syndrome characterized by vertebral-basal artery insufficiency caused by various dynamic and mechanical factors that compress or stimulate the vertebral artery, resulting in vascular flexion and stenosis[9]. Paroxysmal vertigo is the main symptoms in 50%-80% of CSA patients, such as riding on a bus or boat, standing unsteadily consciously,accompanied by headache, tinnitus, nausea, insomnia,blurred vision and other symptoms, causing greater pain to patients, seriously affecting their quality of life. CSA is a degenerative disease, its pathogenesis is complicated, and some pathogenesis has not been fully elucidated. Among them, vertebral artery sympathetic nerve stimulation and bone compression are two clinically recognized major pathogenic factors, which influence each other or cause each other[10]. In addition, in recent years, the role of cervical instability theory in the pathogenesis of CSA has gradually been recognized, such as Zhang Jian et al[11]found that cervical segmental instability will squeeze the vertebral artery, osteophytes at the edge of the vertebral body and uncinate joint constantly stimulating the sympathetic nerve around the vertebral artery, resulting in vertebral artery vasospasm, which leads to insufficient blood supply of the vertebrobasilar, changes in cerebral blood flow parameters, abnormal blood rheology and disorder of microcirculation in the body. Conservative treatment is currently the main method for Western medicine treatment of CSA. The specific treatments include oral vasodilator drugs and anti-arteriosclerosis drugs, traction, hyperbaric oxygen chamber, neck circumference fixation, etc. Although some curative effects have been achieved, there are still some problems such as poor long-term curative effects, many adverse reactions and high recurrence rate.

CSA belongs to the category of "vertigo" and "neck pain" in traditional Chinese medicine. Traditional Chinese medicine studies believe that this disease is caused by fatigue and physical weakness, exogenous pathogenic factors, lack of Qi and blood, deficiency of liver and kidney, phlegm-turbidity obstructing middle-jiao and malnutrition of marrow sea. Lack of Qi and blood,deficiency of liver and kidney, malnutrition of tendon and bone are the internal causes of CSA. Exogenous pathogens and neck strain are the external causes of CSA.This disease belongs to the syndrome of deficiency of origin and excess of substance, and is mainly based on deficiency. The pathogenesis of the disease is related to wind, fire, phlegm and static blood. Acupuncture and massage are the two most widely used methods for treating cervical vertigo in Chinese medicine. They have definite curative effect on improving pain and spasm of neck muscle, increasing blood flow of vertebral artery and restoring the balance of cervical biomechanical[12].Acupuncture and moxibustion treatment of "neck pain"has a long history. As early as in the Su Wen·Gukong Lunpian, there is a record: "Stiff neck (can be treated by selecting acupoints) on the shoulder. Breaking pain(of the back and spine can be treated by)shaking the arms (of the patient)and moxibusting the region of the spine parallel to the elbow(when the arm is put beside the side of the body)" and "Violent wind (may cause)pain of the neck and nape (that can be treated by) needling Fengfu (GV16)located above the first cervical vertebra". From the Qin and Han Dynasties to the Ming and Qing Dynasties,there are more than 190 literatures about acupuncture and moxibustion for the treatment of "neck pain". It shows that Chinese acupuncture has a very rich theoretical basis and practical research in the treatment of "neck pain".Warming needle moxibustion is a treatment method that combines acupuncture and moxibustion. In the process of retaining the needle, the moxa stick is connected to the needle handle and ignited and the heat of the moxa stick is transmitted to the acupuncture point through the needle body, which has the function of activating Qi and blood circulation, warming and dredging meridians.

The prescription of warming needle moxibustion used in this study is Baihui (GV20), Fengchi (GB20)(bilateral) and corresponding Jiaji (EX-B2) of diseased vertebral body, of which Baihui (GV20) located the vertex,the depth of which is the brain, and Baihui (GV20) is on the Governor channel, which runs along inside of the spine. It is the gathering place of Qi and blood of the Five Zang-organs and the Six Fu-organs, and eventually enters into the brain. If the governor vessel is dysfunctional,then the mind loss of nourishment, and Qingyang (Lucid-Yang) does not rise, which will lead to "heavy sensation of head" and "vertigo". Baihui (GV20) is an important acupoint for clinical treatment of vertigo, the moxibustion of it can -strengthen brain and quiet the spirit, induce resuscitaion and open the orifices, accommodate the governor vessel and warm the marrow, elevate the yang and stem desertion. Modern research has shown that acupuncture at Baihui (GV20) can promote the blood flow of the yang channel to the brain, thereby significantly improving the microcirculation and blood supply of the brain, reducing the viscosity of the blood, and gradually improving the symptoms of vertigo[13]; Study of Ren Qinyou et al[14]had confirmed that moxibustion Baihui(GV20) can effectively improve the arterial pulsation index and blood flow velocity of the common carotid artery and posterior cerebral artery in healthy subjects,thereby significantly improving blood supply to the brain. The Fengchi (GB20) is the crossing point of Yang linking vessel, the hand-foot Shaoyang meridian and the Yang heel vessel and is the key point of the gallbladder meridian. The Yang linking vessel maintains the yang qi of the whole body and has the function of regulating qi and blood of the yang channel. The gallbladder meridian belongs to wood and governs upbearing. Therefore, the acupuncture of the Fengfu (GV16) acupoint can play the role of raise out and discharge qi and blood of the yang channel, thus promoting qi and blood to be injected into the brain, and the marrow is nourished, and the vertigo is gradually eliminated. Modern studies have shown that the distribution of the occipital artery, the occipital nerve and the vertebral artery under the Fengchi (GB20) can effectively expand the capillary network of the vertebrobasilar artery system, promote the establishment of collateral circulation, and thus significantly improve the hemorheology of vertebro-basilar artery. Acupuncture at Fengchi (GB20) has a good effect on vertebrobasilar insufficiency[15]. Jiaji (EX-B2) is extra point between the Governor vessel and bladder channel. The Governor vessel regulates he yin and yang of the whole body, qi and blood of the twelve meridians. The bladder channel regulates the function of the whole body. Therefore, the acupuncture at the Jiaji(EX-B2) can be used to free qi and blood, harmonize the yin and yang, and regulate the function of the organs[16]. Study of Zhang Lanjie et al[17]shows that acupuncture at Jiaji (EX-B2) can effectively relieve neck muscle spasm, regulate muscle biomechanical balance, improve topalgia, promote vertebral artery blood flow velocity, improve vertebral artery blood supply, and relieve vertigo symptom.Manipulative treatment of CSA also has a long history,which can effectively relieve inflammatory adhesions of local tissue, relieve muscle spasm, correct vertebral joint disorders, restore cervical vertebral dynamic balance, and improve hypoxia and ischemic of vertebral artery[18]. The manipulation massage of this research is a new method based on the traditional massage technique. It emphasizes that the patient initiatively rotates the cervical vertebra. The patient rotates the cervical vertebra to the maximum extent before the doctor manipulates the technique. After the patient's neck forms a fixed feeling, doctors can complete the manipulation only by pulling up quickly with the help of traction. The manipulation does not cause any harm to the patient, and has the advantages of low treatment cost, simple operation, exact curative effect, and increase synergistic effect with the warming needle moxibustion.

The results showed that the total effective rate of the observation group after treatment was significantly higher than that of the control group, the improvement of the main clinical symptoms (vertigo, headache, neck and shoulder pain, tinnitus), cervical vertebral function(clinical symptoms, clinical examinations, daily life action) and cerebral blood flow parameters (mean blood flow velocity of left vertebral artery, right vertebral artery and basilar artery) was significantly better than that of the control group. It is suggested that warming needle moxibustion combined with manipulation massage can quickly relieve the clinical symptoms of patients with Cervical spondylotic certebral arteriopathy, improve cervical function and cerebral blood flow parameters,increase vertebral-basilar artery blood flow, and promote the recovery of the disease.