Bin-Hong Yan, Kun Niu

1. First Affiliated Hospital of Hainan Medical University, Haikou 570102, China

2. College of Traditional Chinese Medicine, Hainan Medical University, Haikou 571199, China

Keywords:Manipulation Low back pain Infrared thermography 5-HT β-EP

ABSTRACT Objective: To analyze the level changes of the degree of back pain by visual analogue scale(VAS), lumbar function (Japanese Orthopaedic Association Scores,JOA), muscle temperature, serum serotonin 5-hydroxytryptamine (5-HT) and β-endorphin (β-EP) in patients of low back pain(LBP). Methods: 64 LBP patients treated in the tuina department of first affiliated hospital of Hainan Medical University were randomly divided into observation group (32 cases) and control group (32 cases). The control group was treated with traditional filiform acupuncture needling, the observation group was treated with Chinese tuina. VAS,JOA, muscle temperature, 5-HT, β-EP, these indexes were tested before and after treatment.Results: The VAS and JOA score in the observation group were significantly lower than those in the control group (P＜0.01), the muscle temperature in the observation group and the control group increased significantly (P＜0.01), and the observation group was higher than that in the control group (P＜0.05); 5-HT、β-EP was significant difference before and after treatment(P＜0.01), and the level in observation group was significantly higher than that in the control group,the difference was statistically significant (P＜0.05). Conclusion: Chinese tuina has significant clinical efficacy in the treatment of LBP. The medical infrared thermal imaging technology and serum pain detection technology is conducive to objectively helpful to analyze the exact efficacy of tuina in the treatment of LBP and its impact on relevant indexes.

1. Introduction

Low back pain (LBP) refers to pain in the lower back, lumbosacral region, and buttocks, which is common in people of all ages, and is characterized by low back pain and lumbar dysfunction[1]. 70% to 90% of people will experience LBP at least once in their lifetime,and 15% to 20% of people will have persistent low back pain. The incidence of LBP is second only to respiratory tract infection in the proportion of outpatient patients[2-3]. Therefore, patients with LBP should seek immediate medical care and receive symptomatic treatment. In this study, LBP patients in the department of Chinese tuina of the First Affiliated Hospital of Hainan Medical University were divided into groups and compared after treatment. VAS and JOA scales were used to evaluate the degree of pain and lumbar spine function, infrared thermography was used to observe the changes of muscle temperature, and biochemical techniques were used to analyze the level changes of 5-HT and β-EP in serum.Through the above methods, we can objective analysis the clinical efficacy of Chinese tuina therapy and the impact on related indicators.

2. Data and methods

2.1 General data

64 LBP patients admitted to the department of tuina, First Affiliated Hospital of Hainan Medical College from August 2020 to April 2021 were selected and randomly divided into observation group and control group according to the envelope random grouping method, with 32 cases in each group. There were 18 males and 14 females in the control group. The average age was(51.49±3.63)years; the average course of disease was(6.72±1.35) years. There were 16 males and 16 females in the observation group. The average age was(53.18±2.97) years; the average course of disease was(5.93±0.98) years. There was no significant difference in general data between 2 groups (P＞0.05). All patients were diagnosed with LBP according to the diagnostic criteria of LBP in the ＜Chinese Medicine Industry Standard of the People's Republic of China＞,＜Diagnosis and Efficacy Criteria of Orthopaedics and Traumatology of Traditional Chinese Medicine＞ (1994, Ministry of Health) and Tuina Therapeutics (edited by Fan Bing-hua, China Traditional Chinese Medicine Publishing House, the second edition of the new century, June 2019).The specific syndrome type is chronic lumbar muscle strain[1、4].

2.2 Treatment

The control group was treated with filiform acupuncture at Shenshu(BL23), Dachangshu(BL25) and Yaojiaji(EX-B2). Before needling, the acupoints were sterilized, use disposable sterile needle perpendicularly needling 3 acupoints of above, then strengthen the stimulation with electroacupuncture apparatus after obtaining Qi,retained needle for 20 minutes. Needling was given twice a week for one month, about 10 times in total. The operative specification of needling skills and acupoint selection principles refers to the national"13th Five-Year Plan" textbook ＜Acupuncture and Moxibustion＞to ensure the homogeneity of acupuncture treatment. The patients in observation group were treated with Chinese tuina manipulation.The patients lie prostrate, treating loosening manipulation with kneading, pulling and poking to the muscles around the lower lumbar vertebra, the purpose is to relieve soft tissue spasm,continued for about 15 minutes.Then press BL23, BL25 and EX-B2 to strengthen the analgesic effect, each acupoint continued pressing for about 1 minute. Finally, adjust the lumbar facet joints by oblique pulling, then relax and arrange the lumbar muscle by kneading and rolling, continued for about 3 minutes. Chinese tuina was given five times a week for one month, about 26 times in total. The operative specification of Chinese tuina skills refers to the national "13th Five-Year Plan" textbook ＜Chinese Tuina＞ to ensure the homogeneity of manipulation treatment.

2.3 Observation index

① The degree of low back pain and the function of lumbar joints were observed and analyzed in 2 groups. The degree of pain was evaluated with the VAS scale, the score was 0-10, 0 represented no pain symptoms, 10 represented intolerable severe pain and serious impact on it; lumbar joint function was assessed by JOA scale, with a full score of 100, and the higher the score, the better the lumbar function.

② Recording and analysis of infrared thermal imaging results:The TMT medical infrared thermal imager produced by Hangzhou Xinhan Photoelectric Technology Co.Ltd, was used to collect images in the treatment room, the temperature changes of BL23, BL25 and EX-B2 were collected before and after treatment.

③ Collect 4ml non-anticoagulative blood from the elbow vein of the patients in 2 groups before and after the treatment in the morning, after standing for 15 minutes, the supernatant was taken by high-speed centrifugation and stored in a refrigerator at -80℃ for testing, then measured serum 5-HT and β-EP by ELISA.

2.4 Statistical analysis

After collecting the data, SPSS22.0 was used for analysis. The VAS score, JOA score, muscle temperature results and serum test results of 2 groups were expressed with (±s), t test was performed. P＜0.05 indicate the difference was statistically significant. Compared the image changes of 3 acupoints before and after treatment by infrared thermography.

3. Experimental results

3.1 The changes of the degree of back pain and lumbar function

The VAS score and JOA score of the observation group were significantly lower than the control group (P＜0.01), as table 1.

Table 1 Comparison of the degree of back pain and lumbar joint function between 2 groups (points)

3.2 The changes in muscle tissue temperature

The muscle tissue temperature of both 2 groups increased significantly (P＜0.01), and the observation group was higher than control group, with significant difference (P＜0.05), as table 2.

Table 2 Comparison of muscle tissue temperature changes before and after treatment in 2 groups (℃)

3.3 The changes of infrared thermography results

It can be seen from the infrared thermography that the temperature of BL23, BL25 and EX-B2 on both sides of lumbar vertebra increased in both 2 groups after treatment. In control group, the area of temperature rise after treatment was relatively confined to the needling area (Fig.1 and 2); in observation group, there was an oval ring-shaped high temperature area which was consistent with the tuina treatment site.The acupoints area after pressing also showed obvious high temperature image, and the thermogram of the observation group after treatment showed that the range of high temperature area increased and the temperature also increased (Fig.3 and 4).

Figure 1 The control group before treatment

Figure 2 The control group after treatment

Figure 3 The observation group before treatment

Figure 4 The observation group after treatment

3.4 The level changes of 5-HT and β-EP

The levels in both 2 groups were basically the same before treatment, the difference was not statistically significant. Compared with that before treatment, the levels in both 2 groups were significantly increased after treatment (P＜0.01) , and the comparison between 2 groups showed that the curative effect of observation group was better than control group (P＜0.05), as table 3 and 4.

Table 3 Comparison of 5-HT levels before and after treatment in 2 groups (ng/mL)

Table 4 Comparison of β-EP content before and after treatment in 2 groups (ng/mL)

4. Discussion

LBP is generally based on the degenerative changes of lumbar spine and its affiliated tissues, pain is the most common clinical manifestation, chronic lumbar muscle strain is the most common syndrome type, and characterized with high incidence,long course,and easily recurrence[5-6]. With the changes of modern people's study, work and life style, the increase of sedentary, standing and bad posture, and the decrease of physical exercise, the incidence of LBP has increased rapidly, and more than 80% of adults will experience different degrees of low back pain at different stages of their lives[7].Chronic lumbar muscle strain is mainly characterized by extensive and diffuse back pain, which is mainly treated conservatively in clinic. Chinese tuina has the effects of relax the muscles and joints,stimulate the circulation of the blood, loosening adhesions and tissue spasm,it is widely used to promote the functional rehabilitation of chronic lumbar muscle strain.[8-9]. The clinical effect of tuina therapy is remarkable, but its effective mechanism is not fully clear yet, therefore, more studies are needed to explore it[10].

LBP is fall into the part of category of "back pain" in Traditional Chinese Medicine, which is caused by internal injury, exogenous and traumatic injury, and the treatment principles are: syndrome differentiation and treatment, if the symptoms are urgent, the symptoms will be treated first, if the root is urgent, the root will be treated first[11].The treatment of LBP by tuina is guided by the theory of "the disease is in the tendons, and the tendons are regulated",which can dredge the channels and collaterals, regulate Yin and Yang, promote blood circulation by removing blood stasis, relieve swelling and pain, and smooth joints.It plays an important role in promoting the rehabilitation of LBP[12].

LBP usually uses the VAS visual analogue scale to assess the degree of pain. JOA is the Japanese Orthopaedic Association assessment treatment score, which can be used to assess the improvement of lumbar joint function in LBP treatment. Both VAS and JOA are internationally accepted evaluation standards and are widely used in the rehabilitation assessment of orthopaedic diseases[13]. The results of this study showed that the VAS score and JOA score of observation group were significantly lower than control group.It showed that the pain symptoms and dysfunction of the patients were improved after the treatment of tuina.

Medical infrared thermal imaging is a kind of technology which uses infrared detector to convert human body thermal radiation into plane temperature color image. With the development of science and technology, the resolution and definition of this technology are getting higher and higher. In recent years, it has been widely used in clinical diagnosis and curative effect evaluation of orthopaedic diseases[14-15].Some scholars compared the infrared images of 74 patients with cervical spondylosis of vertebral artery type before and after tuina treatment, and found that the neck temperature of patients with improved symptoms after tuina treatment was higher than that before treatment, indicating that tuina treatment could improve local microcirculation, which was conducive to the recovery of vertebral artery blood supply, and that infrared thermography was helpful to objectively evaluate the efficacy of tuina[16].Compared with the control group, the temperature of BL23, BL25 and EX-B2, increased significantly after treatment, and the muscle tissue temperature of observation group was higher than control group, the infrared image of observation group also showed an increasing trend in the range of high temperature area, indicating that the application of infrared thermal imaging technology in the clinical treatment of LBP patients.Tissue temperature changes caused by soft tissue injury around the lumbar spine can be objectively displayed in real time through images, which is conducive to improving the objectivity of the evaluation of treatment results[17].

Endogenous opioid peptides[20]have been found to be an important material basis for analgesia in the study of the mechanism of tuina analgesia. A study on the treatment of lumbar disc herniation with acupuncture and tuina found that the symptoms of low back pain were significantly alleviated after treatment, and the contents of 5-HT and β-EP in the blood were significantly increased.It is considered that the analgesic mechanism of acupuncture and Chinese tuina may be related to the changes of the content of analgesic transmitters in the serum of patients. 5-HT is an important neuroactive substance in the brain stem involved in analgesia. It is not only an inflammatory mediator of pain, but also a neurotransmitter with analgesic effect.It is an important analgesic substance in the central and peripheral system. β-EP is one of the endogenous analgesic substances.Under pathological stimulation, the increase of its content can produce analgesic effect and help to alleviate the pain symptoms of patients[18-19]. Therefore, 5-HT and β-EP were selected as the observation indexes in this study. The results showed that the levels of 5-HT and β-EP in the serum of the patients in both groups were increased after treatment, indicating that both filiform acupuncture needling and Chinese tuina had analgesic effect.

The results of this study show that after tuina treatment, the VAS score and JOA score of LBP patients in observation group are significantly lower than control group, and the temperature of lumbar muscle tissue and content levels of 5-HT and β-EP are also significantly higher than control group, which proves that tuina treatment of LBP is beneficial to the improvement of low back pain symptoms and lumbar joint function. Muscle temperature and serum analgesic transmitters 5-HT and β-EP were used as observation indexes.It is helpful for manipulative doctors to objectively judge the therapeutic effect of manipulation. This study is a clinical observation, and there are still some limitations in the design and implementation of the project. For example, it is not easy to collect the cases of patients who meet the typical diagnostic criteria of LBP.LBP is a syndrome and may have multiple symptoms. Therefore,only LBP patients who meet the typical symptoms of chronic lumbar muscle strain are included in this study. Infrared thermal imaging technology has many advantages, but there are still some limitations,such as unpredictable external factors and patient's own factors will affect the tissue temperature, thus interfering with the accurate generation of infrared thermal imaging. Due to the difference of infrared thermal imaging equipment, the repeatability of the results may also be different.So far, it is difficult to achieve standardization in the clinical application of infrared thermal imaging technology,and it can not become a reliable diagnostic method, but it still has a certain application prospect for analyzing and judging the curative effect of treatment, and it is worth further study and discussion[20].Acupuncture and tuina is a relatively new pain discipline in clinical practice.Although this discipline has formed an independent theory and discipline system, the overall scale of pain discipline in China is relatively little, and the development is not balanced in different regions. It is necessary to strengthen the close combination of basic research and clinical practice of this discipline, and strengthen the integration with the international frontier of pain medicine, so as to vigorously promote the development of clinical and scientific research of this discipline[21].