Online Submissions:http://www.journaltcm.com info@journaltcm.

com

J Tradit Chin Med 2012 September 15; 32(3): 388-392 ISSN 0255-2922 2012 JTCM. All rights reserved.

CLINICAL OBERVATION

Clinical effects of innovative tuina manipulations on treating cervical spondylosis of vertebral artery type and changes in cerebral blood flow

Quanmao Ding, Mingru Yan, Ji Zhou, Lu Yang, Jiang Guo, Jun Wang, Zhiyong Shi, Yixi Wang, Hongsheng Zhao aa
Quanmao Ding, Mingru Yan, Ji Zhou, Lu Yang, Jiang Guo, Jun Wang, Zhiyong Shi, Yixi Wang, Hongsheng Zhao, Tuina Department of Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China Supported by the Fund of Capital Medical Development and Research (No. III-11) and the Subject Growth Fund of Guang'anmen Hospital, China Academy of Chinese Medical Sciences (No. 81392) Correspondence to: Prof. Mingru Yan, Tuina Department of Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China. ymr9889@hotmail.com Telephone: +86-10-88001125 Accepted: August 18, 2011

ments before recovery, while those in the control group required (15 7) treatments before recovery (P<0.05). The clinical symptoms exhibited greater improvement in the test group compared to the control group (P<0.05). There were no differences in cerebral blood flow between the two groups. CONCLUSION: Both innovative Tuina manipulations and routine Tuina manipulations produced satisfactory therapeutic results in vertebral artery type cervical spondylosis patients. However, the innovative manipulation was more effective in improving the functional symptoms, although there were no changes in the cerebral blood flow. 2012 JTCM. All rights reserved. Key words: Tuina; Manipulation, Spinal; Cervical spondylosis; Vertebral artery; Regional blood flow

Abstract
OBJECTIVE: To determine the clinical effect, treatment times, and rheoencephalogram changes in vertebral artery type cervical spondylosis patients treated with innovative Tuina manipulations. METHODS: One hundred and twenty six cervical spondylosis patients (vertebral artery type) were randomly divided into test and control groups. Patients in the test group were treated with innovative Tuina manipulations, while those in the control group were treated with the routine Tuina manipulations according to the textbook of Chinese Massage for Acupuncture and Moxibustion majors. The clinical effects, treatment times, clinical symptoms, and cerebral blood flow were measured. RESULTS: The response to the treatment was 100% in the test group and 88.71% in the control group. Patients in the test group required (7 4) treatJTCM | www. journaltcm. com 388

INTRODUCTION
Cervical spondylosis is a common disease, with an incidence of 3.8%-17.6% in Chinese adults, particularly in those older than 40 years of age.1 Due to the modern unhealthy lifestyle such as long hours in front of computer screens or absence of exercise, and increased work pressure, the morbidity rate associated with cervical spondylosis is increasing and the age of onset is decreasing. Innovative Tuina manipulation was developed by our hospital for treatment of cervical spondylosis. To objectively evaluate the therapeutic effect of Tuina manipulations, we performed a clinical evaluation of their efficacy in 126 patients with cervical spondylosis from Guang'anmen Hospital, China Academy of Chinese Medical Sciences, from November 2003 to July 2006.
September 15, 2012 | volume 32 | Issue 3 |

Ding QM et al. Innovative tuina manipulations on cervical spondylosis

MATERIALS AND METHODS

Inclusion criteria We applied the diagnostic criterion established in the 2nd Symposium Meeting on Cervical Spondylosis (Qingdao, China, October 1992).2 Patients diagnosed with cervical spondylosis (vertebral artery type) were eligible for entry into this study if they: 1) had had cataplexy combined with cervical vertigo, and there was cervical segmental instability or uncovertebral joint hyperosteogeny shown in an X-ray; or 2) had a positive neck torsion test, and evidence of cervical segmental instability or uncovertebral joint hyperosteogeny on X-ray; or 3) exhibited cervical segmental instability or uncovertebral joint hyperosteogeny on X-ray; which was combined with cervical sympathetic symptoms, but without either eye source vertigo, aural vertigo, or vertebrobasilar insufficiency caused by compression of vertebral artery I and vertebral artery III. Further, all subjects agreed to sign the informed consent and completed the treatment on time. Exclusion criteria Patients were excluded if they had a serious primary disease such as severe hypertension, cardiovascular and cerebrovascular diseases, liver disorders, kidney diseases, hematopoietic system diseases, and other life-threatening diseases, or if they were suffering from mental disorders. General materials One hundred and twenty eight vertebral artery type cervical spondylosis patients were randomly divided into test and control groups (n=64 per group). Two patients were excluded from the control group as they did not follow the trial protocol and could not receive the treatment on the schedule, leaving a study population of 126 cases at the end of treatment (36 males and 90 females). Patients ranged from 18-76 years of age, with 20 cases younger than 40 years, 36 between 40-49 years, 35 between 50-59 years, and 37 older than 60 years. There were no differences in the sex and age distribution between the two groups. Administration The subject is authorized by the Ethics Committee of Guang'anmen Hospital, China Academy of Chinese Medical Sciences. And all the patients have read the Informed Consent in CRF and signed separately. In the test group, patients were in the sitting position, and received the following treatments. 1) Neck and shoulder manipulations: A to-and-fro kneading with the thumbs was applied several times on both sides of the cervical vertebrae from the occipitalia to the shoulder to relax the muscles; manipulations for plucking and the relaxing tendon were applied three times on the same area with strength that was tolerable for the patients; and rolling and kneading with the palm were
JTCM | www. journaltcm. com 389

applied on both shoulders for 2 min, followed by pressing of both Fengchi (GB 20) and Jianjing (GB 21) acupoints 30 s each. 2) Occipitalia manipulations: Kneading and pressing with the thumb were applied around the occipital tuberosity for 5 min, the strength of which was increased from mild to strong, but remained tolerable for the patients. The treatments were focused on the areas below or on both sides of the occipital tuberosity, and the acupoints Naokong (GB 19), Naohu (DU 17), and Yamen (DU 15) were then pressed for 30 s on each point. Rubbing with two thumbs and striking with the fingertip were also applied on these areas. 3) Facial manipulations: Pushing with the thumb was applied five times from Yintang (EX-HN3) Shenting (DU 24) Touwei (ST 8) Taiyang (EX-HN5). Next, pressing with the thumb was applied three times along the Du Meridian, Bladder Meridian of Foot-Taiyang, and Gallbladder Meridian of Foot-Shaoyang. Kneading-pressing with the thumb was then applied on the region of muscle convulsion at the point of pain if the patient had a migraine. Finally, Shenting (DU 24), Touwei (ST 8), Baihui (DU 20), and Shuaigu (GB 8) were pressed for 30 s for each point. 4) Adjustment manipulations for joints: Oblique-wrenching neck in a sitting position and wrenching the neck while pressing the shoulder were applied to regulate the cervical joints. The manipulations were same as those recorded in the Massage (5th version).3 Traction with 15-20 kg pulling strength for 10 min was applied to patients with narrowing of the intervertebral space. In the control group, the treatment methods were according to the Textbook of Chinese Massage for Acupuncture and Moxibustion majors (5th ed), and plucking, acupoint-pressing, and oblique-wrenching were applied simultaneously. Observation indexes Three treatment courses were observed and each course was repeated 10 times. Each patient received treatment twice per week. The treatment was stopped when the symptoms disappeared or after three treatment courses, even if the symptoms did not disappear, and the improvement of symptoms (headache, dizziness, and neck or shoulder pain) were evaluated. The rheoencephalogram was examined before and after treatment, and the blood flow rates of the bilateral internal carotid and the vertebral artery were observed. The criteria for evaluating the clinical efficacy of treatments followed the correlated national standards,4 with the following modifications: 1) Effective: the clinical symptoms (radiated pain of the neck and arm, insensitive feeling of the fingertips, brachial plexus force test negative or weakly positive) disappeared or were completely alleviated, and the function was recovered completely; 2) Improvement: the clinical symptoms were partially alleviated and the function partially recovered; 3) Ineffective: there were insignificant changes in clinical symptoms. Clinical symptoms including headache, dizziness, and
September 15, 2012 | volume 32 | Issue 3 |

Ding QM et al. Innovative tuina manipulations on cervical spondylosis neck and shoulder pain, and the treatment times were recorded. The level of dizziness was classified into four grades according to the clinical severity and the effect on patient quality of life, as follows: Grade I: occasional dizziness that is more serious after exertion or during emotion changes, with a normal neck; Grade II: frequent dizziness (>3 times per week) that is more serious after exertion or during emotion changes, with mild limitation of neck function and positional vertigo; Grade III: dizziness occurs continually with serious limitation of neck function, and the body has to turn when the neck turns; and Grade IV: dizziness occurs continually, with serious limitation of neck function that affects normal life and work, and the patient suffers from visual rotation or even vomiting. The grading for headache, neck and shoulder pain referred from the book, Therapeutics of Soft Tissue Injuries5 was as follows: Grade I: no pain; Grade II: mild pain occurs after exertion; Grade III: pain occurs at the beginning of work or activities and alleviates after rest; and Grade IV: continuously intolerable pain regardless of activity or rest. The rheoencephalogram was examined with a MultiDopX transcranial Doppler diagnostic instrument (Compumedics DWL Co., Ltd., Singen, Germany) before and after treatment, and the blood flow rates of bilateral internal carotid and vertebral arteries were determined. Statistical methods SPSS 13.0 statistical software (IBM, Armonk, NY, USA) was used for statistical analyses. The measurement of clinical efficacy was expressed as a percent, while other data were expressed as meanstandard deviation (SD). The inner-group comparison was analyzed by t-test, while the comparisons for each symptom were analyzed by one-way ANOVA. A P-value less than 0.05 was considered statistically significant. Comparison of clinical efficacy In the test group, 64 of 64 patients were effectively treated, with a clinical significant efficacy of 100%. In the control group, 55 of 62 patients were effectively treated (88.7% ), while seven patients exhibited improvement (11.3%). There was a significant increase in clinical efficacy in the test group compared to the control group (P<0.05). Comparison of clinical treatment times The clinical treatment times were 7 4 for the test group and 157 for the control group. There was a significant decrease in the clinical treatment time in the test group compared to the control group (P<0.05). No obvious adverse reactions and complications were found during the treatment in either group. Comparison of clinical symptom improvement In the test group, the clinical treatment times for headache, dizziness, neck pain, and shoulder pain were significantly less than in the control group (P<0.05; Table 1). Nevertheless, in the control group, the clinical symptoms were obviously improved after three course of conventional massage therapy. These data indicate that both the innovative and conventional Tuina manipulations show therapeutic effects, although the innovative manipulation was more efficacious. Comparison of rheoencephalogram There was a significant reduction in the blood flow rate in the right internal carotid artery in the control group after treatment when compared to before treatment (Table 2), while there were no differences in any other groups/variables.

DISCUSSION
The basic principle of Chinese massage for cervical spondylosis is to promote the local blood circulation by removing stasis, and to improve the function of the related internal energy by regulating the cervical joints and correcting abnormal position. Based on our clinical experience of massage practice in our department,
Dizziness 53 148
a

RESULTS
Of the 128 patients enrolled, two control group patients were removed from the study as they did not follow the trial protocol (drop-out rate, 1.56% ), leaving 126 patients in the final study group.
Group Test Control
a

Table 1 Treatment times required until improvement of clinical symptoms ( x s) Case 64 62 Headache 53 138
a

Neck pain 73 157

a

Shoulder pain 54a 137

Note: P<0.05 compared with the control group. Table 2 Changes in blood flow rate assessed by rheoencephalogram ( x s) Group Test Before After Before After Case 64 64 62 62 Left internal carotid 9428 9121 8623 8821 Left vertebral artery 5615 5312 5316 5214 Right internal carotid 9129 9027 8530 9225a Right vertebral artery 5520 5313 5416 5315

Control

Note: aP<0.05 compared with the control group before treatment. JTCM | www. journaltcm. com 390 September 15, 2012 | volume 32 | Issue 3 |

Ding QM et al. Innovative tuina manipulations on cervical spondylosis we recently development an improved Tuina manipulation method, which included manipulations such as kneading, rolling, pressing, plucking, and relaxing tendon that were applied to the neck, shoulder, and occipitalia. The main aims of these additional manipulations were to improve coordination of Qi and blood, warm channel and expel cold, promote the circulation of Qi and remove blood stasis, and to help eliminate the pathological changes and various functional disturbance caused by wind-cold, Qi-stagnancy, and blood stasis. A pushing with the thumb manipulation was then applied on the face, and acupoints of the Du Meridian, Bladder Meridian, and Gallbladder Meridian were finger-pressed to improve the symptoms of headache and dizziness. Finally, oblique-wrenching of the neck in a sitting position and wrenching the shoulder while pressing the shoulder were used to regulate the cervical joints, which could relieve joint locking, synovial incarceration, and the vertebroarterial pressure by moving the intervertebral disk.6 We put a particular emphasis on the manipulations to relax occipitalia, especially below and bilateral to the occipital tuberosity, which is different from the conventional Tuina massage treatment. We found that both normal and innovative Tuina manipulations produced good therapeutic results, with a 100% efficacy in improving symptoms in the test group, and 88.71% in the control group, indicating that the majority of patients could relieve their symptoms and return to normal life after Tuina manipulations. Nevertheless, the treatment times were markedly lower in patients in the test group compared to the control group, indicating that the innovative manipulations exhibited a greater clinical effect. It is important to note that the strength of the wrenching manipulations depends on the patient's age, constitution, disease course, and pathogenetic condition. The practitioner should contact against the tender point with the thumb, then rotate the patient's head in narrow range and adjust the flexion-extension position of the neck in a step-by-step manner until a suitable posture is found. The other hand should be used to rotate the head toward the side on which the neck rotation is limited to its elastic barrier position, then make a sudden and controlled wrenching to expand the rotation over 3-5 degrees. The wrenching manipulation should not be forceful and the arteria carotis communis cannot be pressed to avoid problems caused by carotid sinus oppression.7 Clinical anatomy studies have demonstrated that the inner transverse and sagittal diameters of the transverse process of the cervical vertebra are much longer than the external diameter of the vertebral artery, indicating that the vertebral artery is only compressed when osteophyma forms. Osteophyma of the cervical vertebra and the intervertebral joint usually invades the transverse foramen from the rear, and symptoms appear only when
JTCM | www. journaltcm. com 391

the osteophyma occupies more than one third of the transverse foramen.8 There is also increasing evidence that the symptoms may not be correlated to the osteophyma, as patients with large osteophyma may have no symptoms, while those with small osteophyma or without osteophyma may have obvious symptoms.9 We found similar results in the present study. Stimulus of the cervical sympathetic nerve may also cause reflex contraction of the vertebral artery, causing the lumens to narrow and the blood-supply decrease. In the present study, although we could not prevent osteophyma formation, the reflective contraction of the vertebral artery was markedly improved with the innovative manipulations, and the symptoms were relieved or eliminated. In the test group there was a non-significant trend for reduced brain blood flow after treatment, which was not observed in the control group, suggesting that our innovative manipulation may coordinate the relationship between the osteophyma of the uncovertebral joint and the vertebral artery in the transverse foramen, reduce the compression and stimulus of the vertebral artery, and eventually improve the brain blood flow condition. Further, we found that massage manipulation improved the functional symptoms, but not the symptoms caused by pathological abnormalities such as osteophyma formation and vertebral artery narrowing. In summary, we found that the the innovative Tuina manipulations were more effective than routine Tuina manipulations in improving functional symptoms in vertebral artery type cervical spondylosis patients. Further intensive research on the biomechanical mechanisms and clinical application of manipulations should be performed to promote the development of this therapy.

REFERENCES
1 Zhu AJ. The applied anatomy research in adult cervical spondylosis in age changes with multi-slice spiral CT. Medical Information 2010; 23(5): 1319-1321. Sun Y, Chen Q. The 2nd symposium meeting on cervical spondylosis. China J Surg 1993; 31(8): 472-476. Yu DF. Massage. Shanghai: Shanghai Publishing House of Science and Technology; 2003: 115-118. State Administration of Traditional Chinese Medicine, P. R. China. Standard for diagnosis and curative efficacy evaluation of traditional Chinese medicine disease and syndromes. Nanjing: Nanjing University Press; 1994: 32-34. Sun CX. Therapeutics of Soft Tissue Injures. Shanghai: Publishing House of Shanghai University of Traditional Chinese Medicine; 2000: 137. Zhou J. Mechanism analysis of treating cervical spondylopathy with massage-localized traction of lateral pulling manipulation. Zhong Hua Zhong Yi Yao Za Zhi 2008; 23 (4): 338-340. Ding QM, Yan MR, Zhou J. Clinical study on Treating September 15, 2012 | volume 32 | Issue 3 |

2 3 4

Ding QM et al. Innovative tuina manipulations on cervical spondylosis

126 cases of cervical spondylosis of vertebral artery type with innovative manipulation. Zhong Hua Zhong Yi Yao Za Zhi 2009; 24(7): 767-768. Shan YG, Wei HP. Hyperosteogeny at cervical intervertebral canals: Anatomical study and clinical significance. Zhongguo Lin Chuang Jie Pao Xue Za Zhi l992; 10(1): 21. Zhai SW. The Nosogenesis of cervical spondylosis of vertebral artery type. Zhongguo Kang Fu Yi Xue Za Zhi 2006; 21(7): 668-669.

JTCM | www. journaltcm. com

392

September 15, 2012 | volume 32 | Issue 3 |