Effect of Electroacupuncture Combined with Tuina on Lumbar Muscle Tone in Patients with Acute Lumbar Sprain

Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai 200233, China

CLINICAL STUDY

Effect of Electroacupuncture Combined with Tuina on Lumbar Muscle Tone in Patients with Acute Lumbar Sprain

Fan Yuan-zhi, Wu Yao-chi

Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai 200233, China

Author:Fan Yuan-zhi, M.D., attending physician

Objective: To observe the clinical effect of electroacupuncture (EA) combined with tuina on acute lumbar sprain and lumbar muscle tone before and after treatment.

Methods: A total of 130 acute lumbar sprain cases were randomly allocated into an observation group and a control group, 65 in each group. Cases in the observation group were treated with EA combined with tuina, whereas cases in the control group were treated with Diclofenac Sodium Dual Release Enteric-coated capsules. The muscle tones in two groups were tested before and after treatment.

Results: The recovery rate and overall response rate in the observation group were 66.2% and 93.8% respectively, versus 56.9% and 87.7% in the control group, showing no between-group statistical significances (P＞0.05). After treatment, the force-displacement area under curve (AUC) in both groups showed a significance difference (P＜0.05).

Conclusion: Both EA combined with tuina and aforementioned oral medication have remarkable effects for acute lumbar sprain, and the former can better improve the lumbar muscle tone in patients with acute lumbar sprain.

Acupuncture Therapy; Electroacupuncture; Tuina; Massage; Sprains and Strains; Low Back Pain; Muscle Tone

Acute lumbar sprain refers to soft tissue injury of the low back. It often occurs as a result of improper low back movement and is typically characterized by severe low back pain, limited movement, lumbar muscle stiffness and spasm[1]. It can affect people in all age groups, but mainly the young and middle-aged. Non-medicine acupuncture and tuina can alleviate low back pain due to acute lumbar sprain and help to restore lumbar movement. Over the past two years, we’ve verified the clinical effect of electroacupuncture combined with tuina for acute lumbar sprain and observed the lumbar muscle tone before and after treatment. The results are now summarized as follows.

1 Clinical Materials

1.1 Diagnostic criteria[2]

Having a history of lumbar sprain, often in the young and middle-aged population; severe low back pain on one or both sides, limited movement,inability to roll over the body, sit or walk, and keeping a forced posture to alleviate pain; lumbar and gluteal muscle spasm, palpable cord-like nodules, tenderness in affected area and changed physiological curve of the spine.

1.2 Inclusion criteria

Those who met the above diagnostic criteria; having a duration of less than 3 d; aged between 25 and 60 years; having discontinued other therapies during this study; those who were willing to participate in this study and signed the informed consent.

1.3 Exclusion criteria

Having an allergic constitution; having complications of lumbar intervertebral disc herniation and/or spondylolisthesis, spinal disorders, sacroiliac or hip joint problems and peripheral vascular diseases; having taken glucocorticoids that may affect efficacy evaluation (in conditions such as systemic collagen or immune diseases, acute/chronic infections, etc.); pregnant women; those presenting severe complications or deteriorating conditions; and those who were reluctant to participate in this study, dropped out or lost to follow-up.

1.4 Rejection criteria

Having allergic or severe adverse reactions during the treatment; having life-threatening deteriorating conditions; having given up or combined with other medications after 3 days of treatment; and those who failed to follow the treatment protocol or having incomplete data for efficacy evaluation.

1.5 Statistical method

The SPSS 13.0 version software was used for statistical analysis andRiditanalysis for numeration data. The measurement data were expressed withIndependent samplet-test was used for inter-group comparison and pairedt-test for intra-group comparison. APvalue of less than 0.05 indicates a statistical significance.

1.6 General data

A total of 130 eligible cases from Shanghai Jiao Tong University Affiliated Sixth People’s Hospital were randomly allocated into an observation group and a control group, 65 in each group. There were no between-group significance differences in gender, age and duration (P＞0.05), indicating that the two groups were comparable (Table 1).

Table 1. Between-group comparison of general data

2 Treatment Methods

2.1 Observation group

2.1.1 Electroacupuncture (EA)

Points: Houxi (SI 3) and Ashi points.

Method: The patient was asked to take a side or prone lying position. After routine sterilization using 75% alcohol cotton ball, insert stainless filiform needles of 0.30 mm in diameter and 40 mm in length to a depth of 20-30 mm. Upon arrival of qi, conduct small-amplitude reducing manipulation by lifting and thrusting for 2 min for each point, allowing the needling sensation to radiate towards the upper limb. Then connect the G6805-II electric stimulator with 1 or 2 groups of Ashi points, using a continuous wave, a frequency of 10-25 Hz, a current intensity of 2 mA, and stimulation intensity within the patient’s tolerance. The electric stimulation lasted for 20 min.

Cautions: It’s important for patients to select a comfortable posture. Clinical observation has shown that due to severe pain and difficulty rolling over the body, patients with acute lumbar sprain often choose a side or prone lying position. In case of needle faint, remove the needles immediately and help the patient to lie flat with elevation of legs and drink some water. In case of bleeding and hematoma after needle withdrawal, press the needle hole at least 1-2 min using dry aseptic cotton ball and ask the patient to apply cold compression 3-5 times a day. In case of stuck needle, apply massage to local muscle and slowly remove the needle.

2.1.2 Tuina

Tuina is combined after acupuncture treatment.

With a prone lying position of the patient, the practitioner first applied An-pressing and Rou-kneading to tenderness and surrounding area (Figure 1), coupled with 5-10 min of Tanbo-plucking (Figure 2). For patients with a strong constitution, Gun-rolling manipulation (Figure 3) and acupoint pressure (Figure 4) can be combined.

Figure 1. An-pressing and Rou-kneading manipulations

Figure 2. Tanbo-plucking manipulation

Figure 3. Gun-rolling manipulation

Figure 4. Acupoint pressure

With a supine lying position of the patient, the practitioner stood on one side of the patient and helped the patient with passive hip movement: flexion of the hip and knee on one side and extension of the other side (Figure 5).

With a side lying position of the patient, the practitioner stood facing to the patient, place one hand over the patient’s shoulder and place the elbow joint of the other arm over the patient’s buttock (touching the affected segments with fingers). Then, conduct small-amplitude shaking of the low back towards the same direction, followed by turning the low back to opposite directions using two hands. Pull the pivot (affected segment) with a mild force when the low back rotates to the affected segment (≤30°). A ‘crack’ sound is often heard in the joint. Alternatively, practitioners can feel shifting of posterior joint under their fingers, indicating a successful reduction (Figure 6). It’s advisable to use gentle tuina manipulation and not addict to the‘crack’ sound. The main purpose of tuina is to stretch and relax muscles. Moderate stretch to same and opposite directions is recommended. Pai-tapping and Ca-rubbing manipulations can also be combined.

Figure 5. Passive hip flexion

Figure 6. Ban-pulling manipulation

Electroacupuncture and tuina were conducted once a day, and 6 times made up a course of treatment. The therapeutic efficacy was observed after 2 courses of treatment.

2.2 Control group

Patients in the control group took 75 mg of Diclofenac Sodium Dual Release Enteric-coated capsules at the same time every day after meals for each dose, and 6 times constituted a course of treatment. The therapeutic efficacy was observed after 2 courses of treatment.

3 Therapeutic Efficacy Observation

3.1 Observation indexes

3.1.1 Lumbar muscle tone test

Myotonometer Fast Muscle State Detector (manufactured by American Neurogenic Technologies Inc., NTI) was used to measure the muscle tone. The Myotonometer detector has a metal probe of 1 cm in diameter that is encircled by a plastic sleeve of 3.5 cm in diameter. During test, pre-establish a measurement pressure and apply gentle perpendicular pressure to the skin. The displacement sensor on the probe can measure the displacement of muscle contraction and generate force-displacement value (FDV), which in turn form the area under curve (AUC) with the transverse and vertical axes. The transverse axis indicates applied pressure and the vertical axis indicates the displacement distance of probe. Under same pressure, a bigger FDV produces a bigger AUC value, i.e., a smaller muscle tone; otherwise, a smaller FDV produces a smaller AUC, i.e., a bigger muscle tone.

During test, the patient was asked to take a prone lying position. The affected side of the low back was used for measurement and labelled with a marking pen. The test pressure was pre-established as 3 kg. The initial measurement was done before treatment and the terminal measurement was done immediately after treatment.

3.1.2 Lumbar muscle tenderness test

The M-tone digital tenderness test apparatus (manufactured by Tianjin Mingtong Century Science & Technology Co., Ltd.) was used to measure lumbar muscle tenderness. This apparatus consists of digital voltmeter and signal processing module, which is connected with the pressure receptor. Before test, adjust all parameters to zero. Examine the lumbar tenderness using the thumb and measure the most noticeable tenderness area. Record the initial tenderness-triggering pressure value and keep the same measurement point and pressure value for each test.

The above test was completed by 2 trained personnel. The test was repeated 3 times within 15 min to avoid system error.

3.2 Criteria for therapeutic efficacy

This is based on the therapeutic efficacy criteria for acute lumbar sprain inCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicineby the State Administration of Traditional Chinese Medicine[2].

Recovery: Absence of low back pain and normal activity of the spine.

Better: Alleviated low back pain and almost normal activity of the spine.

Failure: Clinical symptoms remain unchanged.

3.3 Results

3.3.1 Therapeutic efficacy observation in the two groups

The recovery rate and overall response rate in the observation group were 66.2% and 93.8%, versus 56.9% and 87.7% in the control group, showing no statistically significant differences (bothP＞0.05) and indicating that the two treatment protocols share similar efficacies (Table 2).

Table 2. Between-group comparison of clinical efficacy (case)

3.3.2 AUC test results before and after treatment

Before treatment, there was no between-group significant difference in AUC value (P＞0.05). After treatment, there were intra-group and betweengroup significant differences in AUC value (bothP＜0.05), indicating that patients in the observation group obtained better effect in muscle tone than those in the control group (Table 3, Figure 7).

3.3.3 Lumbar muscle tenderness test results before and after treatment

Before treatment, there was no between-group significant difference in lumbar muscle tenderness (P＞0.05). After treatment, there was a intra-group significant difference (P＜0.05), indicating that lumbar muscle tenderness was improved in both groups. In addition, there was a between-group significant difference after treatment (P＜0.05), indicating that patients in the observation group obtained better improvement in lumbar muscle tenderness than those in the control group (Table 4).

3.3.4 Observation of adverse reactions

During the study, patients in both groups did not present abnormal changes in consciousness, sensation, movement, breathing, pulse rate and heart rate.

Table 3. Between-group comparison of lumbar muscle ACU before and after treatment ()

Table 3. Between-group comparison of lumbar muscle ACU before and after treatment ()

Note: Intra-group comparison before and after treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05

Figure 7. Lumbar muscle FDV changes in the two groups

Table 4. Between-group comparison of lumbar muscle tenderness ()

Table 4. Between-group comparison of lumbar muscle tenderness ()

Note: Intra-group comparison before and after treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05

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4 Discussion

In Chinese medicine, acute lumbar sprain falls under the category of ‘low back and leg pain’ due to meridian qi stagnation and blood stasis. In modern medicine, contributing factors of acute lumbar sprain include sudden violent injury, lifting heavy objects, overload, overstrain or improper posture. It mainly involves soft tissues such as muscles, ligament and fascia[3-5].

Acupuncture is remarkably effective for acute lumbar sprain. Literature review over the past 10 years has shown that Houxi (SI 3) is an essential point for acute lumbar sprain. According toNan Jing(Classic of Difficult Issues), Houxi (SI 3) is indicated for‘heaviness of the body and pain of the joints’. As one of the Eight Confluent points, Houxi (SI 3) connects with the Governor Vessel and can therefore regulate qi of the Governor Vessel and alleviate pain. Since it is a point of the Small Intestine Meridian of Hand Taiyang, needling Houxi (SI 3) can treat problems along the Bladder Meridian of Foot Taiyang. In this study, an effect of ‘stimulating multiple points with one needle’ by needling Houxi (SI 3) towards Hegu (LI 4) and Yaotong (EX-UE 7). EA can alleviate pain, circulate qi and blood and regulate muscle tone by altering the ion concentration and distribution with pulse current[6]. Coupled with acupuncture and tuina, it can rapidly alleviate symptoms of acute lumbar sprain.

Acute lumbar sprain is pathologically characterized by increased muscle tone and aseptic inflammation. Elastic and flexible skeletal muscle can resist passive stretch. Biomechanically, muscle tone can be measured according to tissue elasticity through FDV changes displayed by force-displacement characteristics of muscles beneath the measuring probe. In this study, myotonometric fast muscle state detector was used to quantify transverse elasticity, compliance and spasticity. Also, it showed good consistency with other measurement methods (Ashworth scale and surface myoelectricity). Test findings have shown that the average lumbar muscle tone AUC value of patients with acute lumbar sprain is 15.01 (20.35 for healthy subjects), indicating that these patients have higher muscle tone than normal people.

Results of this study have shown that after EA combined with tuina, the lumbar muscle AUC value was increased to (18.82±1.62), having a betweengroup significant difference (P＜0.05). This indicates that this therapy can more substantially improve the lumbar muscle tone of patients with acute lumbar sprain than medication. The following four reasons may explain why tuina manipulation can improve the skeletal muscle tone. First, tuina manipulation may change the calcium ion concentration in skeletal muscle cells. Studies have suggested that major contributing factor of muscle fatigue and injury is the disturbed calcium homeostasis within skeletal muscle cells[7-8]. Although there is no laboratory evidence regarding acute lumbar sprain, this can be true. Second, tuina manipulation can dilate capillaries, increase nutrition supply to local skin and muscles, elevate local tissue temperature, inhibit fibrocyte proliferation and myofibrosis, improve muscle contracture and tension, and thus release spasms and increase joint range of motion[9]. Third, mechanical stimulation by tuina manipulation can activate mechanical sensitive ion channel, which can perceive mechanical force and further transform the mechanical force into biochemical signal[10]. Four, tuina can regulate emotions, relax mind, reduce stress and thus alleviate muscle tension[11-13].

Using patients’ subjective feeling as the evaluation criteria, the VAS scoring method is often influenced by a variety of factors. As a result, this studyemployed tenderness test apparatus for low back pain intensity in diagnosis and rehabilitation evaluation after treatment. The apparatus used in this study is small, non-invasive and easy to be accepted among patients. In addition, the applied force can be adjusted according to individualized conditions. This can increase the objectivity of therapeutic efficacy for acute lumbar sprain.

Results of this study have shown that after EA combined with tuina, the lumbar tenderness value was (8.23±0.86), having a between-group statistical difference (P＜0.05). This indicates that this therapy can more substantially alleviate local tenderness of patients with acute lumbar sprain than medication. This might be related to increased release of analgesic substances including 5-hydroxytryptamine (5-HT), noradrenaline (NA), dopamine (DA) and β-endorphin[14]. This study has suggested that EA combined with tuina can obtain better pain-relief effect than Diclofenac Sodium Dual Release Enteric-coated capsules. This might be related to the immediate analgesic effect of tuina. However, its long-term effect needs further investigation.

This study has confirmed that EA combined with tuina can improve skeletal muscle spasm and reduce muscle tone. It provided theoretical foundation for role of EA and tuina in rehabilitation and evaluation of soft tissue (low back) injury.

Conflict of Interest

There was no conflict of interest in this article.

Acknowledgments

This work was supported by 2010 Special Project of‘Modernization of Chinese Medicine’ of Shanghai Science & Technology Committee (No. 10DZ1974700); Scientific Research Project of Chinese Medicine of Shanghai Health Bureau (No. 2010QL035A).

Statement of Informed Consent

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

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Translator:Han Chou-ping

Wu Yao-chi, chief physician, doctoral supervisor.

E-mail: yuanzhi008@sina.com

R246.2

: A

Date:June 13, 2014