Clinical observation on Nie-pinching spine manipulation combined with point therapy for cerebral palsy in children with spleen deficiency

Tan Xiao-ru (谭晓如), Liu Zhen-huan (刘振寰), Xie Jie-shan (谢洁珊), Jin Bing-xu (金炳旭), Luo Guan-jun (罗冠君), Zhao Wen-jian (招文健), Zhao Yi-li (赵伊黎)

Department of Pediatric Neurological Rehabilitation, Nanhai Maternity and Children’s Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine, Guangdong 528200, China

Clinical observation on Nie-pinching spine manipulation combined with point therapy for cerebral palsy in children with spleen deficiency

Tan Xiao-ru (谭晓如), Liu Zhen-huan (刘振寰), Xie Jie-shan (谢洁珊), Jin Bing-xu (金炳旭), Luo Guan-jun (罗冠君), Zhao Wen-jian (招文健), Zhao Yi-li (赵伊黎)

Department of Pediatric Neurological Rehabilitation, Nanhai Maternity and Children’s Hospital Affiliated to Guangzhou University of Traditional Chinese Medicine, Guangdong 528200, China

Objective:To observe the clinical effect of Nie-pinching spine coupled with point application and injection for cerebral palsy (CP) in children with spleen deficiency.

Tuina; Massage; Chiropractics (TCM); Acupoint Therapy; Acupoint Sticking Therapy; Hydro-acupuncture; Cerebral Palsy; Infant

Cerebral palsy (CP) refers to a group of permanent disorders of movement and posture that are due to brain damage or developmental defects before birth or after the first month of life. This condition often results in complications such as mental retardation, audiovisual impairment, behavior disorder and functional disturbance of vegetative nerve. The rehabilitation efficacy on CP can be affected by multiple factors. A poor constitution due to spleen deficiency and repeated respiratory tract infection are common in CP children. These factors may prolong the rehabilitation process, delay the treatment timing and affect the rehabilitation efficacy.

Children with spleen deficiency often present with a pale complexion, general fatigue, a poor appetite, weight loss, irregular bowel movements (diarrhea or constipation), profuse sweating and frequent commoncolds. This study observed the effect of Nie-pinching spine manipulation combined with point application and injection on spleen-deficiency symptoms in CP children. The results are now summarized as follows.

1 Clinical Materials

1.1 Diagnostic criteria

1.1.1 Diagnosis in Western medicine[1]

Non-progressive disturbances in the brain; motor impairment is associated with the brain; symptoms occurring in infancy; having complications of mental retardation, epilepsy, sensory impairments and other abnormalities; exclusion of central nervous disorder in progressive conditions or temporary delay in motor development.

1.1.2 Diagnosis in Chinese medicine[2]

This was based on the diagnosis for spleen deficiency in theGuiding Principles for Clinical Study of New Chinese Medicines: a poor appetite, reluctance to talk, general fatigue, abdominal distension after eating food, loose stools or stools containing undigested food, a pale tongue with a thin white coating and a weak pulse.

1.1.3 Classification

Spastic: Damage to the pyramidal tract.

Athetoid: Damage to the extrapyramidal tract, manifesting as slow, involuntary, convoluted, writhing or chorea movements, dystonia and tremor, etc.

Ataxic: Damage to the cerebellum.

Hypotonic: Transitional pattern of other types.

Mixed: Presence of two or more patterns simultaneously.

1.2 Inclusion criteria

Those who met the above diagnostic criteria; aged under 3 years old; and the guardian agreed to participate in this study and signed the informed consent.

1.3 Exclusion criteria

Those who were not suitable for point application due to local skin lesion or infection; the guardian refused to sign the informed consent; having received other therapies that may affect the study results; having organic conditions of the heart, lung and kidney; those who failed to meet the inclusion criteria or follow the treatment protocol and those with incomplete clinical data.

1.4 Statistical method

The data processing was done using the SPSS 12.0 version software. The enumeration data comparison including symptom scores was conducted by the Chi-square test. The ranked data comparison was done withRiditanalysis. APvalue of less than 0.05 indicates a statistical significance.

1.5 General data

A total of 70 hospitalized CP infants between June 2013 and June 2014 were randomly allocated into a treatment group (n=35) and a control group (n=35). Of the 70 cases, 40 had spastic CP, 16 had involuntary movement, 2 had ataxia and 12 had mixed types. There were no between-group statistical differences in age, gender and severity (allP＞0.05), indicating that the two groups were comparable (Table 1).

Table 1. Between-group comparison of baseline data

2 Treatment Methods

CP children in both groups received comprehensive rehabilitation therapies. These include drugs, acupuncture, physical training (PT), tuina, speech training (ST) and occupational therapy (OT). The treatments were done once a day, 20 d for a course of treatment. There was a 20-day interval between two courses. The CP children were treated for a total of 3 courses.

2.1 Treatment group

2.1.1 Nie-pinching spine manipulation

With a prone lying position of the child, the practitioner stood on the left and posterior side of the bed: placed the thumbs over the skin close to Changqiang (GV 1) on both sides of the spine and conducted Nie-pinching, Nian-twisting and Ti-lifting using the index and middle fingers. At the same time, moved both hands from bottom to top until Dazhui (GV 14). From the third time, the practitioner lifted the skin perpendicularly (90°) once after every three pinches, this is often followed by a sound, i.e., ‘3 pinching and 1 lifting’. The Nie-pinching spine was done 5-8 times, focusing on Pishu (BL 20) and Weishu (BL 21). After this, the practitioner Nie-pinched the Bladder Meridian on both sides 3 times from bottom to top (Figure 1). The treatment was done twice a day, once in the morning and once in the evening, 20 times made up a course of treatment. There was a 20-day interval between two courses, and the children with CP were treated for a total of 3 courses.

Figure 1. Nie-pinching spine

2.1.2 Point application

Preparation of the self-madeJian Pi Gu YuanPaste to strengthen the spleen and consolidate the Yuan-primordial qi: grind equal parts ofDang Shen(Radix Codonopsis),Bai Zhu(Rhizoma Atractylodis Macrocephalae),Fu Ling(Poria),Huang Qi(Radix Astragali) andFang Feng(Radix Saposhnikoviae) into a fine powder and mix with honey.

Points: Pishu (BL 20), Weishu (BL 21), Guanyuan (CV 4), Tianshu (ST 25), Zhongwan (CV 12) and Shenque (CV 8).

Method: After routine sterilization, herbal pastes (0.5 cm × 0.5 cm) were placed in adhesive non-woven infusion plaster and applied to 4-6 points for each treatment (Figure 2), once every other day. It’s important to observe skin allergy, skin rashes, itching or blisters during the treatment. The plasters were removed after 0.5-2 h and the local area were cleaned with warm water.

Figure 2. Acupoint sticking therapy

2.1.3 Point injection

Injection: Mouse nerve growth factor (18 μg, manufactured by Sinobioway Medicine Co., Ltd., China Food and Drug Administration approval number: 5006S2200).

Points: Bilateral Zusanli (ST 36).

Method: Based on the tolerance of children, 0.3-0.5 mL was injected to each point, 3 times a week, and 20 d made up a course of treatment. There was a 20-day interval between two courses. The treatment was done for a total of 3 courses.

2.2 Control group

In addition to comprehensive rehabilitation training, children in the control group took multi-enzyme tablets (manufactured by Sichuan Yike Pharmaceutical Co., Ltd., China Food and Drug Administration approval number: H51020247, containing 300 mg pancreatic enzyme and 13 mg pepsin). Children under 1 year took 1 tablet a day in two times; and children between 1 and 3 years took 1.5 tablets a day in three times.

3 Clinical Observation

3.1 Therapeutic efficacy criteria

3.1.1 Therapeutic efficacy criteria for spleen deficiency

The therapeutic efficacy criteria for spleen deficiency were based on theGuiding Principles for Clinical Study of New Chinese Medicines[2]and theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[3].

Five major symptoms including a poor appetite, reluctance to talk, general fatigue, abdominal distension after eating food and loose stools were classified into 4 grades (absence, mild, moderate and severe) and marked as 0, 2, 4 and 6 points. The total maximum possible score is 30. A higher score indicates a more severe spleen deficiency. The decrease rate of symptom score was calculated according to the following formula:

Decrease rate of symptom score ＝ (Pre-treatment score － Post-treatment score) ÷ Pre-treatment score×100%.

Recovery: Normal appetite and food intake, almost absence of clinical signs and symptoms, coupled with decrease rate of symptom score ≥95%.

Marked effect: Substantially increased appetite and food intake, remarkable alleviation of clinical signs and symptoms coupled with decrease rate of symptom score ≥70%, but ＜95%.

Improvement: Increased appetite and food intake, alleviated clinical signs and symptoms coupled with decrease rate of symptoms score ≥30%, but ＜70%.

Failure: Appetite, food intake, and clinical signs and symptoms remain unchanged or become aggravated, coupled with decrease rate of symptom score ＜30%.

3.1.2 Criteria for rehabilitation efficacy[4]

The rehabilitation efficacy was evaluated using the gross motor function measure (GMFM) score before and after treatment. The GMFM contains 88 items in 5 gross motor dimensions: A (lying and rolling), B (sitting), C (crawling and kneeling), D (standing) and E (walking,running and jumping). Score of each dimension ＝(Actual score ÷ Dimensional score) × 100%. The Total score ＝ Scores of each dimension ÷ 5. The full marks for the total score and each dimension are both 100. A higher score indicates a better function.

Marked effect: The GMFM score increased by ≥15. Improvement: The GMFM score increased by ≥10 but ＜15.

Failure: The GMFM score increased by ＜10.

3.2 Results

3.2.1 Comparison in spleen-deficiency syndrome

Before treatment, there was no statistical significance in spleen-deficiency syndrome (P＞ 0.05). After treatment, the scores of spleen-deficiency syndrome were significantly decreased in both groups, showing a statistical significance (P＜0.05); and there were between-group statistical significances in scores

(P＜0.05). This indicates that both methods can alleviate spleen-deficiency syndrome in CP kids, but the effect was better in the treatment group than that in the control group (Table 2).

After treatment, the total effective rate of spleendeficiency syndrome in the treatment group was 85.7%, versus 51.4% in the control group, showing a statistical difference (P＜0.05) and indicating a better effect in the treatment group than that in the control group (Table 3).

3.2.2 Comparison in rehabilitation effect

After treatment, the total effective rate of rehabilitation in the treatment group was 77.1%, versus 57.1% in the control group, showing a statistical difference (P＜ 0.05) and indicating a better rehabilitation effect in the treatment group than that in the control group (Table 4).

Table 2. Between-group comparison in scores of spleendeficiency syndrome before and after treatment

Table 2. Between-group comparison in scores of spleendeficiency syndrome before and after treatment

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

Group n Before treatment After treatment Treatment 35 25.80±5.96 5.85±1.521)2)Control 35 24.95±4.35 12.86±3.311)

Table 3. Between-group comparison in spleen-deficiency syndrome effect after treatment (case)

Table 4. Between-group comparison in rehabilitation effect after treatment (case)

4 Discussion

Clinical studies have found that CP kids often present with deficiency of the liver and kidney, and hypofunctions of the spleen and stomach with subsequent insufficiency of qi and blood. As a result, these kids often experience malnutrition, delayed physical development and immune deficiency, especially in kids under 3 years old. Some CP kids may also have difficulty swallowing/chewing and inappropriate complementary feeding. These factors may also contribute to delayed growth and development as well as malnutrition, which can further cause them to be susceptible to infections and affect their quality of life and rehabilitation efficacy. Since the quality of life depends on Yuan-primordial qi and children with CP often have congenital deficiency and weakness of the spleen and stomach, it’s important to reinforce their spleen and stomach.

Manipulation of Nie-pinching spine can stimulate the Governor Vessel and Bladder Meridian to reinforce healthy qi and remove pathogenic factors. Studies have confirmed that Nie-pinching spine manipulation can increase the number of anaerobic bacteria such as bifidobacteria, improve flora distribution, restore immune and chemical barrier and maintain local immunity[5]. Modern medical experiments have proven that this method can increase gastric secretion, increase gastrointestinal motility, enhance the secretion and activity of enzymes, promote mechanical and chemical digestion, boost the gastrointestinal digestion on protein and starch and thus benefit the gastrointestinal function, nutrition and constitution in children with CP[6-7]. Because the spleen dominates muscles, reinforcing the spleen and stomach function in children with CP can increase the muscle strength and thus improve their motor function. Modern medicine believes that the spine is the origin and pathway where the brain andspinal cord connect nerves with organs and tissues. Branches of sympathetic trunk on both sides of the spine reach internal organs. Strong stimulation activates sympathetic nerve and inhibits parasympathetic nerve; whereas soft stimulation inhibits sympathetic nerve and activates parasympathetic nerve[8]. The Nie-pinching spine manipulation consists of soft, three Nie-pinching and one heavy Ti-lifting, which can excite and inhibit vegetative nerve and regulate the digestive system in two ways. In addition, it’s simple, convenient and painless and worth further clinical application both at home and hospital.

Point application is an external therapy to apply Chinese herbal paste to specific points to unblock meridians, regulate qi and blood, reinforce healthy qi, remove pathogenic factors, and balance yin and yang through the combined functions of medicine, meridians and points. Just like the absorption mechanism of transdermal drug delivery in Western medicine, point application makes use of the storing function in stratum corneum, moderate the plasma-drug concentration curve and increase the biological availability of medicine without passing through the stomach and digestive tract[9-10]. TheJian Pi Gu YuanPaste containedDang Shen(Radix Codonopsis),Huang Qi(Radix Astragali),Fu Ling(Poria),Fang Feng(Radix Saposhnikoviae) andBai Zhu(Rhizoma Atractylodis Macrocephalae). TheSi Jun ZiDecoction acts to strengthen the spleen and reinforce qi; andYu Pin FengPowder acts to benefit qi and consolidate the exterior.FangFeng(Radix Saposhnikoviae) is pungent and sweet in taste and enters the Bladder, Liver and Spleen Meridians. Modern studies have proven that it can increase the phagocytic rate and index of macrophages in mice and boost immune function.Bai Zhu(Rhizoma Atractylodis Macrocephalae) is bitter and sweet in taste, warm in property and enters the Spleen and Stomach Meridians. It is often used for weakness of the spleen and stomach, a poor appetite, abdominal fullness and distension, general fatigue and diarrhea. Modern pharmacological studies have proven that it can significantly regulate gastrointestinal function and boost immunity[11-12].

Stomach Meridian is full of qi and blood. Zusanli (ST 36) is the lower He-Sea point of the stomach and can boost immunity, strengthen disease-defending ability, harmonize the spleen and stomach, reinforce qi, remove pathogenic factors, unblock meridians, remove wind, and resolve dampness. Injection of mouse nerve growth factor can circulate qi and blood, activate meridian qi and benefit the body.

Results of this study have suggested that Nie-pinching spine manipulation combined with point application and injection can improve spleen-deficiency symptoms in children with CP, increase their muscle strength and benefit the rehabilitation effect.

Conflict of Interest

There was no conflict of interest in this article.

Acknowledgments

This work was supported by Project of Guangdong Provincial Administration of Traditional Chinese Medicine (广东省中医药管理局课题, No. 21031055).

Statement of Informed Consent

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

Received: 15 January 2015/Accepted: 20 February 2015

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Translator: Han Chou-ping (韩丑萍)

捏脊配合穴位疗法治疗脾虚证脑性瘫痪的临床观察

目的：观察捏脊、穴位贴敷结合穴位注射治疗脾虚证脑性瘫痪(cerebral palsy, CP)的临床疗效。方法：将70例脾虚证CP患儿简单随机法分为治疗组和对照组, 每组35例。治疗组在采用综合康复疗法的基础上加用捏脊、穴位敷贴及穴位注射; 对照组在采用综合康复疗法基础上口服多酶片。两组均治疗20 d为1个疗程, 疗程结束后休息20 d, 再行下一个疗程, 共治疗3个疗程。根据治疗后脾虚证主要症状评分及粗大运动功能评估(gross motor function measure, GMFM)量表评分变化情况评价疗效。结果：治疗3个疗程后, 治疗组脾虚证症状总有效率为85.7%, 对照组为51.4%; 治疗组康复总有效率为77.1%, 对照组为57.1%。治疗组脾虚证症状总有效率及康复总有效率均明显高于对照组, 两组差异均具有统计学意义(均P＜0.05)。结论：在综合康复疗法基础上应用捏脊、穴位贴敷及穴位注射治疗脾虚证CP的疗效优于综合康复疗法结合口服多酶片治疗。

推拿; 按摩; 捏脊; 穴位疗法; 穴位贴敷法; 水针; 脑性瘫痪; 幼儿

R244.1 【

】A

Author: Tan Xiao-ru, attending physician

Liu Zhen-huan, professor, doctoral supervisor.

E-mail: lzh1958424@163.com

Methods:A total of 70 CP children with spleen deficiency were randomly allocated into a treatment group (n=35) and a control group (n=35). Children in the treatment group were treated with comprehensive rehabilitation training, Nie-pinching spine, point application and point injection, whereas children in the control group were treated with comprehensive rehabilitation training and oral administration of multi-enzyme tablets. One course of treatment made up of 20 d. There was a 20-day interval between two courses. The cases were treated for a total of 3 courses. Then the therapeutic efficacies were evaluated using scores of spleen-deficiency symptoms and gross motor function measure (GMFM).

Results:After 3 courses of treatment, the total effective rates for spleen-deficiency symptoms and rehabilitation were 85.7% and 77.1% respectively in the treatment group, versus 51.4% and 57.1% respectively in the control group, showing statistical differences (bothP＜0.05).

Conclusion:In addition to comprehensive rehabilitation training, Nie-pinching spine combined with point application and injection obtained better effects than oral administration of multi-enzyme tablets.