复式针刺补泻对臀大肌挛缩术后髋关节和膝关节屈伸角度的影响

Zheng De-song (郑德松), Zhao Yan (赵岩), Li Qi (李旗), Tian Fu-ling (田福玲)

1 Hebei United University Hospital, Tangshan 063000, China

2 College of Traditional Chinese Medicine, Hebei United University, Tangshan 063000, China

Gluteus maximus contracture is clinically characterized by abnormal gait, small paces, jumping step, cone-shaped buttocks, inability to approximate the knees in a sitting position or to cross legs and both hips in an abducted externally rotated position (frog-leg sign)[1]. Surgical release of the contracture is the treatment of choice in most cases[2-3]. Over the recent years, clinical studies have reported that postoperative functional exercise can facilitate the surgical treatment effect[4-5]. Despite numerous rehabilitation therapies,the underlying mechanism is still unknown. We’ve used complex reinforcing-reducing manipulations to correct the gait following surgery of gluteus maximus contracture. The Lokomat full automatic robot gait evaluation system was used to observe changes in hip/knee flexion and extension angles and explore the action mechanism of acupuncture on this syndrome.The results are now summarized as follows.

1 Clinical Data

1.1 Diagnostic criteria

This was based on the diagnosis criteria for gluteus maximus contracture in relevant literature[6]: abnormal gait (jumping step), cone-shaped buttocks, unable to approximate the knees or cross the legs in a sitting position, both hips in an abducted, externally rotated position and palpable hard band along the gluteus maximus fiber on the affected buttock.

1.2 Inclusion criteria

Those who met the above diagnostic criteria; aged between 3 and 20 with a history of 2-15 years of gluteus maximus contracture surgery; normal bilateral hip joints confirmed by X-ray examination; and those who signed the informed consent.

1.3 Exclusion criteria

Patients with the following conditions were ruled out:mental retardation, congenital myopathy, iliotibial band contracture, systemic sclerosis, congenital dislocation of hip joint, skeletal injury, and nervous system injuries.

1.4 Statistical analysis

The statistical analysis was performed using the SPSS 17.0 version software. The measurement data were evaluated using independent sample and paired sample t-test and expressed with mean ± standard deviation(). A P value of less than 0.05 indicated a statistical significance.

1.5 General materials

A total of 66 patients after surgery of gluteus maximus contracture in the Rehabilitation Department,Hebei United University Hospital were randomly allocated into an observation group and a control group by the random digits table, 33 in each group. There were no between-group statistical differences in gender,age, duration, affected location and severity (P＞0.05)[7],indicating that the two groups were comparable(Table 1).

Table1.Between-group comparison of general materials

2 Treatment Methods

2.1 Observation group

2.1.1 Basic treatment[8]

The basic treatment was conducted 5-7 d after surgery. These include crossed adduction of the lower limbs, passive hip joint flexion, abduction, external rotation, passive gluteal muscle training, hip joint flexion, and squatting down of legs and knees that are placed together. These exercises were gradually increased in intensity and amplitude. The treatment was done once a day, 30 d for a course of treatment.There was a 1-week interval between two courses.The therapeutic efficacy was observed after 3 courses of treatment.

2.1.2 Acupuncture treatment

Points: Biguan (ST 21), Futu (ST 32), Zusanli (ST 36),Liangqiu (ST 34), Xuehai (SP 10), Diji (SP 8),Yanglingquan (GB 34), Zhibian (BL 54), Huantiao(GB 30) and Juliao (GB 29).

Method: Acupuncture was performed on the basis of basic treatment upon 5-7 d of surgery. The patient was first asked to take a supine lying position. The above points were punctured using filiform needles(Huatuo Brand manufactured by Suzhou Medical Appliance Factory) of 0.35 mm in diameter and 50 mm in length. Upon arrival of qi, Biguan (ST 31),Futu (ST 32), Zusanli (ST 36), Liangqiu (ST 34), Xuehai(SP 10), Diji (SP 8) and Yanglingquan (GB 34) were performed with Shao Shan Huo (Mountain-burning Fire) reinforcing manipulation. Biguan (ST 31) and Futu (ST 32) were punctured 40 mm in depth; and Zusanli (ST 36), Xuehai (SP 10), Liangqiu (ST 34), Diji(SP 8) and Yanglingquan (GB 34) were punctured 25 mm in depth. The needles were retained for 30 min.The patient was then asked to change to a prone position. Zhibian (BL 54), Huantiao (GB 30) and Juliao(GB 29) were punctured 40 mm in depth, followed by Tou Tian Liang (Heaven-penetrating Cooling) reducing manipulation. The needles were retained for another 30 min.

The acupuncture treatment was done once a day,30 d for a course of treatment. There was a 1-week interval between two courses. The therapeutic efficacy was observed after 3 courses of treatment.

2.2 Control group

3 Therapeutic Efficacy Observation

3.1 Observation parameters

The Lokomat full automatic robot gait evaluation system was used in this study. The method and parameter regulation were based on relevant literature[9].

3.1.1 Ten-minute endurance shuttle walk test

This test was performed on the basis of normal pulmonary and cardiac functions and within the patient’s tolerance. To enable the patients to fully adapt to Lokomat system, patients were asked to walk 10-15 min before the official test. The official test was conducted after a 24-hour rest upon 1-2 times of experimental walk.

For each test, the patient was given the same guidance and encouragement from the doctor. The distance of 10-minute walk along a straight line to the best of the patient’s effort was recorded. The test was immediately terminated in case of abnormal reactions during the walk test, and the terminated test was considered as failure.

3.1.2 Changes of flexion and extension angles of hip and knee

Hip joint: the hip flexion angle on foot followed(HFA-FF), the maximum of hip flexion angle (MAX-HFA)and the maximum of hip extension angle (MAX-HEA).

Knee joint: the knee flexion angle on foot followed(KFA-FF), the maximum of knee flexion angle on stance phase (MAX-KFA-TP) and the maximum of knee flexion angle on swing phase (MAX-KFA-WP).

3.2 Results

3.2.1 Between-group comparison of hip flexion and extension angles

After treatment, there were significant changes in HFA-FF, MAX-HFA and MAX-HEA in the observation group (P＜0.05); there were significant changes in HFA-FF and MAX-HEA in the control group(P＜0.05);and there were between-group statistical significances in HFA-FF, MAX-HFA and MAX-HEA (P＜0.05). This indicated that patients’ flexion and extension angles of hip in both groups were significantly improved and patients in the observation group obtained better results than that in the control group (Table 2).

3.2.2 Between-group comparison of flexion and extension angles of knee

After treatment, there were significant changes in KFA-FF, MAX-KFA-TP and MAX-KFA-WP in the observation group (P＜0.05); there was significant changes in KFA-FF in the control group(P＜0.05); and there were between-group statistical significances in KFA-FF, MAX-KFA-TP and MAX-KFA-WP (P＜0.05). This indicated that patients’ flexion and extension angles of knee in both groups were significantly improved and patients in the observation group obtained better results than those in the control group (Table 3).

Table2.Between-group comparison of hip flexion and extension angles (, °/s)

Table2.Between-group comparison of hip flexion and extension angles (, °/s)

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

Groupn HFA-FF MAX-HFA MAX-HEA Before treatment After treatment Before treatment After treatment Before treatment After treatment Observation33 20.55±1.84 23.08±1.301)2) 22.17±1.94 25.21±3.191)2) 1.09±1.65 －0.43±1.071)2)Control33 20.53±1.85 22.00±1.341) 22.47±2.14 23.19±1.70 0.92±1.56 0.26±0.981)

Table3.Between-group comparison of knee flexion and extension angles (, °/s)

Table3.Between-group comparison of knee flexion and extension angles (, °/s)

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

Group n KFA-FF MAX-KFA-TP MAX-KFA-WP Before treatment After treatment Before treatment After treatment Before treatment After treatment Observation33 8.06±1.75 5.60±2.451)2) 15.61±3.01 11.35±2.311)2) 38.61±8.95 49.86±9.071)2)Control33 7.85±1.74 6.77±1.981) 14.39±3.31 13.25±2.07 40.28±9.53 45.39±8.22

4 Discussion

Human walking is accomplished with a strategy called the double pendulum through joint flexion and extension of the lower limbs[10]. Due to fibrosis of the gluteus maximus contracture, patients with gluteus maximus contracture are unable to flex and externally rotate both hip joints[11]. This can further affect their knee functions. Their hip and knee functions need full recovery after surgical release of the contracture.

In traditional Chinese medicine (TCM), gluteus maximus contracture falls under the category of Wei-flaccidity syndrome. Contributing factors include contraction of external damp-heat, improper diet and weak constitution due to chronic conditions. These factors may obstruct flow of meridian qi, resulting in muscular atrophy and manifesting as abnormal gait and signs. Since Yangming Meridians are full of qi and blood, they are always selected to treat Wei-flaccidity syndrome. Shao Shan Huo (Mountain-burning Fire)reinforcing manipulation on points of stomach meridian can unblock meridians, supplement qi and nourish blood. Reinforcing Xuehai (SP 10) and Diji(SP 8) can circulate qi and move blood. Reinforcing Yanglingquan (GB 34), the influential point of tendon,can strengthen the tendon and bone. Because the surgical wound is susceptible to redness, swelling and pain, Tou Tian Liang (Heaven-penetrating Cooling)reducing manipulation on Zhibian (BL 54), Huantiao(GB 30) and Juliao (GB 29) can clear heat, resolve swelling and alleviate pain[12-14].

Modern studies have proven that motions of multiple joints are accomplished by contraction and relaxation of muscle groups. Motion of the hip and knee joints during human walking is also accomplished through contraction and relaxation of major muscle groups[15-16]. Contraction and relaxation of muscle groups are associated with muscle strength and muscle tension. Acupuncture can increase muscle strength and decrease muscle tension, further influencing the contraction and relaxation of muscle groups and indirectly affecting the effective joint motions of the lower limbs[17-18]. The findings of this study have suggested that reinforcing-reducing manipulations of Shao Shan Huo (Mountain-burning Fire) and Tou Tian Liang (Heaven-penetrating Cooling)can improve the MAX-HFA, MAX-HEA, KFA-FF,MAX-KFA-WP and MAX-KFA-TP, which indicated that these needling manipulations can indirectly influence the effective motions of hip and knee joints through influencing the muscle strength and muscle tension of the lower limbs, increase the range of motion of the hip and knee joints and thus improve patients’ gait after gluteus maximus contracture.

Despite some improvement achieved in this study,whether acupuncture can help with isolated movement requires further study.

Conflict of Interest

The authors declared that there was no potential conflict of interest.

This work was supported by Tangshan City Science &Technology Program (No.121302118b).

Statement of Informed Consent

All of the patients in the study signed the informed consent.

[1]Ma LQ. Surgical treatment for injection-induced gluteus maximus contracture. Harbin Yiyao, 2005, 25(6): 114-115.

[2]Cheng ZS, Li H. Surgery treatment for gluteal muscle and fascia contracture in adults. J Pract Orthop, 2008,14(7): 439-440.

[3]Ping GX, Huang JK, Qiu DZ, Chen L, Yu HL, Yan JC,Tan YG, Peng W, Li RC. Diagnosis and surgical treatment of severe gluteus maximus contracture. Chin J Orthop, 2003, 23(7): 418-422.

[4]Chen SJ, Li H. Multifactor analysis on the curative effect of acupuncture in patients with cerebral infarction. Chin J Clin Rehabil, 2005, 9(41): 4-5.

[5]Shi XM. Xingnao Kaiqiao Acupuncture therapy for stroke. Chin J Clin Rehabil, 2003, 7(7): 1057-1058.

[6]Ma CX, Fang LG, Liu GL. Injection-induced gluteus maximus contracture. Zhonghua Waike Zazhi, 1987,16(6): 987-990.

[7]Huang YT, Li JW, Lei W. Etiology, category and treatment of gluteal muscle contracture. Zhonghua Guke Zazhi, 1999, 19 (2): 105-108.

[8]Yu H, Zhang CY, Tian LS, Fang J. Exercise training for patients after surgery of gluteus maximus contracture.Xiandai Kangfu, 2010, 5(9): 139.

[9]Guo SM, Li JM, Wu QW, Shen HT. Clinical application of Lokomat automatic robot gait training and assessment system. Zhongguo Yiliao Shebei, 2011, 26(3): 94-96.

[10]Xu GQ, Huang DF, Lan Y, Mao YR, Liu P. Threedimensional kinematic effect of joint movements of lower extremity on walking ability in patients with stroke.Chin J Clin Rehabil, 2004, 8(31): 6816-6818.

[11]Ni B, Li M. The effect of children’s gluteal muscle contracture on skeleton development. Sichuan Daxue Xuebao: Yixue Ban, 2007, 38(4): 657-659.

[12]Qiu JW. Needling techniques of setting fire on the mountain and coolness through penetrating heaven for 24 patients with Bi-impediment syndrome. Guangxi Zhongyiyao, 2000, 23(6): 33.

[13]Wang H. Clinical observation on needling techniques of setting fire on the mountain and coolness through penetrating heaven for 30 cases with cerebral infarction.Zhongguo Zhen Jiu, 1996, 16(6): 13-14.

[14]Yu Y. Talk on acupuncture reinforcing and reducing manipulation. Zhongyiyao Xuekan, 2006, 24(4): 748.

[15]Prestes J, Shiguemoto G, Botero JP, Frollini A, Dias R,Leite R, Pereira G, Magosso R, Baldissera V, Cavaglieri C, Perez S. Effects of resistance training on resistin,leptin, cytokines, and muscle force in elderly post-menopausal women. J Sports Sci, 2009, 27(14):1607-1615.

[16]Dieli-Conwright CM, Spektor TM, Rice JC, Sattler FR,Schroeder ET. Hormone therapy attenuates exerciseinduced skeletal muscle damage in postmenopausal women. J Appl Physiol, 2009, 107(3): 853-858.

[17]Zhang HM, Tang Q. Rehabilitation evaluation on post-stroke abnormal movement pattern prevented and treated with acupuncture and rehabilitation. Zhongguo Zhen Jiu, 2011, 31 (6): 487-492.

[18]Yang XC, He SF, Wang RC, Zhou YM. Observation on curative effect of thermal acupuncture needle muscular stimulation therapy for knee osteoarthritis patients. Zhen Ci Yan Jiu, 2012, 37 (3): 237-241.