Clinical observation on cervical chiropractic for cervical spondylosis of vertebral artery type

Fan Shao-ting (范少挺)

Luohu District Hospital of Traditional Chinese Medicine of Shenzhen, Guangdong Province, Shenzhen 518001, China

In recent years, the incidence of cervical spondylosis has been significantly higher than before, while the affected population trends to be younger[1]. Cervical spondylosis of vertebral artery type (CSA) is a common type and accounts for about 10%-15% of patients with cervical spondylosis[2]. It is characterized by vertigo accompanied by nausea, vomiting and even faint,which seriously affects the quality of life (QOL) of patients. Although there are multiple treatments such as medication, physiotherapy and surgery, their shortcomings include adverse reactions, complicated operation and invasiveness[3]. Recently, chiropractic has been introduced to China and shown good effects in the treatment of spine-related diseases[4-6]. It is a noninvasive and non-drug treatment with simple operation and immediate effect. Chiropractic can be divided into chiropractic for cervical vertebrae, thoracic vertebrae,lumbar vertebrae and pelvis. I used cervical chiropractic to treat patients with CSA. The report is given as follows.

1 Clinical Materials

1.1 Diagnostic criteria

Referring to theGuide of Diagnosis, Treatment and Rehabilitation of Cervical Spondylosis(2010 Edition)[7],the clinical diagnostic criteria of CSA: a cataplexy attack history accompanied by cervical vertigo; positive Spurling’s sign; imaging showed segmental instability or Luschka joint hyperplasia; excluded dizziness caused by other reasons; positive neck movement test.

1.2 Inclusion criteria

Those who met the above diagnostic criteria; aged 35-65 years old; duration ≤5 years; undergone a washout period of over 5 d for those received other non-operative treatments.

1.3 Exclusion criteria

Otogenic vertigo (Meniere's syndrome, benign position vertigo, etc.); ophthalmic dizziness (refractive errors, glaucoma, etc.); brain-derived vertigo(atherosclerosis induced vertebrobasilar blood insufficiency, lacunar infarction, brain tumor, sequelae of traumatic brain injury, etc.); vascular vertigo(hypertension, coronary heart disease; severe heart,lung or brain diseases); suspected or confirmed cervical or spinal canal tumors or bone joint tuberculosis; the transcranial cerebral Doppler (TCD) examination showed one side or both of the vertebral arteries were absent, completely closed, or underdeveloped; cervical spinal canal stenosis or spinal cord compression;cervical instability caused by severe osteoporosis or systemic connective tissue disease; severe skin damage or skin disease in the manipulation area; not cooperating with the treatment, unwilling to accept, or withdraw from the study.

1.4 Statistical method

The SPSS 19.0 version software was used for data analysis. The enumeration data were processed by Chi-square test. Normality test was first employed for measurement data. The measurement data in normal distribution were expressed by mean ± standard deviationComparison within the group before and after treatment used pairedt-test, and comparison between groups used analysis of variance.P＜0.05 indicated that the difference was statistically significant.

1.5 General data

From January 2016 to June 2017, 60 CSA patients from Luohu District Hospital of Traditional Chinese Medicine, Shenzhen, Guangdong Province, who met the inclusion criteria were divided into a treatment group and a control group by random number table method, 30 cases in each group. Age range of the patients in the treatment group was 35-65 years, and the duration was from 6 d to 5 years; in the control group the age was 35-65 years, and the duration was from 8 d to 5 years. There were no significant differences in gender, age and duration between the two groups (allP＞0.05), (Table 1).

Table 1. Comparison of general data of the two groups

2 Methods

2.1 Treatment group

Patients in the treatment group were treated with chiropractic. C1-C7vertebral displacement was confirmed with mouth opening and lateral cervical spine X-ray combined with palpation examination. In accordance with the requirements of the cervical chiropractic, the displacement of the cervical spine was corrected one by one, once every other day, for 7 times.

2.1.1 Cervical chiropractic

Took C1left-posterior rotation displacement for example. The patient took a supine position, with the neck relaxed, and hands relaxed on both sides of the body. The doctor stood to the patient's head, facing the patient. Firstly, applied An-pressing and Rou-kneading manipulations for 3-5 min to relax the neck soft tissue.The doctor squatted slightly to the left of the patient's head. The left forefinger pulp of the doctor was placed on the rear of C1transverse process. The middle finger and ring finger were slightly bent and closely attached to each other. The thumb and palm supported the occipital bone. The right hand palm was gently placed on the patient's right forehead or temporomandibular jaw. With both hands flexing the neck by about 15° and rotating to the right at an appropriate angle, the doctor’s left forefinger felt the small joint activity. When the forefinger felt resistance, a small swift force was given toward the patient's nose tip. Often a ‘click’ sound could be heard, indicating the success of adjustment(Figure 1).

2.1.2 Operation precautions and accident handling

The practice requires gentleness, rapidness, and small amplitude. It could be repeated 2-3 times if the effect was not satisfactory. It’s forbidden to repeatedly or violently manipulate to seek the ‘click’ sound. Before practice, the doctor should explain the main procedure to the patient to eliminate stress. If the muscle tension couldn’t be relieved due to stress, the treatment should be suspended. Few patients’ vertigo might temporarily increase. In this case, a rest for a few minutes could relieve it.

Figure 1. Cervical chiropractic

2.2 Control group

3 Results

3.1 Observation items

The items were tested in all patients before treatment and 7 d after treatment.

3.1.1 Cervical vertigo symptom and functional assessment scale[8]

The maximum score of cervical vertigo symptom and functional assessment scale is 30 points, and it consists the following 5 items.

Vertigo: sixteen points including intensity of vertigo(8 points); number of attacks (4 points); and total duration of attacks (4 points).

Neck and shoulder pain: four points.

Headache: two points.

Daily living and work: four points.

Mental and social adaptability: four points.

According to the score before and after treatment,the improvement index was calculated as: Improvement index = (Post-treatment score - Pre-treatment score) ÷Post-treatment score.

3.1.2 TCD examination

The hemodynamic parameters of left and right vertebral and basilar arteries of all participants were examined using the Elegre SONOLINE color Doppler sonography (Siemens AG, Germany) at 2.5 MHz of probe frequency: peak systolic velocity (Vs), enddiastolic flow velocity (Vd), mean velocity (Vm),pulsatility index (PI) and resistance index (RI). The patients were examined before treatment and 1 week after the treatment respectively, and the test value was printed out.

3.2 Criteria of therapeutic efficacy

Refer to the cervical spondylosis efficacy criteria in theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional ChineseMedicine[9].

Cured: The original main symptoms disappeared;muscle strength, neck and limb function returned to normal.

Improved: The original main symptoms, and function of neck and limb improved.

Failure: No improvement in symptoms.

3.3 Results

3.3.1 Comparison of therapeutic efficacy

The total effective rate was 96.7% in the treatment group and 83.3% in the control group, with a significant difference between the two groups (P＜0.05). The curative rate was 66.7% in the treatment group and 20.0% in the control group. The difference was statistically significant (P＜0.05). These results suggested that the treatment group should be superior to the control group (Table 2).

3.3.2 Comparison of cervical vertigo symptom and functional assessment scale score

The differences in scores in both groups before and after treatment were statistically significant (bothP＜0.01), indicating that both treatment methods were effective. The scores and improvement index were statistically significant different between the two groups after treatment (bothP＜0.05), suggesting that the symptom improvement in the treatment group was better than that in the control group (Table 3).

3.3.3 Comparison of hemodynamic parameters

TCD was used to detect the hemodynamics of vertebral artery and basilar artery. Intra-group comparison: Vs, Vd, Vm, PI and RI of vertebral artery and basilar artery in both groups after treatment were significantly different from those before treatment respectively (P＜0.01 orP＜0.05). Between-group comparison: after treatment, the Vs, Vm and RI of vertebral artery and basilar artery of the treatment group were significantly different from those of the control group (P＜0.01 orP＜0.05), while there were no significant differences in Vd and PI. The above results indicated that the hemodynamic improvements in the treatment group were better than those in the control group (Table 4-Table 6).

Table 2. Comparison of therapeutic efficacy between the two groups (case)

Table 3. Comparison of the scale score and improvement index

Table 3. Comparison of the scale score and improvement index

Note: Compared with before treatment within group, 1) P＜0.01; compared with control group, 2) P＜0.05

Group n Score (point) Ⅰmprovement index Before treatment After treatment Difference value Treatment 30 20.75±3.01 28.93±2.641)2) 9.06±1.522) 0.39±0.072)Control 30 20.68±2.84 24.06±2.311) 4.38±1.48 0.24±0.08

Table 4. Comparison of hemodynamic parameters of basilar artery

Table 4. Comparison of hemodynamic parameters of basilar artery

Note: Ⅰntra-group comparison, 1) P＜0.01, 2) P＜0.05; inter-group comparison, 3) P＜0.01

Group n Time Vs (cm/s) Vd (cm/s) Vm (cm/s) PⅠ RⅠTreatment 30 Before treatment 53.9±5.1 20.3±6.6 35.9±8.5 0.77±0.12 0.58±0.05 After treatment 64.6±6.71)3) 26.3±8.61) 45.9±6.61)3) 0.57±0.132) 0.42±0.022)3)Control 30 Before treatment 56.9±6.1 21.6±7.5 36.9±7.7 0.75±0.12 0.55±0.01 After treatment 60.9±6.41) 27.7±7.61) 41.3±7.91) 0.59±0.162) 0.54±0.022)

Table 5. Comparison of hemodynamic parameters of left vertebral artery

Table 5. Comparison of hemodynamic parameters of left vertebral artery

Note: Ⅰntra-group comparison, 1) P＜0.01, 2) P＜0.05; inter-group comparison, 3) P＜0.01

Group n Time Vs (cm/s) Vd (cm/s) Vm (cm/s) PⅠ RⅠTreatment 30 Before treatment 51.5±6.2 20.7±7.5 36.9±7.8 0.76±0.12 0.56±0.02 After treatment 62.6±5.71)3) 25.7±8.51) 47.4±6.81)3) 0.56±0.132) 0.49±0.032)3)Control 30 Before treatment 51.1±5.3 21.7±7.6 37.8±6.8 0.76±0.11 0.56±0.01 After treatment 60.8±5.71) 24.9±7.41) 43.9±7.71) 0.57±0.162) 0.52±0.022)

Table 6. Comparison of hemodynamic parameters of right vertebral artery

Note: Ⅰntra-group comparison, 1) P＜0.01, 2) P＜0.05; inter-group comparison, 3) P＜0.01

Group n Time Vs (cm/s) Vd (cm/s) Vm (cm/s) PⅠ RⅠTreatment 30 Before treatment 53.5±6.9 21.7±6.3 36.3±6.2 0.74±0.12 0.54±0.03 After treatment 64.2±6.71)3) 26.7±7.21) 48.3±7.81)3) 0.55±0.122) 0.49±0.022)3)Control 30 Before treatment 53.1±8.3 21.3±7.6 37.2±6.7 0.74±0.11 0.55±0.02 After treatment 60.6±7.71) 25.6±7.41) 44.3±7.11) 0.56±0.142) 0.51±0.012)

4 Discussion

The clinical symptoms of CSA are positively correlated with neck activity. The pathogenesis of CSA is complex,and the pathogenesis of ‘cervical instability’ has received more and more acceptance by scholars[10-14].Fan WJ,et al[15]believe that ‘cervical instability’ should be the main cause of vertebrobasilar artery insufficiency.Cervical instability refers to the decreased or lost ability of the cervical spine to maintain its own stability,leading to vertebral subluxation and beyond the physiological limits[16], resulting in cervical disc degeneration, intervertebral instability or osteophyte hyperplasia which oppresses vertebral artery and sympathetic plexus, causing vertebrobasilar insufficiency, and a series of clinical symptoms[17]. The theoretical basis of chiropractic is ‘subluxation of the spine’, which means that the spine deviates from its normal position[18]. Therefore, the concept of cervical subluxation and cervical instability is almost the same.The cervical chiropractic improves the cervical instability by correcting cervical subluxation, to reduce or eliminate pathological stimulation to the vertebral artery and achieve the therapeutic effect.

At present, vasodilator such as flunarizine hydrochloride, a calcium ion antagonist, is often used for vertigo caused by CSA[19]. TCD can accurately measure Vs, Vd, Vm, RI and PI of vertebral artery, and plays an important role in the detection of vertebral artery lesions[20]. A scale that quantifies symptoms can assess the clinical efficacy of acupuncture for CSA, with good validity and reliability[21]. Therefore, flunarizine hydrochloride was chosen as the intervention measure in the control group. TCD was used to check the hemodynamic parameters, and the cervical vertigo symptom and function evaluation scale was selected as the main outcome measurement in order to fully and objectively evaluate the results of this study.

This study shows that cervical chiropractic can improve the vertebral-basilar artery blood flow velocity,reduce its PI and RI, and effectively improve the vertebrobasilar artery blood supply. The curative rate and the total effective rate in the treatment group were higher than those in the control group, which indicated that the cervical spine orthopedic has definite curative effect on CSA, and its curative effect is better than oral flunarizine hydrochloride capsule. Thus it is worthy of widely clinical use. The sample size in this study is small,so we need to expand the sample size in the future and make a further study.

Conflict of Interest

There was no potential conflict of interest in this article.

This work was supported by Project of Luohu District Science and Technology Ⅰnnovation Commission of Shenzhen, Guangdong Province (广东省深圳市罗湖区科技创新局项目, No. 24).

Statement of Informed Consent

Ⅰnformed consent was obtained from all individual participants in this study.

[1] Wu JR, Zhao BH. Study on incidence and main cause of risk population of cervical spondylosis. Dangdai Tiyu Keji,2015, 5(23): 26-27.

[2] Feng SQ, Yang MJ, Kong XH, Cheng JC, Zhao JJ, Zhang T.The change and significance of endothelin in serum of vertebral arterial insufficiency type cervical spondylosis.Zhonghua Guke Zazhi, 1997, 17(6): 387-388.

[3] Chen T, Yao XM. The pathogenesis and treatment progress of cervical spondylosis of vertebral artery type.Heilongjiang Zhongyiyao, 2013, 42(1): 49-50.

[4] Wang HH, Zhang MC, Zhan HS. Enlightenment by chiropractic's developing mode. Zhongguo Gushang, 2011,24(8): 662-666.

[5] World Federation of Chiropractic, World Health Organization. WHO Guidelines on Basic Training and Safety in Chiropractic. Geneva: World Health Organization,2005: 5-17.

[6] Zhang BF, Luo SY. Characteristic of chiropractic manipulation therapy. Linchuang Yixue Gongcheng, 2008,15(10): 72-73.

[7] The Cervical Spondylosis Committee of Chinese Association of Rehabilitation Medicine. The Guide of Diagnosis, Treatment and Rehabilitation of Cervical Spondylosis (2010 Edition). Beijing: Chinese Association of Rehabilitation Medicine, 2010: 1-13.

[8] Wang CH, Zhuo DH. A preliminary evaluation of symptoms and functions of patients with cervical vertigo.Zhongguo Kangfu Yixue Zazhi, 1998, 13(6): 245-247.

[9] State Administration of Traditional Chinese Medicine.Criteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine. Nanjing:Nanjing University Press, 1994: 190.

[10] Wang Y, Shen ZR. Research progress on diagnosis and pathogenetic mechanism of cervical spondylosis of vertebral artery type. Jingyaotong Zazhi, 2006, 2(6): 501-505.

[11] Xiong YH, Du N, Chen WZ. A study for relativity vertebral rotation, vertebral semi-unsteady and color Doppler ultrasongraphy in cervical spondylosis. Zhongguo Zhongyi Gushangke Zazhi, 2005, 13(2): 13-19.

[12] Wang F, Zhang ZL, Liu LC, Yuan ZN. The etiology and treatment of cervical vertigo. Zhongguo Jiaoxing Waike Zazhi, 2002, 9(2): 149-151.

[13] Leng H, Wang SB, Zhao JL, Xu JX. Analysis on diagnosis and treatment of cervical vertigo. Gu Yu Guanjie Sunshang Zazhi, 2002, 17(3): 209-210.

[14] Sun SC, Zhang Q. X-ray observation and diagnosis of cervical spondylosis of vertebral artery type. Zhongguo Zhongyi Gushangke Zazhi, 2000, 8(1): 28-30.

[15] Fan WJ, Du LJ. Research progress of cervical instable associated with vertebrobasilar insufficiency (review).Jingyaotong Zazhi, 2014, 35(3): 213-216.

[16] Li N. Clinical Study on Relationship Between Cervical Unstability and Occurrence of Cervical Vertigo in Youth.Jinan: Master Thesis of Shandong University of Traditional Chinese Medicine, 2012.

[17] Li J, Wei HL. Research progress on mechanism of tuina for cervical spondylosis of vertebral artery type. Shandong Zhongyiyao Daxue Xuebao, 2002, 26(3): 239-241.

[18] Wei XM, Liu JQ. Talk about the future of Chinese spinal manipulation from activator methods chiropractic technique. Zhongguo Zhongyi Gushangke Zazhi, 2011,19(7): 69-70.

[19] Lai JR, Zhong JW, Peng YF, Zhou QM, Wen HZ. Efficacy of alprostadil injection combined with flunarizine hydrochloride capsules rapid relief cervical vertigo.Zhongguo Yiyao Zhinan, 2016, 14(4): 14-15.

[20] Li L, Zhang X, Yang C. Diagnostic value of color Doppler ultrasonography for vertigo caused by cervical spondylosis of vertebral artery type. Zhonghua Quanke Yixue, 2013,11(12): 1959-1960.

[21] Wei Y, Liang WX, Cai YF. Development of functional scale for cervical spondylosis of vertebral artery type.Zhongguo Kangfu Yixue Zazhi, 2003, 18(7): 26-28.