Observation on the Treatment of Belt Vessel Lumbago by Daoyin method with Acupuncture

LI Yong-hong (李永红), SU Feng-zhe (苏凤哲), WANG Xiang (汪 芗), WANG Dan (王 丹),ZHANG Yu (张 俞), CHEN Xiang (陈 响), YU Xin (于 鑫), WANG Hui-min (王慧敏),YANG Wen-ting (杨文婷), WU Hai-long (吴海龙), ZOU Jin-xin (邹金芯)

Tongzhou District Hospital of Integrated Traditional Chinese and Western Medicine, Beijing 101100, China

ABSTRACTObjective:To observe the clinical efficacy of Daoyin method with acupuncture on belt vessel type lumbago, and to evaluate the effectiveness of the method.Methods:A total of 54 patients with belt vessel type lumbago who met the inclusion criteria were randomly divided into two groups, with 27 patients in both groups. Patients in the treatment group were treated by Daoyin with acupuncture on the belt vessel, patients in the control group only received acupuncture on the belt vessel. The visual analogue scale, JOA score, ODI score, and SBI score before and after treatment were observed.Results:There were significant differences in the score changes in both groups before and after treatment, and the difference between the treatment group and the control group was significant. The therapeutic effect in the treatment group is better than the control group. Daoyin with acupuncture has a better effect on belt vessel type lumbago.

KEYWORDS Belt vessel lumbago; Daoyin method; Acupuncture therapy

Belt vessel type lumbago refers to a condition characterized by lumbar and abdominal pain where the belt vessel circulation passing through accompanied by pain or traction tension in the groin due to lumbar and soft tissue injury. Modern medicine believes that its onset is associated with intervertebral disc disease, paraspinal muscle injury,and related nerve irritation pain. It is also called"spinal back and abdominal pain". Its mechanism is associated with multiple factors such as psoas major muscle injury, third lumbar transverse process syndrome, and lumbar disc herniation. The pain signals in the posterior aspect of the disc radiate to the L2 dorsal root ganglion and induce extensive pain in the buttock, root of the thigh, and inguinal region while suffering from lumbago[1]. Anatomy shows that soft tissue (such as the gluteus minimus)injuries and discogenic lumbago sites coincide with the route of belt vessel circulation, which suggests that point selection treatment based on syndrome differentiation is feasible for the treatment of lumbago[2].

Lumbago, also known as "back pain", belongs to the category of arthralgia syndrome in traditional Chinese medicine (TCM). In Qing dynasty, YAO Zhi-an pointed out that the body's flexion, extension and leaning or rising movements all depend on the waist,and there are many meridians running through the waist, such as the bladder meridian, gallbladder meridian, conception vessel, and governor vessel,etc. Therefore, the etiology of lumbago cannot be limited to the liver and kidney. InSu Wen Jing Annotation(《素问经注节解》), "the body's flexion,extension and leaning or rising movements all depend on the waist, so it is easy to cause pain in the waist. From the meridian of foot greater Yang (阳)as a starting point to extra meridians or collaterals,there are meridians, collaterals or vessels running through the waist. It is wrong to think that the only liver and kidney could cause lumbago[3]." Lumbago attacks would affect eight extra meridians and cause simultaneous pain in waist and abdomen along the belt vessel if it occurs recurrently in long term.YE Tian-shi from Qing dynasty pointed out that not only the etiology of pain is related to the liver and kidneys, but must the symptoms and treatments be considered from the eight extra meridians as the course of the disease is long. InClinical Guide and Medical Records(《临证指南医案》), "pain is the disharmony of Qi (气) and blood in the vessels and collaterals, and the treatment should be differentiated depending on meridians or collaterals involved. Diseases in the lower part of body caused by the liver and kidney will also involve the eight extra meridians. If it is not understood, the effort put in is useless work[4]."

The TCM theory believes that the belt vessel run across the waist and abdomen, and has the effect of connecting, restraining, and regulating the meridians in the waist and abdomen. The disease in the belt vessel is mainly manifested as the discomfort and pain in the site through which it passes. InLingshu•Jing Bie(《灵枢•经别篇》), "from the kidney meridian of foot lesser Yin (阴) to the popliteal fossa of knee, then going towards bladder meridian of foot greater Yang and meeting with it, then up to the kidney, and exiting at the fourteenth thoracic vertebra, they all belong to the belt vessel[5]." InClassic of Questioning(《难经》), the belt vessel start with the hypochondrium and run a circle around the body[6]. WANG Shu-he from Jin Dynasty said inPulse Classic(《脉经》), when diagnosing the disease on the belt vessel, the pain ranged from left and right sides around the navel, to lumbar,abdomen and spine, and directly to the inner thigh[7].WANG Huai-yin from Song Dynasty pointed out that belt vessel like a belt could restrict and regulate various meridians. InTaiping Holy Prescriptions for Universal Relief(《太平圣惠方》), the belt vessel start with the hypochondrium and run a circle around the body...around the body like a belt[8]. The symptoms of belt vessel lumbago, such as back soreness, limb heaviness, bearing down of the waist and abdomen, and cold pain, etc. were consistent with the symptoms of belt vessel disease in theClassic of Questioning. InClassic of Questioning,what is extra meridian disease like? Disease of the belt vessel is manifested as abdominal fullness and weakness like sitting in the water[6]. Frequent and long-term attack of diseases will certainly hurt the collateral vessel, and cause blood stasis. Therefore,it is suitable to adopt the method of nourishing and promoting blood circulation. YE Tian-shi from Qing Dynasty pointed out that, frequent and longterm attack of the disease would certainly hurt the collateral vessel, and collaterals were places where blood accumulates. So chronic illness will definitely lead to collateral blockage[9]. CHEN Xiuyuan from Qing Dynasty pointed out that, physicians generally treated lumbago from the kidney. Belt vessel lumbago should be treated by acupuncture.InMedical Conformity Record(《医学从众录》), the liver, spleen, stomach and governor vessel are all affected by this disease, which should be carefully differentiated. "When the belt vessel disease attacks,there is tapping feeling at the bar in both hands,the waist is weak like when sitting in the water. It should be treated by acupuncture"[10]ZHANG Lu from Qing Dynasty pointed out that, Belt vessel lumbago is best treated by the method of dispersing accumulation and relieving pain. InZHANG'S Yitong(《张氏医通》), the feeling of lumbago is like a tight belt, which belongs to belt vessel disease. The potent pungent flavor could be used to disperse the belt vessel's accumulation and sweet flavor could be applied to relax belt vessel's tension[11].

CLINICAL DATA

General Information

All of the 54 patients (24 males and 30 females,the youngest 21 years old and the oldest 78 years old; the disease course ranging from 1 month to the longest 15 months) were recruited from patients who visited our acupuncture and moxibustion department and orthopedic surgery department in clinic or ward from March 2017 to February 2018. A total of 54 patients were randomly divided into observation group (n=27) and control group (n=27) through random number table. There was no significant difference in gender, age, and disease duration between the two groups (P＞0.05), which make the two groups comparable, as shown in Table 1.

Diagnostic Criteria

Western medicine diagnostic criteria

Lumbago in Western medicine is associated with soft tissue injury in the waist and buttock,vertebral instability, lumbar facet joint disorders,vertebral degeneration, and disc herniation[12].CT or MRl examination confirmed the diagnosis in all cases, which is consistent with the above conditions. The diagnostic criteria established by the 2007 edition of the Chinese Medical Association"Guidelines for Clinical Diagnosis and Treatment •Pain Volume" states, most of patients have a history of lumbar trauma, chronic strain, or exposure to cold and dampness before onset, with lumbosacral pain or accompanied by lower extremity radiating pain as the main symptoms, and tenderness or radiating pain beside the spinous process of the diseased lumbar spine.

Table 1. Comparison of General Information of the Two Groups

Table 1. Comparison of General Information of the Two Groups

Group Cases Male Female Age (Years) Durations(Months)Treatment 27 13 14 48.83±17.75 4.3±2.98 Control 27 11 16 47.07±17.16 4.2±3.16

TCM diagnostic criteria

"Diagnostic and Therapeutic Criteria for TCM Diseases" was referred. Key points in the diagnosis of lumbago are as follows. ① Lumbar and abdominal pain with pain or traction tension in the inguinal and medial femoral regions. ② Patients may have lumbosacral muscle soreness on one or both sides,which is sometimes mild and sometimes severe,aggravated after exertion, and relieved after rest. ③Mild tenderness of paralumbar muscles on one or both sides, and generally no significant disturbance of low back and leg movements.

Inclusion Criteria

①Meeting the above diagnostic criteria. ② Aged 18-65 years old. ③ Diagnosed by CT or MRI, the course of disease＞2 weeks. ④ No related surgical history or surgical indications, visual analogue scale(VAS measurement value ＜7 cm). ⑤ Signing the informed consent.

Exclusion Criteria

①Combined with lumbar tuberculosis,tumor, spinal deformity, severe osteoporosis, etc..②Combined with cardiovascular and cerebrovascular,liver and kidney or gastrointestinal serious diseases and psychiatric patients. ③Patients with bleeding tendency or taking anticoagulant drugs. ④Receiving other related treatments. ⑤Pregnant women.

Observation Indicators

VAS score

Huskisson "VAS" was used for assessment.By using a 10 cm long VAS scale, the patient was asked to mark a number from 0 to 10. The high score indicates more severe pain[13].

JOA score

Before and after treatment for self-symptoms,clinical signs, daily life movements, and bladder function, totaling 0–29 points were scored, with lower scores indicating more severe dysfunction[14].

Oswestry dysfunction index (ODI) score

The index is tested to assess the degree of pain and impact on daily life. It is divided into nine aspects,intensity of pain, holding stuff, walking, sitting and standing, self-care, sleep, and social activities[15].Scoring 0 to 5 points (representing severity) for each question according to the situation. The high score indicates that the more severe the dysfunction[16].

Stenosis Bothersomeness Index (SBI) score

The score includes pain, numbness, and weakness in the lower limbs and groin, and low back or leg pain when standing. Each item is scored from 0 to 5, and the score was increased with the severity.

Efficacy Evaluation Criteria

It was evaluated with reference to the"Diagnostic and Therapeutic Criteria for TCM Syndrome"[17]. Recovered: pain and related symptoms disappear, with an improvement rate of ＞75%. Markedly effective: pain and related symptoms disappear, but sometimes lumbar pain, with an improvement rate of 50%-75%. Effective: pain and related symptoms relieved, with an improvement rate of 30%-50%, recurrent after treatment withdrawal. Uneffective: pain and related symptoms and signs not improved or even aggravated, with an improvement rate of＜30%.

Statistical Methods

SPSS 10.0 statistical software was used for statistical processing. Quantitative data was measured by mean ± standard deviationGroupttest was used for comparison, and analysis of variance was used for within-group comparison.The difference was statistically significant ifP＜0.05.

TREATMENT METHODS

The treatment group received Daoyin and acupuncture at acupoints on belt vessel.

Daoyin method: Take standing or sitting position, keep feet apart in distance of shoulder width. Both upper limbs naturally were raised, and lower the palms. The hypochondriac rib was pushed and rubbed from the waist forward to the abdomen,around the 14 vertebrae of the waist and back where belt vessel runs through. From the place below the lateral thorax, palm move downward slantly along the front edge of the anterior superior ilium crest and slanty move to the lower abdomen. It covers acupoints such as Mingmen (DU4), Jiaji (EX-B2),Shenshu (BL23), Zhangmen (LR13), Daimai (GB26),Wushu (GB27), Weidao (GB28), etc.. The strength increases gradually with tolerance as the limit[18].Take the lateral decubitus position, the palm pushed and rubbed from the spine outside, gently press and pluck along the direction of the belt vessel. After the surrounding muscles are relaxed, the palm plucked key acupoints such as Daimai (GB26), Wushu(GB27), Weidao (GB28), etc. with the manipulation strength starting from light to heavy[19].

Acupuncture: Acupoints Mingmen (DU4), L2-L4 Jiaji (EX-B2), Shenshu (BL23), Zhangmen (LR13),Daimai (GB26), Wushu (GB27), Weidao (GB28),Weizhong (BL40), Zusanli (ST36), Xuanzhong(GB39), etc. were selected. After disinfecting the skin,a filiform needle of in suitable length was selected,and the needle for 30 minutes after arrival of Qi was keep.

The control group received acupuncture without Daoyin method.

The above treatment was performed once a day,5 times a week, 10 times as a course of treatment, for a total of 2 courses of treatment. After the treatment,the two groups were evaluated for efficacy.

RESULTS

Comparison of VAS Score and JOA Score Before and After Treatment in the Two Groups

Both groups were compared with the score before treatment (P＜0.05). The therapeutic effect in the treatment group is better than the control group(P＜0.05). It is shown in Table 2.

Comparison of ODI Score and SBI Score Before and After Treatment in the Two groups

The changes before and after treatment in the two groups were statistically significant (P＜0.05),indicating that both therapies could reduce pain and improve quality of life. The efficacy in the treatment group was better than the control group (P＜0.05). It is shown in Table 3.

DISCUSSION

Belt vessel lumbago belongs to the category of "waist and leg pain" and "arthralgia" in TCM.The damage of the belt vessel can lead to waist soreness, heaviness in limbs, bearing down inlumbar and abdomen and cold pain. Its etiology is mostly liver and kidney insufficiency, external contraction of wind-cold and dampness pathogen,or phlegm stasis causing blocked meridians and collaterals, and stagnation of Qi and blood may bring about pain. Belt vessel running near the fourteenth thoracic vertebra of the back and waist, goes down obliquely from area under the lateral thorax, meet at points Daimai (GB26), Wushu (GB27) and Weidao(GB28) on the gallbladder meridian of foot lesser Yang. That is to say, the belt vessel starting from Daimai (GB26) moves forward and downward along the front edge of the anterior superior ilium crest and then goes slantly to the lower abdomen,passes through the pathway of Qi to the center of the lower abdomen, and goes around the body in a circle. WANG Shu-he from Jin Dynasty said inPulse Classic, when diagnosing the disease on the belt vessel, the pain ranged from left and right sides around the navel, to lumbar, abdomen and spine,and directly to the inner thigh. WANG Ken-tang from Ming Dynasty pointed out that, it is a syndrome of asthenia in origin and asthenia in superficiality, and the treatment should be based on both manifestation and root cause of disease. InStandards for Diagnosis and Treatment(《证治准绳》), wind, dampness, cold,heat, consumption, blood stasis, stagnation of Qi,and phlegm are all the superficial manifestation, while kidney deficiency is the root. Studies have shown that acupuncture at Beishu points on the back of the waist may contact the posterior branches of T12, L1,L2, L3, and L4 spinal nerves[20], affecting the body's somatic and sympathetic nerve function. Lumbar joint disease and soft tissue injury, manifested as extensive waist and buttock pain with groin pain and discomfort, fit in with belt vessel disease.[21]

Table 2. Comparison of VAS Score and JOA Score Between the Two Groups Before and After Treatment Point)

Table 2. Comparison of VAS Score and JOA Score Between the Two Groups Before and After Treatment Point)

Group Cases VAS score JOA score Before After Before After Treatment 27 1.83±0.95 0.97±1.03 2.80±2.51 3.93±2.63 Control 27 1.73±0.94 1.43±1.07 2.83±2.64 3.03±2.57

Table 3. Comparison of ODI Scores and SBI Scores Between the Two Groups Before and After Treatment Point)

Table 3. Comparison of ODI Scores and SBI Scores Between the Two Groups Before and After Treatment Point)

Group Cases ODI score SBI score Before After Before After Treatment 27 21.07±12.59 13.97±9.41 7.27±4.46 3.47±3.00 Control 27 21.10±12.97 17.23±10.46 7.37±4.16 4.93±3.35

Daoyin method for the treatment of pain has been documented in ancient TCM books. Pain due to external pathogens of cold-dampness attacking and induced insufficient healthy Qi internally can be relieved by pushing and pressing method to gently supplementing Yang-Qi.Suwen•Tiaojinglun Chapter(《素问•调经论篇》): The pathogen of cold and dampness attacks people, the skin could not contract and the muscle becomes stiff and tight,then blood stasis and absence of defensive Qi occurs, therefore it leads to deficiency. Pressing could active the defensive Qi to warm, and it could relieve the symptoms and reducing pain[22]. In Qing Dynasty, ZHANG Zhi-cong's further explanation is as follows. Cold-dampness pathogens damage the Yang Qi. The pathogens entering the muscle will cause stiffness and tightness, then the stagnant flow of nutrient blood and the insecurity of defensive Qi for the exterior lead to deficiency. InHuangdi Neijing Suwen Variorum(《黄帝内经•素问集注》),"this insufficiency of exterior Qi could be warmed by inducing the interior Qi out through pressing, and the symptoms could be relieved and pain reduced.[23]" In Ming Dynasty, ZHU Su pointed out that massaging the bilateral hypochondria with hands can promote Qi and blood circulation and make the five internal organs peaceful. InPrescriptions for Universal Relief(《普济方》), it is stated that "massage the bilateral hypochondria with hands. After a long time,the kidneys was to warm them. This is the health preservation behavior. It helps the spleen and kidneys to transport and transform "water and soil"of the body. Then the body return to the natural diet and digestion. The circulation of blood vessels is smooth and the organs are in peace[24]. Manipulation on belt vessel can promote the contraction of the transverse abdominis muscle, which is like putting pressure on abdomen as a belt, and it would enhance the stability of the lumbar spine. Therefore,manipulation on the belt vessel can enhance the stability of the lumbar spine and relieve low back pain[25].

The treatment of belt vessel lumbago should be based on "unblocking the belt vessel". Selecting acupuncture points along the belt vessel on the waist and abdomen could be conducted as stated in the following[26]. InLingshu•Diankuang Chapter(《灵枢•癫狂篇》): "Apply moxibustion on the belt vessel and keep threecunaway from the waist";A-B Classic of Acupuncture and Moxibustion(《针灸甲乙经》): "People with lumbago unable to turn around, Zhangmen (LR13) is the key acupoint for treatment.[27]" In Ming dynasty, LI Shi-zhen described the circulation route and acupuncture points of the belt vessel in more detail.An Examination of the Eight Extra Meridians(《奇经八脉考》): "The belt vessel starts at the Zhangmen (LR13) on foot Jueyin(厥阴) meridian in hypochondrium, and passes the same acupoint Daimai (GB26) as foot lesser Yang meridian. It circles around the body like a belt. Besides, it meets foot lesser Yang meridian at Wushu (GB27), Weidao (GB28), Fanba acupoint"[28].In Ming dynasty, GAO Wu pointed out the location of the acupoint Daimai (GB26) in detail.Acupuncture and Moxibustion Juying(《针灸聚英》): "Belt vessel starts from hypochondrium and runs around the body in a circle. The belt vessel disease will cause the disorder in waist and abdomen, in the state of watery bag. The belt vessel is located 1.8 Cun (寸)below the hypochondrium. It is called the belt vessel because it runs round the body like a belt[29]. The acupoints in the area where the belt vessel runs include: Mingmen (DU4), Jiaji (EX-B2), Shenshu(BL23), Zhangmen (LR13), Daimai (GB26), Wushu(GB27), Weidao (GB28), etc.. TCM believes that the pathogenesis of lumbago is deficiency-excess in complexity, and most patients with lumbago have the characteristics of insufficient Qi and blood and external pathogens attacking. LI Yong-cui from Qing dynasty pointed out treating the secondary aspect for emergency, and the primary aspect for chronicity.Zhengzhi Huibu(《证治汇补》): "The priority to treat the waist disease is tonifying the kidney, and then the following treatment will cover all six pathogens that could be seen. The secondary aspect was treated if it is urgent and the primary aspect was treated if it is urgent. For the early onset pain, it is suitable to unblock the pathogen stagnation and regulate meridians. For the chronic pain, it is more suitable to tonify the renal Yang and nourish blood and Qi.[30]" Mingmen (DU4) and Shenshu (BL23) are points for replenishing original Yin and original Yang;Zhangmen (LR13) and Daimai (GB26) are used for regulating Qi and promoting blood circulation. Local acupuncture points of Jiaji (EX-B2), Wushu (GB27)and Weidao (GB28) are where "the meridian passes and the treatment involves". They could treat the pain, numbness, cramps and other syndromes in the circulation area of belt vessel. The combination of acupoints can achieve the effects of unblocking and regulating the belt vessel, promoting blood circulation and removing blood stasis, regulating Qi and relieving pain. Weizhong (BL40) takes the meaning of "seek Weizhong in the back". Zusanli(ST36) could replenish Qi and blood. The marrow gather at Xuanzhong (GB39), the waist is the house for kidneys. The kidney governs the bones and produces marrow, so selection of this acupoint could nourish the kidney and relieve pain.