Effects of horse-riding squat exercise plus Governor Vessel-regulating Tuina therapy on static balance function in patients with stroke

WU Ji (吴佶), HUANG Chunshui (黄春水), ZHAO Yun (赵芸), XUE Kun (薛堃), LU Yusun (陆虞荪)Shanghai Changning Tianshan Traditional Chinese Medicine Hospital, Shanghai 200051, China

Abstract

Keywords: Tuina; Massage; Horse-riding Squat Exercise; Stroke; Poststroke Syndrome; Hemiplegia; Balance Function

At present, stroke has become a common clinical disease with high incidence, high disability, and high mortality.According to statistics, the annual incidence of stroke in China is 120-180 in 100 000, and the disability rate is as high as 86.5%[1].About 75% of stroke patients have impairments in the motor system,sensory system, and activities of daily living (ADL)[2].Balance dysfunction is a common daily problem in stroke patients, greatly affecting their daily life, living,and working.And dynamic balance function is the key to improving the prognosis of stroke patients with hemiplegia.

The treatment of balance disorders after stroke can be divided into two major fields: traditional Chinese medicine (TCM) and modern rehabilitation medicine.Our previous studies showed that horse-riding squat exercise in TCM[3]or Governor Vessel-regulating Tuina(Chinese therapeutic massage) therapy[4]both improved balance dysfunction in stroke patients.However, the previous evaluation indicators were mainly based on the balance scale, and the objectivity and quantification were not strong[3-6].With the development of computer technology and balance dysfunction research, some new treatment techniques and evaluation methods have been developed and applied.The static balancer efficiently evaluates the balance function[6].Therefore, we used a static balancer in this study to observe the effect of horse-riding squat exercise and Tuina therapy alone or in combination on the static balance function of stroke patients in order to evaluate the effect of TCM therapy on static balance dysfunction more objectively and quantitatively.

1 Clinical Materials

1.1 Diagnostic criteria

This study referred to the diagnostic criteria for cerebral infarction (acute ischemic stroke) and cerebral hemorrhage in theGuidelines and Consensus on Diagnosis and Treatment of Cerebrovascular Diseases in China (2016)[7].The stroke was confirmed by clinical diagnosis and head CT or MRI examination.

1.2 Inclusion criteria

Those who met the diagnostic criteria; with a Berg balance assessment ＜20 points according to the Berg balance scale; with stable vital signs; aged 40-70 years old, gender unlimited; 1-3 months after stroke onset;agreed and signed the informed consent.

1.3 Exclusion criteria

Those who had an infarction in the brain stem or cerebellar area, or proprioception disorder; patients with congestive heart failure or respiratory failure;patients with malignant tumors; those who had malignant progressive hypertension; patients with active liver disease or renal insufficiency; patients with apraxia of the affected limb, agnosia, hemianopsia or hemispatial neglect; those who had conscious, mental or intellectual disabilities; those who could not cooperate during the trial.

1.4 Elimination and dropout criteria

Those who or their guardians did not cooperate with treatment protocol during the trial; those who had severe adverse reactions (such as skin damage) and were not suitable to continue the trial; those who dropped out during the trial; lost during follow-up.

1.5 Statistical methods

All data were statistically analyzed by the SPSS version 22.0 statistical software.The measurement data were all in normal distribution and expressed as mean ±standard deviation.The pairedt-test was applied to intra-group comparisons.And the analysis of variance was applied to the comparisons between the groups.The counting data were analyzed by Chi-square test.Rank-sum test was used for comparisons of ranked data.P＜0.05 was considered to indicate a statistically significant difference.

1.6 General data

This clinical study was reviewed and approved by the Ethics Committee of Shanghai Changning Tianshan Traditional Chinese Medicine Hospital, and the clinical trial approval number was 2019TSKY14.A total of 176 cases were enrolled.They were hospitalized in the Second Department of Rehabilitation of Shanghai Changning Tianshan Traditional Chinese Medicine Hospital between November 2019 and November 2020.The patients were divided into a control group, a horseriding squat + Tuina group, a horse-riding squat group,and a Tuina group by the random number table method,with 44 cases in each group.During the trial, one case in the Tuina group dropped out due to intolerance to Tuina treatment.There were no statistically significant differences in the general data of gender, age, duration of disease, and stroke type among the four groups(P＞0.05), indicating that they were comparable (Table 1).

Table 1 Comparison of the general data among the four groups

2 Treatment Methods

2.1 Control group

Physical therapy with balance training was performed by a rehabilitation therapist, including trunk muscle, hip joint, and knee joint control training, sitting balance training, weight transfer training, and ADL training,20 min/time, 5 times a week.

2.2 Horse-riding squat group

The horse-riding squat group was treated with additional horse-riding squat exercises based on the treatment of the control group.

The patient took a knee-bending squat position, with the back leaning against the wall, and the left foot moved one step to the left.The distance between the two heels was as wide as the shoulder breadth.The knees and toes were slightly buckled inward, while the heels were slightly pushed outward, with the toes in an inner “八”-shape.The patient had the upper body and chest straight, slightly forward, with the abdomen tucked in.The weight was placed between the legs, and the head was as if against something.The eyes looked at the front horizontally, and the breathing should be natural.The training intensity increased gradually.In the beginning, the knees flexed slightly, with the knee flexion controlled at 30°.With the increase of training times, the patient’s center of gravity was gradually lowered under tolerable conditions until the knee flexion reached 60°.See Figure 1.

Figure 1 Horse-riding squat exercise

The patient had 3 groups of horse-riding squat exercise each time and took a 2 min rest after each group was completed.After the last group of training,the patient spanked the lower limb muscles for 3 min to relax the muscles.The training lasted for 30 min in total,5 times a week, which was once a day from Monday to Friday consecutively, and Saturday and Sunday as a break.

2.3 Tuina group

The Tuina group was treated with additional Governor Vessel-regulating Tuina therapy based on the treatment of the control group.

The patient took a prone position.The physician applied rolling manipulation for releasing the back muscles of the patient.The manipulation was performed up and down 2-3 times, with a frequency of 120-150 times/min (Figure 2).

The physician pressed and kneaded the Governor Vessel along the spine with the thumb or thenar, gently at first and then heavily, from top to bottom, and paused at the points to perform pressing and kneading manipulations.The manipulations were performed for 15-20 s each time and repeated 3 times to produce a topical warm feeling (Figure 3).

Rolling manipulation was performed up and down 5-6 times along the bilateral Bladder Meridian, with a frequency of 120-150 times/min, lasting for 15-20 s each time (Figure 4).

Figure 2 Rolling manipulation for releasing the back muscles

Figure 3 Pressing and kneading the Governor Vessel with palmar root

Figure 4 Rolling the bilateral Bladder Meridian

The physician plucked the bilateral sacrospinalis(Figure 5).The manipulation should be gentle but deep penetrating in the process of plucking.Pressing and kneading manipulations were performed at Jiaji (EX-B2)with stronger stimulation.Then the physician applied linear rubbing manipulation to the Governor Vessel and bilateral Bladder Meridian on the low back till heat penetration (Figure 6).

The Governor Vessel-regulating Tuina therapy was performed 20 min per time, once a day from Monday to Friday, and Saturday and Sunday as a break.

Figure 5 Plucking the bilateral sacrospinalis

Figure 6 Linear rubbing along the Governor Vessel and bilateral Bladder Meridian on the low back

2.4 Horse-riding squat + Tuina group

Based on the treatment in the control group, the same horse-riding squat exercise in the horse-riding squat group and the same Governor Vessel-regulating Tuina therapy in the Tuina group were performed.After the horse-riding squat exercise, a 5-10 min break was taken, and then the Governor Vessel-regulating Tuina therapy was performed.

2.5 Treatment time and precautions

The balance function of the patients was evaluated after 4 weeks of treatment.All other physical therapy related to the treatment of the disease was discontinued in the four groups during the treatment.Patients were advised to avoid spicy, cold, or other irritating food; avoid excessive mental stress, and keep light-hearted; pay attention to rest and avoid overwork.

3 Treatment Results

3.1 Observation items

The static balance function of the TecnoBody PK254P static balance instrument (TecnoBody, Italy) was used for measurement before and after treatment.The patient stood on a fixed electronic balance board with the assistance of the physician, and the position coordinates of the first test were recorded according to the balance board coordinates, so that the same position coordinates could be used for the next assessment.After inputting general data, the physician selected the static stability evaluation module for testing.The patient lifted his chest and head, fixed his eyes on the marker in front of him, and tried to hold the posture for 30 s.

Length of motion refers to the total trajectory length of the body’s center of gravity movement during the test, indicating the speed and amplitude of the center of gravity movement.A value greater than 250 mm indicates an abnormality.

An elliptical area of motion refers to the total area contained in the trajectory of the body’s center of gravity movement during the test, indicating the magnitude of the body’s center of gravity movement.A value greater than 200 mm2indicates an abnormality.All patients were tested twice consecutively, and the better observation indicator was selected.

3.2 Results

Before treatment, there were no statistical differences in the ellipse area of motion or the length of motion among the four groups (P＞0.05).After treatment, the ellipse area of motion and the length of motion in all four groups were reduced, and the intragroup differences were statistically significant (P＜0.05).See Table 2.

The differences in the ellipse area of motion before and after treatment in the horse-riding squat + Tuina group and the horse-riding squat group were greater than that in the control group, and the between-group differences were statistically significant (P＜0.05).The difference in the ellipse area of motion before and after treatment in the horse-riding squat + Tuina group was more notable than that in the Tuina group, and the difference between the groups was statistically significant (P＜0.05).The differences in the length of motion before and after treatment in the horse-riding squat + Tuina group, the horse-riding squat group, and the Tuina group were greater than that in the control group, and the between-group differences were statistically significant (P＜0.05).There was no statistically significant difference in pairwise comparisons between the horse-riding squat + Tuina group, the horse-riding squat group, and the Tuina group (P＞0.05).See Table 2.

4 Discussion

Stroke is one of the four major difficult diseases in TCM, mainly manifested by sudden fainting,unconsciousness, hemiplegia, deviation of mouth and eyes, and speech disadvantage.Some scholars have proposed that post-stroke balance dysfunction belongs to the category of “tendon disease”in TCM, and that“tendon”is the main location of post-stroke balance dysfunction[8].Clinically, the muscle regions take the meridians as the basis.The theory of muscle regions highly summarizes the human bones and their affiliated tissues, as well as the regulating effect of the twelve muscle regions on the bones[9-11].The viewpoint of tendon disease in TCM has actively and effectively guided the clinical treatment of balance dysfunction in stroke patients.Ba Duan Jin (Eight-section Exercise), Wu Qin Xi (Five Mimic-animal Exercise), Dao Yin (Physical and Breathing Exercise) therapy, Tai Ji Quan (Shadow Boxing), and Shaolin Gongfa (Shaolin Exercise) are common methods for the treatment of this disease[12-15].

Table 2 Comparison of the ellipse area and length of motion among the four groups before and after treatment

Table 2 Comparison of the ellipse area and length of motion among the four groups before and after treatment

Note: BT=Before treatment; AT=After treatment; DBAT=Difference before and after treatment; compared with the same group before treatment, 1) P＜0.05; compared with the control group, 2) P＜0.05; compared with the Tuina group, 3) P＜0.05.

Group n Ellipse area of motion/mm2Length of motion/mm BT AT DBAT BT AT DBAT

Horse-riding squat is the basic stance form of Shaolin Neigong (Shaolin Internal Exercise)[16].In the training,the lower limbs are mainly controlled by flexors, so that the knees are bent and squatted, and the knees and toes are slightly buckled, and the horse-riding squat posture is maintained by the contraction of its antagonistic muscle-quadriceps femoris.The center of gravity is between the two knees, which has the effect of improving the muscle strength of the lower limbs[17].Horse-riding squat exercise, as one of the isometric contraction training, can effectively strengthen muscle strength and endurance, increase the effective physiological cross-sectional area of the muscle, and increase the synthesis of muscle fiber contractile protein.After training, the weight-bearing of the affected lower limb can be practiced, which is conducive to the symmetrical distribution of the center of gravity and the enhancement of the static balance function.

Tuina is one of the most important nonpharmaceutical natural therapies in China.It mainly uses manipulations such as pushing, grasping, pressing,kneading, pinching, point-pressing, and patting to produce a direct impact on different points on the patient’s body surface, so as to achieve the effects of unblocking meridians and collaterals, promoting Qi flow and blood circulation, eliminating pathogenic factors and reinforcing healthy Qi, and regulating and harmonizing Yin and Yang.The location of stroke is in the brain, and thus it is closely related to the Governor Vessel[18].Governor Vessel-regulating Tuina therapy improves the static balance function of patients by enhancing tissue excitation, changing abnormal movement patterns, promoting balance and coordination between muscle groups, enhancing muscle endurance and exercise accuracy, improving walk stability and symmetry, and reducing energy consumption[19].

Improving balance ability is of great significance to the recovery of motor function in stroke patients.The balance function requires the coordination of multiple muscle groups and bones.Movement in daily life depends on the maintenance of static and dynamic balance[20].Static balance refers to the ability to maintain balance when the human body is in a static state.It is completed by isometric contraction of muscles and joint contraction of muscles on both sides of joints, which is the basis for balance function[21].The ellipse area of motion and length of motion are quantified forms reflecting the overall stability of static balance function in patients with hemiplegia.The ellipse area of motion in normal people is small, and the length of motion is short; in people with hemiplegia,the ellipse area of motion and length of motion both increase and are proportional to the severity of balance disorder[22].

Based on the previous studies[3-4], we combined horse-riding squat exercise with Governor Vesselregulating Tuina therapy to observe the effect on static balance function in stroke patients.Results showed that after the rehabilitation training under the guidance of the physician, the static balance dysfunction of the patients reduced.On this basis of rehabilitation training,horse-riding squat exercise and Governor Vesselregulating Tuina therapy used alone or in combination both had better effects than rehabilitation training alone.Among these, the horse-riding squat exercise plus Governor Vessel-regulating Tuina therapy had a better effect in reducing the ellipse area of motion than Governor Vessel-regulating Tuina therapy.And there were no statistical differences in reducing the length of motion between the combined treatment and the two methods used alone.Thus, traditional Gongfa and Tuina therapy, used alone or in combination, can effectively improve the static balance function in patients after stroke.

In this study, the ellipse area and length of motion were used to evaluate the effect of traditional Chinese Gongfa and Governor Vessel-regulating Tuina therapy on static balance function in patients after stroke,providing clinical evidence for further development of this treatment and inspiring the treatment of poststroke balance dysfunction.

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Acknowledgments

This work was supported by 2017 Traditional Chinese Medicine Dominant Diseases Cultivation Project of Shanghai Traditional Chinese Medicine Development Office: Balance Dysfunction after Stroke (2017 上海市中医药发展办公室中医优势病种培育项目-中风后平衡功能障碍, No.Zybz-2017039).

Statement of Informed Consent

Informed consent was obtained from all individual participants.

Received: 7 December 2021/Accepted: 30 September 2022References

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