Triple needling plus moxibustion and Tanbo-plucking tender points for the third lumbar vertebra transverse process syndrome

Guo Qing (郭清), Hua Yu (華宇), Sheng Feng (盛鋒), Song Jia-fu (宋加富), Wang Hai-qin (王海琴), Liu Xia (劉霞)

1 Community Health Service Center, Huajing Township, Xuhui District, Shanghai, Shanghai 200231, China

2 Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200030, China

3 Tongji Hospital, Tongji University, Shanghai 200065, China

Triple needling plus moxibustion and Tanbo-plucking tender points for the third lumbar vertebra transverse process syndrome

Guo Qing (郭清)1, Hua Yu (華宇)1, Sheng Feng (盛鋒)2, Song Jia-fu (宋加富)1, Wang Hai-qin (王海琴)1, Liu Xia (劉霞)3

1 Community Health Service Center, Huajing Township, Xuhui District, Shanghai, Shanghai 200231, China

2 Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200030, China

3 Tongji Hospital, Tongji University, Shanghai 200065, China

Objective:To observe the clinical efficacy of triple needling plus moxibustion and Tanbo-plucking tender points in treating the third lumbar vertebra transverse process syndrome.

Methods:Totally 108 patients with the third lumbar vertebra transverse process syndrome were randomized into two groups, 56 cases in the observation group were intervened by triple needling method plus moxibustion and Tanbo-plucking tender points; 52 cases in the control group were by acupuncture plus moxibustion. The pain rating index (PRI), visual analogue scale (VAS), and present pain intensity (PPI) from the short-form McGill pain questionnaire (SF-MPQ) were observed before and after intervention for comparing the therapeutic efficacy.

Results:The total effective rate was 96.4% in the observation group versus 76.9% in the control group, and the difference was statistically significant (P＜0.05). After intervention, the sensory-PRI, affective-PRI, total-PRI, VAS, and PPI scores were markedly changed in both groups (P＜0.05). The difference in comparing the change of clinical sign score was statistically significant between the two groups (P＜0.05). The follow-ups performed 4 weeks and 8 weeks after treatment showed that there were significant differences in comparing the relapse rate between the two groups (P＜0.05).

Conclusion:Triple needling plus moxibustion and Tanbo-plucking tender points can produce a better efficacy in treating the third lumbar vertebra transverse process syndrome than acupuncture plus moxibustion alone, and the relapse rate is relatively low.

Acupuncture Therapy; Moxibustion Therapy; Triple Needling; Shao Shan Huo (Mountain-burning Fire); Tuina; Massage; Low Back Pain; 3rd Lumbar Vertebra Syndrome

The third lumbar vertebra transverse process syndrome is caused by acute injury or strain and/or external contraction of pathogens such as wind, cold and damp, leading to non-bacterial inflammation, adhesion, degeneration, and thickening of transverse process of the third lumbar vertebra and subsequent stimulation to the lumbar spinal nerve, majorly characterized by lower back and hip pain[1-3]. The third lumbar vertebra transverse process syndrome often affects young manual workers with a predilection towards males, and is one of the common causes of low back and leg pain[4-6]. During the recent two years, weadopted triple needling plus moxibustion and Tanboplucking the tender points in treating 56 cases with the third lumbar vertebra transverse process syndrome, and compared its efficacy with treatment of acupuncturemoxibustion. The report is given as follows.

1 Clinical Data

1.1 Diagnostic criteria

It’s according to the diagnostic criteria of the third lumbar vertebra transverse process syndrome from the Criteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[7]: a history of lumbar sprain, chronic strain or contracting cold in lower back; more often seen in the young manual workers; pain on one side of lower back, becoming obvious by bending forward, aggravated in early morning or by sitting or standing for a long time, sometimes may radiate down to the knees; tenderness at the transverse process of the third lumbar vertebra, and nodes may be palpated; overlong, hypertrophic, or asymmetric transverse process of the third lumbar vertebra found in X-ray examination.

1.2 Inclusion criteria

Conforming to the above diagnostic criteria; not limited by age or gender; willing to participate in the study and having signed the informed consent form.

1.3 Exclusion criteria

Differentiated as syndrome of qi-blood stagnation; lumbago due to bone hyperplasia, tumor or intervertebral disc degeneration; complications including cardio-cerebrovascular diseases, dysfunction of liver or kidney, or life-threatening primary diseases; mental disorders; women during pregnancy or lactation period; receiving other treatments rather than those involved in this study and influencing the evaluation of therapeutic efficacy.

1.4 Drop-out criteria

Unable to finish the treatment; unable to follow the intervention protocol; severe complications or aggravation during the treatment.

1.5 General data

Totally 108 subjects were enrolled, all from the Acupuncture-moxibustion or Tuina Department from Community Health Service Center, Huajing Township, Xuhui District, Shanghai, between June 2012 and June 2014. They were randomized into an observation group and a control group by the random number table. There were no significant differences in comparing the general data of gender, age, and disease duration (P＞0.05), indicating the comparability (Table 1).

Table 1. Comparison of general data

2 Treatment Methods

2.1 Observation group

2.1.1 Triple needling

Point: Ashi point.

Method: The patient took a prone position and the practitioner stood by the side of the patient. After routine sterilization, the filiform needles of 0.30 mm in diameter and 50-75 mm in length were used. First, the projection of the transverse process tip of the third lumbar vertebra on body surface (also the tender point) was perpendicularly punctured. Then, the points 1-2 cm beyond and beneath the first needle were punctured at an angle of 45° towards the first needle. The needles were inserted until the resistant feeling was felt (suggesting that the needle tip had touched the tip of the transverse process of the third lumbar vertebra), and then the needle was uplifted by 0.1-0.2 cun. When the needling sensation was obtained, the three needles were applied with Shao Shan Huo (Mountain-burning Fire) needling manipulation: the needling depth was divided into three layers, i.e. superficial, middle, and deep layers, or into two layers, i.e. superficial and deep layers. For each layer from deep to superficial, quick thrusting and slow lifting manipulations were applied 9 times, which was named one degree. The manipulation was performed repeatedly till warm and hot feeling was produced in the topical area.

2.1.2 Moxibustion

When the warm or hot needling sensation was produced, the needles were inserted till the deep layer and a moxa roll of 3 cm in length was placed onto the needle handle. The moxa was ignited and then replaced by a new one when it’s burnt out. Each point was treated by 3 segments of moxa roll[8-10]. The needles were removed when the third segment was burnt out.The needle holes were pressed immediately when the needles were removed (Figure 1).

2.1.3 Tanbo-plucking the tender points

The patient took a prone position. The practitioner stood by the side and applied Gun-rolling, Tanboplucking, and Rou-kneading manipulations to the affected area, and Tanbo-plucking was taken as the main manipulation.

Gun-rolling: Gun-rolling manipulation was applied to the sacrospinalis and the transverse process of the third lumbar vertebra on the affected side for 3-5 min, for promoting the topical blood circulation, unblocking collaterals, and releasing muscular tension.

Figure 1. Triple needling plus warm needling moxibustion

Tanbo-plucking: The tender points on the transverse process of the third lumbar vertebra and on buttock were pressed by the belly of two thumbs till a distending feeling was produced. Then Tanbo-plucking manipulation was applied by working across the muscle fibers repeatedly from gentle to heavy and from shallow to deep. Digital Rou-kneading manipulation was used together with the Tanbo-plucking manipulation, for relieving spasm and pain, and releasing the adhesion of soft tissues. The Tanbo-plucking manipulation was performed for 3-5 min each time.

Rou-kneading: Rou-kneading manipulation was applied with the palm at the tender points for 3 min following Tanbo-plucking manipulation, for releasing pain induced by treatment.

2.2 Control group

2.2.1 Acupuncture

Major points: Ashi point, Qihaishu (BL 24), Dachangshu (BL 25), Zhibian (BL 54), Ciliao (BL 32), and Weizhong (BL 40).

Adjunct points: Yaoyangguan (GV 3) was added for invasion of external pathogens; Shenshu (BL 23) and Mingmen (GV 4) were added for kidney deficiency.

Method: Same position and needles were adopted in the control group. When the needles were inserted by 1.2-1.5 cun, lifting-thrusting and twirling manipulations were applied. Shenshu (BL 23) and Mingmen (GV 4) were reinforced while the rest points were reduced. The needles were lifted up by 0.1-0.2 cun when needling qi was obtained, and the needles were retained for 30 min.

2.2.2 Moxibustion

Each time, 2-3 points were selected to receive the same warm needling moxibustion treatment.

3 Observation of Therapeutic Efficacy

3.1 Measurements

3.1.1 Symptom rating score

The short-form McGill pain questionnaire (SF-MPQ) was adopted to evaluate the Low back pain before and after intervention, including pain rating index (PRI), visual analogue scale (VAS), and present pain intensity (PPI). The scores were determined and confirmed by the patients themselves. One specially-assigned statistician was in charge of calculating the scores at each time point. The higher the score, the severer the pain.

3.1.2 Clinical sign rating score

The clinical sign was scored by a specific person who was not involved in treatment and trained for judging objectively and fairly.

The clinical sign was majorly scored according to clinical examinations, including the count of tender points, movement range of lower back and legs, andskin temperature, color, and swelling degree of the affected area. The total score would be the sum of the sub-item scores, and the detailed scoring criteria are as below.

Tenderness: No tenderness at the transverse process of the third lumbar vertebra, scored 0; mild pain which should be triggered by greater force, scored 1; moderate pain, scored 2; serious pain which could be evoked by only a gentle touch , scored 3.

Tenderness count: No tenderness, scored 0; one tender point, scored 1; two tender points, scored 2; tender points ≥3, scored 3.

Movement range: Normal movement of lower back and legs, scored 0; slightly limited movement but without interfering with activities of daily life, scored 1; obviously limited movement, scored 2; inability to move lower back and legs or to get up from bed, scored 3.

Skin temperature in the affected area: Normal skin temperature, scored 0; slightly increased temperature, scored 1; obvious increase of temperature, scored 2.

Skin color of the affected area: Normal skin color, scored 0; slightly red skin, scored 1; obviously red skin, or with purple or bruise, scored 2.

Swelling: No swelling in lower back, scored 0; slightly swelling which required careful examination to find out, scored 1; obviously swelling which can be detected by inspection, scored 2.

3.2 Criteria of therapeutic efficacy

It’s referring the criteria of therapeutic efficacy for the third lumbar vertebra transverse process syndrome from the Criteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[7].

Recovery: Low back pain was gone, and the function was restored.

Improved: Low back pain was reduced, the function was basically restored, but overwork may still cause pain or discomfort.

Invalid: Low back pain was not significantly reduced, and the movement was limited.

3.3 Statistical method

3.4 Treatment results

3.4.1 Comparison of clinical efficacy

The total effective rate was 96.4% in the observation group versus 76.9% in the control group, and the difference was statistically significant (P＜0.05). It indicates that the therapeutic efficacy of the observation group was significantly higher than that of the control group (Table 2).

3.4.2 Comparison of SF-MPQ

Before intervention, there was no significant difference in comparing the SF-MPQ score between the two groups (P＞0.05). After intervention, all item scores of the SF-MPQ dropped significantly (all P＜0.05) in the two groups except VAS and PPI in the control group, and the decreases in the observation group were statistically more significant than that in the control group (all P＜0.05). It suggests that the pain was released more significantly in the observation group (Table 3).

3.4.3 Comparison of clinical sign score

Before intervention, there was no significant difference in comparing clinical sign score between the two groups (P＞0.05). The scores dropped significantly in both groups after intervention, and there was a significant difference in comparing the changes between the two groups (P＜0.05), indicating that the improvement of clinical sign was more significant in the observation group (Table 4).

Table 2. Comparison of clinical efficacy (case)

Table 3. Comparison of SF-MPQ score

Table 3. Comparison of SF-MPQ score

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 Time Sensory-PRI (point)Affective-PRI (point)Total-PRI (point)VAS (cm) PPI (point) Observation 56 Before treatment After treatment Control 52 Before treatment After treatment 15.98±3.12 9.53±1.621)2)15.92±3.06 13.38±1.711)6.61±1.22 3.42±0.961)2)6.58±1.18 4.41±1.041)21.78±2.12 12.38±1.581)2)20.98±1.19 16.87±1.461)5.34±1.19 2.36±0.971)2)5.44±1.28 4.34±1.14 3.14±0.70 1.52±0.471)2)3.22±0.71 2.66±0.48

Table 4. Comparison of clinical sign score

Table 4. Comparison of clinical sign score

Note: Compared with the control group, 1) P＜0.05

Group n Before treatment After treatment Difference t-value P-value Observation 56 8.11±1.37 3.24±0.94 4.71±1.321)21.93 0.00 Control 52 7.96±1.54 5.24±1.36 2.38±0.74 9.55 0.00 t-value 0.54 -8.94 P-value 0.59 0.00

3.4.4 Comparison of the relapse rate

According to the follow-up study on the effective cases, the relapse rate of 4 weeks and 8 weeks after the intervention were respectively 7.4% and 16.7% in the observation group, versus 27.5% and 45.0% in the control group, and the differences were statistically significant (P＜0.05). It suggests that the relapse rate of the observation group was markedly lower than that of the control group (Table 5).

Table 5. Comparison of relapse rate (case)

4 Discussion

The development of the third lumbar vertebra transverse process syndrome is related to the anatomical features of the third lumbar vertebra. The third lumbar vertebra is located in the center of the lumbar vertebrae. It’s highly flexible and has two long transverse processes, from where originate the musculus psoas major and quadrates lumborum, and the underlying fascias of transverse abdominis muscle and latissimus dorsi muscle are also attached to the processes. When lumbar and abdominal muscles contract forcefully, the transverse processes of the third lumbar vertebra will endure great stress, which may tear or injure the attached muscles, subsequently leading to nonbacterial inflammation and fibrosis of adjacent nerves, and hence there develops the third lumbar vertebra transverse process syndrome[11-12].

In traditional Chinese medicine (TCM), the third lumbar vertebra transverse process syndrome falls under the scope of lower back pain or Bi-impediment syndrome. It’s believed that long-term strain or invasion of external pathogens such as wind, cold, and damp to the lower back will lead to blocked meridians and qi-blood stagnation, which will result in pain. As a type of the twelve needling techniques[13-15], triple needling is usually applied to treat Bi-impediment disorders located in narrow but deep areas. The Shao Shan Huo (Mountain-burning Fire) needling manipulation is a complex reinforcing method, and can be used to treat deficient and cold syndromes. With the three needles used together with the Shao Shan Huo (Mountainburning Fire) needling manipulation and pressing needle holes after removal of needles, it does not only effectively improve the topical qi-blood circulation, but also release the adhesion and pain. Moxibustion produces a mild hot stimulation which is transported into the body via acupoints to promote blood circulation, for dispelling cold and ceasing pain, warming and unblocking meridians and collaterals, and dispersing stasis. The modern experiments and clinical practices have proven that moxibustion works to regulate the organic functions, promote metabolism, enhance the number of blood and white blood cells as well as the function of phagocytes, and modulate the immune function[16-18]. Tanbo-plucking manipulation is a comparatively heavy manipulation in tuina therapy and is performed focused on the tender points[19-23]. When muscular spasm is relieved by manipulations of Gunrolling and Rou-kneading, Tanbo-plucking manipulation is conducted on the tender points, from shallow to underlying layers and from mild to heavy strength, to produce distending, numb or sour sensations within patients’ maximum endurance. This method cannot only regulate and harmonize qi and blood, enhance the pain threshold, but also soften and unblock the stasis[24].

This study adopted triple needling, moxibustion, and Tanbo-plucking manipulations to treat the third lumbar vertebra transverse process syndrome, and achieved higher therapeutic efficacy than acupuncture plus moxibustion. This method selected fewer acupoints, and it’s easy-to-operate and highly secure.

Conflict of Interest

The authors declared that there was no conflict of interest in this article.

Acknowledgments

This work was supported by Shanghai Community Project of Traditional Chinese Medicine (上海市社區中醫藥特色項目, No: SHJCZYYNLTS-SQZYYTS-21).

Statement of Informed Consent

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

Received: 25 August 2014/Accepted: 12 October 2014

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Translator: Hong Jue (洪玨)

齊刺加灸結合痛點彈撥治療第三腰椎橫突綜合征

目的：觀察齊刺加灸結合痛點彈撥治療第三腰椎橫突綜合征的臨床療效。方法：將108例第三腰椎橫突綜合征患者隨機分為兩組，觀察組56例予齊刺、艾灸及痛點彈撥治療；對照組52例予針刺、艾灸治療。觀察治療前后兩組患者簡化McGill疼痛問卷(short-form McGill pain questionnaire, SF-MPQ)中疼痛分級指數(pain rating index, PRI)，視覺模擬量表(visual analogue scale, VAS)及現有疼痛強度(present pain intensity, PPI)評分的變化，并進行療效比較。結果：觀察組總有效率為96.4%，對照組為76.9%，兩組總有效率差異有統計學意義（P＜0.05）。兩組患者治療前后PRI感覺分、PRI情感分、PRI總分、VAS評分、PPI評分的差值比較，差異均有統計學意義(P＜0.05)。兩組治療前后臨床體征評分差值比較，差異有統計學意義(P＜0.05)。治療后4星期及治療后8星期，兩組復發率差異均有統計學意義(P＜0.05)。結論：齊刺加灸結合痛點彈撥治療第三腰椎橫突綜合征療效優于針刺加灸治療，且復發率低。

針刺療法; 灸法; 齊刺; 燒山火; 推拿; 按摩; 腰痛; 第三腰椎橫突綜合征

R246.2 【

】A

roups both

intervention once a day, 7 sessions as a treatment course, with a 3-day interval between two courses. The therapeutic efficacy was evaluated after the first and second course respectively. A 4-week and a 8-week follow-ups were then conducted.

Author: Guo Qing, bachelor, attending physician.

E-mail: xintianw@163.com