The Clinical Curative Effect Analysis And Biomechanical Study Of Lumbar Joint Manipulation

The Spinal Manipulation therapy is always recommended as a treatment for the degenerative diseases of the spine for the national health prevention and treatment guidelines. However, the spinal manipulation is still controversial for safety and regulatory issues. The reason is that the related mechanisms and basic clinical research is difficult to elaborate the clinical significance comprehensively and objectively. First of all, the current based biochemical experimental researches mainly focused on the vertebral body, but less attention to the paraspinal soft tissues. The injury of soft tissues is often directly related to the safety and efficacy evaluation of the manipulation. Secondly, there are seldom researches about the affection of manipulation to the paraspinal soft tissues, but it happens to be the key point of the clinical spinal injury. Therefore, this study aims at discussing the influence on the spinal muscle and the mechanism of the injuries of the two therapies. This has important clinical significance for the establishment of security principle of spinal manipulation.In the first part of the research, by using digital speckle correlation technology, the study measure the stress changes of the muscles, pressure of the lumbar disc and joint. The study observed the strain of paraspinal muscle under the different conditions of various manipulations in anatomy experiment. It is not only discuss the mechanics characteristic of the spinal manipulation, but also provide biological mechanics experimental basis data of manipulation.In the second part of the research, lumbar spine muti-body dynamic model was established by using muti-body dynamics software. The model can not only objective simulation data of muscle stress under the spine manipulation, but also provides a important method for the spinal mechanics experimental study.In the third part of the research, clinical contrast research are established by using the Feng’s manipulation which are of good repeatability, pure stress, high patient adherence, intention to conceal technique. The study used the special stress monitoring methods and special design of the control. Finally the study completed the comparison of curative effect and side effects between the two manipulations. It put forward the mechanical principle of manipulation.Research purposes:1In a fresh corpse experiment, we get the strain and pressure data of lumbar disc, vertebral and paraspinal muscle under the mobilization and thrusting manipulation by using digital speckle technology. We can analyze the characteristics of manipulation under the data.2Building the spine muti-body dynamics model:the study calculates the mechanical response of paraspinal muscle on different spinal manipulation. The model also was verified by test data of anatomy.3The controlled clinical trial compare the effectiveness and safety of thrusting manipulation and mobilization manipulation based on the controlled and repeatable principles.The research content:1Mechanical experiments of thrusting manipulation and mobilization1.1The new method of muscle strain measurement:The study measure muscle strain on the thrusting manipulation and mobilization through the three-dimensional speckle method. It also measure stress change between the surface and deep soft tissue. The result provides the basis for safe and effective manipulation treatment.1.2By fresh cadaver biomechanical test, the study observes the rule of soft tissue deformation, disc pressure and joints on the thrusting manipulation and mobilization.2Based on the data and the multi-body dynamics software, the study build muti-body dynamics model of the lumbar spine including the main muscle and ligament. The study analyzes the mechanics effect of the thrusting manipulation and the mobilization.3The pressure measurement on body and clinical effect observation of the spinal thrusting manipulation and mobilization:observe the clinical effectiveness and safety of thrusting manipulation and mobilization through the stress analysis system.Research methods:1Biomechanical experiments of the lumbar joint manipulation.1.1preparation of specimen:The specimen is a40years old man with acute death (48hours inside nasty frozen).The spine was scanned and assessment with CT and MRI. Preparation of specimen on25℃temperature, humidity45%,(including T12to pelvis, upper T12and fixed with the lower pelvis resin embedding), fixed with biomechanical machine, T12vertebral body equipped with rotating rod, the pressure load was administered (150N load with the upper body weight).The spinal specimen was to prevent water loss with water bath.1.2The measurement method:1.2.1Lumbar disc pressure monitor:pressure sensors implanted within the lumbar disc, the pressure transmitter monitor disc pressure changes after calibration using the establishment of pressure measuring system.1.2.2The joint pressure monitor:pressure sensor (the United States, Flexforce) implanted into the joints to monitor the pressure changes of lumbar zygapophyseal joints after calibration.1.2.3Thumb pressure monitor:the performer wears a pressure sensor (the United States, Flexforce) on his thumb; monitor the thumb pressure changes of different manipulation after calibration.1.2.4The muscle strain measurements by using Digital speckle method:set up the digital speckle dynamic strain measurement system, speckle was sprayed on specimens, monitoring muscle strain.1.3Simulates manipulation:1.3.1Rotation:the specimen rotated3times in5s with the Angle of20degrees under the150N loading, and then returned to the neutral position, every movement pause for10seconds.1.3.2The mobilization:the specimen rotated3times in5s with the Angle of20degrees under the150N loading. As the same time, thumb pressing on L4spinous with the horizontal torsional force of1kg,5s, rotate3times, and then go back to the neutral position. Every movement pauses for10seconds.1.3.3The thrusting manipulation:when specimen rotate to15degrees in3s, pause for0.5s, then turn five degrees within0.4s, at the same time giving the force of3kg.2Researches of Spine multi-body dynamics model and simulation manipulation study2.1Spine multi-body dynamics model:Spine specimens are scanned by64-slice CT and3.0T MR.Then the study build the lumbar spine bones, muscles, ligaments, lumbar Disc, joint model respectively by using the multi-body dynamics software.2.1.1Skeleton Model:Skeleton Model builds by the multi-body dynamics software-ThuDynamics.(Aerospace college of Tsinghua University). The model geometry information and quality information were provided by the OpenSim skeleton model.2.1.2Facet contact model:Hertz contact model.2.1.3Lumbar Disc model:shear beam lumbar Disc model2.1.4Ligament model:nonlinear rope unit2.1.5Lumbar skeletal model:Hill tendon model2.2Mechanical analysis of three different loads2.2.1Mechanical loading conditions:In the calculation, the loaded curve data come from the biomechanical machine data. It is simulated at T10-T11Vertebral body,which is loaded machine rotational force applied by biomechanics, in order to make the analog position flex and rotate20degrees. Then it repeats the rotation process, and in the horizontal direction L4spine, the thumb is exerted on the spine to measure curve of the mechanical load.2.2.2Mechanics outcome measureThe study loads three mechanical states on the spine model. Then model calculates pressure variation of lumbar Disk and joint and the responded trend of depth of muscles. Compare it with the real experimental results of corpse and prove the scientificity of the model, as well as analyze the mechanical characteristics of manipulation. The basic methods and statistics could be provided for the study of bio-mechanics technique mechanics by the research.3Analysis of the clinic effect of thrusting manipulation and mobilization3.1Case choose:The study chooses the patients diagnosed with lumbar disc herniation by MRI department of Osteopathic therapy in the Air force General Hospital from January2012to January2014.They were divided into3groups random.3.2Treatment3.2.1Basic conservative treatment:rest in bed, analgesic, dehydration, TCM hot herb, and so on.3.2.2Manipulation interventions3.2.2.1ManipulationGroup A:thrusting manipulationGroup B:mobilizationGroup C:Placebo3.2.2.2Course of treatment:twice a week for all patients in fifteen days, and inspection in the first and fifteenth day of hospital.3.3.3Index observed3.3.3.1Oswestry disability index3.3.3.2Quantitative symptom evaluation:Structure disorder symptoms and nerve root stimulation signs checked by physical check.3.3.3.3Collection of mechanical data of manipulations:The study collects the thumb pressure while doing the manipulation by the thumb pressure measurement and analysis system.The study use the data collected as the basic data for the analysis of the manipulation injury.The results:1Biomechanical study of lumbar joint manipulation 1.1The joint pressureThe joint pressure of L3-4and L4-5:thrusting manipulation> mobilization> rotation, In the condition of the three kinds of mechanics, the joint pressure is significant difference.The joint pressure of L5-S1:The pressure of rotation is lower than thrusting manipulation and mobilization, while there is little difference between thrusting manipulation and mobilization.1.2Lumbar disc pressure:The pressure of rotation is lower than thrusting manipulation and mobilization, while the pressures of thrusting manipulation are the biggest among the three groups.1.3The results of muscle strain by using the digital speckle method:1.3.1The feasibility and accuracy of measuring muscle strain by the digital speckle methodThe displacement of muscle of the Specimens is closest to the actual displacement of biomechanics machine by the digital speckle method.The displacement and strain of each observation point conform to the characteristics of Muscle biomechanics.The result proved that it is accurate to measure the muscle deformation by the digital speckle method. Also it can truthfully reflect the material properties of muscle.1.3.2Comparing the strain of three areas among group A (rotation), group B (mobilization) and group C (thrusting manipulation).1.3.2.1Surface muscle’s strains on Y direction:The strain of the upper and middle muscle is big change on the thrusting manipulation. For botom muscle, there is no significant difference among the three loadings in y direction.1.3.2.2Surface muscle’s strains on shear direction:In the upper and middle muscle, there is little significant difference on three conditions.In the botom muscle, strain changes smaller than other group on the rotation condition. There is little significant difference between mobilization and thrusting manipulation. 1.3.2.3Deep Muscle on y direction:In the upper part (point1) and the middle part (point2), strain changes smaller than other group on the rotation condition. There is no significant difference between mobilization and thrusting manipulation. In the botom muscle (point3), the strains on the rotation and mobilization manipulation are smaller than thrusting manpulation.1.3.2.4Deep Muscle on shear direction:In the upper part (point1) and the middle part (point2), strain changes smaller than other group on the rotation condition. There are no significant difference between the mobilization and thrusting manipulation. In the botom muscle (point3), the strains on the rotation and mobilization are smaller than thrusting manipulation.1.4The thumb pressure changes under thrusting manipulation and mobilization:The thumb pressure of the thrusting manipulation is three times than mobilization.2Spinal muti-body dynamics modeling and the results of the simulation manipulation2.1Spinal multibody dynamics model:The spine specimen is scaned by CT and MRI. Through Multi-body dynamics software—"ThuDynamics" from Tsinghua University, the study respectively build model of lumbar bone, muscle, ligament, intervertebral disc and articular contact.2.2Model calculates results in rotation, mobilization, and thrusting manipulation condition:2.2.1Joint pressure:thrusting manipulation> mobilization> rotation.The result consistent with the result of specimen experiment.2.2.2The pressure changes of disc:The result is consistent with the trend of data in specimen experiment.L3-4,L4-5:Thrusting manipulation> mobilization> rotation.L5-S1:The pressure of intervertebral disc in rotation is lower than other groups. There is not difference between mobilization and thrusting manipulation.2.3.3Muscle strain trends:2.3.3.1Surface muscle:The muscle strain of rotation is smaller than mobilization and thrusting manipulation.2.3.3.2Deep muscle group (multifidus muscle):The muscle strain of rotation is smaller than mobilization and thrusting manipulation. This result is accord with the data measured in the specimen.3The study of physical measurement and curative effect analysis in thrusting manipulation and mobilization.3.1The baseline of sex proportion, age and so on is similar among thrusting manipulation group, mobilization group and the placebo group.3.2The comparison of ODI index:The ODI index of thrusting manipulation group and mobilization group are significantly better than placebo group.The changes of ODI index are extremely significant before and after the treatment. But there is no significant difference between the thrusting manipulation group and mobilization group.3.3Nerve root signs index (RS):The RS of thrusting manipulation group and mobilization group are significantly better than placebo group. The changes are extremely significant before and after the treatment. But there is no significant difference between the thrusting manipulation group and mobilization group.3.4paraspinal signs index (PS):The PS of thrusting manipulation group and mobilization group are significantly better than placebo group. The changes are extremely significant before and after the treatment. But there are no significant difference between the thrusting manipulation group and mobilization group.3.5The thumb stress analysis:The peak stress between the two groups (N), the time reaching the peak force (s) and pulling speed (N/s) are extremely significant difference (p=0.0001<0.01) between the thrusting manipulation group and mobilization group.3.6adverse reactions analysis:2patients in the thrusting manipulation group withdrew from the observation because side effects.There are no serious adverse reactions in the other two groups, but the incidence of adverse reactions was no significant difference (p=0.238>0.05) among the three groups.Conclusion1The result of muscle strain is accurate and feasible by the digital speckle image correlation technology.2The result of muscle strain by the lumbar muti-body dynamics model is consistent with the results from the experiment. The model can simulate stress of the muscles and the pressure of joints, intervertebral disc in different manipulations.3There are significant influence of joints and deep muscles than lumbor disc in mobilization. There are significant influence of joints, muscles and lumbor disc in thrusting manipulation. The stress concentrates in the twisting force center.4There are no significant difference between the thrusting manipulation group and mobilization group in curative effect. However, the mobilization is safer because its force is smaller.