| Study background:Lumbar disc herniation (LDH) is a disease related to degeneration of lumbar spinal column, in which the degeneration of intervertebral disc is the key point. The pathomechanics of the disease includs the rupture of annulus fibrosus, the bulging or protrusion of nucleus pulposus, and nerve roots compression or stimulation. The patients will present virous symptoms caused by irritating nerve roots, such as low back pain, sciatica, intermittent neurogenical claudication, numbness, muscle spasm, muscle paralysis, and so on. The pathogenesis of LDH has not not yet been cleared and conclusive ever since its discovered, though, virous elements might be related to the causes of the trouble such as structures deformation, trauma or degeneration of spinal column, and the occurrence will be different in different races and occupations. The risk will be higher in smoking people and pregnant women. Above all, prolonged sitting position might play a key role in the high risk of occurance because of the weakness, tiredness and imbalance of paraspinal muscle and ligments.We could not find LDH in the disease item of Traditional Chinese Medicine (TCM), but signs and symptoms will be LDH are included into a trouble called "stagnation syndrome of qi and blood". There are three main types of the trouble as following: "blood stasis due to stagnation of qi", "wind-cold-dampness" and "deficiency of the kidney". For "blood stasis due to stagnation of qi". The patients may describe an injury in history and present obovious spine list. The pain located at a fixed point of lumbar spine and radiate to one or both lower extremities. Dark purplish tongue proper and astringe or stringlike rapid pulse will be detected. For "wind-cold-dampness", there is often no obvious history of injury. Paraspinal muscle pain and radiate pain can be detected with the fearture of stable and progressively ehanced features along with time, especially with cold weather or enviorment. A putrid and pale coated tongue will be found and a slow and deep pulse will be detected. For "deficiency of the kidney", it is often caused by improper treatment for acute injury or weekness of habitus or deficiency of kidney essence. The symptom will be intermittent for years with more or less trouble in daily life. A pale face, breathe heart and atony will be detected. In west medicine, LDH is first proposed by Mixter and Barr in 1934, diagnoses mainly depend on clinical symptoms, physical examination, image examination, electrophysiologic examination.Concerning the treatment of LDH, there are always different theories from TCM and west medicine guiding to so many specific methods. One principle is identical from both is that the surgery should be taken into account if symptoms and signs maintaining unchangble after 6 months conservative treatment. Although the methods of surgery for LDH has progressively and rapidly developed in recent years, but still can't successfully control the relapse and complications caused by an unstable spine due to operation. Conservative treatments is then popularly applied and generally accepted by the most of the patients nowadays with various quomodos, such as traction, physical therapy, massage, chiropractic, etc. How to evaluate the curative effect of conservative treatment become a key point in promoting the treatment and convincing both the scholars and patients as well. In surgery evaluation, we usually adopt JOA score or Oswestry score as idexes. But in conservative treatment, we usually adopt self-assessment of the symptoms, ASLR and DFTF, etc. But all of these indexes don't coordinate well with clinical situation. Needle EMG has also been used to determine whether nerve roots were scathed. But the outcome would not change correspondingly when clinical symptoms alleviate, there is an urgent need for clinicians then to have a sensitive, objective and quantitative electrophysiology index for curative effect estimation.Previous studies showed that anatomical and histological changes appeared in postierous joints and paraspinal muscles at involved segment in LDH patients, such as laxation of joints ligament, muscle atrophy, characteristic changes of muscle fiber, decrease of noumenon receptive organ, delay of movement reaction time. These findings proved that the detection of paraspinal muscle fatigue and cooresponding changes may symbolize the clinical situation of LDH patient. Measurement of paraspinal muscle fatigue property and coorespondence could provide valuable index for the evaluation of the concervative curative effect. Surface electronic myography (sEMG) is then taken into account. ?Recently, sEMG was widely applied in many fields as indexes of muscle fatigue and correspondence., such as health care, clinical neurology, gynecological medicine, stomatological medicine, otolaryngological medicine, sport medicine and ergonomics, We have retrospected interrelated studies in the past ten years and find MFs(median frequency slope) is generally accepted as fatigue index and FER(flexion and extension ratio) as correspondence index. We also select them in this study to examine paraspinal muscle in LDH patients. The study aimed to provide some sensitive, objective and quantitative index to evaluate curative effect. Objective1) Reproducibility of MFs is to be tested when paraspinal muscle contract isotonically in sEMG test and so does the FER when paraspinal muscle flex and extend; 2) To determine whether there is difference between LDH patients and normal people in MFs and FER during sEMG test,. 3) To figure out the correspondence between indexes (MFs and FER) of sEMG and general indexes (VAL JOA ASLR DFTF) before and after conservative treatment.. Research programs1．The reproducibility study of MFs and FER during sEMG testing1．1 Main workThis part of the research is to analyse reproducibility of MFs when paraspinal muscle contract isotonically and FER when paraspinal muscle flex and extend in normal subjects based on repeated measurement reliability testing intra class coefficient.1．2 Methods1．2．1 Samples18 normal subjects were tested in the study.1．2．2 Idexes collection proccessMFs: Referring to Biering-S(?)rensen test the subjects is asked to lie down on the table in prone position with the hip and lower extremities fixed by straps and the head suspended in midair 15cm high.The subjest could either put his arms aside of his trunk or across infront of his chest and kept in this supportless position to make a isotonical muscle contaction of lower back during the test.. The frequency index will ?then be recorded at the each side of paraspinal muscle at the level of L for 30 seconds by Mega-T8 sEMG monitor. Each subject was tested 3 times with 5 min interval in order to avoid system error. We settled the MFs based on the average of three recordings after the test.FER: Referring to Sihvonen test, the subject was bending forward to 90°from erect positon and kept in this position for 5 seconds, and then stand back to erect position during the test. The process was repeated for 5 times.1．2．3 CalculationMFs: The slope of median frequency (Hz/m) is measured and recorded indicating the index of frequency when the paraspinal muscle contracted isotonically.FER: AEMG were measured and recorded at both bending phase and extending phase with ratio (uv/uv) computed between two phrases as the index of FER.1．2．4 Characteristic feature observationDescribing characteristic of normal subject's sEMG and analyzing the reproducibility of tests of 3 times.1．3 Results1．3．1 The reproducibility of the indexes testedFERThe study compared three recordings tested at different times by General Linear Model for Repeated Measures and find that there is no significant difference among them with the p>0．05 at both side (p =0．697 at left side and p=0．532 at right side). The study also statistically analysis the Intraclass correlation coefficient (ICC) with three tests and find that there is a highly significant correlation of ICC at both side with the p<0．01 (ICC=0．941 at left side, and ICC=0．981 at right side).MFsThe study also compared three recordings tested at different times by General Linear Model for Repeated Measures and find that there is no significant difference among them with the p>0．05 at both side (p =0．559 at left side and p=0．427 at right side). The study also statistically analysis the Intraclass correlation coefficient (ICC) with three tests and find that there is a highly significant correlation of ICC at both side with the p<0．01 (ICC=0．908 at left side, and ICC=0．997 at right side). 2．The study on the difference between LDH patients and normal people based on sEMG test2．1 Main worksWe recorded MFs when paraspinal muscle contract isotonically and FER when paraspinal muscle flex and extend in both patients group and normal subjects.2．2 Methods2．2．1 Samples18 normal subjects were selected according as a control group and 71 patients with LDH in the study.2．2．2 Testing proccessThe same as in item "1．1．1" above.2．2．3 Summarize the general feature of sEMGThe study analysis and sumarize the general features of sEMG in both patient group and control group.2．3 Results2．3．1 General features of sEMG in LDH patientsIn the erect standing or fully bending position of the patients, we could still recorded electrophysiological signal of paraspinal muscle by sEMG with no special features. While during the isotonic constraction of paraspnial muscle by 20% MVC, the MF descend correspondingly but not paralleled at both side. The involed side is always tested stronger signal than the healthy side.2．3．2 General features of sEMG in normal subjectsIn the erect standing or fully bending position of the normal subjects, we could hardly recorded electrophysiological signal of paraspinal muscle by sEMG While during the isotonic constraction of paraspnial muscle by 20% MVC, the MF descend correspondingly and nearly paralleled at both side.2．3．3 Comparison study of normal subjects between two sides of paraspinal musclesThe recordings data of FER shows a normal distribution statistically at both sideof spine (FER=0．46±0．16 at left side with p＝0．819, FER=0．47±0．14 at right side with p=0．986) . We then tested the data with paired-samples T test and find no significant difference in between (p=0．779) . The recordings data of MFs also shows a normal distribution statistically at both side of spine (MFs=2．25±3．86 at left side with p＝0．791, MFs＝1．62±3．55 at right side with p=0．892) . We then tested the data with paired-samples T test and find no significant difference in between (p=0．423) .2．3．3 Comparison study of the patients between two sides of paraspinal musclesThe recordings data of FER shows a normal distribution statistically at both side of spine (FER=0．90±0．28 at left side with p=0．972, FER=0．86±0．28 at right side with p=0．905) . We then tested the data with paired-samples T test and find no significant difference in between (p=0．141) .The recordings data of MFs also shows a normal distribution statistically at both side of spine (MFs=2．21±5．65 at theleft side with p=0．814, MFs=2．44±7．07 at the right side with p=0．861) . We then tested the data with paired-samples T test and find no significant difference in between (p=0．810) .2．3．4 Comparison study between the normal subjects and the patientsThe recordings data of FER shows a normal distribution statistically in both group (FER=0．47±0．15 in normal subjects with p=0．934, FER=0．88±0．28 in patients group with p=0．995) . We then tested the data with paired-samples T test and find a very significant difference in between (p<0．01) .The recordings data of MFs also shows a normal distribution statistically in both group (MFs=1．93±3．67 in normal subjects with p=0．934, MFs=2．44±6．42 in patients group with p=0．885) . We then tested the data with paired-samples T test and find a very significant difference in between (p<0．01) .2．3．5 Comparison study between the painful side and normal side of spine in the patients groupThe recordings data of FER shows a normal distribution statistically at both side of spine in the patients group (FER=0．94±0．29 at painful side with p=0．977, MFs=0．82±0．26 in normal side with p=0．784) . We then tested the data with paired-samples T test and find a very significant difference in between (p<0．01) .The recordings data of MFs also shows a normal distribution statistically at both side of spine in the patients group (MFs=4．90±6．56 at painful side with p=0．931, MFs=0．01±5．28 in normal side with p=0．698) . We then tested the data with paired-samples T test and find a very significant difference in between (p<0．01) .3．Correlation study between sEMG testing results and the quantified clinicalmanifestation of LDH patienrs.3．1 Main workThe study also conducted a correlation study between the recording of MFs and FER of sEMG and recording of VAL, JOA, ASLR and DFTF before and after conservative treatment, which might be a reflection of patients's clinical state.3．2 Methods3．2．1 Samples81 cases of LDH were selected in this part of study according to criteria settled by the study.3．2．2 ProccessThe same as in item "1．1．1" above.3．2．3 Corelation study between changes of MFs and FER after the treatment and the changes of other quantified indexes of clinical manifestation such as VAL, JOA, ASLR and DFTF.3．3 Results3．3．1 Correlation study between the quantified indexes of clinical manifestation (ASLR, DFTF, VAL and JOA) and recording data of FER and MFs before the treatment.The recordings data of FER, MFs and all of the quantified indexes shows a normal distribution statistically with p>0．05 (p=0．883 for FER, p=0．888 for MFs, p=0．731 for ASLR, p=0．692 for DFTF, p=0．783 for VAL, and p= 0．687 for JOA).We then take a correlation study between FER and all of the other indexes and find no significant correlation in between (p>0．05) with the correlation coefficient 0．208 for correlating to ALSR,-0．087 for correlating to DFTF, 0．002 for correlating to VAL, and 0．057 for correlating to JOA,We also take a correlation study between MFs and all of the other indexes and still find no significant difference in between (p>0．05) with the correlation coefficient-0．109 for correlating to ASLR, 0．097 for correlating to DFTF,-0．037 for correlating to VAL, and-0．036 for correlating to JOA. 3．3．2 Correlation study between the quantified indexes of clinical manifestation (ASLR, DFTF, VAL and JOA) and recording data of FER and MFs after the treatment.The recordings data of FER, MFs and all of the quantified indexes shows a normal distribution statistically with p>0．05 (p=0．691 for FER, p=0．777 for MFs, p＝0．225 for ASLR, p＝0．488 for DFTF, p=0．369 for VAL, and p= 0．108 for JOA).We then take a correlation study between FER and all of the other indexes and find no significant correlation in between (p>0．05) with the correlation coefficient 0．107 for correlating to ALSR, 0．010 for correlating to DFTF, 0．031 for correlating to VAL, and 0．073 for correlating to JOA.We also take a correlation study between MFs and all of the other indexes and still find no significant difference in between (p>0．05) with the correlation coefficient 0．003 for correlating to ASLR,-0．004 for correlating to DFTF,-0．177 for correlating to VAL, and 0．108 for correlating to JOA.3．3．3 Correlation study between the changes of quantified indexes of clinical manifestation (ASLR, DFTF, VAL and JOA) and changes of FER and MFs after the treatment.The recordings data of the changes of FER, MFs after the treatment and all of the quantified indexes were proved to obey a normal distribution statistically with p>0．05 (p=0 0．826 for the changes of FER, p=0．759 for MFs, p=0．690 for ASLR, p=0．685 for DFTF, p=0．953 for VAL, and p= 0．705 for JOA).We then take a correlation study between the changes of FER and changes of the other quantified linical indexes and find a significant correlation in between (p>0．05) with the correlation coefficient 0．382 for correlating to ALSR, 0．387 for correlating to DFTF, 0．248 for correlating to VAL, and 0．323 for correlating to JOA.We also take a correlation study between the changes of MFs and changes of the other quantified linical indexes and, once again, find a significant correlation in between (p>0．05) with the correlation coefficient 0．586 for correlating to ALSR, 0．413 for correlating to DFTF, 0．425 for correlating to VAL, and 0．510 for correlating to JOA. Conclusion1．The testing data of FER by sEMG during flex-extension movement of paraspinal mascle were porved statistically reproducible with great significance. So does the testing data of MFs.2．There are significant differences of FER and MFs between normal subjects and LDH patients. While there is no significant difference of FER and MFs between left side and right side of spine in both groups. There is also significant difference of FER and MFs between painful side and opposite side in LDH patients.3．There are no significant correlatoin between recording data of FER and MFs and the quantified indexes of clinical manifestation (ASLR,DFTF,VAL,JOA) before the conservative treatment. And there are significant correlation between the change of FER MFs and change of those indexes of clinical menafestation after the treatment, which showed that FER and MFs could be used as sensitive and quantified indexes to evaluate LDH patient and therapeutic effect of a certain treatment. |
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