| Lumbar Disc Herniation is the most common disc-like illness of chronic diseases, one of the high incidence diseases in our country. Long-term clinical practice has proved what China Journal of Orthopaedics and Traumatology manipulation is excat efficacy for this disease, which is an important means of clinical non-surgical therapy of choice.Manipulation is one of the core techniques of treatment of the disease, is simple, effective and quick, a wide range of clinical applications. The Dutch Health Care Committee and the North American Spine Surgery Association of clincal guidelines are recommended in early lumbar disc herniation of patients without cauda equina syndrome treated conservatively, including manipulations. Manipulation therapy used more and more widely, the mechanics of manipulation researched more and more deeply at home and abroad. Many researchers use more research means and methods to clarify the role of the manipulation,the study of manipulation acquired the stage of good results. Deeper research of manipulation is challenging.Manipulation used in lumbar disc degeneration or disc herniation is not closely combined with clinical in vivo measurement data in Biomechanical study,the mechanical parameters of the experimental setup is also much to learn from the literature, the results and conclusions are difficult to fully explain the mechanics of manipulation in clinical pathological state effect mechanism.Furthermore, the existing researches use non-mechanical mechanism of animal model as the Study objectless human lumbar spine specimens,which model lacks spine mechanics mechanism of characteristics, difficult to close a real clinical pathological state. This study is just to elaborate above-mentioned problems,and clinical practice,useing human lumbar specimens in vitro to studyjn order to elaborate deeply the mechanism of manipulation、the role of the characteristics and security, provide important reference for clinical and scientific research. and has important practical significance guidance clinical.This study comes from the2010National Natural Science Foundation 《A study to lumbar prominent segment of the internal structure visualization by analog manipulation》 and Beijing Natural Science Foundation《A study about Biomechanical mechanism of kneading manipulation of TCM in Non-specific Low Back Pain from the view point of the "Disease area in the soft tissues, cure the soft tissues"》. In response to these issues and clinical practice two experiments has explored:Firstly, a simulated model of IDD or LDH in vitro experiment under cyclic loading pressure conditions was done and this condition was confirmed by heights about anterior, mid and posterior vertebral body and intervertebral space and three-dimensional motion analysis; Secondly, in order to explain the motions of related segments, pure motion was loaded based on the LDH model and simulated manipulation of oblique-pulling on different vertebral angles were conducted. Thirdly, two positions and four simulated manipulation of oblique-pulling methods were conducted on BOSE dynamic/static material testing machine to test the lumbar intradiscal pressure, for the sake of evaluating the mechanism and safety of this manipulation.Experiment IAimsl.To study close to the clinical practice after conducting the manipulation in simulated experiment.2.To make an objective and clear description on the results from the changes of segments motions changes and operating characteristics of lumbar manipulation.MethodsTwelve processed calf lumbar spine specimens were used on the BOSE dynamic/static material testing machine. The cyclic loading was conducted as following:The Adams, MA, Hutton WC lumbar segment cyclic fatigue loading mechanical modeling was referred to in the processing, which lasted6hours.60cycles/min,21600rpm,300N initial pressure,750N peak pressure,8°flexion of cyclic loading was loaded on the specimens in the whole processing. The loading in the form of sinusoidal waveform started from mild cyclic loading and the peak pressure is gradually increased to a maximum.Movement loading system was connected with the cyclic loading before and after the loading.6Nm movement was loaded to test lumbar three-dimensional motion and the process of the simulated manipulation. Six movement directions such as flexion, extension, left-handed, right-handed, left bending and right bending were tested in three statuses including neutral, loaded and unloaded status. Motion capturing system was used to collect information with60HZ fruquency and ls acquisition. All information was saved as.prj format.CT scanner (Lightspeedl6) was used to capture the cyclic loading process before and after the loading, which is produced by GE Company.The heights about anterior, mid and posterior vertebral body of L3, L4and L5were measured. The intervertebral space of L3-L4, L4-L5, and L5-S1from anterior, mid and posterior heights was measured. The segment maximum movement range of L3-L4, L4-L5, and L5-S1in six directions and neutral zone were measured. Angular displacements of L3, L4, and L5in six directions was measured.Statistic analysis:All statistical tests were two-sided tests. Measurement data were expressed as mean±SD and analyzed using SPSS13.0software. Data were subjected to homogeneity test for variance. Data of homogeneity of variance were analyzed with one-way analysis and mean between two groups was compared using Student-Newman-Keuls q test. Data of heterogeneity of variance were analyzed with Welch, and mean between two groups was compared using Dunnett T3test. P<0.05was considered statistically significant.Results1. Paired t test was used to compare the intervertebral space heights of L3-L4-. L4-L5、L5-S1in twelve specimens before and after cyclic loading. There is significant difference (P<0.05) and all the space heights were lower after the cyclic loading.2. Although, vertebral body heights of L3、L4、L5were lower, there is no significant difference after the cyclic loading by paired t test (P>0.05)3. There is a significant difference on segment movement of the L3-L4、L4-L5、 L5-S1in the six movement directions and neutral zone after cyclic loading by paired ttest (P<0.05)4.During the left-handed, right-handed, simulated manipulation of oblique-pulling, L3, L4, L5vertebral motions were coupled motion, while rotating happened the same time with the vertebral flexion or extension or bending movement.During the right side manipulation of oblique-pulling, single-factor analysis of variance showed that there is no significant difference in the disc group flexion and extension, lateral bending, rotation angle displacement (P>0.05), but the results showed a trend of the displacement of axial rotation angle less than flexion and extension, lateral bending.The single-factor analysis of variance between discs on flexion and extension, lateral bending, rotation angle displacement showed no significant difference (P>0.05), the rotation angle displacement reduced sequentially, like L3> L4> L5, bending angle displacement decreased like L3> L4> L5. During the left side manipulation of oblique-pulling, The vertebral rotation angle displacement of L5is less than the flexion and extension angle displacement with a statistically significant difference (P<0.05). However, the single-factor analysis of variance for the other discs movement in the six directions showed no statistic differences (P>0.05). The rotation angle displacement reduced sequentially like L3>L4>L5.5. The comparison between the left side and right side manipulation showed that the displacement in the left bending of the L3is less than the right rotation, with a statistically significant difference (P<0.05), but the other directions angle displacement analysis has no statistical differences (P>0.05) by paired T test. For L4and L5,there is no statistical differences in all movement directions (P>0.05).Conclusion1. It means that such a cyclic loading succeeded in simulating the second stage of disc degeneration-unstable period.After cyclic loading, a physiological joint capsule laxity has formed; there was a abnormal activity and instability for the small facet.2. It could explain that the angle displacement of flexion is one of the mechanisms of manipulation of oblique-pulling treating spinal endogenous waist and leg joint pain.Rotating manipulation of L3, L4, and L5vertebral body produced a conjugate movement including flexion than rotation; however, the angle displacemengt of lateral bending must to be explored.3. We also found that the pulling strength may gradually increase with rotating manipulation of oblique-pulling of L3, L4and L5, which make it more difficult in clinical practice. The difference between the left and right flipping may come from the ipsilateral muscle with high stress or long-term muscle tension and joint stiffness.Experiment ⅡAims1. To explore two positions and four manipulation methods treating intradiscal pressure under cyclic loading. 2. To evaluate the safety of the manipulation method under cyclic loading.3. To explore the mechanism of the manipulation method under cyclic loading.4. To investigate the effects on different discs by the manipulation method under cyclic loading.MethodsA mini pressure sensor (Model060) with the amplifier was connected to the computer through the USB7360data acquisition system, to create a pressure testing systems.After experiment I twelve processed calf lumbar spine specimens were used on the on BOSE dynamic/static material testing machine. The mini pressure sensor was implanted in the lumbar disc by2mm Kirschner needles or thoracic puncture needles, which were connected with the pressure testing systems.Four different simulated loading conditions for the manipulation was set on the BOSE dynamic/static material testing machine,such as the-500N sitting rotating oblique pulling,-300N sitting rotating pulling, the ON supine traditional oblique pulling and the+100N supine oblique pulling.The loading program was written by the software of Wintest software control torque and angle on the BOSE machine. The details are pre-loading with7.5Nm, flip loading with25Nm, flipping time covering0.05s,0.10s and0.15s.Two small pre loading/unloading were done before the experiment, to reduce the impact of lumbar viscoelastic. There will be30seconds stay after each small pre loading/unloading, allowing the lumbar tiny moving. The formal measurement began with the3rd loading.Five sets of data were collected during this experiment including:a. the intervertebral disc pressure values at baseline on the supine and sitting positions for L3-L4, L4-L5and L5-S1;b. the intervertebral disc pressure values at baseline for L3-L4,L4-L5and L5-S1by four different pulling methods;c. the intradiscal pressure values by four different pulling methods with7.5Nm loading and25Nm loading for L3-L4, L4-L5and L5-S1;d. the intradiscal pressure values by four different pulling methods with7.5Nm loading and25NmL loading of lumbar rotation angle for L3-L4, L4-L5and L5-S1;e. the intradiscal pressure values by four different pulling methods with25NmL loading of three different time period (0.05s,0.10s, and0.15s flipping time) for L3-L4, L4-L5and L5-S1. Statistic analysis:All statistical tests were two-sided tests. Measurement data were expressed as mean±SD and analyzed using SPSS13.0software. Data were subjected to homogeneity test for variance. Data of homogeneity of variance were analyzed with one-way analysis and mean between two groups was compared using Student-Newman-Keuls q test. Data of heterogeneity of variance were analyzed with Welch, and mean between two groups was compared using Dunnett T3test. P<0.05was considered statistically significant.Results1. All the four manipulition methods could improve the intradiscal pressure. There was a linear increase of intradiscal pressure with the constant change of the rotation angle. There was an intradiscal pressure transient plateau when the preloading reached7.5Nm. The intradiscal pressure increased rapidly and a’V shaped trough could be formed during the25Nm flipping phase, in which the pressure reached a maximum at the time points,0.05s,0.10s and0.15s, and then reset automatically.2. The L4-L5disc intradiscal pressures were the highest in two different positions under the cyclic loading. One was in the sitting position, from high to low as following:L4-L5> L5-S1> L3-L4. The other was in the supine position, from high to low as following:L4-L5> L5-S1> L3-L4. There was a significant difference (P<0.05) between the L3-L4and L4-L5in both positions. However all intradiscal pressures in sitting position were higher than in supine position (P<0.05).3.The intradiscal pressure values of L4-L5at baseline in the position of-300N and-500N sitting oblique pulling were the highest, having a significant difference (P <0.05). The corresponding intervertebral disc pressure at baseline between the position of-300N group and-500N group, the pressures of L3-L4and L4-L5in-500N group were higher than in-300N group (P<0.05),but the pressure of L5-S1comparison having no significant difference (P>0.05)4.The intradiscal pressure values of L4-L5at baseline in the position of+100N and ON supine oblique pulling were the highest, having a significant difference (P<0.05). The corresponding intervertebral disc pressure at baseline between the position of+100N group and ON group, the pressures of L3-L4and L4-L5in+100N group were higher than in ON group (P<0.05),but the pressure of L5-S1comparison having no significant difference (P>0.05) 5. All the intradiscal pressure values of L3-L4,L4-5L and L5-S1at baseline in the position of supine oblique pulling were lower than in the sitting position with significant difference (P<0.05). And the intradiscal pressure values of L4-5L at baseline in the positions of300N, ON and100N were lower than in the position of-500N.6.There were no significant differences for all the intradiscal pressure values of L3-L4,L4-5L and L5-S1in the positions of500N,-300N,+100N and ON before and after the manipulation of oblique-pulling (P>0.05)7. There was a significant difference (P<0.05) about the intradiscal pressures compared in the lumbar rotation angle with25Nm and the preloading of7.5Nm preloaded by the paired T-test.8. The intradiscal pressures of L3-L4in the positions of25Nm, ON and+100N were higher than in the position of7.5Nm, with significant difference (P<0.05). The intradiscal pressures of L4-L5in the positions of25Nm,-500N,-300N and ON were higher than in the position of7.5Nm, with significant difference (P<0.05). The intradiscal pressures of L4-L5in the positions of-500N,-300N. ON and+100N were higher than in the position of7.5Nm, with significant difference (P<0.05).9. The related statistical analysis showed that the intradiscal pressure differences in the position of simulated7.5Nm loading and the preloading25Nm have a significant correlation with the rotating angle, with the Pearson correlation coefficient0.919.10. The single-factor analysis of variance showed that the intradiscal pressures of L3-L4,L4-L5and L5-S1in different pulling phases and positions by four different oblique pulling methods have no statistical difference (P>0.05)Conclusions1. The characteristics of the lumbar intradiscal pressures under the cyclic loading are as following:pressures in the sitting position different from the supine position, the highest pressures from L4-L5. the lowest from L3-L4in both positions, all the pressures in the sitting positions higher than in the supine positions.2. During the manipulation, the intradiscal pressures increased and degenerative intervertebral disc deformation aggravated with more strength and lower safety.3. The intradiscal pressures in supine position are lower than in sitting position. The traditional manipulation of oblique-pulling and the+100N supine manipulation of oblique-pulling seems much safer.4. The manipulation of oblique-pulling could lower the intradiscal pressure with tractions, especially for the L3-L4and L4-L5disc degeneration diseases. The manipulation of oblique-pulling in the sitting position should minimize flexion, while giving200N traction, which could ensure the safety.5. We could conclude that the mechanism of the manipulation is dual roles of the intradiscal pressure quickly increasing and the activity of the lumbar spine increasing.6. We could infer that practitioners could use different manipulation of oblique-pulling methods according to different segments of disc degeneration flexibly. For instance, the four pulling methods could be used for the L5-S1disc degeneration diseases, four oblique wrench method can be used; sitting,-300N sitting position and the traditional oblique pulling could be used to treat the L4-5disc degeneration diseases; traditional oblique pulling and+100N oblique pull with tractions could be more helpful for the L3-L4disc degeneration diseases.7. The intradiscal pressure will produce a significant change within0.15s pulling-time and a wider range of effective pulling-time time still need further research. |
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