挥鞭样损伤相关疾患经筋辨证探索与中医症、证分布特点研究
摘要
挥鞭样损伤相关疾患(Whiplash-Associated Disorders, WAD)是指车辆行驶中遭受后方或侧面撞击,致使驾驶员和乘客颈部突然经历加速-减速动力变化所造成骨骼或软组织损伤的各种临床表现。在美国,WAD是交通事故后最常见的残障性疾患之一,其发生率约为每年人口的千分之3.8,每年与挥鞭样损伤有关的花费(包括治疗、诊断、保险、赔偿等)高达290亿美元。近年来,随着中国居民车辆拥有率的迅速提高,挥鞭样损伤相关疾患亦逐渐引起人们的重视。
辨证论治是中医学的特色和精华,虽然针灸在治疗挥鞭样损伤相关疾患方面具有一定的优势与特色,但有关挥鞭样损伤相关疾患中医辨证规律的研究阙如。因此,本研究拟以经筋理论为指导,通过理论研究,梳理、归纳挥鞭样损伤相关疾患的经筋辨证模式；通过临床调查研究,并结合多种无监督数据分析方法,总结挥鞭样损伤相关疾患中医症、证分布与及证、症之间关系,为今后建立挥鞭样损伤相关疾患中医辨证诊断规范提供依据,以提高中医针灸诊治挥鞭样损伤相关疾患的临床水平
目的
1梳理、归纳挥鞭样损伤相关疾患的经筋辨证模式,总结各类型的“筋结点”(压痛点)与经证。
2基于局部和全身辨证,探讨挥鞭样损伤相关疾患的中医症、证分布特点。
3基于局部和全身辨证,探讨挥鞭样损伤相关疾患的中医证候与症状、体征之间的关系。
方法
1理论研究
运用经筋理论分析挥鞭样损伤的病机,并结合西医解剖学来分析颈部经筋循行的相应结构；根据颈部活动功能的特点,梳理、总结挥鞭样损伤不同经筋的“筋结点”和相应的经证,归纳其辨证要点,并作为临床调查的依据。
2临床研究
在文献回顾、分析的基础上并结合临床经验,编制挥鞭样损伤相关疾患中医四诊信息采集表；采用临床流行病学横断面调查的方法,于2010年8月到2011年9月在美国纽约州与加利福尼亚州两地11个诊所对313例符合纳入标准的挥鞭样损伤相关疾患病人中医症状和医生经验辨证进行调查,应用EpiData 3.0软件建立数据库,运用SPSS17.0软件对症状与证候的分布情况以及症状之间、证候之间的相关性进行分析。
采用相关分析、因子分析、聚类分析等多种无监督数据统计方法,对通过调查获取的中医症状进行分析,提取挥鞭样损伤相关疾患常见证候的症状,总结挥鞭样损伤相关疾患中医证与症状之间的关系。
结果
1理论研究
在经筋理论的指导下,根据挥鞭样损伤相关疾患颈部局部表现,将其证型及辨证要点归纳如下：
(1)太阳经证：颈部广泛痉挛、屈伸不利,肩贞、肩外俞、肩中俞、天窗、天柱、玉枕、颈3-7棘突以及与太阳经交会的完骨、大椎、陶道等处广泛压痛；
(2)少阴经证：颈部深处疼痛、屈曲困难、头晕,枕骨下缘和颈3-6的横突有压痛；
(3)少阳经证：头颈支撑不适、侧屈困难,肩髎、天髎、天牖、风池以及天鼎穴处明显压痛；
(4)阳明经证：颈不可左右视、颈部掣引疼痛、肩不举,肩髃、巨骨、天鼎、扶突、人迎、缺盆等穴处明显压痛。
又根据全身症状表现进行辨证,急性期多属于气滞证与血瘀证,慢性期多属于气血亏虚证、痰湿阻络证和肝肾不足证。
2临床研究
2.1挥鞭样损伤相关疾患中医症分布规律的研究
(1)编制挥鞭样损伤相关疾患中医四诊信息采集表：调查内容包括一般资料、病史特征、颈部疼痛强度(视觉模拟疼痛评分,患者自评)、颈椎功能障碍指数量表(患者自评)、颈部体征(颈椎关节活动度和神经系统检查)及中医症状与体征。其中中医症状与体征包括经筋“筋结点”压痛情况、局部经筋症状、肢体症状、头面部症状、全身症状、饮食口味相关症状、二便相关症状、睡眠相关症状、精神症状、舌象、脉象、调查者印象(包括挥鞭样损伤疾患分级、中医病名、经筋辨证和其他辨证结果)
(2)调查对象病史特征：本研究共调查313例急性(72小时内)与亚急性(72小时至三月)挥鞭样损伤相关疾患病人,均为美国纽约州与加州的门诊患者。结果显示男性185例,女性128例,平均年龄36.6±0.69岁,车祸时驾驶车辆者192例,约半数为后尾撞击造成的挥鞭样损伤。本组病例的职业以无业人士、服务业者、学生与劳工居多。挥鞭样损伤相关疾患分级为Ⅰ级者11例,Ⅱ级者为276例,Ⅲ级者为26例。视觉模拟疼痛评分(VAS)的平均分为6.33±0.098,属于中等程度疼痛；颈椎功能障碍指数量表(NDI)平均总分为16.55+0.66,总体上为中度功能障碍。
(3)中医症的分布规律：各种症状出现频率在50%以上的症状仅6个：颈痛、颈部僵硬、失眠、肩痛、乏力与头痛,这与经筋循行规律相符。基于313例挥鞭样损伤相关疾患患者临床表现发生的频次,其常见症状、体征归纳如下(按频次降序排列)：①经筋“筋结点”(压痛点)主要位于肩外俞、肩中俞、天窗、颈3-6棘突、大椎、风池、天髎、天鼎；②经筋辨证要点：颈部广泛痉挛(太阳)、侧屈困难(少阳)、屈伸不利(太阳)、颈部掣引疼痛(阳明)、颈不可左右视(阳明)、头颈支撑不适(少阳)、颈部深处疼痛伴屈曲困难(少阴)；③肢体、头面部常见症状：颈痛、颈部僵硬、肩痛、头痛、手臂痛、手指麻木；④全身常见症状：失眠、乏力、焦虑恐惧、抑郁、身重、头晕；⑤常见舌象：红舌、淡红舌、淡紫舌、淡白舌、胖大舌、齿痕舌、裂纹舌、舌下络脉异常(增长或青紫或增粗)、白苔、薄苔、润苔、厚苔、腐腻苔；⑥常见脉象：沉脉、弦脉、滑脉、紧脉、细脉、数脉、涩脉。
(4)症状间的相关性：各经筋“筋结点”与本经的经证表现均密切相关,少阴“筋结点”与所有经证的表现密切相关,少阳“筋结点”除与本经经证表现相关外还与阳明经证的表现相关,而阳明“筋结点”仅与本经证的表现相关；密切相关特异性较强的是太阳经证的“屈伸不利”、少阳经证的“头颈支撑不适”与“侧屈困难”、阳明经证的“肩不举”。
2.2挥鞭样损伤相关疾患中医证候分布规律的研究
(1)经筋辨证：以太阳经筋证型为多见,这与手、足太阳经筋合并分布成为后项部最主要的经筋有关。但多数患者以复合证的形式出现：2个证型的组合以太阳+阳明、太阳+少阳、少阳+阳明为主；3个证型的组合以太阳+少阳+阳明最多见；也有4个证型的组合。
(2)其他辨证：以气滞证为最多见,这也符合挥鞭样损伤相关疾患的中医病机,同时与阳经经筋“其筋多刚”的特点有关,故容易受伤而造成局部气机阻滞。
(3)各辨证间的相关性分析表明：气滞证、血瘀证与少阴经证、少阳经证之间、少阴经证与各项辨证之间有密切相关关系；而气血亏虚与阳明经证之间有相关性。
(4)证候类型与病期、分级及车祸类型之间的相关性：无明显相关。
(5)经筋证候类型与颈椎关节活动度的相关性：经统计分析,具有明显负相关者为太阳经证与前屈、后伸、左旋、右旋,阳明经证与前屈、左侧屈、左旋、右旋；少阴、少阳经证与各项关节活动度均密切负相关。
(6)经筋证候类型与颈椎功能障碍指数量表(NDI)之间的相关性：问卷十个项目均与太阳经证有密切相关关系,各项项目与各经筋辨证证候表现大多都具有相关关系,但是“提举物品”与少阴经证、阳明经证无关,“阅读”与少阳经证、阳明经证无关,“专心”与少阳经证无关,“头痛”与阳明经证无关。
(7)经筋证候类型与视觉疼痛模拟评分(VAS)之间的相关性：太阳、少阴、少阳经证均与之密切相关,其中又与少阳经证相关系数最高。
(8)经筋证候类型与挥鞭样损伤相关疾患分级的相关性：与各经筋类型均密切相关,其中又以与少阴经证相关系数最高。
(9)其他证型与颈椎关节活动度、颈椎功能障碍指数量表(NDI)、视觉疼痛模拟评分(VAS)、挥鞭样损伤相关疾患分级之间的相关性：气滞证、血瘀证与这四项观察指标均密切相关；气血亏虚证与颈椎功能障碍指数量表中“专心”密切相关。肝肾不足者与疾患分级有关。
2.3挥鞭样损伤相关疾患中医证与症状之间关系的研究
本研究进一步运用多种无监督数据统计方法,如相关性分析、因子分析、聚类分析以明确证候类型与症状之间的关系。
(1)辨证类型与症状间的相关性分析：具有统计学意义的相关性(P<0.01或P<0.05)并以相关系数排序最前的5位进行总结,其结果如下。
①经筋辨证类型与症状相关性
太阳经证：颈部广泛痉挛、屈伸不利、颈部深处疼痛伴屈曲困难、头晕、头痛；
少阴经证：头晕、颈部深处疼痛伴屈曲困难、颈部广泛痉挛、目昏、上肢沉重；
少阳经证：侧屈困难、头颈支撑不适、头痛、颈不可左右视、失眠；
阳明经证：颈部掣引疼痛、颈不可左右视、肩不举、颈部僵硬、颈部深处疼痛伴屈
曲困难；
②其他辨证类型与症状相关性
气滞证：失眠、侧屈困难、头痛、目昏、头晕；
血瘀证：失眠、头痛、侧屈困难、目昏、头晕；
气血亏虚证：纳呆、便溏、乏力、焦虑恐惧、急躁易怒；齿痕舌,脉节律不齐；
痰湿阻络证：颈部掣引疼痛、身重；腐腻苔；
肝肾不足证：面部烘热、目昏、腰膝酸软、颈部深处疼痛伴屈曲困难、便溏；裂纹舌、剥脱苔。
从上述结果表明经筋辨证的证候类型与其经证的症状基本符合,太阳经证还包括了少阴经证的症状表现,少阳经证涵盖了阳明经证的症状表现,而阳明经证包含了少阴经证的症状表现。结果还表明少阴经证与所有症状均相关,所以少阴经筋辨证临床意义不大。
相关分析发现的另一特点是气滞证与血瘀证的症状相关性基本相同。是否可以这样理解,临床上以疼痛的性质、程度来辨识两证,同时结合其他症状来加以鉴别,但本组观察对象的全身症状项目相对较少,如何来区别两证的相关性,有待进一步研究。
气虚亏虚证、痰湿阻络证、肝肾不足证的症状(包括舌脉)与其病机基本符合。
(2)因子分析结果：
通过因子分析将一般症状分为十一类：肝郁脾虚症状(懒言、颈部深处疼痛伴屈曲困难、头晕、口苦、便溏)；血虚、肝症状(头晕、目昏)；睡眠症状(失眠)；肝、胆、气郁症状(抑郁、焦虑恐惧)；气滞、血瘀、阳明经筋症状(颈不可左右视、颈部掣引疼痛)；脾、胃、湿阻症状(纳呆、恶心)；气滞、血瘀、少阳经筋症状(侧屈困难)；湿阻、太阳经筋症状(颈部广泛痉挛、身重)；津亏症状(口咽干)；肝、热盛症状(急躁易怒、便秘)；肝、肾、虚症状(腰膝酸软、手指麻木)。这些因子分类的结果主要体现了气虚、血虚、气滞、血瘀、津亏、肝、脾、肾、胆、胃、湿、热与经络(太阳、少阳、阳明等经筋)等基本证候类型或构成证候的证候要素。
(3)聚类分析结果
通过聚类分析将症状分为三类：肝火上炎(肝阳上亢)(头晕、目昏、口咽干、急躁易怒、便秘);气郁湿阻、筋脉阻滞(抑郁、焦虑恐惧、颈部广泛痉挛、身重、腰膝酸软、手指麻木)；脾虚湿阻、筋脉阻滞(懒言、颈部深处疼痛伴屈曲困难、头晕、口苦、便溏、纳呆、恶心、侧屈困难)。这是对挥鞭样损伤相关疾患局部和全身症状的一个综合结果,一般临床辨证不会考虑有关肝火上炎或肝阳上亢,但无监督的数据分析反映了这些联系,这对临床拓展思路有指导意义,并对本疾患慢性发展趋势的了解有一定意义。
回顾古代文献,《内经》有“肝之俞在颈项”之说(《素问·金匮真言论》,头颈为肝胆经脉所过,如其经脉之气失和,可见颈项僵硬疼痛之症。聚类分析结果的这种提示,与古代经典理论不谋而合。
结论
1通过文献分析,总结了文献中挥鞭样损伤相关疾患的症状与证候分布特点,编制了挥鞭样损伤相关疾患中医临床四诊信息采集表,并在美国人群中进行调查研究,总结了挥鞭样损伤相关疾患临床症状、证候及中医证与症状之间的关系；通过数据研究,初步明确了各证型与症状间的对应关系。对于今后深入研究挥鞭样损伤相关疾患的中医证候辨证规律打下了基础。
2研究表明基于经筋理论对挥鞭样损伤相关疾患颈部局部表现进行辨证分型是可行的,能够比较准确地辨识并反映其软组织损伤的特征,同时考虑“筋结点”压痛情况与不同经证的症状能够明确不同经筋辨证,由之而进行辨证论治。经筋辨证以及基于全身症状的其他中医辨证分型模式,对于临床诊断与疗效评估有着明显的指导意义。
3通过理论研究归纳总结出挥鞭样损伤相关疾患经筋辨证四个证型及其症状,经验辨证与数据统计分析的结果表明均有对应意义,但少阴经证与几乎所有的参数、证型、症状均有相关意义,而且与其他经筋证型有重复现象,是否有必要保留此经证、或归类于太阳经证有待于进一步深入研究。
4中医临床辨证的规范尚有待于深入研究。经过千百年沉淀的中医学,蕴藏着无数的宝贵经验,但临诊辨证手段繁多,并无统一与规范。本研究所运用的经筋辨证适宜于颈部软组织损伤的诊疗,尚未被临床广泛应用。如何运用现代手段对不同辨证方法加以整理、论证、提炼,并使之规范化、标准化乃当务之急。
Whiplash is an acceleration-deceleration mechanism of energy transfering to the neck. Due to rear-end or side-impact motor vehicle collisions, such an impact may result in bony or soft-tissue injury (whiplash injury), which may lead to a variety of clinical manifestations (whiplash-associated disorders, WAD). It is considered as one of the most common disorders leading to disability after traffic accidents in the United States. The incidence rate is about 3.8 per thousand each year.The annual related costs amount to over 29 billion dollars, which includes treatment, diagnosis, insurance and reimbursement. Recently, the personal ownership of automobiles in China has significantly increased so that whiplash-associated disorders have drawn increasing attention.
Syndrome differentiation is feature and essence of traditional Chinese medicine.Unfortunately corresponding research on WAD syndromes related to traditional Chinese medicine (TCM) has not been conducted, even though acupuncture has been proved more superior and significant in treating whiplash-associated disorders. To fill this gap, this study intends to concentrate on the theoretical and clinical bases of the meridian sinew theory of traditional Chinese medicine. Through theoretical study, it aims to classify and formulate a model of differentiation patterns (syndromes) related to meridian sinews for whiplash-associated disorders, and also to define the tender points and symptoms of each of four meridian sinew syndromes. By conducting a clinical survey backed up by different ways of statistical data analysis, this study aims to summarize the distribution characteristics of TCM symptoms and syndromes as well as the correlation between the symptoms and syndromes of WAD. This work seeks to provide a basis for future establishment of diagnostic standards of TCM syndrome differentiation, and to enhance the therapeutic effects of acupuncture applied to treat WAD.
Objectives
1 To classify and generalize the model of differentiation patterns related to meridian sinew theory, and to define the tender points and symptoms of each differentiation syndrome for whiplash-associated disorders.
2 To explore the distribution characteristics of TCM symptoms and syndromes of whiplash-associated disorders based on local (meridian sinew) and general differentiation.
3 To explore the correlation between the TCM syndromes of whiplash-associated disorders and their corresponding symptoms and signs based on local (meridian sinew) and general differentiation.
Methods
1 Theoretical study
Based on meridian sinew theory, the pathogenesis of whiplash injury was analyzed. According to modern anatomy, an anatomical representation of the structure and route of meridian sinew pathways in the neck region was described.And according to the motion activities of the neck, the tender points and corresponding symptoms of each meridian sinew differentiation syndrome were classified and summarized. This provided a basis for the later clinical survey.
2 Clinical study
Based on literature review and clinical experience, a Clinical Survey Form for Whiplash-Associated Disorders (WAD) in Traditional Chinese Medicine was designed.
This cross-sectional survey of TCM symptoms and syndromes for WAD investigated TCM symptoms of 311 patients who met inclusive criteria in 11 clinics located in New York and California states from August,2010 to September,2011. It included the impressions of the investigating practitioners with respect to syndrome differentiation. The database was established with EpiData 3.0 software and SPSS 17.0 software was applied to analyze the distribution status and the correlations among symptoms as well as among syndromes.
The study analyzed the TCM symptoms data acquired through the clinical survey, refined the symptoms of common syndromes of whiplash-associated disorders, and summarized the correlations between syndromes and symptoms utilizing different unsupervised statistical methods such as correlation analysis, factor analysis and cluster analysis.
Results
1 Theoretical study
Based on meridian sinew theory, the tender points and corresponding symptoms of each differentiation syndrome of whiplash-associated disorders were classified and summarized. According to the local symptoms of the neck in WAD patients, the types of meridian sinew differentiation and their main manifestations are listed as follows:
(1) Taiyang Meridian Sinew Syndrome:widespread spasm and tenderness in the neck, problems of extension and flexion; tender points on Jianzhen (SI 9), Jianwaishu (SI 14), Jianzhongshu (SI 15), Tianchuan (SI 17) Tianzhu (BL 10), Yuzhen (BL 9), C3-6 Spinal Process, Dazhui (GV 14) and Taodao (GV 13).
(2) Shaoyin Meridian Sinew Syndrome:deep pain in the neck, difficulty in flexion, dizziness; tender points on the Lower Edge of the Occipitus and C3-6 Transverse Process.
(3) Shaoyang Meridian Sinew Syndrome:neck discomfort with a tendency for hands to support the head, difficulty in lateral flexion; tender points on Jianliao (SJ 14), Tianliao (SJ 14), Tianyou (SJ 16), Fengchi (GB 20) and Tianding (LI 17).
(4) Yangming Meridian Sinew Syndrome:difficulty in head rotation, stiffness and pain during neck movement, inability to raise the shoulder; tender points on Tianding (LI 17), Jianyu (LI 15), Jugu (LI 16), Futu (LI 18), Renying (ST 9) and Quepen (ST 12).
Besides meridian sinew differentiation, the general symptoms presented in WAD patients should also be viewed through other sets of syndrome differentiation. Qi stagnation syndrome and blood stasis syndrome are mostly seen during the acute stage and Qi& blood deficiency syndrome, phlegm-dampness blocking channels ayndrome and insufficiency of the liver & kidney syndrome are seen more during the chronic stage.
2 Clinical study
2.1 Study on the distribution characteristics of TCM symptoms of whiplash-associated disorders (WAD)
2.1.1 Clinical Survey Form for Whiplash-Associated Disorders (WAD) in traditional Chinese medicine. The survey form included general data, history, intensity of the neck pain (self-evaluated by the Visual Analogue Scale, VAS), Neck Disability Index Scale (NDI, self-evaluated), signs in the neck region (Range of Motion of the neck and some neurological examinations) as well as TCM symptoms and signs. The latest one included meridian sinew tender points, local meridian sinew symptoms, extremity symptoms, head and facial region symptoms, general body symptoms, diet and taste symptoms, bowel movement and urination symptoms, sleep related symptoms, mental symptoms, tongue features and pulse phenomena as well as the impressions of the investigating practitioners, which included the grading of WAD, TCM diagnosis, conclusion of meridian sinew syndromes and other general syndromes.
2.1.2 General data of the subjects:This survey investigated 313 cases of whiplash-associated disorders during the acute stage (less than 72 hours after the accident) and sub-acute stage (between 72 hours and 3 months after the accident) in 11 out-patient clines located in New York and California states.185 of the cases were male and 128 were female and the average age in the group was 36.6±0.69 years old.192 cases were drivers during the accident and more than half of the patients experienced rear-end collision. The occupations of this group were mainly unemployed, service personnel, students and laborers. The statistics showed a total of 11 cases of GradeⅠpatients and 276 cases of GradeⅡ, as well as 26 cases belonging to GradeⅢ. The average score of the Visual Analogue Scale (VAS) was 6.33±0.098, which means that those patients had a medium intensity of pain on average. The average score of the Neck Disability Index Scale (NDI) sums to 16.55±0.66, which indicated a medium level of disability.
2.1.3 Distribution characteristics of TCM symptoms:Only 6 symptoms presented in over 50% of the cases:neck pain, neck stiffness, insomnia, shoulder pain, tiredness and headache, and those phenomena coincided with the ancient theory of meridian sinew distribution. Based on the cross-sectional clinical survey of TCM symptoms and syndromes in 313 cases of whiplash-associated disorders, the common symptoms of WAD were summarized as the following according to the frequency data analysis (arrayed in a descending sequence):
(1) Tender points of the meridian sinew were discovered mainly on Jianwaishu (SI 14), Jianzhongshu (SI 15), Tianchuan (SI 17), C3-6 Spinal Process, Dazhui (GV 14), Fengchi (GB 20), Tianliao (SJ 15) and Tianding (LI 17).
(2) Symptoms of the meridian sinew syndromes were mainly widespread spasm and tenderness in the neck (Taiyang), difficulty in lateral flexion (Shaoyang), problems of extension and flexion (Taiyang), stiffness and pain during neck movement (Yangming), difficulty in head rotation (Yangming), neck discomfort with a tendency for hands to support the head (Shaoyang), and deep pain in the neck and difficulty in flexion (Shaoyin).
(3) Symptoms in the extremities and head and facial region appeared mainly as neck pain, neck stiffness, shoulder pain, headache, arm pain and finger numbness.
(4) General body symptoms presented mainly as insomnia, fatigue, anxiety, depression, body heaviness and dizziness.
(5) Tongue features mainly showed up as red tongue, light red tongue, light purple tongue, pale tongue, enlarged tongue, tooth-marked tongue, cracked tongue, abnormal sublingual veins (extended, or purple in color, or thicker), white coating, thin coating, moist coating, thick coating, and greasy coating.
(6) Pulse phenomena included deep pulse, wiry pulse, slippery pulse, tight pulse, thready pulse, rapid pulse and choppy pulse.
2.1.4 Correlations among symptoms:Data analysis indicated that all the different meridian sinews'tender points are significantly correlated to each corresponding meridian sinew, tender points in the Shaoyin meridian sinew are significantly correlated to all meridian sinew syndromes, tender points in the Shaoyang meridian sinew are also correlated to the Yangming syndrome, but tender points in the Yangming meridian sinew are only con-elated to its own meridian sinew syndrome. The following symptoms are statistically more significant with strong specificity in different syndromes:problems of extension and flexion (Taiyang), neck discomfort with a tendency for hands to support the head (Shaoyang), difficulty in lateral flexion (Shaoyang), and inability to raise the shoulder (Yangming).
2.2 Distribution characteristics of TCM syndromes of whiplash-associated disorders (WAD)
(1) Meridian sinew syndrome of WAD:The mostly seen is Taiyang syndrome, which is understandable since both the hand and foot Taiyang meridian sinews merge in the posterior of the neck as the main meridian sinews in the local area. The majority of cases presented as combinations of two together (Taiyang+Yangming, Taiyang+Shaoyang, and Taiyang+Yangming), or three together (mostly Taiyang+Shaoyang+Yangming), or even four in combination.
(2) Other TCM syndromes:Qi stagnation syndrome is the mainly seen. This phenomenon corresponds to the TCM pathogenesis of whiplash-associated disorders and is also related to the characteristics of rigidity of Yang median sinews, which are mostly distributed in the neck region.
(3) Correlations among TCM syndromes:Qi stagnation syndrome and blood stasis syndrome are significantly correlated to the Shaoyin and Shaoyang meridian sinew syndromes. Shaoyin meridian sinew syndromes showed significant correlation to all different syndromes. Also, Qi and blood deficiency syndrome has a correlation with Yangming meridian sinew syndrome.
(4) Correlations between TCM syndromes and stages, grades and collision types:There are no correlations among them.
(5) Correlations between the meridian sinew syndromes and the Range of Motion (ROM) of the neck:The correlation analysis indicated a significant negative correlation between Taiyang meridian sinew syndrome and the motions of flexion, extension, left rotation and right rotation, and between Yangming meridian sinew syndrome and the motions of flexion, left lateral flexion, left rotation and right rotation. The Shaoyin and Shaoyang meridian sinew syndromes were negatively correlated to all 6 motions of the neck.
(6) Correlations between the meridian sinew syndromes and the Neck Disability Index Scale (NDI):all the 10 indices were significantly correlated to the Taiyang meridian sinew syndrome. Most of the indices were correlated to all meridian sinew syndromes except the following:"lifting" and Shaoyin and Yangming syndromes, "reading" and Shaoyang and Yangming syndromes, "attention" and Shaoyang syndrome, and "headache" and Yangming syndrome.
(7) Correlations between the meridian sinew syndromes and the Visual Analogue Scale (VAS):Taiyang, Shaoyin and Shaoyin meridian sinew syndromes were significantly correlated, especially the Shaoyang syndrome having the highest correlation coefficient.
(8) Correlations between meridian sinew syndromes and the grading of WAD:all meridian sinew syndromes have significant correlation, especially the Shaoyin syndrome having the highest correlation coefficient.
(9) Correlations between the other TCM syndromes and the Range of Motion of the neck, the Neck Disability Index scale (NDI), the Visual Analogue Scale (VAS) and the grading of WAD:Qi stagnation syndrome and blood stasis syndrome have significant correlation with the above four parameters. Qi and blood deficiency syndrome has a significant correlation with the index of "attention" in NDI. Liver and kidney insufficiency syndrome has correlation to WAD grading.
2.3 Study on the correlations between TCM differentiation syndromes and their corresponding symptoms of whiplash-associated disorders (WAD)
The correlations between TCM differentiation and corresponding symptoms were further defined by applying unsupervised statistical methods such as correlation analysis, factor analysis and cluster analysis.
2.3.1 Correlation analysis:The summary of correlative relationships is listed in the following, with the top five priorities related to the correlation coefficient having statistical significance (P<0.01 or P<0.05).
(1) Correlations between the meridian sinews syndromes and symptoms:
●Taiyang meridian sinew syndrome:Widespread spasms and tenderness in the neck, problems of extension and flexion, pain in the deep area of the neck and difficulty in flexion, dizziness, and headache.
●Shaoyin meridian sinew syndrome:dizziness, deep pain in the neck with difficulty in flexion, widespread spasms and tenderness in the neck, blurred vision, and upper extremity heaviness.
●Shoayang meridian sinew syndrome:difficulty in lateral flexion, neck discomfort with a tendency for hands to support the head, headache, difficulty in head rotation, insomnia.
●Yangming meridian sinew syndrome:stiffness and pain during neck movement, difficulty in head rotation, inability to raise the shoulder, neck stiffness, deep pain in neck and difficulty in flexion.
(2) Correlations between other TCM syndromes and symptoms:
●Qi stagnation syndrome:insomnia, difficulty in lateral flexion, headache, blurred vision, dizziness.
●Blood stasis syndrome:insomnia, headache, difficulty in lateral flexion, blurred vision, dizziness.
●Qi and blood deficiency syndrome:poor appetite, loose stools, fatigue, anxiety, and irritability, tooth-marked tongue and irregular rhythm pulse.
●Phlegm-dampness blocking the meridian syndrome:stiffness and pain during neck movement, body heaviness, and greasy tongue coating.
●Liver and kidney insufficiency syndrome:facial warmth, blurred vision, lumbar and knee weakness, deep pain in the neck and difficulty in flexion, loose stools; tongue cracks, peeling coating.
The above correlation analysis indicates that the symptoms are basically consistent with each corresponding syndrome in meridian sinew differentiation. Furthermore, the data also shows that the Taiyang meridian sinew syndrome includes some symptoms of the Shaoyin meridian sinew syndrome, the Shaoyang meridian sinew syndrome covers some symptoms of the Yangming meridian sinew syndrome, and the Yangming meridian sinew syndrome correlates with some symptoms of the Shaoyin meridian sinew syndrome. The outcomes also indicate that the Shaoyin meridian sinew syndrome correlates to all symptoms belonging to various syndromes and thus the Shaoyin meridian sinew syndrome seems to have no clinical significance.
The correlation analysis also discovered that the correlative symptoms of the Qi stagnation syndrome and the blood stasis syndrome are almost the same. This may be explained by the fact that clinically these two syndromes are identified according to the characteristics and severity of pain combined with general manifestations; however, the subjects in this trial have less whole body general manifestations. Further study is needed to identify the correlations of these two syndromes.
The symptoms, including tongue and pulse features, essentially coincide with their pathogenesis in the following syndromes:Qi and blood deficiency syndrome, phlegm-dampness blocking syndrome, and liver and kidney insufficiency syndrome.
2.3.2 Factor analysis:
Factor analysis resulted in a total of 11 categories of general symptoms:liver stagnation and spleen deficiency symptoms (unwillingness to talk, deep pain in the neck and difficulty in flexion, dizziness, bitter taste in the mouth, loose stools); blood deficiency and liver symptoms (dizziness and blurred vision); sleep related symptoms (insomnia); liver, gallbladder, and Qi stagnation symptoms (depression, anxiety); Qi stagnation, blood stasis, Yangming meridian sinew syndromes (difficulty in head rotation, stiffness and pain during neck movement); spleen, stomach, dampness accumulation symptoms (poor appetite, nausea); Qi stagnation, blood stasis, Shaoyang meridian sinew symptoms (difficulty in lateral flexion); Taiyang meridian sinew and dampness symptoms (widespread spasm and tenderness in the neck, heavy limbs); fluid insufficiency symptoms (dry mouth); liver, excessive heat symptoms (irritability, constipation); liver, kidney deficiency symptoms (soreness in the lower back and knees, numbness in the fingers). Thus it mainly presents the basic TCM syndromes and/or syndrome factors related to Qi deficiency, blood deficiency, Qi stagnation, blood stasis, fluid insufficiency, liver, spleen, kidney, gallbladder, stomach, dampness, heat, as well as local meridian sinews such as Taiyang, Shaoyang and Yangming meridian sinews.
2.3.3 Cluster analysis:
Cluster analysis resulted in three categories of symptoms:liver fire upward flaring or hyperactivity of liver-Yang (dizziness, blurred vision, dry mouth, irritability, constipation); Qi stagnation and dampness accumulation and local meridian sinew stagnation (depression, anxiety, widespread spasm and tenderness in the neck,body heaviness, soreness and weakness of the lower back and knee, finger numbness); spleen deficiency with dampness accumulation and local meridian sinew stagnation (unwilling to talk, deep pain in the neck and difficulty in flexion, dizziness, bitter mouth, loose stools, poor appetite, nausea, difficulty in lateral flexion). This is a comprehensive analysis considering the local and general symptoms. Usually the pathogenesis of liver fire upward flaring or hyperactivity of liver-Yang are not considered during syndrome differentiation based on clinical experience, but the unsupervised data analysis indicates this kind of correlation. This will be significant for developing therapeutic strategies and predicting the trend of chronic development of WAD.
In the Inner Classic of the Yellow Emperor, it was said that "the transporting point of the liver is located in the neck region" since the neck region is the pathway of the liver and gallbladder channels. If the Qi in those channels is disordered, symptoms such as neck pain and stiffness could occur. Thus the cluster analysis outcome coincides with the classical theory.
Conclusions
1 Through literature analysis, the distribution characteristics of the symptoms and syndromes of whiplash-associated disorders were summarized, a Clinical Survey Form of Whiplash-Associated Disorders in TCM was generated, an investigation among American patients was carried out, and the regularity of clinical symptoms, syndromes and syndrome differentiation of WAD was explored. Through data analysis, the corresponding relationships of symptoms in different syndromes were preliminarily discovered. It provided a basis for future studies on the regularity of TCM syndromes of WAD.
2 It is practical to have syndrome differentiation for the local neck symptoms of whiplash-associated disorders based on the meridian sinew theory, presenting characteristics of the soft tissue injury could be identify correctly. The differentiation of meridian sinews should comprehensively consider both the tenderness points and corresponding symptoms related to meridian sinew syndromes. Thus the therapeutic methods could be determined based on the associated meridian sinew syndrome. The model of meridian sinew syndromes and other TCM syndromes could be significant for diagnosis and assessment in clinical practice.
3 The four types of meridian sinew differentiation in the neck and their corresponding symptoms were formulated according to theoretical study and clinical experience, which were presented as significant correlations through statistical analysis. However, the Shaoyin Meridian Sinew Syndrome is correlated significantly with almost all parameters, syndrome types and most symptoms, which are also repeated in the other meridian sinew syndromes. It needs further study to determine whether this type should be eliminated or should be combined with Taiyang Meridian Sinew Syndrome.
4 The standards of TCM clinical differentiation should be further studied. After thousands of years of accumulated wisdom, TCM contains numerous treasures and rich experience but the syndrome patterns are so complicated and lack any unity or standards. Meridian sinew differentiation is suitable for neck soft tissue injury but is still not being applied by most practitioners. It is important and urgent to classify, verify and refine different syndrome differentiations with modern scientific methods and to make them standardized.
辨证论治是中医学的特色和精华,虽然针灸在治疗挥鞭样损伤相关疾患方面具有一定的优势与特色,但有关挥鞭样损伤相关疾患中医辨证规律的研究阙如。因此,本研究拟以经筋理论为指导,通过理论研究,梳理、归纳挥鞭样损伤相关疾患的经筋辨证模式；通过临床调查研究,并结合多种无监督数据分析方法,总结挥鞭样损伤相关疾患中医症、证分布与及证、症之间关系,为今后建立挥鞭样损伤相关疾患中医辨证诊断规范提供依据,以提高中医针灸诊治挥鞭样损伤相关疾患的临床水平
目的
1梳理、归纳挥鞭样损伤相关疾患的经筋辨证模式,总结各类型的“筋结点”(压痛点)与经证。
2基于局部和全身辨证,探讨挥鞭样损伤相关疾患的中医症、证分布特点。
3基于局部和全身辨证,探讨挥鞭样损伤相关疾患的中医证候与症状、体征之间的关系。
方法
1理论研究
运用经筋理论分析挥鞭样损伤的病机,并结合西医解剖学来分析颈部经筋循行的相应结构；根据颈部活动功能的特点,梳理、总结挥鞭样损伤不同经筋的“筋结点”和相应的经证,归纳其辨证要点,并作为临床调查的依据。
2临床研究
在文献回顾、分析的基础上并结合临床经验,编制挥鞭样损伤相关疾患中医四诊信息采集表；采用临床流行病学横断面调查的方法,于2010年8月到2011年9月在美国纽约州与加利福尼亚州两地11个诊所对313例符合纳入标准的挥鞭样损伤相关疾患病人中医症状和医生经验辨证进行调查,应用EpiData 3.0软件建立数据库,运用SPSS17.0软件对症状与证候的分布情况以及症状之间、证候之间的相关性进行分析。
采用相关分析、因子分析、聚类分析等多种无监督数据统计方法,对通过调查获取的中医症状进行分析,提取挥鞭样损伤相关疾患常见证候的症状,总结挥鞭样损伤相关疾患中医证与症状之间的关系。
结果
1理论研究
在经筋理论的指导下,根据挥鞭样损伤相关疾患颈部局部表现,将其证型及辨证要点归纳如下：
(1)太阳经证：颈部广泛痉挛、屈伸不利,肩贞、肩外俞、肩中俞、天窗、天柱、玉枕、颈3-7棘突以及与太阳经交会的完骨、大椎、陶道等处广泛压痛；
(2)少阴经证：颈部深处疼痛、屈曲困难、头晕,枕骨下缘和颈3-6的横突有压痛；
(3)少阳经证：头颈支撑不适、侧屈困难,肩髎、天髎、天牖、风池以及天鼎穴处明显压痛；
(4)阳明经证：颈不可左右视、颈部掣引疼痛、肩不举,肩髃、巨骨、天鼎、扶突、人迎、缺盆等穴处明显压痛。
又根据全身症状表现进行辨证,急性期多属于气滞证与血瘀证,慢性期多属于气血亏虚证、痰湿阻络证和肝肾不足证。
2临床研究
2.1挥鞭样损伤相关疾患中医症分布规律的研究
(1)编制挥鞭样损伤相关疾患中医四诊信息采集表：调查内容包括一般资料、病史特征、颈部疼痛强度(视觉模拟疼痛评分,患者自评)、颈椎功能障碍指数量表(患者自评)、颈部体征(颈椎关节活动度和神经系统检查)及中医症状与体征。其中中医症状与体征包括经筋“筋结点”压痛情况、局部经筋症状、肢体症状、头面部症状、全身症状、饮食口味相关症状、二便相关症状、睡眠相关症状、精神症状、舌象、脉象、调查者印象(包括挥鞭样损伤疾患分级、中医病名、经筋辨证和其他辨证结果)
(2)调查对象病史特征：本研究共调查313例急性(72小时内)与亚急性(72小时至三月)挥鞭样损伤相关疾患病人,均为美国纽约州与加州的门诊患者。结果显示男性185例,女性128例,平均年龄36.6±0.69岁,车祸时驾驶车辆者192例,约半数为后尾撞击造成的挥鞭样损伤。本组病例的职业以无业人士、服务业者、学生与劳工居多。挥鞭样损伤相关疾患分级为Ⅰ级者11例,Ⅱ级者为276例,Ⅲ级者为26例。视觉模拟疼痛评分(VAS)的平均分为6.33±0.098,属于中等程度疼痛；颈椎功能障碍指数量表(NDI)平均总分为16.55+0.66,总体上为中度功能障碍。
(3)中医症的分布规律：各种症状出现频率在50%以上的症状仅6个：颈痛、颈部僵硬、失眠、肩痛、乏力与头痛,这与经筋循行规律相符。基于313例挥鞭样损伤相关疾患患者临床表现发生的频次,其常见症状、体征归纳如下(按频次降序排列)：①经筋“筋结点”(压痛点)主要位于肩外俞、肩中俞、天窗、颈3-6棘突、大椎、风池、天髎、天鼎；②经筋辨证要点：颈部广泛痉挛(太阳)、侧屈困难(少阳)、屈伸不利(太阳)、颈部掣引疼痛(阳明)、颈不可左右视(阳明)、头颈支撑不适(少阳)、颈部深处疼痛伴屈曲困难(少阴)；③肢体、头面部常见症状：颈痛、颈部僵硬、肩痛、头痛、手臂痛、手指麻木；④全身常见症状：失眠、乏力、焦虑恐惧、抑郁、身重、头晕；⑤常见舌象：红舌、淡红舌、淡紫舌、淡白舌、胖大舌、齿痕舌、裂纹舌、舌下络脉异常(增长或青紫或增粗)、白苔、薄苔、润苔、厚苔、腐腻苔；⑥常见脉象：沉脉、弦脉、滑脉、紧脉、细脉、数脉、涩脉。
(4)症状间的相关性：各经筋“筋结点”与本经的经证表现均密切相关,少阴“筋结点”与所有经证的表现密切相关,少阳“筋结点”除与本经经证表现相关外还与阳明经证的表现相关,而阳明“筋结点”仅与本经证的表现相关；密切相关特异性较强的是太阳经证的“屈伸不利”、少阳经证的“头颈支撑不适”与“侧屈困难”、阳明经证的“肩不举”。
2.2挥鞭样损伤相关疾患中医证候分布规律的研究
(1)经筋辨证：以太阳经筋证型为多见,这与手、足太阳经筋合并分布成为后项部最主要的经筋有关。但多数患者以复合证的形式出现：2个证型的组合以太阳+阳明、太阳+少阳、少阳+阳明为主；3个证型的组合以太阳+少阳+阳明最多见；也有4个证型的组合。
(2)其他辨证：以气滞证为最多见,这也符合挥鞭样损伤相关疾患的中医病机,同时与阳经经筋“其筋多刚”的特点有关,故容易受伤而造成局部气机阻滞。
(3)各辨证间的相关性分析表明：气滞证、血瘀证与少阴经证、少阳经证之间、少阴经证与各项辨证之间有密切相关关系；而气血亏虚与阳明经证之间有相关性。
(4)证候类型与病期、分级及车祸类型之间的相关性：无明显相关。
(5)经筋证候类型与颈椎关节活动度的相关性：经统计分析,具有明显负相关者为太阳经证与前屈、后伸、左旋、右旋,阳明经证与前屈、左侧屈、左旋、右旋；少阴、少阳经证与各项关节活动度均密切负相关。
(6)经筋证候类型与颈椎功能障碍指数量表(NDI)之间的相关性：问卷十个项目均与太阳经证有密切相关关系,各项项目与各经筋辨证证候表现大多都具有相关关系,但是“提举物品”与少阴经证、阳明经证无关,“阅读”与少阳经证、阳明经证无关,“专心”与少阳经证无关,“头痛”与阳明经证无关。
(7)经筋证候类型与视觉疼痛模拟评分(VAS)之间的相关性：太阳、少阴、少阳经证均与之密切相关,其中又与少阳经证相关系数最高。
(8)经筋证候类型与挥鞭样损伤相关疾患分级的相关性：与各经筋类型均密切相关,其中又以与少阴经证相关系数最高。
(9)其他证型与颈椎关节活动度、颈椎功能障碍指数量表(NDI)、视觉疼痛模拟评分(VAS)、挥鞭样损伤相关疾患分级之间的相关性：气滞证、血瘀证与这四项观察指标均密切相关；气血亏虚证与颈椎功能障碍指数量表中“专心”密切相关。肝肾不足者与疾患分级有关。
2.3挥鞭样损伤相关疾患中医证与症状之间关系的研究
本研究进一步运用多种无监督数据统计方法,如相关性分析、因子分析、聚类分析以明确证候类型与症状之间的关系。
(1)辨证类型与症状间的相关性分析：具有统计学意义的相关性(P<0.01或P<0.05)并以相关系数排序最前的5位进行总结,其结果如下。
①经筋辨证类型与症状相关性
太阳经证：颈部广泛痉挛、屈伸不利、颈部深处疼痛伴屈曲困难、头晕、头痛；
少阴经证：头晕、颈部深处疼痛伴屈曲困难、颈部广泛痉挛、目昏、上肢沉重；
少阳经证：侧屈困难、头颈支撑不适、头痛、颈不可左右视、失眠；
阳明经证：颈部掣引疼痛、颈不可左右视、肩不举、颈部僵硬、颈部深处疼痛伴屈
曲困难；
②其他辨证类型与症状相关性
气滞证：失眠、侧屈困难、头痛、目昏、头晕；
血瘀证：失眠、头痛、侧屈困难、目昏、头晕；
气血亏虚证：纳呆、便溏、乏力、焦虑恐惧、急躁易怒；齿痕舌,脉节律不齐；
痰湿阻络证：颈部掣引疼痛、身重；腐腻苔；
肝肾不足证：面部烘热、目昏、腰膝酸软、颈部深处疼痛伴屈曲困难、便溏；裂纹舌、剥脱苔。
从上述结果表明经筋辨证的证候类型与其经证的症状基本符合,太阳经证还包括了少阴经证的症状表现,少阳经证涵盖了阳明经证的症状表现,而阳明经证包含了少阴经证的症状表现。结果还表明少阴经证与所有症状均相关,所以少阴经筋辨证临床意义不大。
相关分析发现的另一特点是气滞证与血瘀证的症状相关性基本相同。是否可以这样理解,临床上以疼痛的性质、程度来辨识两证,同时结合其他症状来加以鉴别,但本组观察对象的全身症状项目相对较少,如何来区别两证的相关性,有待进一步研究。
气虚亏虚证、痰湿阻络证、肝肾不足证的症状(包括舌脉)与其病机基本符合。
(2)因子分析结果：
通过因子分析将一般症状分为十一类：肝郁脾虚症状(懒言、颈部深处疼痛伴屈曲困难、头晕、口苦、便溏)；血虚、肝症状(头晕、目昏)；睡眠症状(失眠)；肝、胆、气郁症状(抑郁、焦虑恐惧)；气滞、血瘀、阳明经筋症状(颈不可左右视、颈部掣引疼痛)；脾、胃、湿阻症状(纳呆、恶心)；气滞、血瘀、少阳经筋症状(侧屈困难)；湿阻、太阳经筋症状(颈部广泛痉挛、身重)；津亏症状(口咽干)；肝、热盛症状(急躁易怒、便秘)；肝、肾、虚症状(腰膝酸软、手指麻木)。这些因子分类的结果主要体现了气虚、血虚、气滞、血瘀、津亏、肝、脾、肾、胆、胃、湿、热与经络(太阳、少阳、阳明等经筋)等基本证候类型或构成证候的证候要素。
(3)聚类分析结果
通过聚类分析将症状分为三类：肝火上炎(肝阳上亢)(头晕、目昏、口咽干、急躁易怒、便秘);气郁湿阻、筋脉阻滞(抑郁、焦虑恐惧、颈部广泛痉挛、身重、腰膝酸软、手指麻木)；脾虚湿阻、筋脉阻滞(懒言、颈部深处疼痛伴屈曲困难、头晕、口苦、便溏、纳呆、恶心、侧屈困难)。这是对挥鞭样损伤相关疾患局部和全身症状的一个综合结果,一般临床辨证不会考虑有关肝火上炎或肝阳上亢,但无监督的数据分析反映了这些联系,这对临床拓展思路有指导意义,并对本疾患慢性发展趋势的了解有一定意义。
回顾古代文献,《内经》有“肝之俞在颈项”之说(《素问·金匮真言论》,头颈为肝胆经脉所过,如其经脉之气失和,可见颈项僵硬疼痛之症。聚类分析结果的这种提示,与古代经典理论不谋而合。
结论
1通过文献分析,总结了文献中挥鞭样损伤相关疾患的症状与证候分布特点,编制了挥鞭样损伤相关疾患中医临床四诊信息采集表,并在美国人群中进行调查研究,总结了挥鞭样损伤相关疾患临床症状、证候及中医证与症状之间的关系；通过数据研究,初步明确了各证型与症状间的对应关系。对于今后深入研究挥鞭样损伤相关疾患的中医证候辨证规律打下了基础。
2研究表明基于经筋理论对挥鞭样损伤相关疾患颈部局部表现进行辨证分型是可行的,能够比较准确地辨识并反映其软组织损伤的特征,同时考虑“筋结点”压痛情况与不同经证的症状能够明确不同经筋辨证,由之而进行辨证论治。经筋辨证以及基于全身症状的其他中医辨证分型模式,对于临床诊断与疗效评估有着明显的指导意义。
3通过理论研究归纳总结出挥鞭样损伤相关疾患经筋辨证四个证型及其症状,经验辨证与数据统计分析的结果表明均有对应意义,但少阴经证与几乎所有的参数、证型、症状均有相关意义,而且与其他经筋证型有重复现象,是否有必要保留此经证、或归类于太阳经证有待于进一步深入研究。
4中医临床辨证的规范尚有待于深入研究。经过千百年沉淀的中医学,蕴藏着无数的宝贵经验,但临诊辨证手段繁多,并无统一与规范。本研究所运用的经筋辨证适宜于颈部软组织损伤的诊疗,尚未被临床广泛应用。如何运用现代手段对不同辨证方法加以整理、论证、提炼,并使之规范化、标准化乃当务之急。
Whiplash is an acceleration-deceleration mechanism of energy transfering to the neck. Due to rear-end or side-impact motor vehicle collisions, such an impact may result in bony or soft-tissue injury (whiplash injury), which may lead to a variety of clinical manifestations (whiplash-associated disorders, WAD). It is considered as one of the most common disorders leading to disability after traffic accidents in the United States. The incidence rate is about 3.8 per thousand each year.The annual related costs amount to over 29 billion dollars, which includes treatment, diagnosis, insurance and reimbursement. Recently, the personal ownership of automobiles in China has significantly increased so that whiplash-associated disorders have drawn increasing attention.
Syndrome differentiation is feature and essence of traditional Chinese medicine.Unfortunately corresponding research on WAD syndromes related to traditional Chinese medicine (TCM) has not been conducted, even though acupuncture has been proved more superior and significant in treating whiplash-associated disorders. To fill this gap, this study intends to concentrate on the theoretical and clinical bases of the meridian sinew theory of traditional Chinese medicine. Through theoretical study, it aims to classify and formulate a model of differentiation patterns (syndromes) related to meridian sinews for whiplash-associated disorders, and also to define the tender points and symptoms of each of four meridian sinew syndromes. By conducting a clinical survey backed up by different ways of statistical data analysis, this study aims to summarize the distribution characteristics of TCM symptoms and syndromes as well as the correlation between the symptoms and syndromes of WAD. This work seeks to provide a basis for future establishment of diagnostic standards of TCM syndrome differentiation, and to enhance the therapeutic effects of acupuncture applied to treat WAD.
Objectives
1 To classify and generalize the model of differentiation patterns related to meridian sinew theory, and to define the tender points and symptoms of each differentiation syndrome for whiplash-associated disorders.
2 To explore the distribution characteristics of TCM symptoms and syndromes of whiplash-associated disorders based on local (meridian sinew) and general differentiation.
3 To explore the correlation between the TCM syndromes of whiplash-associated disorders and their corresponding symptoms and signs based on local (meridian sinew) and general differentiation.
Methods
1 Theoretical study
Based on meridian sinew theory, the pathogenesis of whiplash injury was analyzed. According to modern anatomy, an anatomical representation of the structure and route of meridian sinew pathways in the neck region was described.And according to the motion activities of the neck, the tender points and corresponding symptoms of each meridian sinew differentiation syndrome were classified and summarized. This provided a basis for the later clinical survey.
2 Clinical study
Based on literature review and clinical experience, a Clinical Survey Form for Whiplash-Associated Disorders (WAD) in Traditional Chinese Medicine was designed.
This cross-sectional survey of TCM symptoms and syndromes for WAD investigated TCM symptoms of 311 patients who met inclusive criteria in 11 clinics located in New York and California states from August,2010 to September,2011. It included the impressions of the investigating practitioners with respect to syndrome differentiation. The database was established with EpiData 3.0 software and SPSS 17.0 software was applied to analyze the distribution status and the correlations among symptoms as well as among syndromes.
The study analyzed the TCM symptoms data acquired through the clinical survey, refined the symptoms of common syndromes of whiplash-associated disorders, and summarized the correlations between syndromes and symptoms utilizing different unsupervised statistical methods such as correlation analysis, factor analysis and cluster analysis.
Results
1 Theoretical study
Based on meridian sinew theory, the tender points and corresponding symptoms of each differentiation syndrome of whiplash-associated disorders were classified and summarized. According to the local symptoms of the neck in WAD patients, the types of meridian sinew differentiation and their main manifestations are listed as follows:
(1) Taiyang Meridian Sinew Syndrome:widespread spasm and tenderness in the neck, problems of extension and flexion; tender points on Jianzhen (SI 9), Jianwaishu (SI 14), Jianzhongshu (SI 15), Tianchuan (SI 17) Tianzhu (BL 10), Yuzhen (BL 9), C3-6 Spinal Process, Dazhui (GV 14) and Taodao (GV 13).
(2) Shaoyin Meridian Sinew Syndrome:deep pain in the neck, difficulty in flexion, dizziness; tender points on the Lower Edge of the Occipitus and C3-6 Transverse Process.
(3) Shaoyang Meridian Sinew Syndrome:neck discomfort with a tendency for hands to support the head, difficulty in lateral flexion; tender points on Jianliao (SJ 14), Tianliao (SJ 14), Tianyou (SJ 16), Fengchi (GB 20) and Tianding (LI 17).
(4) Yangming Meridian Sinew Syndrome:difficulty in head rotation, stiffness and pain during neck movement, inability to raise the shoulder; tender points on Tianding (LI 17), Jianyu (LI 15), Jugu (LI 16), Futu (LI 18), Renying (ST 9) and Quepen (ST 12).
Besides meridian sinew differentiation, the general symptoms presented in WAD patients should also be viewed through other sets of syndrome differentiation. Qi stagnation syndrome and blood stasis syndrome are mostly seen during the acute stage and Qi& blood deficiency syndrome, phlegm-dampness blocking channels ayndrome and insufficiency of the liver & kidney syndrome are seen more during the chronic stage.
2 Clinical study
2.1 Study on the distribution characteristics of TCM symptoms of whiplash-associated disorders (WAD)
2.1.1 Clinical Survey Form for Whiplash-Associated Disorders (WAD) in traditional Chinese medicine. The survey form included general data, history, intensity of the neck pain (self-evaluated by the Visual Analogue Scale, VAS), Neck Disability Index Scale (NDI, self-evaluated), signs in the neck region (Range of Motion of the neck and some neurological examinations) as well as TCM symptoms and signs. The latest one included meridian sinew tender points, local meridian sinew symptoms, extremity symptoms, head and facial region symptoms, general body symptoms, diet and taste symptoms, bowel movement and urination symptoms, sleep related symptoms, mental symptoms, tongue features and pulse phenomena as well as the impressions of the investigating practitioners, which included the grading of WAD, TCM diagnosis, conclusion of meridian sinew syndromes and other general syndromes.
2.1.2 General data of the subjects:This survey investigated 313 cases of whiplash-associated disorders during the acute stage (less than 72 hours after the accident) and sub-acute stage (between 72 hours and 3 months after the accident) in 11 out-patient clines located in New York and California states.185 of the cases were male and 128 were female and the average age in the group was 36.6±0.69 years old.192 cases were drivers during the accident and more than half of the patients experienced rear-end collision. The occupations of this group were mainly unemployed, service personnel, students and laborers. The statistics showed a total of 11 cases of GradeⅠpatients and 276 cases of GradeⅡ, as well as 26 cases belonging to GradeⅢ. The average score of the Visual Analogue Scale (VAS) was 6.33±0.098, which means that those patients had a medium intensity of pain on average. The average score of the Neck Disability Index Scale (NDI) sums to 16.55±0.66, which indicated a medium level of disability.
2.1.3 Distribution characteristics of TCM symptoms:Only 6 symptoms presented in over 50% of the cases:neck pain, neck stiffness, insomnia, shoulder pain, tiredness and headache, and those phenomena coincided with the ancient theory of meridian sinew distribution. Based on the cross-sectional clinical survey of TCM symptoms and syndromes in 313 cases of whiplash-associated disorders, the common symptoms of WAD were summarized as the following according to the frequency data analysis (arrayed in a descending sequence):
(1) Tender points of the meridian sinew were discovered mainly on Jianwaishu (SI 14), Jianzhongshu (SI 15), Tianchuan (SI 17), C3-6 Spinal Process, Dazhui (GV 14), Fengchi (GB 20), Tianliao (SJ 15) and Tianding (LI 17).
(2) Symptoms of the meridian sinew syndromes were mainly widespread spasm and tenderness in the neck (Taiyang), difficulty in lateral flexion (Shaoyang), problems of extension and flexion (Taiyang), stiffness and pain during neck movement (Yangming), difficulty in head rotation (Yangming), neck discomfort with a tendency for hands to support the head (Shaoyang), and deep pain in the neck and difficulty in flexion (Shaoyin).
(3) Symptoms in the extremities and head and facial region appeared mainly as neck pain, neck stiffness, shoulder pain, headache, arm pain and finger numbness.
(4) General body symptoms presented mainly as insomnia, fatigue, anxiety, depression, body heaviness and dizziness.
(5) Tongue features mainly showed up as red tongue, light red tongue, light purple tongue, pale tongue, enlarged tongue, tooth-marked tongue, cracked tongue, abnormal sublingual veins (extended, or purple in color, or thicker), white coating, thin coating, moist coating, thick coating, and greasy coating.
(6) Pulse phenomena included deep pulse, wiry pulse, slippery pulse, tight pulse, thready pulse, rapid pulse and choppy pulse.
2.1.4 Correlations among symptoms:Data analysis indicated that all the different meridian sinews'tender points are significantly correlated to each corresponding meridian sinew, tender points in the Shaoyin meridian sinew are significantly correlated to all meridian sinew syndromes, tender points in the Shaoyang meridian sinew are also correlated to the Yangming syndrome, but tender points in the Yangming meridian sinew are only con-elated to its own meridian sinew syndrome. The following symptoms are statistically more significant with strong specificity in different syndromes:problems of extension and flexion (Taiyang), neck discomfort with a tendency for hands to support the head (Shaoyang), difficulty in lateral flexion (Shaoyang), and inability to raise the shoulder (Yangming).
2.2 Distribution characteristics of TCM syndromes of whiplash-associated disorders (WAD)
(1) Meridian sinew syndrome of WAD:The mostly seen is Taiyang syndrome, which is understandable since both the hand and foot Taiyang meridian sinews merge in the posterior of the neck as the main meridian sinews in the local area. The majority of cases presented as combinations of two together (Taiyang+Yangming, Taiyang+Shaoyang, and Taiyang+Yangming), or three together (mostly Taiyang+Shaoyang+Yangming), or even four in combination.
(2) Other TCM syndromes:Qi stagnation syndrome is the mainly seen. This phenomenon corresponds to the TCM pathogenesis of whiplash-associated disorders and is also related to the characteristics of rigidity of Yang median sinews, which are mostly distributed in the neck region.
(3) Correlations among TCM syndromes:Qi stagnation syndrome and blood stasis syndrome are significantly correlated to the Shaoyin and Shaoyang meridian sinew syndromes. Shaoyin meridian sinew syndromes showed significant correlation to all different syndromes. Also, Qi and blood deficiency syndrome has a correlation with Yangming meridian sinew syndrome.
(4) Correlations between TCM syndromes and stages, grades and collision types:There are no correlations among them.
(5) Correlations between the meridian sinew syndromes and the Range of Motion (ROM) of the neck:The correlation analysis indicated a significant negative correlation between Taiyang meridian sinew syndrome and the motions of flexion, extension, left rotation and right rotation, and between Yangming meridian sinew syndrome and the motions of flexion, left lateral flexion, left rotation and right rotation. The Shaoyin and Shaoyang meridian sinew syndromes were negatively correlated to all 6 motions of the neck.
(6) Correlations between the meridian sinew syndromes and the Neck Disability Index Scale (NDI):all the 10 indices were significantly correlated to the Taiyang meridian sinew syndrome. Most of the indices were correlated to all meridian sinew syndromes except the following:"lifting" and Shaoyin and Yangming syndromes, "reading" and Shaoyang and Yangming syndromes, "attention" and Shaoyang syndrome, and "headache" and Yangming syndrome.
(7) Correlations between the meridian sinew syndromes and the Visual Analogue Scale (VAS):Taiyang, Shaoyin and Shaoyin meridian sinew syndromes were significantly correlated, especially the Shaoyang syndrome having the highest correlation coefficient.
(8) Correlations between meridian sinew syndromes and the grading of WAD:all meridian sinew syndromes have significant correlation, especially the Shaoyin syndrome having the highest correlation coefficient.
(9) Correlations between the other TCM syndromes and the Range of Motion of the neck, the Neck Disability Index scale (NDI), the Visual Analogue Scale (VAS) and the grading of WAD:Qi stagnation syndrome and blood stasis syndrome have significant correlation with the above four parameters. Qi and blood deficiency syndrome has a significant correlation with the index of "attention" in NDI. Liver and kidney insufficiency syndrome has correlation to WAD grading.
2.3 Study on the correlations between TCM differentiation syndromes and their corresponding symptoms of whiplash-associated disorders (WAD)
The correlations between TCM differentiation and corresponding symptoms were further defined by applying unsupervised statistical methods such as correlation analysis, factor analysis and cluster analysis.
2.3.1 Correlation analysis:The summary of correlative relationships is listed in the following, with the top five priorities related to the correlation coefficient having statistical significance (P<0.01 or P<0.05).
(1) Correlations between the meridian sinews syndromes and symptoms:
●Taiyang meridian sinew syndrome:Widespread spasms and tenderness in the neck, problems of extension and flexion, pain in the deep area of the neck and difficulty in flexion, dizziness, and headache.
●Shaoyin meridian sinew syndrome:dizziness, deep pain in the neck with difficulty in flexion, widespread spasms and tenderness in the neck, blurred vision, and upper extremity heaviness.
●Shoayang meridian sinew syndrome:difficulty in lateral flexion, neck discomfort with a tendency for hands to support the head, headache, difficulty in head rotation, insomnia.
●Yangming meridian sinew syndrome:stiffness and pain during neck movement, difficulty in head rotation, inability to raise the shoulder, neck stiffness, deep pain in neck and difficulty in flexion.
(2) Correlations between other TCM syndromes and symptoms:
●Qi stagnation syndrome:insomnia, difficulty in lateral flexion, headache, blurred vision, dizziness.
●Blood stasis syndrome:insomnia, headache, difficulty in lateral flexion, blurred vision, dizziness.
●Qi and blood deficiency syndrome:poor appetite, loose stools, fatigue, anxiety, and irritability, tooth-marked tongue and irregular rhythm pulse.
●Phlegm-dampness blocking the meridian syndrome:stiffness and pain during neck movement, body heaviness, and greasy tongue coating.
●Liver and kidney insufficiency syndrome:facial warmth, blurred vision, lumbar and knee weakness, deep pain in the neck and difficulty in flexion, loose stools; tongue cracks, peeling coating.
The above correlation analysis indicates that the symptoms are basically consistent with each corresponding syndrome in meridian sinew differentiation. Furthermore, the data also shows that the Taiyang meridian sinew syndrome includes some symptoms of the Shaoyin meridian sinew syndrome, the Shaoyang meridian sinew syndrome covers some symptoms of the Yangming meridian sinew syndrome, and the Yangming meridian sinew syndrome correlates with some symptoms of the Shaoyin meridian sinew syndrome. The outcomes also indicate that the Shaoyin meridian sinew syndrome correlates to all symptoms belonging to various syndromes and thus the Shaoyin meridian sinew syndrome seems to have no clinical significance.
The correlation analysis also discovered that the correlative symptoms of the Qi stagnation syndrome and the blood stasis syndrome are almost the same. This may be explained by the fact that clinically these two syndromes are identified according to the characteristics and severity of pain combined with general manifestations; however, the subjects in this trial have less whole body general manifestations. Further study is needed to identify the correlations of these two syndromes.
The symptoms, including tongue and pulse features, essentially coincide with their pathogenesis in the following syndromes:Qi and blood deficiency syndrome, phlegm-dampness blocking syndrome, and liver and kidney insufficiency syndrome.
2.3.2 Factor analysis:
Factor analysis resulted in a total of 11 categories of general symptoms:liver stagnation and spleen deficiency symptoms (unwillingness to talk, deep pain in the neck and difficulty in flexion, dizziness, bitter taste in the mouth, loose stools); blood deficiency and liver symptoms (dizziness and blurred vision); sleep related symptoms (insomnia); liver, gallbladder, and Qi stagnation symptoms (depression, anxiety); Qi stagnation, blood stasis, Yangming meridian sinew syndromes (difficulty in head rotation, stiffness and pain during neck movement); spleen, stomach, dampness accumulation symptoms (poor appetite, nausea); Qi stagnation, blood stasis, Shaoyang meridian sinew symptoms (difficulty in lateral flexion); Taiyang meridian sinew and dampness symptoms (widespread spasm and tenderness in the neck, heavy limbs); fluid insufficiency symptoms (dry mouth); liver, excessive heat symptoms (irritability, constipation); liver, kidney deficiency symptoms (soreness in the lower back and knees, numbness in the fingers). Thus it mainly presents the basic TCM syndromes and/or syndrome factors related to Qi deficiency, blood deficiency, Qi stagnation, blood stasis, fluid insufficiency, liver, spleen, kidney, gallbladder, stomach, dampness, heat, as well as local meridian sinews such as Taiyang, Shaoyang and Yangming meridian sinews.
2.3.3 Cluster analysis:
Cluster analysis resulted in three categories of symptoms:liver fire upward flaring or hyperactivity of liver-Yang (dizziness, blurred vision, dry mouth, irritability, constipation); Qi stagnation and dampness accumulation and local meridian sinew stagnation (depression, anxiety, widespread spasm and tenderness in the neck,body heaviness, soreness and weakness of the lower back and knee, finger numbness); spleen deficiency with dampness accumulation and local meridian sinew stagnation (unwilling to talk, deep pain in the neck and difficulty in flexion, dizziness, bitter mouth, loose stools, poor appetite, nausea, difficulty in lateral flexion). This is a comprehensive analysis considering the local and general symptoms. Usually the pathogenesis of liver fire upward flaring or hyperactivity of liver-Yang are not considered during syndrome differentiation based on clinical experience, but the unsupervised data analysis indicates this kind of correlation. This will be significant for developing therapeutic strategies and predicting the trend of chronic development of WAD.
In the Inner Classic of the Yellow Emperor, it was said that "the transporting point of the liver is located in the neck region" since the neck region is the pathway of the liver and gallbladder channels. If the Qi in those channels is disordered, symptoms such as neck pain and stiffness could occur. Thus the cluster analysis outcome coincides with the classical theory.
Conclusions
1 Through literature analysis, the distribution characteristics of the symptoms and syndromes of whiplash-associated disorders were summarized, a Clinical Survey Form of Whiplash-Associated Disorders in TCM was generated, an investigation among American patients was carried out, and the regularity of clinical symptoms, syndromes and syndrome differentiation of WAD was explored. Through data analysis, the corresponding relationships of symptoms in different syndromes were preliminarily discovered. It provided a basis for future studies on the regularity of TCM syndromes of WAD.
2 It is practical to have syndrome differentiation for the local neck symptoms of whiplash-associated disorders based on the meridian sinew theory, presenting characteristics of the soft tissue injury could be identify correctly. The differentiation of meridian sinews should comprehensively consider both the tenderness points and corresponding symptoms related to meridian sinew syndromes. Thus the therapeutic methods could be determined based on the associated meridian sinew syndrome. The model of meridian sinew syndromes and other TCM syndromes could be significant for diagnosis and assessment in clinical practice.
3 The four types of meridian sinew differentiation in the neck and their corresponding symptoms were formulated according to theoretical study and clinical experience, which were presented as significant correlations through statistical analysis. However, the Shaoyin Meridian Sinew Syndrome is correlated significantly with almost all parameters, syndrome types and most symptoms, which are also repeated in the other meridian sinew syndromes. It needs further study to determine whether this type should be eliminated or should be combined with Taiyang Meridian Sinew Syndrome.
4 The standards of TCM clinical differentiation should be further studied. After thousands of years of accumulated wisdom, TCM contains numerous treasures and rich experience but the syndrome patterns are so complicated and lack any unity or standards. Meridian sinew differentiation is suitable for neck soft tissue injury but is still not being applied by most practitioners. It is important and urgent to classify, verify and refine different syndrome differentiations with modern scientific methods and to make them standardized.
引文
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