不同颈椎旋转手法的比较及其所致咔哒声响的临床研究
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摘要
颈椎疾病是临床常见病和多发病,推拿手法是治疗颈椎疾病的有效方法。推拿学作为一门古老又年轻的中西医结合临床学科,其手法的广泛应用和明显滞后的学科基础及临床研究水平形成了鲜明的对比。在颈椎疾病的推拿手法中,最常用的手法是颈椎旋转手法,疗效确切,但有一定危险性。推拿手法流派众多,各自形成各自的体系,在治疗颈椎疾病中都有一定疗效,但是迄今没有相应的临床研究来比较他们之间的疗效差异,以消除门户之见。颈椎旋转手法在操作时,常常会发出可闻及的咔哒声响,此声响是扳法的特别效应,医生和患者往往想当然地把此声响作为旋转手法复位成功的标志,但是至今未有实验证实声响和复位存在对应关系,即有声响是否一定意味着复位,同时复位是否一定会有声响。此外对于患者而言,出现了声响会有怎样的心理应激反应,有没有适当的方法做出相应调整,这些都缺乏相应的研究。
以往对于颈椎旋转手法的研究,在手法疗效和声响作用机制的探讨上,主观臆测的成分较多。一些涉及推拿问题的基础科学研究,仍然处于起步阶段。很多基础研究甚至基于一些想当然的生活常识作为出发点,得出的结论自然置信度较低。在临床疗效的评估上,以往的评估往往局限于对疾病的症状和体征的好转的主观评价,这样造成了两个研究上的缺陷：缺少对疾病本身的相对客观的可比较的评价和缺少对患者综合健康水平的评估。这与现代医学的客观性、标准化、可比较和以患者的整体康复为中心的主旨相违背。
颈椎旋转手法在获得很好临床疗效的同时,也造成一些医源性损伤。这些损伤发生率不高,其严重程度各异,但负面影响极大,造成了包括医护人员和接受推拿服务的人们对推拿学的偏见,使得他们在接受旋转手法时存在一定的心理障碍甚至抵触情绪,对推拿疗法的广泛应用有不利影响。
为了预防颈椎旋转手法造成不必要的医疗损伤,探讨手法引发的咔哒声响的实际意义,有必要对不同门派的颈椎旋转手法以及有无声响者的疗效差异进行比较研究,比较他们的疼痛和生存质量的改善情况,进而对手法所致咔哒声响进行采集分析和比较研究,以评估咔哒声响的临床意义。此外,对咔哒声响的心理应激效应也应做一番研究,以了解声响对患者有何心理影响,如何进行心理干预,为脊柱推拿的配套解释工作(即中医所说的“治神”)提供依据。为此,本课题试图从临床疗效分析、临床试验研究和临床心理研究三个角度入手,研究颈椎旋转手法及其产生的咔哒声响的实际意义,为进一步改进颈椎旋转手法提供科学基础。
第一部分临床疗效研究：不同旋转手法治疗颈源性头痛的疗效观察
目的：比较四种不同的颈椎旋转推拿手法治疗颈源性头痛的疗效以及对患者生存质量的改善情况,并探讨有无咔哒声响者的疗效和生存质量改善的差异,以了解声响与疗效是否存在关联。方法：采用随机对照的观察分析方法,病例来自于武警广东省总队医院疼痛康复中心门诊颈源性头痛患者(患者均签署知情同意书),参考Sjaastad和国际颈源性头痛研究会提出的颈源性头痛诊断标准制定纳入标准、排除标准及剔除标准,严格按照此标准纳入病例,根据首次就诊先后顺序随机分为四组：甲组、乙组、丙组和丁组。随机分配方法：按首次就诊先后次序编号,凡编号为4m-3(m为正整数)者编入甲组,凡编号为4m-2者编入乙组,编号为4m-1者编入丙组,编号为4m者编入丁组。治疗方法：选择两名经验丰富的推拿医生,一人对四组患者分别实施掌托端提旋转手法、冯氏定点旋转手法、孙氏旋转手法和龙氏旋转手法,旋转手法结束后,另一人对患者进行标准化放松手法。手法共进行4周,每周3次(隔日或隔2日1次),共12次。在每周第1次治疗时,先实施旋转手法,然后进行标准化放松手法。每周第2、3次治疗均只采用放松手法。评价方法：采用简化McGill疼痛量表(Short-form McGill Pain Questionnaire, SF-MPQ)评估患者临床疗效和简化健康状况量表(short-form health survey, SF-36)评价生存质量。在每次旋转手法操作时,由专人记录有无发生咔哒声响。统计分析方法：使用SPSS13.0统计软件建立数据库并进行分析,分析方法包括描述性统计、组内自身前后比较(配对t检验)及组间比较t检验,以及基于一般线性模型(GLM)的单因素方差分析。结果：各组患者的基线数据(性别、年龄、文化程度、低头习惯、是否接受推拿治疗和病程)差异无统计学意义(P>0.05),中医症候分布构成比经Z检验,差异无统计学意义(P=0.865),具有可比性。治疗前四组患者的疼痛和生存质量评分差异无显著性意义(P>0.05),具有可比性。治疗后四组患者的疼痛和生存质量评分差异亦无显著性意义(P>0.05),四组患者的疼痛和生存质量较之治疗前均有显著改善(P<0.05)。在各项指标治疗前后评分差值的比较上,四组患者组间SF-MPQ评分差值差异均无显著性意义(P>0.05),在生存质量各维度治疗前后评分差值差异中,只有生理功能(F=3.826,P=0.013)组间差异有显著性意义,生理功能改善情况从高到低的顺序为：乙组>丙组>甲组>丁组,其中乙组和甲组之间、乙组和丁组之间差异有显著性意义(P=0.008和P=0.002),其余各组间差异不显著。在对有无声响患者治疗前后差值进行比较后发现,发现有无声响者的SF-MPQ评分差值差异有显著性意义(t=-2.379,P=0.02)。在生存质量各维度评分中,生理职能(t=3.383,P=0.001),躯体疼痛(t=2.047,P=0.044),总体健康(t=14.600,P<0.001),精力(t=2.295,P=0.024)和精神健康(t=2.492,P=0.015)评分差值差异有显著性意义,其他维度(生理功能、社会功能和情感职能)评分差值差异无显著性意义。结论：①对于颈源性头痛而言,四种旋转手法都能起到治疗效果,都能改善疼痛症状,提高生存质量。其中,定点旋转手法疗效相对较好。②复位时有咔哒声响发生者的其疼痛症状和生存质量改善要优于无声响者。
第二部分临床实验研究：不同旋转手法所致咔哒声响的采集与分析
为了比较不同颈椎旋转手法产生咔哒声响的差异,本课题采用随机对照的试验研究方法,对咔哒声响进行了采集和比较分析,共进行了两次试验：
试验一：目的：研究两种颈椎旋转手法作用时咔哒声响次数,并进行比较分析。方法：72名健康在校大学生,随机分为两组：实验1组和对照1组,均采用先向左后向右扳动的颈椎旋转手法,其中实验1组施行常规快速颈椎旋转手法,左右各2次；对照1组施行慢速颈椎旋转手法,左右各2次。间隔一周后进行第二轮实验,仍然随机分为两组,实验2组和对照2组,均采用先向右后向左扳动的颈椎旋转手法,其中实验2组仍施行常规快速颈椎旋转手法,左右各2次,对照2组仍施行慢速颈椎旋转手法,左右各2次。运用自行设计的声响采集系统对手法所致的咔哒声响进行采集,分析其发出声响的数量,并进行统计学分析。使用SPSS13.0统计软件建立数据库并进行分析,分析方法包括描述性统计、组内自身前后比较(配对t检验)及组间比较t检验。结果：第1次旋转时结果如下：①在向左和向右旋转至生理极限过程中即有咔哒声响产生,结果显示,向左旋转时,实验1组和对照1组相比,Z=0.192,P=0.847,实验2组和对照2组相比,z=-1.473,P=0.141,向右旋转时,实验1组和对照1组相比,Z=--0.200,P=0.841,实验2组和对照2组相比,Z=-1.091,P=0.275,可见各组出现的咔哒声响次数差异无显著性意义；②在亚生理区内继续旋转出现的咔哒声响,结果显示,向左旋转时,实验1组和对照1组相比,Z=-3.422,P=0.001,实验2组和对照2组相比,z=-3.402,P=0.001,向右旋转时,实验1组和对照1组相比,Z=-2.220,P=0.026,实验2组和对照2组相比,Z=-2.516,P=0.012,可见各组出现的咔哒声响次数差异有显著性意义。③对向左与向右旋转产生的咔哒声响次数比较,结果显示,实验1组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异有显著性意义(z=-2.297,P=0.022),向右产生的声响次数少于向左者；实验2组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异也有显著性意义(z=-1.988,P=0.047),向左产生的声响次数少于向右者。可见,实验组向一侧旋转产生的声响次数多于紧接着向对侧旋转产生的声响。对照1组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异无显著性意义(z=-0.315,P=0.753)；对照2组在亚生理区内继续向左旋转出现的声响次数跟向右旋转相比差异也无显著性意义(Z=-1.667,P=0.096)。可见,对照组向一侧旋转产生的声响次数与紧接着向对侧旋转产生的声响次数无显著性差异。第2次重复实施颈部旋转手法时产生咔哒声响次数的比较结果发现,四组受试者在全部操作过程中出现了极少的咔哒声响,无统计学意义。结论：①在亚生理区范围内,用短促力实施快速旋转颈椎能产生较多的咔哒声响,缓慢旋转颈椎产生的咔哒声响次数较少；②在亚生理区范围内,用短促力向一侧实施快速旋转产生的咔哒声响次数要多于紧接着向对侧施术产生的声响,但向一侧实施慢速用力旋转产生的咔哒声响次数要与紧接着向对侧施术产生的声响差异不显著；③重复旋转颈椎产生极少的咔哒声响。
试验二：目的：研究不同方式旋转颈椎引发的咔哒声响次数,并进行比较分析。方法：96名健康在校大学生,随机均分为四组,分别实施端提旋转手法、定点旋转手法、孙氏旋转手法和单纯旋转手法。每名受试者均先向左侧旋转,再向右侧旋转。运用自行设计的声响采集系统对手法所致的咔哒声响进行采集,并对声响数量进行统计学分析。统计分析方法：使用SPSS13.0统计软件建立数据库并进行分析,分析方法包括描述性统计、组间比较采用秩和检验,组间声响构成比分析采用分层X2检验。结果：向左旋转时四组患者产生的咔哒声响次数有显著性差异(X2=9.837,P=0.020),向右旋转时四组患者产生的咔哒声响次数无显著性差异(X2=5.162,P=0.163)。在向左旋转产生的声响次数中,平均声响次数由多到少的顺序为：丁组>甲组>丙组>乙组,即单纯旋转手法>端提旋转手法>孙氏旋转手法>定点旋转手法。在各组内部,采用配对资料的秩和检验对向左和向右旋转产生的声响次数进行比较,发现乙组向左和向右旋转产生的声响次数差异无显著性意义(Z=-1.732,P=0.083),甲组、丙组和丁组向左和向右旋转产生的声响次数差异均有显著性意义(分别为z=-3.000,P=0.003；z=-2.236,P=0.025；Z=-3.000,P=0.003)。对声响构成比进行分析后发现,向左旋转时,四组声响次数构成比比较X2=13.25,P=0.039,表明向左旋转时四组受试者的声响构成比差异有显著性意义。向右旋转时,X2=17.62,P=0.007,表明向右旋转时四组受试者的声响构成比差异有显著性意义。对四组受试者的声响构成比差异进—步作两两比较,只有乙组与丁组和丙组与丁组相比声响构成比差异具有显著性意义(分别为P=0.008和P=0.005)。结论：①采取轴向牵引下实施旋转手法出现单次声响的概率较高,在临床旋转复位施术时能提高复位的准确性,减少无关声响；②肘托牵引的效用要优于掌托牵引；③定点旋转手法并不能减少咔哒声响的发生,可见定点旋转施术只是相对的定点,而非精确的定点。④快速上提对咔哒声响次数并无明显影响,但快速旋转对声响次数有明显影响。
对两次试验进行综合讨论后还认为,咔哒声响是颈椎椎间小关节被动运动至接近极限时出现的伴随现象。这种现象,在正常和异常的颈椎椎间小关节中都可能出现。出现这种声响后,往往提示关节被动活动接近极限,继续被动活动可能造成损伤。正常和异常的椎间小关节主动或被动活动到一定程度,都可能出现咔哒声响。这种声响,可能是正常关节受到扳动时发出的气穴现象,也可能是异常关节复位(合臼)时的伴随现象。颈椎旋转手法出现咔哒声响与复位并无严格的一一对应的关系,可能是复位成功的标志,也可能是与复位无关的普通现象。
第三部分临床心理研究：旋转手法所致咔哒声响的心理效应研究
目的：探讨旋转手法所致咔哒声响的心理应激反应,并探讨心理干预对这-应激反应的影响。方法：采用随机对照的观察分析方法,受试者来自健康在校学生(患者均签署知情同意书),使用单纯随机法,随机分为两组：实验组(62例)和对照组(63例)。手法操作和心理干预方法：选择一名经验丰富的推拿医生和一名心理医生,总共进行两次试验(两次试验时间间隔一周)。在两次试验中推拿医生均对实验组采用实验组采用掌托端提旋转手法,并产生咔哒声响(无声响者将被排除),对照组采用安慰手法,保证不产生咔哒声响(有声响者将被排除)。在第一次试验中,心理医生对旋转手法及其产生的咔哒声响不做任何解释,在第二次试验中,心理医生对旋转手法及其产生的咔哒声响做出解释。评价方法：采用应激反应问卷调查表(Stress Reaction Questionnaire, SRQ)评估受试者心理应激状态。统计方法：使用SPSS13.0统计软件建立数据库并进行分析,分析方法包括描述性统计、组内自身前后比较(配对t检验)、组间比较t检验以及X2检验。结果：两组患者的基线数据(性别、年龄、身高、体重)差异无统计学意义(P>0.05),具有可比性。在第一次试验时,操作前两组受试者心理应激评分差异无显著性意义(t=0.351,P=0.726),操作后两组受试者心理应激评分差异有显著性意义(t=3.152,P=0.002),实验组评分低于对照组。各组操作前后对比发现,实验组操作前后心理应激评分差异有显著性意义(t=5.899,P=0.000),操作后评分较低,对照组操作前后心理应激评分差异无显著性意义(t=1.329,P=0.189)。以上结果表明,出现咔哒声响者产生了一定程度的应激反应,无咔哒声响者基本上无应激反应。在第二次试验时,操作前两组受试者心理应激评分差异无显著性意义(t=0.301,P=0.764),操作后两组受试者心理应激评分差异有显著性意义(t=5.603,P=0.000),实验组评分高于对照组。各组操作前后对比发现,实验组操作前后心理应激评分差异有显著性意义(t=-20.014,P=0.000),操作后评分较高,对照组操作前后心理应激评分差异无显著性意义(t=0.992,P=0.325)。以上结果表明,进行心理干预后,出现咔哒声响者的心理应激反应有所减轻,无咔哒声响者仍然基本上无心理应激反应。结论：在对旋转手法产生的咔哒声响不做任何解释的情况下,旋转手法及其产生声响会使受试者产生应激反应。适当的支持性心理干预方法能够降低患者的应激反应,改善受试者的心理状态。
The diseases of cervical vertebrae are very common and frequently encountered. Manipulation treatment is an effective way. As an ancient and youthful subject, the manipulation treatments are widely used, while the studies on the manipulation are poor. The most common manipulation in treating the cervical vertebrae diseases is cervical rotatory manipulation. The rotatory manipulation is very effective while there is something dangerous in the method. In China, there are many cliques of mani-pulation. All of them are effective, but no one studied the differences among them. When we use the rotatory manipulation to operate, we usually hear the cracking sounds, which are the special effects of the manipulation. Both doctors and patients think the sounds are the sign of successful reset, while there are no experiments in proving the corresponding relations between the sounds and the reset. That is to say, if we hear the sounds, the reset is successful. And while we reset the joint, we can surely hear the sounds.
There are many assumptions in the former study. Some preclinical medicine study on the manipulation are on the start phase. Some preclinical medicine study are based on some common senses and take them for granted, which is hardly to believe. In the previous study the assessment of the clinical effects were usually based on evaluating the symptom and sign of the disease, which caused to two defects in those researches:incomparable and unilateral. Modern medical study must be objective, standard, comparable and integral rehabilitation.
Cervical rotatory manipulation can cure the cervical diseases, meanwhile it can cause some iatrogenic damages. Although the probability of the iatrogenic damages is very low, the downside influence is great. It made many doctors and patients do not trust manipulation treatment. Some patients even refused to accept the treatment, which is an obstruction to popularize it.
In order to prevent the iatrogenic damages caused by rotatory manipulation and study its practical significance, it is necessary to compare the difference among some representative rotatory manipulation and the difference between the group which has cracking sounds and which has no cracking sounds. The main assessment indexes are pain and quality of life. Then we should make an experiment to collect the cracking sounds caused by cervical rotatory manipulation and compare them to evaluate the clinical significance. Furthermore, we shall study the stress reaction caused by cracking sounds to discuss whether cracking sounds affect the mental state and how to intervene, then we can make more adaptable interpretation to improve the mental state of the patients when we are treating. Therefore, our project are based on the viewpoints ofstudy the clinical effectiveness, the clinical experiment and the cinlical psychology, studying the cervical rotatory manipulation and the clinical significanceof the cracking sounds to make the manipulation better.
The first chapter Study on the clinical effectiveness:the difference of effectiveness of four different representative kinds of cervical rotatory manipulation in treating the cervicogenic headache
Objective:to compare the effectiveness of four different representative kinds of cervical rotatory manipulation and improvement of the quality of life in treating the cervicogenic headache, and also study the difference of the effectiveness and the quality of life between the those patients who has the cracking sounds and those patients who has no cracking sounds. Then we can study the relationship of the cracking sounds and the effectiveness.
Method:The research is a four-group balanced randomized control trial, in which four different groups received four different cervical rotatory manipulation. And then we observe and analye the effectiveness by random and comparison means. All medical cases are from the outpatient service department of the pain rehabilitation center of the armed police forces hospital of Guangdong Province. All of the patients signed the informed consent. We consult the diagnosis criterion of cervicogenic headache raised by Sjaastad and the International Cervicogenic Headache Research Center to institute the internal, external and rejective standard. All cases were recruited in accordance with the standard. The random assignment method is a simple randomization way by the turns of patients first seeing the doctor to treat the cervicogenic headache. The number of the cases is compiled like this:the cases whose number is 4m-3 (m is positive integer) were assigned into group A; the cases whose number is 4m-2 (m is positive integer) were assigned into group B. the cases whose number is 4m-1 (m is positive integer) were assigned into group C. the cases whose number is 4m (m is positive integer) were assigned into group D. Treatment methods: two experienced doctors majoring in medical manipulation were selected to operate the whole manipulation, one doctor used four different kinds of cervical rotatory manipulation to treat, such as lifting rotatory manipulation by hands, Feng's cervical rotatory and local manipulation, Sun's rotatory manipulation and Long's rotatory manipulation. When the rotatory manipulation was over, the other doctor used standard relaxing manipulation to relax the muscles and press the nerves in the of occipital triangle area. It took four weeks in finishing the whole treatment. We operated the treatment three times a week, and twelve times in all. Every week we began the manipulation with our different kinds of cervical rotatory manipulation and followed with the standard relaxing manipulation for the first time. For the second and third time, only the standard relaxing manipulation is used. Assessment methods:the short-form McGill pain questionnaire (SF-MPQ) was used to evaluate the pain of the cervicogenic headache and short-form health survey (SF-36) was used to evaluate the quality of life. When the cervical rotatory manipulation being operated, the cracking sounds caused by the rotatory manipulation was recorded by specially-assigned person. Statistical method:all data was input into SPSS13.0 to establish a database, and statistical analysis was performed using methods of descriptive analysis, paired—sample t test and independent t test, and One way analysis of varience (One Way ANOVA) based on general linear model (GLM) in SPSS13.0.
ResuIts:There were no significant differences in the baseline data of the four different groups (P>0.05), such as sex, age, degree of education, lowing head habbits and facts of receiving manipulation treatment and course of the disease. There were also no significant differences in the proportion of the symptom of the cervicogenic headache in Traditional Chinese Medicine (TCM) byχ2 test and can be compared (P =0.865). Before the treatment, there were also no significant differences in the score of the pain and quality of life of the four groups and can be compared (P>0.05) After the treatment, there were also no significant differences in the score of the pain and quality of life of the four groups(P>0.05). The pain and quality of life after the treatment were better than those before the treatment (P<0.05).Comparing the differentials of the score of all the index between before and after the treatment. there was no significant differences in the score of the pain the short-form McGill pain questionnaire among the four groups (P>0.05). Comparing the differentials of the score of all the dimensionality of the quality of life, there was significant differences only in the score of the physiological functioning (F=3.826, P=0.013) and there were also no significant differences in the score of other index (P>0.05). The turn of the score of the physiological function is group B, group C, group A, group D. There were significant differences between the score of physiological function of the group B and group A (P=0.008), group B and group D (P=0.002). There were also no significant differences in the score of other index between the score of physiological function of the other groups. Comparing the differentials of the score of all the dimensionality of the pain and the quality of life between the cases which have cracking sounds and which have no cracking sounds, we found that there were significant differences in the score of the short-form McGill pain questionnaire (t=-2.379, P=0.02), physiological accountability (t=3.383, P=0.001), body pain (t=2.047, P=0.044), general health (t=4.600, P<0.001), Vitality (t=2.295, P=0.024) and mental health (t=2.492, P=0.015). There were also no significant differences in the the differentials of score of other index such as physiological functioning, social functioning and role-emotional.
Conclusion:as the cervicogennic headache is concerned, all of the four different kinds of cervical rotatory manipulation can gain good effect. The pain of the cases can relieve and the quality of life can be improved, while the cervical rotatory and local manipulation is the best. The progress of the pain and quality of life of those who have cracking sounds is better than those who have cracking sounds.
The second chapter Collection and comparison of the times of cracking sounds during different cervical rotatory manipulations
In order to study the difference of times of cracking sounds caused by different kinds of cervical rotatory manipulation, we collected and compared the times of cracking sounds during different cervical rotatory manipulations. The research included two balanced randomized control trials.
The first trial:Objective:To study the difference of times of cracking sounds caused by two different kinds of cervical rotatory manipulation. Method:72 healthy students were divided into two groups:the first experimental group and the second control group. Common cervical rotatory manipulation was performed in the first experimental group and uniform-speed cervical rotatory manipulation was performed in the first control group. Both of them were rotated to the left then to the right. We did the other experiment a week after the first one. In this experiment, the students were also divided into two groups:the second experimental group and the second control group. Common cervical rotatory manipulation was performed in the second experimental group and uniform-speed cervical rotatory manipulation was performed in the second control group. Both of them were rotated to the right then to the left. Each student was operated twice on the left side and right side in both experiments. A set of equipment designed for acoustic signal acqusition was applied to collect the cracking sounds, followed by statistical analysis of the data collected. Statistical method:all data was input into SPSS13.0 to establish a database, and statistical analysis was performed using methods of descriptive analysis, paired—sample t test and independent t test in SPSS13.0. Results:At the first time, the times of cracking sounds is different significantly in the sub-physiological area of the the fist experimental group and the first control group(to the left,t=4.077, P=0.009; to the right, t=2.017,P=0.047). the times of cracking sounds is also different significantly in the sub-physiological area of the the second experimental group and the second control group(to the left,t=2.014, P=0.048; to the right, t=3.281, P=0.002). To the first experimental group, the times of cracking sounds is different significantly in the sub-physiological area between to the left and to the right (t=1.87, P=0.007). To the second experimental group, the times of cracking sounds is also different significantly in the sub-physiological area between to the left and to the right (t=4.077, P=0.009). To the first control group, the times of cracking sounds is not different significantly in the sub-physiological area between to the left and to the right (t=0.499, P=0.620). To the second control group, the times of cracking sounds is also different significantly in the sub-physiological area between to the left and to the right (t=1.825, P =0.072).While at the second time, the times of cracking sounds is almost the same (P >0.05). Conclusion:If sudden force is used in the cervical rotatory manipulation in the sub-physiological area, it can cause more cracking sounds. The cracking sounds of the rotation to the offside would be effected after they were caused by the rapid ratation.
The second trial:Objective:To study the difference of times of cracking sounds caused by four different kinds of cervical rotatory manipulations. Method:96 healthy college students were divided into four groups. Four different kinds of cervical rotatory manipulations were used for them. They were lift and rotation manipulation, local and rotation manipulation, Sun's rotation manipulation and pure rotation manipulation. Each student was rotated to the left side first and then to the right side. A set of equipment designed for acoustic signal acqusition was applied to collect the cracking sounds, followed by statistical analysis of the data collected. Statistical method:all data was input into SPSS 13.0 to establish a database, and statistical analysis was performed using methods of descriptive analysis, paired—sample t test and independent t test, and chi-square test in SPSS 13.0. Results:When we rotated to the left, we found the times of cracking sounds caused by local and rotation manipulation and Sun's rotation were less than the other two manipulation, and the proportion of one time of sound was higher. When we rotated to the right, we found the times of cracking sounds caused by the four different kinds of cervical rotatory manipulations were close to every other. Conclusion:When rotating the cervical vertebrae, we can reduce the times of cracking sounds by exerting axial scretching force, and the the proportion of one time of sound is higher. We can improve the accuracy and pertinency of bonesetting in this way.
After comprehensive analysis and discussion we find that the cracking sounds are following phenomenon when cervical intervertebral joint is passively moved to approaching the ultimate limit. If it is passively moved continuously the joint, the joint may get injured. This phenomenon can occurred in both normal cervical intervertebral joint and abnormal one. The cracking sounds are possible to happen when the cervical intervertebral joint and abnormal one are moved to approaching the ultimate limit. The cracking sounds might be cavitation of nomal cervical intervertebral joint and might also be following phenomenon of reduction of nomal cervical intervertebral joint. There is no one-to-one correspondence between the cracking sounds and the reduction of the cervical intervertebral joint.
The third chapter Study on the psychological effect of the cracking sounds caused by cervical rotatory manipulation
Objective:to study the psychological effects of stress of the cracking sounds of caused by cervical rotatory manipulation and then study the influence on the effects by psychological intervention.
Method:The research is a two-group balanced randomized control trial, in which the two groups received different cervical rotatory manipulation. And then we observed and analyzed the effectiveness by random and comparison means. All the subjects were healthy students in college and signed the informed consent. All of them were recruited in accordance with the inclusion and exclusion standard and assigned into experimental group (62 subjects) and control group (63 subjects). Treatment methods:two experienced doctors were selected to take part in the study, one doctor majoring in medical manipulation operated the cervical rotatory manipulation and the other was a psychologist who take the psychological intervention. There were two experiments in all and the latter one was done a week after the first one. In the two experiments, the manipulation doctor used two different kinds of cervical rotatory manipulation to operate.The lifting rotatory manipulation by hands was used in the experimental group and the placebo manipulation was used in the control group. There were cracking sounds in the experimental group and those subjects who had no sounds were rejected. There were no cracking sounds in the control group and those subjects who had sounds were rejected. In the first experiment, the psychologist did not interpret the rotatory manipulation and the cracking sounds caused by it. While in the second experiment, the psychologist did some interpretation about the rotatory manipulation and the cracking sounds caused by it. Assessment methods:the Stress Reaction Questionnaire (SRQ) was used to evaluate the stress reaction of all the subjects before and after operating the manipulation.Statistical method:all data was input into SPSS 13.0 to establish a database, and statistical analysis was performed using methods of descriptive analysis, paired—sample t test and independent t test in SPSS13.0.
Results:There were no significant differences in the baseline data of the two groups and can be compared (P>0.05), such as sex, age, height and weight. In the first experiment, there were no significant differences in the score of stress reaction between the two groups before operating the rotatory manipulation (t=-0.351, P=0.726). While after operating the rotatory manipulation, there were significant differences in the score of stress reaction between the two groups (t=-3.152, P=0.002). The score of the experimental group were lower than those of the control group. Comparing the score between before and after operating the rotatory manipulation, we can find that there were significant difference in the score of the experimental group (t=2.684, P=0.008). The score after operating the rotatory manipulation were lower than those before operating the rotatory manipulation. While there were no significant difference in the score of the experimental group (t=-0.209, P=0.835). It indicated that there were stress reaction if the cracking sounds occurred and there were no stress reaction if the cracking sounds did not occur. In the second experiment, there were no significant differences in the score of stress reaction between the two groups before operating the rotatory manipulation (t=-0.301, P=0.764). While after operating the rotatory manipulation, there were significant differences in the score of stress reaction between the two groups (t=5.603, P< 0.001). The score of the experimental group were higher than those of the control group. Comparing the score between before and after operating the rotatory manipulation, we can find that there were significant difference in the score of the experimental group (t=-20.014, P<0.001). The score after operating the rotatory manipulation were lower than those before operating the rotatory manipulation. While there were no significant difference in the score of the experimental group (t=-0.992, P=0.325). It indicated that stress reaction relieved if the cracking sounds occurred and there were no stress reaction if the cracking sounds did not occur after psychological intervention.
Conclusion:If no psychological intervention was used when the cracking sounds occurred, there were stress reaction to a certain extent caused by cervical rotatory manipulation and the cracking sounds. Proper supportive psychological intervention can relieve the stress reaction and improve the mentation of the subjects.
以往对于颈椎旋转手法的研究,在手法疗效和声响作用机制的探讨上,主观臆测的成分较多。一些涉及推拿问题的基础科学研究,仍然处于起步阶段。很多基础研究甚至基于一些想当然的生活常识作为出发点,得出的结论自然置信度较低。在临床疗效的评估上,以往的评估往往局限于对疾病的症状和体征的好转的主观评价,这样造成了两个研究上的缺陷：缺少对疾病本身的相对客观的可比较的评价和缺少对患者综合健康水平的评估。这与现代医学的客观性、标准化、可比较和以患者的整体康复为中心的主旨相违背。
颈椎旋转手法在获得很好临床疗效的同时,也造成一些医源性损伤。这些损伤发生率不高,其严重程度各异,但负面影响极大,造成了包括医护人员和接受推拿服务的人们对推拿学的偏见,使得他们在接受旋转手法时存在一定的心理障碍甚至抵触情绪,对推拿疗法的广泛应用有不利影响。
为了预防颈椎旋转手法造成不必要的医疗损伤,探讨手法引发的咔哒声响的实际意义,有必要对不同门派的颈椎旋转手法以及有无声响者的疗效差异进行比较研究,比较他们的疼痛和生存质量的改善情况,进而对手法所致咔哒声响进行采集分析和比较研究,以评估咔哒声响的临床意义。此外,对咔哒声响的心理应激效应也应做一番研究,以了解声响对患者有何心理影响,如何进行心理干预,为脊柱推拿的配套解释工作(即中医所说的“治神”)提供依据。为此,本课题试图从临床疗效分析、临床试验研究和临床心理研究三个角度入手,研究颈椎旋转手法及其产生的咔哒声响的实际意义,为进一步改进颈椎旋转手法提供科学基础。
第一部分临床疗效研究：不同旋转手法治疗颈源性头痛的疗效观察
目的：比较四种不同的颈椎旋转推拿手法治疗颈源性头痛的疗效以及对患者生存质量的改善情况,并探讨有无咔哒声响者的疗效和生存质量改善的差异,以了解声响与疗效是否存在关联。方法：采用随机对照的观察分析方法,病例来自于武警广东省总队医院疼痛康复中心门诊颈源性头痛患者(患者均签署知情同意书),参考Sjaastad和国际颈源性头痛研究会提出的颈源性头痛诊断标准制定纳入标准、排除标准及剔除标准,严格按照此标准纳入病例,根据首次就诊先后顺序随机分为四组：甲组、乙组、丙组和丁组。随机分配方法：按首次就诊先后次序编号,凡编号为4m-3(m为正整数)者编入甲组,凡编号为4m-2者编入乙组,编号为4m-1者编入丙组,编号为4m者编入丁组。治疗方法：选择两名经验丰富的推拿医生,一人对四组患者分别实施掌托端提旋转手法、冯氏定点旋转手法、孙氏旋转手法和龙氏旋转手法,旋转手法结束后,另一人对患者进行标准化放松手法。手法共进行4周,每周3次(隔日或隔2日1次),共12次。在每周第1次治疗时,先实施旋转手法,然后进行标准化放松手法。每周第2、3次治疗均只采用放松手法。评价方法：采用简化McGill疼痛量表(Short-form McGill Pain Questionnaire, SF-MPQ)评估患者临床疗效和简化健康状况量表(short-form health survey, SF-36)评价生存质量。在每次旋转手法操作时,由专人记录有无发生咔哒声响。统计分析方法：使用SPSS13.0统计软件建立数据库并进行分析,分析方法包括描述性统计、组内自身前后比较(配对t检验)及组间比较t检验,以及基于一般线性模型(GLM)的单因素方差分析。结果：各组患者的基线数据(性别、年龄、文化程度、低头习惯、是否接受推拿治疗和病程)差异无统计学意义(P>0.05),中医症候分布构成比经Z检验,差异无统计学意义(P=0.865),具有可比性。治疗前四组患者的疼痛和生存质量评分差异无显著性意义(P>0.05),具有可比性。治疗后四组患者的疼痛和生存质量评分差异亦无显著性意义(P>0.05),四组患者的疼痛和生存质量较之治疗前均有显著改善(P<0.05)。在各项指标治疗前后评分差值的比较上,四组患者组间SF-MPQ评分差值差异均无显著性意义(P>0.05),在生存质量各维度治疗前后评分差值差异中,只有生理功能(F=3.826,P=0.013)组间差异有显著性意义,生理功能改善情况从高到低的顺序为：乙组>丙组>甲组>丁组,其中乙组和甲组之间、乙组和丁组之间差异有显著性意义(P=0.008和P=0.002),其余各组间差异不显著。在对有无声响患者治疗前后差值进行比较后发现,发现有无声响者的SF-MPQ评分差值差异有显著性意义(t=-2.379,P=0.02)。在生存质量各维度评分中,生理职能(t=3.383,P=0.001),躯体疼痛(t=2.047,P=0.044),总体健康(t=14.600,P<0.001),精力(t=2.295,P=0.024)和精神健康(t=2.492,P=0.015)评分差值差异有显著性意义,其他维度(生理功能、社会功能和情感职能)评分差值差异无显著性意义。结论：①对于颈源性头痛而言,四种旋转手法都能起到治疗效果,都能改善疼痛症状,提高生存质量。其中,定点旋转手法疗效相对较好。②复位时有咔哒声响发生者的其疼痛症状和生存质量改善要优于无声响者。
第二部分临床实验研究：不同旋转手法所致咔哒声响的采集与分析
为了比较不同颈椎旋转手法产生咔哒声响的差异,本课题采用随机对照的试验研究方法,对咔哒声响进行了采集和比较分析,共进行了两次试验：
试验一：目的：研究两种颈椎旋转手法作用时咔哒声响次数,并进行比较分析。方法：72名健康在校大学生,随机分为两组：实验1组和对照1组,均采用先向左后向右扳动的颈椎旋转手法,其中实验1组施行常规快速颈椎旋转手法,左右各2次；对照1组施行慢速颈椎旋转手法,左右各2次。间隔一周后进行第二轮实验,仍然随机分为两组,实验2组和对照2组,均采用先向右后向左扳动的颈椎旋转手法,其中实验2组仍施行常规快速颈椎旋转手法,左右各2次,对照2组仍施行慢速颈椎旋转手法,左右各2次。运用自行设计的声响采集系统对手法所致的咔哒声响进行采集,分析其发出声响的数量,并进行统计学分析。使用SPSS13.0统计软件建立数据库并进行分析,分析方法包括描述性统计、组内自身前后比较(配对t检验)及组间比较t检验。结果：第1次旋转时结果如下：①在向左和向右旋转至生理极限过程中即有咔哒声响产生,结果显示,向左旋转时,实验1组和对照1组相比,Z=0.192,P=0.847,实验2组和对照2组相比,z=-1.473,P=0.141,向右旋转时,实验1组和对照1组相比,Z=--0.200,P=0.841,实验2组和对照2组相比,Z=-1.091,P=0.275,可见各组出现的咔哒声响次数差异无显著性意义；②在亚生理区内继续旋转出现的咔哒声响,结果显示,向左旋转时,实验1组和对照1组相比,Z=-3.422,P=0.001,实验2组和对照2组相比,z=-3.402,P=0.001,向右旋转时,实验1组和对照1组相比,Z=-2.220,P=0.026,实验2组和对照2组相比,Z=-2.516,P=0.012,可见各组出现的咔哒声响次数差异有显著性意义。③对向左与向右旋转产生的咔哒声响次数比较,结果显示,实验1组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异有显著性意义(z=-2.297,P=0.022),向右产生的声响次数少于向左者；实验2组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异也有显著性意义(z=-1.988,P=0.047),向左产生的声响次数少于向右者。可见,实验组向一侧旋转产生的声响次数多于紧接着向对侧旋转产生的声响。对照1组在亚生理区内继续向左旋转出现的咔哒声响次数跟向右旋转相比差异无显著性意义(z=-0.315,P=0.753)；对照2组在亚生理区内继续向左旋转出现的声响次数跟向右旋转相比差异也无显著性意义(Z=-1.667,P=0.096)。可见,对照组向一侧旋转产生的声响次数与紧接着向对侧旋转产生的声响次数无显著性差异。第2次重复实施颈部旋转手法时产生咔哒声响次数的比较结果发现,四组受试者在全部操作过程中出现了极少的咔哒声响,无统计学意义。结论：①在亚生理区范围内,用短促力实施快速旋转颈椎能产生较多的咔哒声响,缓慢旋转颈椎产生的咔哒声响次数较少；②在亚生理区范围内,用短促力向一侧实施快速旋转产生的咔哒声响次数要多于紧接着向对侧施术产生的声响,但向一侧实施慢速用力旋转产生的咔哒声响次数要与紧接着向对侧施术产生的声响差异不显著；③重复旋转颈椎产生极少的咔哒声响。
试验二：目的：研究不同方式旋转颈椎引发的咔哒声响次数,并进行比较分析。方法：96名健康在校大学生,随机均分为四组,分别实施端提旋转手法、定点旋转手法、孙氏旋转手法和单纯旋转手法。每名受试者均先向左侧旋转,再向右侧旋转。运用自行设计的声响采集系统对手法所致的咔哒声响进行采集,并对声响数量进行统计学分析。统计分析方法：使用SPSS13.0统计软件建立数据库并进行分析,分析方法包括描述性统计、组间比较采用秩和检验,组间声响构成比分析采用分层X2检验。结果：向左旋转时四组患者产生的咔哒声响次数有显著性差异(X2=9.837,P=0.020),向右旋转时四组患者产生的咔哒声响次数无显著性差异(X2=5.162,P=0.163)。在向左旋转产生的声响次数中,平均声响次数由多到少的顺序为：丁组>甲组>丙组>乙组,即单纯旋转手法>端提旋转手法>孙氏旋转手法>定点旋转手法。在各组内部,采用配对资料的秩和检验对向左和向右旋转产生的声响次数进行比较,发现乙组向左和向右旋转产生的声响次数差异无显著性意义(Z=-1.732,P=0.083),甲组、丙组和丁组向左和向右旋转产生的声响次数差异均有显著性意义(分别为z=-3.000,P=0.003；z=-2.236,P=0.025；Z=-3.000,P=0.003)。对声响构成比进行分析后发现,向左旋转时,四组声响次数构成比比较X2=13.25,P=0.039,表明向左旋转时四组受试者的声响构成比差异有显著性意义。向右旋转时,X2=17.62,P=0.007,表明向右旋转时四组受试者的声响构成比差异有显著性意义。对四组受试者的声响构成比差异进—步作两两比较,只有乙组与丁组和丙组与丁组相比声响构成比差异具有显著性意义(分别为P=0.008和P=0.005)。结论：①采取轴向牵引下实施旋转手法出现单次声响的概率较高,在临床旋转复位施术时能提高复位的准确性,减少无关声响；②肘托牵引的效用要优于掌托牵引；③定点旋转手法并不能减少咔哒声响的发生,可见定点旋转施术只是相对的定点,而非精确的定点。④快速上提对咔哒声响次数并无明显影响,但快速旋转对声响次数有明显影响。
对两次试验进行综合讨论后还认为,咔哒声响是颈椎椎间小关节被动运动至接近极限时出现的伴随现象。这种现象,在正常和异常的颈椎椎间小关节中都可能出现。出现这种声响后,往往提示关节被动活动接近极限,继续被动活动可能造成损伤。正常和异常的椎间小关节主动或被动活动到一定程度,都可能出现咔哒声响。这种声响,可能是正常关节受到扳动时发出的气穴现象,也可能是异常关节复位(合臼)时的伴随现象。颈椎旋转手法出现咔哒声响与复位并无严格的一一对应的关系,可能是复位成功的标志,也可能是与复位无关的普通现象。
第三部分临床心理研究：旋转手法所致咔哒声响的心理效应研究
目的：探讨旋转手法所致咔哒声响的心理应激反应,并探讨心理干预对这-应激反应的影响。方法：采用随机对照的观察分析方法,受试者来自健康在校学生(患者均签署知情同意书),使用单纯随机法,随机分为两组：实验组(62例)和对照组(63例)。手法操作和心理干预方法：选择一名经验丰富的推拿医生和一名心理医生,总共进行两次试验(两次试验时间间隔一周)。在两次试验中推拿医生均对实验组采用实验组采用掌托端提旋转手法,并产生咔哒声响(无声响者将被排除),对照组采用安慰手法,保证不产生咔哒声响(有声响者将被排除)。在第一次试验中,心理医生对旋转手法及其产生的咔哒声响不做任何解释,在第二次试验中,心理医生对旋转手法及其产生的咔哒声响做出解释。评价方法：采用应激反应问卷调查表(Stress Reaction Questionnaire, SRQ)评估受试者心理应激状态。统计方法：使用SPSS13.0统计软件建立数据库并进行分析,分析方法包括描述性统计、组内自身前后比较(配对t检验)、组间比较t检验以及X2检验。结果：两组患者的基线数据(性别、年龄、身高、体重)差异无统计学意义(P>0.05),具有可比性。在第一次试验时,操作前两组受试者心理应激评分差异无显著性意义(t=0.351,P=0.726),操作后两组受试者心理应激评分差异有显著性意义(t=3.152,P=0.002),实验组评分低于对照组。各组操作前后对比发现,实验组操作前后心理应激评分差异有显著性意义(t=5.899,P=0.000),操作后评分较低,对照组操作前后心理应激评分差异无显著性意义(t=1.329,P=0.189)。以上结果表明,出现咔哒声响者产生了一定程度的应激反应,无咔哒声响者基本上无应激反应。在第二次试验时,操作前两组受试者心理应激评分差异无显著性意义(t=0.301,P=0.764),操作后两组受试者心理应激评分差异有显著性意义(t=5.603,P=0.000),实验组评分高于对照组。各组操作前后对比发现,实验组操作前后心理应激评分差异有显著性意义(t=-20.014,P=0.000),操作后评分较高,对照组操作前后心理应激评分差异无显著性意义(t=0.992,P=0.325)。以上结果表明,进行心理干预后,出现咔哒声响者的心理应激反应有所减轻,无咔哒声响者仍然基本上无心理应激反应。结论：在对旋转手法产生的咔哒声响不做任何解释的情况下,旋转手法及其产生声响会使受试者产生应激反应。适当的支持性心理干预方法能够降低患者的应激反应,改善受试者的心理状态。
The diseases of cervical vertebrae are very common and frequently encountered. Manipulation treatment is an effective way. As an ancient and youthful subject, the manipulation treatments are widely used, while the studies on the manipulation are poor. The most common manipulation in treating the cervical vertebrae diseases is cervical rotatory manipulation. The rotatory manipulation is very effective while there is something dangerous in the method. In China, there are many cliques of mani-pulation. All of them are effective, but no one studied the differences among them. When we use the rotatory manipulation to operate, we usually hear the cracking sounds, which are the special effects of the manipulation. Both doctors and patients think the sounds are the sign of successful reset, while there are no experiments in proving the corresponding relations between the sounds and the reset. That is to say, if we hear the sounds, the reset is successful. And while we reset the joint, we can surely hear the sounds.
There are many assumptions in the former study. Some preclinical medicine study on the manipulation are on the start phase. Some preclinical medicine study are based on some common senses and take them for granted, which is hardly to believe. In the previous study the assessment of the clinical effects were usually based on evaluating the symptom and sign of the disease, which caused to two defects in those researches:incomparable and unilateral. Modern medical study must be objective, standard, comparable and integral rehabilitation.
Cervical rotatory manipulation can cure the cervical diseases, meanwhile it can cause some iatrogenic damages. Although the probability of the iatrogenic damages is very low, the downside influence is great. It made many doctors and patients do not trust manipulation treatment. Some patients even refused to accept the treatment, which is an obstruction to popularize it.
In order to prevent the iatrogenic damages caused by rotatory manipulation and study its practical significance, it is necessary to compare the difference among some representative rotatory manipulation and the difference between the group which has cracking sounds and which has no cracking sounds. The main assessment indexes are pain and quality of life. Then we should make an experiment to collect the cracking sounds caused by cervical rotatory manipulation and compare them to evaluate the clinical significance. Furthermore, we shall study the stress reaction caused by cracking sounds to discuss whether cracking sounds affect the mental state and how to intervene, then we can make more adaptable interpretation to improve the mental state of the patients when we are treating. Therefore, our project are based on the viewpoints ofstudy the clinical effectiveness, the clinical experiment and the cinlical psychology, studying the cervical rotatory manipulation and the clinical significanceof the cracking sounds to make the manipulation better.
The first chapter Study on the clinical effectiveness:the difference of effectiveness of four different representative kinds of cervical rotatory manipulation in treating the cervicogenic headache
Objective:to compare the effectiveness of four different representative kinds of cervical rotatory manipulation and improvement of the quality of life in treating the cervicogenic headache, and also study the difference of the effectiveness and the quality of life between the those patients who has the cracking sounds and those patients who has no cracking sounds. Then we can study the relationship of the cracking sounds and the effectiveness.
Method:The research is a four-group balanced randomized control trial, in which four different groups received four different cervical rotatory manipulation. And then we observe and analye the effectiveness by random and comparison means. All medical cases are from the outpatient service department of the pain rehabilitation center of the armed police forces hospital of Guangdong Province. All of the patients signed the informed consent. We consult the diagnosis criterion of cervicogenic headache raised by Sjaastad and the International Cervicogenic Headache Research Center to institute the internal, external and rejective standard. All cases were recruited in accordance with the standard. The random assignment method is a simple randomization way by the turns of patients first seeing the doctor to treat the cervicogenic headache. The number of the cases is compiled like this:the cases whose number is 4m-3 (m is positive integer) were assigned into group A; the cases whose number is 4m-2 (m is positive integer) were assigned into group B. the cases whose number is 4m-1 (m is positive integer) were assigned into group C. the cases whose number is 4m (m is positive integer) were assigned into group D. Treatment methods: two experienced doctors majoring in medical manipulation were selected to operate the whole manipulation, one doctor used four different kinds of cervical rotatory manipulation to treat, such as lifting rotatory manipulation by hands, Feng's cervical rotatory and local manipulation, Sun's rotatory manipulation and Long's rotatory manipulation. When the rotatory manipulation was over, the other doctor used standard relaxing manipulation to relax the muscles and press the nerves in the of occipital triangle area. It took four weeks in finishing the whole treatment. We operated the treatment three times a week, and twelve times in all. Every week we began the manipulation with our different kinds of cervical rotatory manipulation and followed with the standard relaxing manipulation for the first time. For the second and third time, only the standard relaxing manipulation is used. Assessment methods:the short-form McGill pain questionnaire (SF-MPQ) was used to evaluate the pain of the cervicogenic headache and short-form health survey (SF-36) was used to evaluate the quality of life. When the cervical rotatory manipulation being operated, the cracking sounds caused by the rotatory manipulation was recorded by specially-assigned person. Statistical method:all data was input into SPSS13.0 to establish a database, and statistical analysis was performed using methods of descriptive analysis, paired—sample t test and independent t test, and One way analysis of varience (One Way ANOVA) based on general linear model (GLM) in SPSS13.0.
ResuIts:There were no significant differences in the baseline data of the four different groups (P>0.05), such as sex, age, degree of education, lowing head habbits and facts of receiving manipulation treatment and course of the disease. There were also no significant differences in the proportion of the symptom of the cervicogenic headache in Traditional Chinese Medicine (TCM) byχ2 test and can be compared (P =0.865). Before the treatment, there were also no significant differences in the score of the pain and quality of life of the four groups and can be compared (P>0.05) After the treatment, there were also no significant differences in the score of the pain and quality of life of the four groups(P>0.05). The pain and quality of life after the treatment were better than those before the treatment (P<0.05).Comparing the differentials of the score of all the index between before and after the treatment. there was no significant differences in the score of the pain the short-form McGill pain questionnaire among the four groups (P>0.05). Comparing the differentials of the score of all the dimensionality of the quality of life, there was significant differences only in the score of the physiological functioning (F=3.826, P=0.013) and there were also no significant differences in the score of other index (P>0.05). The turn of the score of the physiological function is group B, group C, group A, group D. There were significant differences between the score of physiological function of the group B and group A (P=0.008), group B and group D (P=0.002). There were also no significant differences in the score of other index between the score of physiological function of the other groups. Comparing the differentials of the score of all the dimensionality of the pain and the quality of life between the cases which have cracking sounds and which have no cracking sounds, we found that there were significant differences in the score of the short-form McGill pain questionnaire (t=-2.379, P=0.02), physiological accountability (t=3.383, P=0.001), body pain (t=2.047, P=0.044), general health (t=4.600, P<0.001), Vitality (t=2.295, P=0.024) and mental health (t=2.492, P=0.015). There were also no significant differences in the the differentials of score of other index such as physiological functioning, social functioning and role-emotional.
Conclusion:as the cervicogennic headache is concerned, all of the four different kinds of cervical rotatory manipulation can gain good effect. The pain of the cases can relieve and the quality of life can be improved, while the cervical rotatory and local manipulation is the best. The progress of the pain and quality of life of those who have cracking sounds is better than those who have cracking sounds.
The second chapter Collection and comparison of the times of cracking sounds during different cervical rotatory manipulations
In order to study the difference of times of cracking sounds caused by different kinds of cervical rotatory manipulation, we collected and compared the times of cracking sounds during different cervical rotatory manipulations. The research included two balanced randomized control trials.
The first trial:Objective:To study the difference of times of cracking sounds caused by two different kinds of cervical rotatory manipulation. Method:72 healthy students were divided into two groups:the first experimental group and the second control group. Common cervical rotatory manipulation was performed in the first experimental group and uniform-speed cervical rotatory manipulation was performed in the first control group. Both of them were rotated to the left then to the right. We did the other experiment a week after the first one. In this experiment, the students were also divided into two groups:the second experimental group and the second control group. Common cervical rotatory manipulation was performed in the second experimental group and uniform-speed cervical rotatory manipulation was performed in the second control group. Both of them were rotated to the right then to the left. Each student was operated twice on the left side and right side in both experiments. A set of equipment designed for acoustic signal acqusition was applied to collect the cracking sounds, followed by statistical analysis of the data collected. Statistical method:all data was input into SPSS13.0 to establish a database, and statistical analysis was performed using methods of descriptive analysis, paired—sample t test and independent t test in SPSS13.0. Results:At the first time, the times of cracking sounds is different significantly in the sub-physiological area of the the fist experimental group and the first control group(to the left,t=4.077, P=0.009; to the right, t=2.017,P=0.047). the times of cracking sounds is also different significantly in the sub-physiological area of the the second experimental group and the second control group(to the left,t=2.014, P=0.048; to the right, t=3.281, P=0.002). To the first experimental group, the times of cracking sounds is different significantly in the sub-physiological area between to the left and to the right (t=1.87, P=0.007). To the second experimental group, the times of cracking sounds is also different significantly in the sub-physiological area between to the left and to the right (t=4.077, P=0.009). To the first control group, the times of cracking sounds is not different significantly in the sub-physiological area between to the left and to the right (t=0.499, P=0.620). To the second control group, the times of cracking sounds is also different significantly in the sub-physiological area between to the left and to the right (t=1.825, P =0.072).While at the second time, the times of cracking sounds is almost the same (P >0.05). Conclusion:If sudden force is used in the cervical rotatory manipulation in the sub-physiological area, it can cause more cracking sounds. The cracking sounds of the rotation to the offside would be effected after they were caused by the rapid ratation.
The second trial:Objective:To study the difference of times of cracking sounds caused by four different kinds of cervical rotatory manipulations. Method:96 healthy college students were divided into four groups. Four different kinds of cervical rotatory manipulations were used for them. They were lift and rotation manipulation, local and rotation manipulation, Sun's rotation manipulation and pure rotation manipulation. Each student was rotated to the left side first and then to the right side. A set of equipment designed for acoustic signal acqusition was applied to collect the cracking sounds, followed by statistical analysis of the data collected. Statistical method:all data was input into SPSS 13.0 to establish a database, and statistical analysis was performed using methods of descriptive analysis, paired—sample t test and independent t test, and chi-square test in SPSS 13.0. Results:When we rotated to the left, we found the times of cracking sounds caused by local and rotation manipulation and Sun's rotation were less than the other two manipulation, and the proportion of one time of sound was higher. When we rotated to the right, we found the times of cracking sounds caused by the four different kinds of cervical rotatory manipulations were close to every other. Conclusion:When rotating the cervical vertebrae, we can reduce the times of cracking sounds by exerting axial scretching force, and the the proportion of one time of sound is higher. We can improve the accuracy and pertinency of bonesetting in this way.
After comprehensive analysis and discussion we find that the cracking sounds are following phenomenon when cervical intervertebral joint is passively moved to approaching the ultimate limit. If it is passively moved continuously the joint, the joint may get injured. This phenomenon can occurred in both normal cervical intervertebral joint and abnormal one. The cracking sounds are possible to happen when the cervical intervertebral joint and abnormal one are moved to approaching the ultimate limit. The cracking sounds might be cavitation of nomal cervical intervertebral joint and might also be following phenomenon of reduction of nomal cervical intervertebral joint. There is no one-to-one correspondence between the cracking sounds and the reduction of the cervical intervertebral joint.
The third chapter Study on the psychological effect of the cracking sounds caused by cervical rotatory manipulation
Objective:to study the psychological effects of stress of the cracking sounds of caused by cervical rotatory manipulation and then study the influence on the effects by psychological intervention.
Method:The research is a two-group balanced randomized control trial, in which the two groups received different cervical rotatory manipulation. And then we observed and analyzed the effectiveness by random and comparison means. All the subjects were healthy students in college and signed the informed consent. All of them were recruited in accordance with the inclusion and exclusion standard and assigned into experimental group (62 subjects) and control group (63 subjects). Treatment methods:two experienced doctors were selected to take part in the study, one doctor majoring in medical manipulation operated the cervical rotatory manipulation and the other was a psychologist who take the psychological intervention. There were two experiments in all and the latter one was done a week after the first one. In the two experiments, the manipulation doctor used two different kinds of cervical rotatory manipulation to operate.The lifting rotatory manipulation by hands was used in the experimental group and the placebo manipulation was used in the control group. There were cracking sounds in the experimental group and those subjects who had no sounds were rejected. There were no cracking sounds in the control group and those subjects who had sounds were rejected. In the first experiment, the psychologist did not interpret the rotatory manipulation and the cracking sounds caused by it. While in the second experiment, the psychologist did some interpretation about the rotatory manipulation and the cracking sounds caused by it. Assessment methods:the Stress Reaction Questionnaire (SRQ) was used to evaluate the stress reaction of all the subjects before and after operating the manipulation.Statistical method:all data was input into SPSS 13.0 to establish a database, and statistical analysis was performed using methods of descriptive analysis, paired—sample t test and independent t test in SPSS13.0.
Results:There were no significant differences in the baseline data of the two groups and can be compared (P>0.05), such as sex, age, height and weight. In the first experiment, there were no significant differences in the score of stress reaction between the two groups before operating the rotatory manipulation (t=-0.351, P=0.726). While after operating the rotatory manipulation, there were significant differences in the score of stress reaction between the two groups (t=-3.152, P=0.002). The score of the experimental group were lower than those of the control group. Comparing the score between before and after operating the rotatory manipulation, we can find that there were significant difference in the score of the experimental group (t=2.684, P=0.008). The score after operating the rotatory manipulation were lower than those before operating the rotatory manipulation. While there were no significant difference in the score of the experimental group (t=-0.209, P=0.835). It indicated that there were stress reaction if the cracking sounds occurred and there were no stress reaction if the cracking sounds did not occur. In the second experiment, there were no significant differences in the score of stress reaction between the two groups before operating the rotatory manipulation (t=-0.301, P=0.764). While after operating the rotatory manipulation, there were significant differences in the score of stress reaction between the two groups (t=5.603, P< 0.001). The score of the experimental group were higher than those of the control group. Comparing the score between before and after operating the rotatory manipulation, we can find that there were significant difference in the score of the experimental group (t=-20.014, P<0.001). The score after operating the rotatory manipulation were lower than those before operating the rotatory manipulation. While there were no significant difference in the score of the experimental group (t=-0.992, P=0.325). It indicated that stress reaction relieved if the cracking sounds occurred and there were no stress reaction if the cracking sounds did not occur after psychological intervention.
Conclusion:If no psychological intervention was used when the cracking sounds occurred, there were stress reaction to a certain extent caused by cervical rotatory manipulation and the cracking sounds. Proper supportive psychological intervention can relieve the stress reaction and improve the mentation of the subjects.
引文
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