循环载荷条件下模拟腰椎扳法对椎间盘内压的影响
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摘要
腰椎间盘突出症(Lumbar Disc Herniation, LDH)是最常见的椎间盘类疾病,是我国的慢性病、高发病之一。长期大量的临床实践证明,中医骨伤手法对该病疗效确切,是临床非手术疗法中首选的重要手段,其中扳法又是治疗该病的核心手法之一,操作简便、见效迅捷,临床应用十分广泛。荷兰保健委员会及北美脊柱外科协会临床指南均推荐在没有马尾神经综合症的早期患者腰椎间盘突出症采用保守治疗,其中包括手法。众多研究者采用更多的研究手段和方法从力学、神经生理学、解剖学等多角度阐明扳法的作用,扳法的研究取得了阶段性成果。更深层次的扳法研究是具有挑战性的。腰椎间盘退变很多扳法研究并没有紧密结合临床在体测量数据,力学参数也多从文献中汲取,其结果和结论难以充分说明扳法在临床病理状态下作用的力学效应机理。现有研究多采用非力学机制动物造模作为研究对象,较少采用全腰椎标本,模型缺乏脊柱力学作用机制特征,很难接近临床病理状态。本研究即针对上述问题,结合临床实际,采用离体腰椎标本进行研究,以期深入阐释扳法的作用机理及安全性等,为临床和科研提供重要的参考指标,并对指导临床使用具有重要现实意义。
本研究来源于2010国家自然基金《模拟斜扳手法对腰椎突出节段内在结构影响的可视化研究》、北京市自然基金《“从病在筋,调之筋”研究按揉理筋手法在非特异性下腰痛中的力学机制》。研究分两个实验：首先通过在离体标本上进行循环载荷,以期模拟椎间盘退变或者突出的临床病理状态,通过腰椎CT扫描椎间隙、椎体高度和腰椎三维运动确认病理状态,在此基础上模拟扳法旋转时椎体角度位移变化,以阐释手法作用时椎体相关节段的运动方式；然后在此病理状态下通过BOSE动/静态材料试验机进行两种体位、四种载荷的扳法模拟,测试腰椎间盘内压,研究椎间盘退变状态下手法作用机制、安全性评估。
本论文创新是对离体标本施加循环载荷,模拟出腰椎间盘退变病理状态,在此基础上探讨了脊柱在手法力作用下的运动变化特征；从手法作用力时椎间盘内压的变化,探讨了病理状态下手法作用机制和作用特点。在此基础上的研究数据和结论更加真实、更具有临床意义,此前国内尚未见同类研究,对现代中医骨科手法的基础研究应有启发和借鉴之处。
实验一
[研究目的]
1、通过循环载荷模拟腰椎间盘退变病理状态,使扳法研究贴近临床实际而更具意义和价值；
2、模拟椎间盘退变病理状态下,研究扳法旋转时腰椎共轭运动特征和操作特点。
[研究方法]
十二具离体腰椎处理后固定在BOSE动／静态材料试验机上,利用BOSE动／静态材料试验机控制循环载荷。加载方案：结合Adams M A、Hutton W C腰椎节段循环疲劳负荷力学造模方法,对标本进行6小时,60循环/分钟,21600转,300N初始压力,750N峰值压力,8°前屈的循环载荷,以正弦波形加载,初始时循环载荷为轻度,峰值压力逐渐增加到最大值。
循环载荷前后分别连接力矩加载系统,悬挂加载6Nm扭矩,测试腰椎三维运动信息和模拟扳法旋转过程。依次进行前屈、后伸、左旋、右旋、左侧弯、右侧弯六个运动方向的测试,每组测试中立位、加载和卸载三种状态,利用Motion运动捕捉系统采集标本信息,频率60HZ,采集时间1s；全部采集所得运动信息以.p巧保存处理。
循环载荷前后对标本采用GE公司Lightspeed16层螺旋CT扫描仪进行CT扫描。
CT测量L3、L4、L5椎体前、中、后高度；L3-L4、L4-L5、L5-S1椎间隙前、中、后高度；三维运动分析系统计算L3-L4、L4-L5、L5-S1节段屈伸、侧弯、旋转最大运动范围、中性区；模拟扳法旋转时L3、L4、L5椎体屈伸、侧弯、旋转角度位移。
统计分析：所有统计检验均采用双侧检验,使用SPSS13.0软件处理。符合正态分布者,用x±SD表示平均值加减标准差；组间用配对t检验,组内数据经方差齐性检验,方差相齐者用S-N-K双侧检验,方差不齐者用Dunnett's T3检验。P值小于或者等于0.05将被视为所有检验的差别有统计意义。
[研究结果]
1、循环载荷前后12个标本L3-L4、L4-L5. L5-S1共计36个间盘的椎间隙高度进行配对样本T检验,椎间隙前高、中高、后高在循环载荷后均降低,有显著性差异(P<0.05)。
2、循环载荷前后12个标本L3、L4、L5共计36个椎体的高度进行配对样本T检验,椎体前高、中高、后高在循环载荷后均有降低趋势,无显著性差异(P>0.05)。
3、循环载荷后,L3-L4、L4-L5、L5-S1节段屈伸、侧弯、旋转运动范围、中性区均增加,与加载前进行配对T检验,各节段屈伸、侧弯、旋转运动范围、中性区均有显著性差异(P<0.05)
4、左、右侧旋转扳动过程中,L3、L4、L5椎体的运动是共轭运动,旋转同时椎体也进行屈或伸、侧弯运动。右侧旋转斜扳时各间盘组内屈伸、侧弯、旋转角度位移单因素方差分析,无显著性差异(P>0.05),轴向旋转角度位移有小于屈伸、侧弯角度位移的趋势；各间盘组间屈伸、侧弯、旋转角度位移单因素方差分析,无显著性差异(P>0.05),旋转角度位移L3>L4>L5依次减小,侧弯角度位移L3>L4>L5,依次减小。左侧旋转斜扳时L5椎体旋转角度位移小于屈伸角度位移,有显著性差异(P<0.05)；其余各间盘组内屈伸、侧弯、旋转角度位移单因素方差分析,无显著性差异(P>0.05)；各间盘组间进行屈伸、侧弯、旋转角度位移单因素方差分析,无显著性差异(P>0.05),但是旋转角度位移L3>L4>L5,依次减小。
5、左、右侧旋转扳动过程中,不同椎体的角度位移比较。L3椎体在左右旋转时,屈伸、侧弯、旋转角度位移配对T检验,左旋转L3椎体侧弯角度位移小于右旋转,有显著性差异(P<0.05),其余方向的角度位移无显著性差异(P>0.05)；L4、L5椎体在左右旋转时,屈伸、侧弯、旋转角度位移配对T检验,三方向角度位移变化无显著性差异(P>0.05)。
[研究结论]
1、有效的循环载荷可以模拟椎间盘退变的第二阶段—不稳定期。循环载荷后,椎间隙变窄,同时形成生理范围内小关节囊松弛,椎间关节小的异常活动和不稳定。
2、屈伸角度位移变化有可能也是扳法治疗脊源性腰腿痛的联合作用机制之一,L3、L4、L5椎体旋转时,伴随更大角度的屈伸；侧弯角度位移在扳法中的作用仍需进一步研究。
3、临床上在对L3、L4、L5椎体进行旋转扳动时,扳动难度和力量可能会依次逐渐增加；左右两侧扳动的差别部分来自患侧肌肉高应力或者长期肌肉紧张而产生的关节僵硬。
实验二
[研究目的]
1、循环载荷条件下,分析两种体位、四种不同载荷扳法的椎间盘内压特征；
2、循环载荷条件下,分析扳法操作的安全性；
3、循环载荷条件下,研究扳法的作用机制；
4、循环载荷条件下,研究扳法对不同间盘的操作特点。
[研究方法]
采用微型压力传感器(Model060)接驳放大器,通过USB7360数据采集系统连接电脑,建立压力测试采集系统；通过已知压力传感器标定微型压力传感器系数备用。
十二具腰椎标本在实验一循环载荷后处理后,通过胸椎穿刺针或者直径2mm克氏针将微型压力传感器植入腰椎间盘,连接压力测试采集系统。然后标本固定在BOSE动/静态材料试验机上,模拟四种不同载荷扳法：-500N坐位旋转扳法,-300N坐位旋转扳法,ON卧位传统斜扳,+100N卧位斜扳。使用BOSE机Wintest软件控制扭矩和角度,编写运行程序。加载方案：预加载扭矩7.5Nm,扳动扭矩25Nm,扳动时间0.05s、0.10s、0.15s。实验前进行2次加载/卸载小量程预处理,减少腰椎粘弹性影响。每次处理后停留30秒,允许腰椎蠕变,使实验结果稳定,第3次加载时正式测量。
采集卧位、坐位L3-L4、L4-L5、L5-S1椎间盘内压基线值；四种不同载荷扳法L3-L4、L4-L5、L5-S1椎间盘内压基线值和复位值；四种不同载荷扳法预加载相7.5Nm和扳动相25NmL3-L4、L4-L5、L5-S1椎间盘内压值；四种不同载荷扳法预加载相7.5Nm和扳动相25Nm腰椎旋转角度；25Nm扳动相时0.05s、O.10s、0.15s扳动时间L3-L4、L4-L5、L5-S1椎间盘内压值。
统计分析：所有统计检验均采用双侧检验,使用SPSS13.0软件处理。符合正态分布者,用x±sD表示平均值加减标准差；组间用配对t检验,组内数据经方差齐性检验,方差相齐者用S-N-K双侧检验,方差不齐者用Dunnett's T3检验。P值小于或者等于0.05将被视为所有检验的差别有统计意义。
[研究结果]
1、四种载荷扳法实施过程中都会使椎间盘内压增高,并且随着旋转角度的不断变化,椎间盘内压呈线性增加；预加载相达到7.5Nm时,出现椎间盘内压短暂平台期,25Nm的扳动相时椎间盘内压快速增加,呈“V”型波谷,椎间盘内压在0.05s、0.10s、0.15s内达到最大值,然后完成自动复位。
2、循环载荷条件下,两种体位间盘椎间盘内压均以L4-L5为最高,坐位椎间盘内压由高到低依次为：L4-L5>L5-S1>L3-L4,有显著性差异(P<0.05)；卧位椎间盘内压L3-L4最低,与L4-L5相比有显著性差异(P<0.05)；循环载荷条件下,两种体位对应椎间盘内压均以坐位高,有显著性差异(P<0.05)。
3、循环载荷条件下,-300N、-500N组椎间盘内压基线值均以L4-L5为最高,有显著性差异(P<0.05)；两组对应间盘内压基线值比较,-500N载荷组L3-L4、L4-L5压力均高于-300N(P<0.05),而两组间L5-S1间盘内压基线值无显著性差异(P>0.05)。
4、循环载荷条件下,+100N、ON载荷组椎间盘内压基线值均以L4-L5为最高,有显著性差异(P<0.05)；两组对应椎间盘内压基线值比较,ON载荷组L3-L4、L4-L5椎间盘内压均高于+100N(P<0.05),而两组间L5-S1椎间盘内压基线值无显著性差异(P>0.05)。
5、循环载荷条件下,L3-L4、L4-5L、L5-S1间盘+100N、ON载荷组椎间盘内压基线值均低于坐位,有显著性差异(P<0.05)；其中L4-L5椎间盘内压基线值-300N、ON、100N载荷组均低于-500N组。
6、循环载荷条件下,L3-L4、L4-L5、L5-S1间盘在-500N、-300N、+100N、ON载荷组椎间盘内压基线值与复位值比较,均无显著性差异(P>0.05)。
7、25Nm扳动相腰椎旋转角度与7.5Nm预加载相配对T检验,有显著性差异(P<0.05)。
8、L3-L4椎间盘内压,25Nm在ON和+100N载荷组椎间盘内压值高于7.5Nm,有显著性差异(P<0.05)；L4-L5椎间盘内压,25Nm在-500N、-300N和ON载荷组椎间盘内压值高于7.5Nm,有显著性差异(P<0.05)；L5-S1椎间盘内压,在-500N、-300N和ON、+100N载荷组椎间盘内压值高于7.5Nm,有显著性差异(P<0.05)。
9、7.5Nm预加载相和25Nm扳动相椎间盘内压差和旋转角度差相关分析,Pearson相关系数为0.919,呈显著相关。
10、不同扳动相时间L3-L4、L4-L5、L5-S1椎间盘内压进行单因素方差分析,四种不同载荷扳法各椎间盘内压比较,无显著性差异(P>0.05)。
[研究结论]
1、循环载荷条件下,腰椎间盘内压特征：坐位椎间盘内压均高于卧位,两种体位椎间盘内压L4-L5最高,L3-L4最低；
2、扳法操作过程中,椎间盘内压增高,会加重退变间盘形变,使操作安全性降低。
3、从体位上看,扳法操作时卧位较坐位椎间盘内压低,ON卧位传统斜扳、+100N卧位斜扳更安全。
4、牵引下扳动可以降低椎间盘内压,尤其对L3-L4、L4-L5间盘退变类疾病；坐位旋转扳时应减少前屈,给予200N的牵引,可以增加手法安全性。
5、扳法治疗椎间盘退变类疾病的机制应是椎间盘内压快速升高和腰椎活动度增大的联合作用。
6、临床上不同节段退变间盘可以采用更有针对性的扳法进行操作。L5-S1间盘四种载荷扳法均可采用；L4-5椎间盘-500N、-300N坐位旋转扳法和ON传统斜扳均有作用；L3-L4椎间盘ON传统斜扳和+100N牵伸斜扳更有针对性。
7、在0.15s扳动时间以内,椎间盘内压都会产生变化显著,更大范围的有效扳动时间仍需进一步研究。
Lumbar Disc Herniation is the most common disc-like illness of chronic diseases, one of the high incidence diseases in our country. Long-term clinical practice has proved what China Journal of Orthopaedics and Traumatology manipulation is excat efficacy for this disease, which is an important means of clinical non-surgical therapy of choice.Manipulation is one of the core techniques of treatment of the disease, is simple, effective and quick, a wide range of clinical applications. The Dutch Health Care Committee and the North American Spine Surgery Association of clincal guidelines are recommended in early lumbar disc herniation of patients without cauda equina syndrome treated conservatively, including manipulations. Manipulation therapy used more and more widely, the mechanics of manipulation researched more and more deeply at home and abroad. Many researchers use more research means and methods to clarify the role of the manipulation,the study of manipulation acquired the stage of good results. Deeper research of manipulation is challenging.Manipulation used in lumbar disc degeneration or disc herniation is not closely combined with clinical in vivo measurement data in Biomechanical study,the mechanical parameters of the experimental setup is also much to learn from the literature, the results and conclusions are difficult to fully explain the mechanics of manipulation in clinical pathological state effect mechanism.Furthermore, the existing researches use non-mechanical mechanism of animal model as the Study objectless human lumbar spine specimens,which model lacks spine mechanics mechanism of characteristics, difficult to close a real clinical pathological state. This study is just to elaborate above-mentioned problems,and clinical practice,useing human lumbar specimens in vitro to studyjn order to elaborate deeply the mechanism of manipulation、the role of the characteristics and security, provide important reference for clinical and scientific research. and has important practical significance guidance clinical.
This study comes from the2010National Natural Science Foundation 《A study to lumbar prominent segment of the internal structure visualization by analog manipulation》 and Beijing Natural Science Foundation《A study about Biomechanical mechanism of kneading manipulation of TCM in Non-specific Low Back Pain from the view point of the "Disease area in the soft tissues, cure the soft tissues"》. In response to these issues and clinical practice two experiments has explored:Firstly, a simulated model of IDD or LDH in vitro experiment under cyclic loading pressure conditions was done and this condition was confirmed by heights about anterior, mid and posterior vertebral body and intervertebral space and three-dimensional motion analysis; Secondly, in order to explain the motions of related segments, pure motion was loaded based on the LDH model and simulated manipulation of oblique-pulling on different vertebral angles were conducted. Thirdly, two positions and four simulated manipulation of oblique-pulling methods were conducted on BOSE dynamic/static material testing machine to test the lumbar intradiscal pressure, for the sake of evaluating the mechanism and safety of this manipulation.
Experiment I
Aims
l.To study close to the clinical practice after conducting the manipulation in simulated experiment.
2.To make an objective and clear description on the results from the changes of segments motions changes and operating characteristics of lumbar manipulation.
Methods
Twelve processed calf lumbar spine specimens were used on the BOSE dynamic/static material testing machine. The cyclic loading was conducted as following:
The Adams, MA, Hutton WC lumbar segment cyclic fatigue loading mechanical modeling was referred to in the processing, which lasted6hours.60cycles/min,21600rpm,300N initial pressure,750N peak pressure,8°flexion of cyclic loading was loaded on the specimens in the whole processing. The loading in the form of sinusoidal waveform started from mild cyclic loading and the peak pressure is gradually increased to a maximum.
Movement loading system was connected with the cyclic loading before and after the loading.6Nm movement was loaded to test lumbar three-dimensional motion and the process of the simulated manipulation. Six movement directions such as flexion, extension, left-handed, right-handed, left bending and right bending were tested in three statuses including neutral, loaded and unloaded status. Motion capturing system was used to collect information with60HZ fruquency and ls acquisition. All information was saved as.prj format.
CT scanner (Lightspeedl6) was used to capture the cyclic loading process before and after the loading, which is produced by GE Company.
The heights about anterior, mid and posterior vertebral body of L3, L4and L5were measured. The intervertebral space of L3-L4, L4-L5, and L5-S1from anterior, mid and posterior heights was measured. The segment maximum movement range of L3-L4, L4-L5, and L5-S1in six directions and neutral zone were measured. Angular displacements of L3, L4, and L5in six directions was measured.
Statistic analysis:All statistical tests were two-sided tests. Measurement data were expressed as mean±SD and analyzed using SPSS13.0software. Data were subjected to homogeneity test for variance. Data of homogeneity of variance were analyzed with one-way analysis and mean between two groups was compared using Student-Newman-Keuls q test. Data of heterogeneity of variance were analyzed with Welch, and mean between two groups was compared using Dunnett T3test. P<0.05was considered statistically significant.
Results
1. Paired t test was used to compare the intervertebral space heights of L3-L4-. L4-L5、L5-S1in twelve specimens before and after cyclic loading. There is significant difference (P<0.05) and all the space heights were lower after the cyclic loading.
2. Although, vertebral body heights of L3、L4、L5were lower, there is no significant difference after the cyclic loading by paired t test (P>0.05)
3. There is a significant difference on segment movement of the L3-L4、L4-L5、 L5-S1in the six movement directions and neutral zone after cyclic loading by paired ttest (P<0.05)
4.During the left-handed, right-handed, simulated manipulation of oblique-pulling, L3, L4, L5vertebral motions were coupled motion, while rotating happened the same time with the vertebral flexion or extension or bending movement.
During the right side manipulation of oblique-pulling, single-factor analysis of variance showed that there is no significant difference in the disc group flexion and extension, lateral bending, rotation angle displacement (P>0.05), but the results showed a trend of the displacement of axial rotation angle less than flexion and extension, lateral bending.
The single-factor analysis of variance between discs on flexion and extension, lateral bending, rotation angle displacement showed no significant difference (P>0.05), the rotation angle displacement reduced sequentially, like L3> L4> L5, bending angle displacement decreased like L3> L4> L5. During the left side manipulation of oblique-pulling, The vertebral rotation angle displacement of L5is less than the flexion and extension angle displacement with a statistically significant difference (P<0.05). However, the single-factor analysis of variance for the other discs movement in the six directions showed no statistic differences (P>0.05). The rotation angle displacement reduced sequentially like L3>L4>L5.
5. The comparison between the left side and right side manipulation showed that the displacement in the left bending of the L3is less than the right rotation, with a statistically significant difference (P<0.05), but the other directions angle displacement analysis has no statistical differences (P>0.05) by paired T test. For L4and L5,there is no statistical differences in all movement directions (P>0.05).
Conclusion
1. It means that such a cyclic loading succeeded in simulating the second stage of disc degeneration-unstable period.After cyclic loading, a physiological joint capsule laxity has formed; there was a abnormal activity and instability for the small facet.
2. It could explain that the angle displacement of flexion is one of the mechanisms of manipulation of oblique-pulling treating spinal endogenous waist and leg joint pain.Rotating manipulation of L3, L4, and L5vertebral body produced a conjugate movement including flexion than rotation; however, the angle displacemengt of lateral bending must to be explored.
3. We also found that the pulling strength may gradually increase with rotating manipulation of oblique-pulling of L3, L4and L5, which make it more difficult in clinical practice. The difference between the left and right flipping may come from the ipsilateral muscle with high stress or long-term muscle tension and joint stiffness.
Experiment Ⅱ
Aims
1. To explore two positions and four manipulation methods treating intradiscal pressure under cyclic loading.
2. To evaluate the safety of the manipulation method under cyclic loading.
3. To explore the mechanism of the manipulation method under cyclic loading.
4. To investigate the effects on different discs by the manipulation method under cyclic loading.
Methods
A mini pressure sensor (Model060) with the amplifier was connected to the computer through the USB7360data acquisition system, to create a pressure testing systems.
After experiment I twelve processed calf lumbar spine specimens were used on the on BOSE dynamic/static material testing machine. The mini pressure sensor was implanted in the lumbar disc by2mm Kirschner needles or thoracic puncture needles, which were connected with the pressure testing systems.Four different simulated loading conditions for the manipulation was set on the BOSE dynamic/static material testing machine,such as the-500N sitting rotating oblique pulling,-300N sitting rotating pulling, the ON supine traditional oblique pulling and the+100N supine oblique pulling.The loading program was written by the software of Wintest software control torque and angle on the BOSE machine. The details are pre-loading with7.5Nm, flip loading with25Nm, flipping time covering0.05s,0.10s and0.15s.Two small pre loading/unloading were done before the experiment, to reduce the impact of lumbar viscoelastic. There will be30seconds stay after each small pre loading/unloading, allowing the lumbar tiny moving. The formal measurement began with the3rd loading.
Five sets of data were collected during this experiment including:
a. the intervertebral disc pressure values at baseline on the supine and sitting positions for L3-L4, L4-L5and L5-S1;
b. the intervertebral disc pressure values at baseline for L3-L4,L4-L5and L5-S1by four different pulling methods;
c. the intradiscal pressure values by four different pulling methods with7.5Nm loading and25Nm loading for L3-L4, L4-L5and L5-S1;
d. the intradiscal pressure values by four different pulling methods with7.5Nm loading and25NmL loading of lumbar rotation angle for L3-L4, L4-L5and L5-S1;
e. the intradiscal pressure values by four different pulling methods with25NmL loading of three different time period (0.05s,0.10s, and0.15s flipping time) for L3-L4, L4-L5and L5-S1.
Statistic analysis:All statistical tests were two-sided tests. Measurement data were expressed as mean±SD and analyzed using SPSS13.0software. Data were subjected to homogeneity test for variance. Data of homogeneity of variance were analyzed with one-way analysis and mean between two groups was compared using Student-Newman-Keuls q test. Data of heterogeneity of variance were analyzed with Welch, and mean between two groups was compared using Dunnett T3test. P<0.05was considered statistically significant.
Results
1. All the four manipulition methods could improve the intradiscal pressure. There was a linear increase of intradiscal pressure with the constant change of the rotation angle. There was an intradiscal pressure transient plateau when the preloading reached7.5Nm. The intradiscal pressure increased rapidly and a'V shaped trough could be formed during the25Nm flipping phase, in which the pressure reached a maximum at the time points,0.05s,0.10s and0.15s, and then reset automatically.
2. The L4-L5disc intradiscal pressures were the highest in two different positions under the cyclic loading. One was in the sitting position, from high to low as following:L4-L5> L5-S1> L3-L4. The other was in the supine position, from high to low as following:L4-L5> L5-S1> L3-L4. There was a significant difference (P<0.05) between the L3-L4and L4-L5in both positions. However all intradiscal pressures in sitting position were higher than in supine position (P<0.05).
3.The intradiscal pressure values of L4-L5at baseline in the position of-300N and-500N sitting oblique pulling were the highest, having a significant difference (P <0.05). The corresponding intervertebral disc pressure at baseline between the position of-300N group and-500N group, the pressures of L3-L4and L4-L5in-500N group were higher than in-300N group (P<0.05),but the pressure of L5-S1comparison having no significant difference (P>0.05)
4.The intradiscal pressure values of L4-L5at baseline in the position of+100N and ON supine oblique pulling were the highest, having a significant difference (P<0.05). The corresponding intervertebral disc pressure at baseline between the position of+100N group and ON group, the pressures of L3-L4and L4-L5in+100N group were higher than in ON group (P<0.05),but the pressure of L5-S1comparison having no significant difference (P>0.05)
5. All the intradiscal pressure values of L3-L4,L4-5L and L5-S1at baseline in the position of supine oblique pulling were lower than in the sitting position with significant difference (P<0.05). And the intradiscal pressure values of L4-5L at baseline in the positions of300N, ON and100N were lower than in the position of-500N.
6.There were no significant differences for all the intradiscal pressure values of L3-L4,L4-5L and L5-S1in the positions of500N,-300N,+100N and ON before and after the manipulation of oblique-pulling (P>0.05)
7. There was a significant difference (P<0.05) about the intradiscal pressures compared in the lumbar rotation angle with25Nm and the preloading of7.5Nm preloaded by the paired T-test.
8. The intradiscal pressures of L3-L4in the positions of25Nm, ON and+100N were higher than in the position of7.5Nm, with significant difference (P<0.05). The intradiscal pressures of L4-L5in the positions of25Nm,-500N,-300N and ON were higher than in the position of7.5Nm, with significant difference (P<0.05). The intradiscal pressures of L4-L5in the positions of-500N,-300N. ON and+100N were higher than in the position of7.5Nm, with significant difference (P<0.05).
9. The related statistical analysis showed that the intradiscal pressure differences in the position of simulated7.5Nm loading and the preloading25Nm have a significant correlation with the rotating angle, with the Pearson correlation coefficient0.919.
10. The single-factor analysis of variance showed that the intradiscal pressures of L3-L4,L4-L5and L5-S1in different pulling phases and positions by four different oblique pulling methods have no statistical difference (P>0.05)
Conclusions
1. The characteristics of the lumbar intradiscal pressures under the cyclic loading are as following:pressures in the sitting position different from the supine position, the highest pressures from L4-L5. the lowest from L3-L4in both positions, all the pressures in the sitting positions higher than in the supine positions.
2. During the manipulation, the intradiscal pressures increased and degenerative intervertebral disc deformation aggravated with more strength and lower safety.
3. The intradiscal pressures in supine position are lower than in sitting position. The traditional manipulation of oblique-pulling and the+100N supine manipulation of oblique-pulling seems much safer.
4. The manipulation of oblique-pulling could lower the intradiscal pressure with tractions, especially for the L3-L4and L4-L5disc degeneration diseases. The manipulation of oblique-pulling in the sitting position should minimize flexion, while giving200N traction, which could ensure the safety.
5. We could conclude that the mechanism of the manipulation is dual roles of the intradiscal pressure quickly increasing and the activity of the lumbar spine increasing.
6. We could infer that practitioners could use different manipulation of oblique-pulling methods according to different segments of disc degeneration flexibly. For instance, the four pulling methods could be used for the L5-S1disc degeneration diseases, four oblique wrench method can be used; sitting,-300N sitting position and the traditional oblique pulling could be used to treat the L4-5disc degeneration diseases; traditional oblique pulling and+100N oblique pull with tractions could be more helpful for the L3-L4disc degeneration diseases.
7. The intradiscal pressure will produce a significant change within0.15s pulling-time and a wider range of effective pulling-time time still need further research.
本研究来源于2010国家自然基金《模拟斜扳手法对腰椎突出节段内在结构影响的可视化研究》、北京市自然基金《“从病在筋,调之筋”研究按揉理筋手法在非特异性下腰痛中的力学机制》。研究分两个实验：首先通过在离体标本上进行循环载荷,以期模拟椎间盘退变或者突出的临床病理状态,通过腰椎CT扫描椎间隙、椎体高度和腰椎三维运动确认病理状态,在此基础上模拟扳法旋转时椎体角度位移变化,以阐释手法作用时椎体相关节段的运动方式；然后在此病理状态下通过BOSE动/静态材料试验机进行两种体位、四种载荷的扳法模拟,测试腰椎间盘内压,研究椎间盘退变状态下手法作用机制、安全性评估。
本论文创新是对离体标本施加循环载荷,模拟出腰椎间盘退变病理状态,在此基础上探讨了脊柱在手法力作用下的运动变化特征；从手法作用力时椎间盘内压的变化,探讨了病理状态下手法作用机制和作用特点。在此基础上的研究数据和结论更加真实、更具有临床意义,此前国内尚未见同类研究,对现代中医骨科手法的基础研究应有启发和借鉴之处。
实验一
[研究目的]
1、通过循环载荷模拟腰椎间盘退变病理状态,使扳法研究贴近临床实际而更具意义和价值；
2、模拟椎间盘退变病理状态下,研究扳法旋转时腰椎共轭运动特征和操作特点。
[研究方法]
十二具离体腰椎处理后固定在BOSE动／静态材料试验机上,利用BOSE动／静态材料试验机控制循环载荷。加载方案：结合Adams M A、Hutton W C腰椎节段循环疲劳负荷力学造模方法,对标本进行6小时,60循环/分钟,21600转,300N初始压力,750N峰值压力,8°前屈的循环载荷,以正弦波形加载,初始时循环载荷为轻度,峰值压力逐渐增加到最大值。
循环载荷前后分别连接力矩加载系统,悬挂加载6Nm扭矩,测试腰椎三维运动信息和模拟扳法旋转过程。依次进行前屈、后伸、左旋、右旋、左侧弯、右侧弯六个运动方向的测试,每组测试中立位、加载和卸载三种状态,利用Motion运动捕捉系统采集标本信息,频率60HZ,采集时间1s；全部采集所得运动信息以.p巧保存处理。
循环载荷前后对标本采用GE公司Lightspeed16层螺旋CT扫描仪进行CT扫描。
CT测量L3、L4、L5椎体前、中、后高度；L3-L4、L4-L5、L5-S1椎间隙前、中、后高度；三维运动分析系统计算L3-L4、L4-L5、L5-S1节段屈伸、侧弯、旋转最大运动范围、中性区；模拟扳法旋转时L3、L4、L5椎体屈伸、侧弯、旋转角度位移。
统计分析：所有统计检验均采用双侧检验,使用SPSS13.0软件处理。符合正态分布者,用x±SD表示平均值加减标准差；组间用配对t检验,组内数据经方差齐性检验,方差相齐者用S-N-K双侧检验,方差不齐者用Dunnett's T3检验。P值小于或者等于0.05将被视为所有检验的差别有统计意义。
[研究结果]
1、循环载荷前后12个标本L3-L4、L4-L5. L5-S1共计36个间盘的椎间隙高度进行配对样本T检验,椎间隙前高、中高、后高在循环载荷后均降低,有显著性差异(P<0.05)。
2、循环载荷前后12个标本L3、L4、L5共计36个椎体的高度进行配对样本T检验,椎体前高、中高、后高在循环载荷后均有降低趋势,无显著性差异(P>0.05)。
3、循环载荷后,L3-L4、L4-L5、L5-S1节段屈伸、侧弯、旋转运动范围、中性区均增加,与加载前进行配对T检验,各节段屈伸、侧弯、旋转运动范围、中性区均有显著性差异(P<0.05)
4、左、右侧旋转扳动过程中,L3、L4、L5椎体的运动是共轭运动,旋转同时椎体也进行屈或伸、侧弯运动。右侧旋转斜扳时各间盘组内屈伸、侧弯、旋转角度位移单因素方差分析,无显著性差异(P>0.05),轴向旋转角度位移有小于屈伸、侧弯角度位移的趋势；各间盘组间屈伸、侧弯、旋转角度位移单因素方差分析,无显著性差异(P>0.05),旋转角度位移L3>L4>L5依次减小,侧弯角度位移L3>L4>L5,依次减小。左侧旋转斜扳时L5椎体旋转角度位移小于屈伸角度位移,有显著性差异(P<0.05)；其余各间盘组内屈伸、侧弯、旋转角度位移单因素方差分析,无显著性差异(P>0.05)；各间盘组间进行屈伸、侧弯、旋转角度位移单因素方差分析,无显著性差异(P>0.05),但是旋转角度位移L3>L4>L5,依次减小。
5、左、右侧旋转扳动过程中,不同椎体的角度位移比较。L3椎体在左右旋转时,屈伸、侧弯、旋转角度位移配对T检验,左旋转L3椎体侧弯角度位移小于右旋转,有显著性差异(P<0.05),其余方向的角度位移无显著性差异(P>0.05)；L4、L5椎体在左右旋转时,屈伸、侧弯、旋转角度位移配对T检验,三方向角度位移变化无显著性差异(P>0.05)。
[研究结论]
1、有效的循环载荷可以模拟椎间盘退变的第二阶段—不稳定期。循环载荷后,椎间隙变窄,同时形成生理范围内小关节囊松弛,椎间关节小的异常活动和不稳定。
2、屈伸角度位移变化有可能也是扳法治疗脊源性腰腿痛的联合作用机制之一,L3、L4、L5椎体旋转时,伴随更大角度的屈伸；侧弯角度位移在扳法中的作用仍需进一步研究。
3、临床上在对L3、L4、L5椎体进行旋转扳动时,扳动难度和力量可能会依次逐渐增加；左右两侧扳动的差别部分来自患侧肌肉高应力或者长期肌肉紧张而产生的关节僵硬。
实验二
[研究目的]
1、循环载荷条件下,分析两种体位、四种不同载荷扳法的椎间盘内压特征；
2、循环载荷条件下,分析扳法操作的安全性；
3、循环载荷条件下,研究扳法的作用机制；
4、循环载荷条件下,研究扳法对不同间盘的操作特点。
[研究方法]
采用微型压力传感器(Model060)接驳放大器,通过USB7360数据采集系统连接电脑,建立压力测试采集系统；通过已知压力传感器标定微型压力传感器系数备用。
十二具腰椎标本在实验一循环载荷后处理后,通过胸椎穿刺针或者直径2mm克氏针将微型压力传感器植入腰椎间盘,连接压力测试采集系统。然后标本固定在BOSE动/静态材料试验机上,模拟四种不同载荷扳法：-500N坐位旋转扳法,-300N坐位旋转扳法,ON卧位传统斜扳,+100N卧位斜扳。使用BOSE机Wintest软件控制扭矩和角度,编写运行程序。加载方案：预加载扭矩7.5Nm,扳动扭矩25Nm,扳动时间0.05s、0.10s、0.15s。实验前进行2次加载/卸载小量程预处理,减少腰椎粘弹性影响。每次处理后停留30秒,允许腰椎蠕变,使实验结果稳定,第3次加载时正式测量。
采集卧位、坐位L3-L4、L4-L5、L5-S1椎间盘内压基线值；四种不同载荷扳法L3-L4、L4-L5、L5-S1椎间盘内压基线值和复位值；四种不同载荷扳法预加载相7.5Nm和扳动相25NmL3-L4、L4-L5、L5-S1椎间盘内压值；四种不同载荷扳法预加载相7.5Nm和扳动相25Nm腰椎旋转角度；25Nm扳动相时0.05s、O.10s、0.15s扳动时间L3-L4、L4-L5、L5-S1椎间盘内压值。
统计分析：所有统计检验均采用双侧检验,使用SPSS13.0软件处理。符合正态分布者,用x±sD表示平均值加减标准差；组间用配对t检验,组内数据经方差齐性检验,方差相齐者用S-N-K双侧检验,方差不齐者用Dunnett's T3检验。P值小于或者等于0.05将被视为所有检验的差别有统计意义。
[研究结果]
1、四种载荷扳法实施过程中都会使椎间盘内压增高,并且随着旋转角度的不断变化,椎间盘内压呈线性增加；预加载相达到7.5Nm时,出现椎间盘内压短暂平台期,25Nm的扳动相时椎间盘内压快速增加,呈“V”型波谷,椎间盘内压在0.05s、0.10s、0.15s内达到最大值,然后完成自动复位。
2、循环载荷条件下,两种体位间盘椎间盘内压均以L4-L5为最高,坐位椎间盘内压由高到低依次为：L4-L5>L5-S1>L3-L4,有显著性差异(P<0.05)；卧位椎间盘内压L3-L4最低,与L4-L5相比有显著性差异(P<0.05)；循环载荷条件下,两种体位对应椎间盘内压均以坐位高,有显著性差异(P<0.05)。
3、循环载荷条件下,-300N、-500N组椎间盘内压基线值均以L4-L5为最高,有显著性差异(P<0.05)；两组对应间盘内压基线值比较,-500N载荷组L3-L4、L4-L5压力均高于-300N(P<0.05),而两组间L5-S1间盘内压基线值无显著性差异(P>0.05)。
4、循环载荷条件下,+100N、ON载荷组椎间盘内压基线值均以L4-L5为最高,有显著性差异(P<0.05)；两组对应椎间盘内压基线值比较,ON载荷组L3-L4、L4-L5椎间盘内压均高于+100N(P<0.05),而两组间L5-S1椎间盘内压基线值无显著性差异(P>0.05)。
5、循环载荷条件下,L3-L4、L4-5L、L5-S1间盘+100N、ON载荷组椎间盘内压基线值均低于坐位,有显著性差异(P<0.05)；其中L4-L5椎间盘内压基线值-300N、ON、100N载荷组均低于-500N组。
6、循环载荷条件下,L3-L4、L4-L5、L5-S1间盘在-500N、-300N、+100N、ON载荷组椎间盘内压基线值与复位值比较,均无显著性差异(P>0.05)。
7、25Nm扳动相腰椎旋转角度与7.5Nm预加载相配对T检验,有显著性差异(P<0.05)。
8、L3-L4椎间盘内压,25Nm在ON和+100N载荷组椎间盘内压值高于7.5Nm,有显著性差异(P<0.05)；L4-L5椎间盘内压,25Nm在-500N、-300N和ON载荷组椎间盘内压值高于7.5Nm,有显著性差异(P<0.05)；L5-S1椎间盘内压,在-500N、-300N和ON、+100N载荷组椎间盘内压值高于7.5Nm,有显著性差异(P<0.05)。
9、7.5Nm预加载相和25Nm扳动相椎间盘内压差和旋转角度差相关分析,Pearson相关系数为0.919,呈显著相关。
10、不同扳动相时间L3-L4、L4-L5、L5-S1椎间盘内压进行单因素方差分析,四种不同载荷扳法各椎间盘内压比较,无显著性差异(P>0.05)。
[研究结论]
1、循环载荷条件下,腰椎间盘内压特征：坐位椎间盘内压均高于卧位,两种体位椎间盘内压L4-L5最高,L3-L4最低；
2、扳法操作过程中,椎间盘内压增高,会加重退变间盘形变,使操作安全性降低。
3、从体位上看,扳法操作时卧位较坐位椎间盘内压低,ON卧位传统斜扳、+100N卧位斜扳更安全。
4、牵引下扳动可以降低椎间盘内压,尤其对L3-L4、L4-L5间盘退变类疾病；坐位旋转扳时应减少前屈,给予200N的牵引,可以增加手法安全性。
5、扳法治疗椎间盘退变类疾病的机制应是椎间盘内压快速升高和腰椎活动度增大的联合作用。
6、临床上不同节段退变间盘可以采用更有针对性的扳法进行操作。L5-S1间盘四种载荷扳法均可采用；L4-5椎间盘-500N、-300N坐位旋转扳法和ON传统斜扳均有作用；L3-L4椎间盘ON传统斜扳和+100N牵伸斜扳更有针对性。
7、在0.15s扳动时间以内,椎间盘内压都会产生变化显著,更大范围的有效扳动时间仍需进一步研究。
Lumbar Disc Herniation is the most common disc-like illness of chronic diseases, one of the high incidence diseases in our country. Long-term clinical practice has proved what China Journal of Orthopaedics and Traumatology manipulation is excat efficacy for this disease, which is an important means of clinical non-surgical therapy of choice.Manipulation is one of the core techniques of treatment of the disease, is simple, effective and quick, a wide range of clinical applications. The Dutch Health Care Committee and the North American Spine Surgery Association of clincal guidelines are recommended in early lumbar disc herniation of patients without cauda equina syndrome treated conservatively, including manipulations. Manipulation therapy used more and more widely, the mechanics of manipulation researched more and more deeply at home and abroad. Many researchers use more research means and methods to clarify the role of the manipulation,the study of manipulation acquired the stage of good results. Deeper research of manipulation is challenging.Manipulation used in lumbar disc degeneration or disc herniation is not closely combined with clinical in vivo measurement data in Biomechanical study,the mechanical parameters of the experimental setup is also much to learn from the literature, the results and conclusions are difficult to fully explain the mechanics of manipulation in clinical pathological state effect mechanism.Furthermore, the existing researches use non-mechanical mechanism of animal model as the Study objectless human lumbar spine specimens,which model lacks spine mechanics mechanism of characteristics, difficult to close a real clinical pathological state. This study is just to elaborate above-mentioned problems,and clinical practice,useing human lumbar specimens in vitro to studyjn order to elaborate deeply the mechanism of manipulation、the role of the characteristics and security, provide important reference for clinical and scientific research. and has important practical significance guidance clinical.
This study comes from the2010National Natural Science Foundation 《A study to lumbar prominent segment of the internal structure visualization by analog manipulation》 and Beijing Natural Science Foundation《A study about Biomechanical mechanism of kneading manipulation of TCM in Non-specific Low Back Pain from the view point of the "Disease area in the soft tissues, cure the soft tissues"》. In response to these issues and clinical practice two experiments has explored:Firstly, a simulated model of IDD or LDH in vitro experiment under cyclic loading pressure conditions was done and this condition was confirmed by heights about anterior, mid and posterior vertebral body and intervertebral space and three-dimensional motion analysis; Secondly, in order to explain the motions of related segments, pure motion was loaded based on the LDH model and simulated manipulation of oblique-pulling on different vertebral angles were conducted. Thirdly, two positions and four simulated manipulation of oblique-pulling methods were conducted on BOSE dynamic/static material testing machine to test the lumbar intradiscal pressure, for the sake of evaluating the mechanism and safety of this manipulation.
Experiment I
Aims
l.To study close to the clinical practice after conducting the manipulation in simulated experiment.
2.To make an objective and clear description on the results from the changes of segments motions changes and operating characteristics of lumbar manipulation.
Methods
Twelve processed calf lumbar spine specimens were used on the BOSE dynamic/static material testing machine. The cyclic loading was conducted as following:
The Adams, MA, Hutton WC lumbar segment cyclic fatigue loading mechanical modeling was referred to in the processing, which lasted6hours.60cycles/min,21600rpm,300N initial pressure,750N peak pressure,8°flexion of cyclic loading was loaded on the specimens in the whole processing. The loading in the form of sinusoidal waveform started from mild cyclic loading and the peak pressure is gradually increased to a maximum.
Movement loading system was connected with the cyclic loading before and after the loading.6Nm movement was loaded to test lumbar three-dimensional motion and the process of the simulated manipulation. Six movement directions such as flexion, extension, left-handed, right-handed, left bending and right bending were tested in three statuses including neutral, loaded and unloaded status. Motion capturing system was used to collect information with60HZ fruquency and ls acquisition. All information was saved as.prj format.
CT scanner (Lightspeedl6) was used to capture the cyclic loading process before and after the loading, which is produced by GE Company.
The heights about anterior, mid and posterior vertebral body of L3, L4and L5were measured. The intervertebral space of L3-L4, L4-L5, and L5-S1from anterior, mid and posterior heights was measured. The segment maximum movement range of L3-L4, L4-L5, and L5-S1in six directions and neutral zone were measured. Angular displacements of L3, L4, and L5in six directions was measured.
Statistic analysis:All statistical tests were two-sided tests. Measurement data were expressed as mean±SD and analyzed using SPSS13.0software. Data were subjected to homogeneity test for variance. Data of homogeneity of variance were analyzed with one-way analysis and mean between two groups was compared using Student-Newman-Keuls q test. Data of heterogeneity of variance were analyzed with Welch, and mean between two groups was compared using Dunnett T3test. P<0.05was considered statistically significant.
Results
1. Paired t test was used to compare the intervertebral space heights of L3-L4-. L4-L5、L5-S1in twelve specimens before and after cyclic loading. There is significant difference (P<0.05) and all the space heights were lower after the cyclic loading.
2. Although, vertebral body heights of L3、L4、L5were lower, there is no significant difference after the cyclic loading by paired t test (P>0.05)
3. There is a significant difference on segment movement of the L3-L4、L4-L5、 L5-S1in the six movement directions and neutral zone after cyclic loading by paired ttest (P<0.05)
4.During the left-handed, right-handed, simulated manipulation of oblique-pulling, L3, L4, L5vertebral motions were coupled motion, while rotating happened the same time with the vertebral flexion or extension or bending movement.
During the right side manipulation of oblique-pulling, single-factor analysis of variance showed that there is no significant difference in the disc group flexion and extension, lateral bending, rotation angle displacement (P>0.05), but the results showed a trend of the displacement of axial rotation angle less than flexion and extension, lateral bending.
The single-factor analysis of variance between discs on flexion and extension, lateral bending, rotation angle displacement showed no significant difference (P>0.05), the rotation angle displacement reduced sequentially, like L3> L4> L5, bending angle displacement decreased like L3> L4> L5. During the left side manipulation of oblique-pulling, The vertebral rotation angle displacement of L5is less than the flexion and extension angle displacement with a statistically significant difference (P<0.05). However, the single-factor analysis of variance for the other discs movement in the six directions showed no statistic differences (P>0.05). The rotation angle displacement reduced sequentially like L3>L4>L5.
5. The comparison between the left side and right side manipulation showed that the displacement in the left bending of the L3is less than the right rotation, with a statistically significant difference (P<0.05), but the other directions angle displacement analysis has no statistical differences (P>0.05) by paired T test. For L4and L5,there is no statistical differences in all movement directions (P>0.05).
Conclusion
1. It means that such a cyclic loading succeeded in simulating the second stage of disc degeneration-unstable period.After cyclic loading, a physiological joint capsule laxity has formed; there was a abnormal activity and instability for the small facet.
2. It could explain that the angle displacement of flexion is one of the mechanisms of manipulation of oblique-pulling treating spinal endogenous waist and leg joint pain.Rotating manipulation of L3, L4, and L5vertebral body produced a conjugate movement including flexion than rotation; however, the angle displacemengt of lateral bending must to be explored.
3. We also found that the pulling strength may gradually increase with rotating manipulation of oblique-pulling of L3, L4and L5, which make it more difficult in clinical practice. The difference between the left and right flipping may come from the ipsilateral muscle with high stress or long-term muscle tension and joint stiffness.
Experiment Ⅱ
Aims
1. To explore two positions and four manipulation methods treating intradiscal pressure under cyclic loading.
2. To evaluate the safety of the manipulation method under cyclic loading.
3. To explore the mechanism of the manipulation method under cyclic loading.
4. To investigate the effects on different discs by the manipulation method under cyclic loading.
Methods
A mini pressure sensor (Model060) with the amplifier was connected to the computer through the USB7360data acquisition system, to create a pressure testing systems.
After experiment I twelve processed calf lumbar spine specimens were used on the on BOSE dynamic/static material testing machine. The mini pressure sensor was implanted in the lumbar disc by2mm Kirschner needles or thoracic puncture needles, which were connected with the pressure testing systems.Four different simulated loading conditions for the manipulation was set on the BOSE dynamic/static material testing machine,such as the-500N sitting rotating oblique pulling,-300N sitting rotating pulling, the ON supine traditional oblique pulling and the+100N supine oblique pulling.The loading program was written by the software of Wintest software control torque and angle on the BOSE machine. The details are pre-loading with7.5Nm, flip loading with25Nm, flipping time covering0.05s,0.10s and0.15s.Two small pre loading/unloading were done before the experiment, to reduce the impact of lumbar viscoelastic. There will be30seconds stay after each small pre loading/unloading, allowing the lumbar tiny moving. The formal measurement began with the3rd loading.
Five sets of data were collected during this experiment including:
a. the intervertebral disc pressure values at baseline on the supine and sitting positions for L3-L4, L4-L5and L5-S1;
b. the intervertebral disc pressure values at baseline for L3-L4,L4-L5and L5-S1by four different pulling methods;
c. the intradiscal pressure values by four different pulling methods with7.5Nm loading and25Nm loading for L3-L4, L4-L5and L5-S1;
d. the intradiscal pressure values by four different pulling methods with7.5Nm loading and25NmL loading of lumbar rotation angle for L3-L4, L4-L5and L5-S1;
e. the intradiscal pressure values by four different pulling methods with25NmL loading of three different time period (0.05s,0.10s, and0.15s flipping time) for L3-L4, L4-L5and L5-S1.
Statistic analysis:All statistical tests were two-sided tests. Measurement data were expressed as mean±SD and analyzed using SPSS13.0software. Data were subjected to homogeneity test for variance. Data of homogeneity of variance were analyzed with one-way analysis and mean between two groups was compared using Student-Newman-Keuls q test. Data of heterogeneity of variance were analyzed with Welch, and mean between two groups was compared using Dunnett T3test. P<0.05was considered statistically significant.
Results
1. All the four manipulition methods could improve the intradiscal pressure. There was a linear increase of intradiscal pressure with the constant change of the rotation angle. There was an intradiscal pressure transient plateau when the preloading reached7.5Nm. The intradiscal pressure increased rapidly and a'V shaped trough could be formed during the25Nm flipping phase, in which the pressure reached a maximum at the time points,0.05s,0.10s and0.15s, and then reset automatically.
2. The L4-L5disc intradiscal pressures were the highest in two different positions under the cyclic loading. One was in the sitting position, from high to low as following:L4-L5> L5-S1> L3-L4. The other was in the supine position, from high to low as following:L4-L5> L5-S1> L3-L4. There was a significant difference (P<0.05) between the L3-L4and L4-L5in both positions. However all intradiscal pressures in sitting position were higher than in supine position (P<0.05).
3.The intradiscal pressure values of L4-L5at baseline in the position of-300N and-500N sitting oblique pulling were the highest, having a significant difference (P <0.05). The corresponding intervertebral disc pressure at baseline between the position of-300N group and-500N group, the pressures of L3-L4and L4-L5in-500N group were higher than in-300N group (P<0.05),but the pressure of L5-S1comparison having no significant difference (P>0.05)
4.The intradiscal pressure values of L4-L5at baseline in the position of+100N and ON supine oblique pulling were the highest, having a significant difference (P<0.05). The corresponding intervertebral disc pressure at baseline between the position of+100N group and ON group, the pressures of L3-L4and L4-L5in+100N group were higher than in ON group (P<0.05),but the pressure of L5-S1comparison having no significant difference (P>0.05)
5. All the intradiscal pressure values of L3-L4,L4-5L and L5-S1at baseline in the position of supine oblique pulling were lower than in the sitting position with significant difference (P<0.05). And the intradiscal pressure values of L4-5L at baseline in the positions of300N, ON and100N were lower than in the position of-500N.
6.There were no significant differences for all the intradiscal pressure values of L3-L4,L4-5L and L5-S1in the positions of500N,-300N,+100N and ON before and after the manipulation of oblique-pulling (P>0.05)
7. There was a significant difference (P<0.05) about the intradiscal pressures compared in the lumbar rotation angle with25Nm and the preloading of7.5Nm preloaded by the paired T-test.
8. The intradiscal pressures of L3-L4in the positions of25Nm, ON and+100N were higher than in the position of7.5Nm, with significant difference (P<0.05). The intradiscal pressures of L4-L5in the positions of25Nm,-500N,-300N and ON were higher than in the position of7.5Nm, with significant difference (P<0.05). The intradiscal pressures of L4-L5in the positions of-500N,-300N. ON and+100N were higher than in the position of7.5Nm, with significant difference (P<0.05).
9. The related statistical analysis showed that the intradiscal pressure differences in the position of simulated7.5Nm loading and the preloading25Nm have a significant correlation with the rotating angle, with the Pearson correlation coefficient0.919.
10. The single-factor analysis of variance showed that the intradiscal pressures of L3-L4,L4-L5and L5-S1in different pulling phases and positions by four different oblique pulling methods have no statistical difference (P>0.05)
Conclusions
1. The characteristics of the lumbar intradiscal pressures under the cyclic loading are as following:pressures in the sitting position different from the supine position, the highest pressures from L4-L5. the lowest from L3-L4in both positions, all the pressures in the sitting positions higher than in the supine positions.
2. During the manipulation, the intradiscal pressures increased and degenerative intervertebral disc deformation aggravated with more strength and lower safety.
3. The intradiscal pressures in supine position are lower than in sitting position. The traditional manipulation of oblique-pulling and the+100N supine manipulation of oblique-pulling seems much safer.
4. The manipulation of oblique-pulling could lower the intradiscal pressure with tractions, especially for the L3-L4and L4-L5disc degeneration diseases. The manipulation of oblique-pulling in the sitting position should minimize flexion, while giving200N traction, which could ensure the safety.
5. We could conclude that the mechanism of the manipulation is dual roles of the intradiscal pressure quickly increasing and the activity of the lumbar spine increasing.
6. We could infer that practitioners could use different manipulation of oblique-pulling methods according to different segments of disc degeneration flexibly. For instance, the four pulling methods could be used for the L5-S1disc degeneration diseases, four oblique wrench method can be used; sitting,-300N sitting position and the traditional oblique pulling could be used to treat the L4-5disc degeneration diseases; traditional oblique pulling and+100N oblique pull with tractions could be more helpful for the L3-L4disc degeneration diseases.
7. The intradiscal pressure will produce a significant change within0.15s pulling-time and a wider range of effective pulling-time time still need further research.
引文
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