| Objective:To analyze the clinical characteristics of "jin-gu imbalance" in adolescent idiopathic scoliosis(AIS)patients by means of medical imaging,surface myoelectricity,and biomechanics,and to explore the clinical efficacy of "equal attention to jin and gu" treatment principle.First,the potential correlation between 3D parameters of the spine and paravertebral electrophysiological characteristics of the spinal "jin-gu imbalance" in Lenke Ⅰ patients with moderate scoliosis was analyzed.Secondary,construct a Lenke Ⅰ-type“tensile integrity”finite element model of the spine including bones and muscles,and verify the validity of the“jin-gu imbalance”model;Thirdly,according to the research on bone and muscle correlation,simulate the Cheneau brace correction scheme and apply different pressure correction force combinations to analyze the mechanical response characteristics of brace correction to bones,muscles,and growth plates under the overall tension system,To verify the corrective pressure that is beneficial to the growth and development of bones under the“balance of jin and gu”.Finally,design braces for patients according to the results of finite element analysis.A prospective control design was used to administer acupuncture at“Ashi point”in the patients with paravertebral muscle activation imbalance after wearing the brace.The clinical effect of comprehensive treatment was observed longitudinally.MethodsStudy Ⅰ:Thirty-four patients with AIS with major thoracic curvature were included in this cross-sectional study.Firstly,EOS imaging system was used to capture the posterior and anterior position of the patient,and microdose imaging was used to obtain the full frontal and lateral spine view.The whole spine modeling was selected on sterEOS software to generate 3D spine model,and the 3D parameters were measured and obtained.① Global balance:coronal global balance parameter(C7PL-CSVL),sagittal vertical axis(SVA)of sagittal global balance;② Regional balance:shoulder height(RSH),lateral pelvic tilt(LPT);③Local balance parameters:coronal Cobb Angle,apical vertebra translation(AVT)of main thoracic curve and lumbar curve were recorded as AVTMT and AVTL,respectively.Sagittal plane parameters:lumbar spine(thoracic kyphosis(TK)T4/T12,lumbar lordosis(LL),sacral slope(SS),and pelvic incidence Angle(pelvic incidence,PI)and the pelvic inclination Angle(pelvic tilt,PT);Axial plane parameters:Axial rotation of Apical vertebral column(AVR)and Axial rotation of the pelvis(PAR)were recorded,respectively.Secondly,The DELSYS(Model Trigno,Boston,USA)16-channel EMG test system was used to collect surface EMG signals,which were marked on the body surface of the paraspinal muscles on both sides corresponding to the upper and lower end vertebrae and apex vertebral bodies of thoracic and lumbar scoliosis point,test the surface electromyographic signal of the subject when standing habitually;select the surface electromyographic index as the root mean square value(RMS),and calculate the RMS contrast value of the convex and concave paraspinal muscles at different marker points for further data analyze.Then,use SPSS23.0 software analysis for statistical analysis,compare the difference in the RMS ratio of each marker point between the two groups,and perform multiple stepwise regression analysis on the RMS ratio of the marker point with the difference and the imaging 3D parameters to verify the correlation between them.Study Ⅱ:A 13-year-old female patient with AIS was enrolled.Her weight is 43Kg and her height is 153cm.Risser sign is grade Ⅲ.According to the Rigo classification method,it was A3 type,and the EOS image examination results suggested the presence of main thoracic curve,proximal thoracic curve and lumbar curve.For the subjects’ 3D CT imaging data,the Mimics 21.0 3D medical image reconstruction software,Geomagic Studio 2017 reverse engineering processing software,Solidworks 2018CAD software,and ANSYS 17.0 finite element analysis software were used for the corresponding processing and processing of the original image modeling,in order to establish the skeletal muscle finite element model of the whole spine.The model geometry,segmental range of motion and muscle axial force were verified after gravity loading to evaluate the effectiveness and reliability of the model.Study Ⅲ:The established and validated AIS finite element model Lenke Ⅰ was used to simulate the brace correction scheme,so as to observe the correction effects of different correction pressures.According to the correctional mechanics mechanism of Rigo splint design,the correlation between muscle activation and pelvic parameters was studied,and the boundary conditions were simulated to constrain the bone.The correction force combination of the two groups of braces was set respectively.Group A was the average pressure obtained from the pressure sensor collection and testing,and group B was the pressure value reported in the finite element related literature.To simulate the "three-point force" system of brace correction,the effective pressure area of brace was set with reference to previous research literature.The corrected thrust of main chest bend was applied to the right chest position,the corrected reaction force to main chest bend was applied to the left armpit and the left waist rear,and the extended tension was applied to the bilateral armpit(400N on the left side,400N on the left side,400N on the left side,200N to the right)simulates the "Bending effect" and anti-gravity effect of the gimlet.The imaging parameters,the ratio of muscle axial force to concave-convex,the concave/convex ratio and the front/rear ratio of von Mises stress distribution on the sensitive layer of growth plate load were compared before and after the correction,so as to verify whether the "jin-gu balance" was achieved during the correction process.Study Ⅳ:A randomized controlled cohort study design was used to observe the efficacy of brace combined with acupuncture.With reference to the finite element simulation results of Study 3,the brace was designed for the patient.All patients are wearing the same Cheneau brace after adaptation check double plane X-ray,to determine the main chest bend Cobb correction rate>50%of the target.Pressure sensors were installed to measure the patient’s corrective pressure and total time spent wearing the brace each day.Scoliosan spinal threedimensional ultrasound was used in both groups during monthly follow-up to ensure optimal brace correction.After brace adaptation,paravertebral surface electromyography RMS values of patients were analyzed.In the control group,the parts with RMS ratio imbalance were treated as ashi points for acupuncture while brace brace,while the control group maintained the original brace treatment plan.Imaging parameters,muscle activation characteristics and quality of life scores were observed longitudinally in both groups after 6 months of intervention.ResultsStudy Ⅰ:34 patients with AIS(age 13.6±2.3,BMI(kg/m2)17.9± 0.9)were enrolled,including 30 females and 4 males.(1)The results of global,regional and local spinal balance parameters are shown below。①Coronal global balance parameters(C7PL-CSVL)was 2.2cm± 0.9,indicating the presence of coronal global imbalance.The SVA parameters of the sagittal plane were 2.7±0.5cm,indicating that there was no sagittal global imbalance.②RSH parameters of regional balance:The measured shoulder height of patients in this group was 1.5±0.7cm,indicating mild shoulder imbalance;LPT was 10.0±0.6mm,indicating a mild pelvic imbalance.③Local balance 3D parameters,coronal plane:Cobb Angle of main thoracic curve=31.3±5.4°,Cobb=21.5±4.6,AVTMT=21±6mm,AVTL=9±4mm,LPT=7.4±4.8;Axial plane parameters:AVRMT 11.1±4.2,AVRL 9.0±6.3;PAR=-7.4±3.8;Sagittal plane parameters:TK=17.9±7.0,LL=37.5 ±9.3,PT=5.6±9.1,PI=39.7± 12.8,SS=34.4±7.7.(2)The correlation between RMS ratio features and imaging parameters is as follows.RMS numerical characteristics of sEMG with different markers:There was no significant difference in the RMS values obtained from the left and right sides of the T2 and L2 markers(P>0.05),but the median RMS ratio of the top vertebra near T8 in the main thoracic curve was 1.56(1.27,1.80),and that of the L5 marker near the lower lumbar curve was 0.78(0.51,0.90).There was statistical significance in RMS of concave-convex side(P<0.05).According to the stepwise linear correlation analysis between the ratio of the concave-convex side of T8 markers(T8Ratio)and the 3D parameters of the spine and pelvis,AVRMT,TK and LPT were the correlation variables in the T8Ratio regression analysis,R2=0.78.The regression model equation is as follows:T8Ratio=0.7360.055AVRMT+0.126C7PLCSVL+0.17LPT-0.20TK;According to the stepwise linear correlation analysis between the ratio of the concave-convex side of L5 markers(L5Ratio)and the 3D parameters of the spine and pelvis,AVRL and PAR were the correlation variables in the L5Ratio regression analysis,R2=0.73.The regression model equation is:L5Ratio=0.8510.38AVRL+0.30AVTL.Study Ⅱ:A finite element model of Lenke Ⅰ AIS was established to constrain and fix the central point of the sacrum and allow T1 to bend forward,bend laterally and translate vertically.First,gravity loads were applied to the upper surface of each vertebra.The loads on the spine included the gravity acting on the vertebra and the muscle forces maintaining spinal stability.With reference to previous literature,the stress on the spine of patients with habitual standing posture was simulated:It was assumed that the gravity of the load on the vertebral body acted on the center of the growth plate at the top of the vertebral body along the Z-axis,and the weight of the patient was 42kg.The load on each vertebral body was calculated according to the formula.After loading the gravity,the geometric similarity of the model was verified,and the segmental joint motion was simulated and verified.It indicates that the model is valid and reliable.Based on the constructed and verified finite element model of adolescent idiopathic scoliosis Lenk I the correction scheme of braces was simulated,and the effect of different pressures on the parameter correction of spinal skeletal deformity was simulated.According to the correction mechanical mechanism designed by Rigo classification brace,the correlation between muscle activation and pelvic parameters was studied,and the boundary conditions of the simulation were set with constraints on bones.The correction force combination of the two groups of braces was set respectively.Group A was the average pressure obtained from the pressure sensor collection and testing,and group B was the pressure value reported in the finite element related literature.To simulate the "three-point force" system of brace correction,the effective pressure area of brace was set with reference to previous research literature.The corrected thrust of main chest bend was applied to the right chest position,the corrected reaction force to main chest bend was applied to the left armpit and the left waist rear,and the extended tension was applied to the bilateral armpit(400N on the left side,400N on the left side,400N on the left side,200N to the right)simulates the "Bending effect" and anti-gravity effect of the gimlet.The imaging parameters,the ratio of muscle axial force to concave-convex,the concave/convex ratio and the front/rear ratio of von Mises stress distribution on the sensitive layer of growth plate load were compared before and after the correction,so as to verify whether the "jin and gu balance"was achieved during the correction process.Study Ⅲ:In the finite element analysis of bracing simulation,the imaging parameters and the ratio parameters of muscle axial force and growth plate obtained are as follows.(1)Imaging parameters of the two groups under different pressures:The imaging parameters of the two groups under different braced corrected pressures were different as follows:The measured values of Cobb Angle,TK,LL,and AVT of the main and proximal thoracic curve were as follows after pressure correction in the two groups:The Cobb Angle changed greatly under the correction force of group A.The Cobb Angle of the main thoracic curve was 21°,and that of the proximal thoracic curve was 27.5°,with the Cobb correction rates of 47%and 6.9%,respectively.The Cobb correction rates of group B were 30%and 21%,respectively.The TK of group A was reduced from 11° to 8.5°,and that of group B was 11.3°.The LL decreased in both groups of correction forces,but it was still within the normal range.In group A,the AVT of the main thoracic curve and the proximal thoracic curve changed from 2.2cm and 0.5cm to 0.8cm and 0.1cm,respectively,while in group B,the AVT was 1.4cm and 0.4cm.(2)The ratio of axial force to bump of the anterior muscle group was>1.0,while the ratio of bump to bump of the posterior muscle of the trunk was<1.0,suggesting that the axial force of the convex muscle of the back of the curved trunk was greater than that of the concave side,while the axial force of the abdominal muscle was concave>convex side.In group A,except the rectus abdominis,the concave axial force was higher than the convex force,and the ratio of concave and convex was between 1.12 and 5.10.The imbalance was more significant than before the correction.In group B,the ratio of axial force to concaveconvex of back muscles was still significant in quadratus lumbis and multifidus,while the ratio of axial force to concave-convex of other muscles was balanced.(3)von Mises stress distribution in the sensitive layer of growth plates under the combination of corrected pressures in both groups:the concave/convex ratio and the front/back ratio of T2 growth plates under the correction force in groups A and B were greater than those before the correction,and the concave/convex stress ratio at the upper and lower surface of T2 in group A was greater than that in group B.The front/back ratio of the upper surface of group A was lower than that of group B,while the front/back ratio of the lower surface of group A was higher than that of group B.The stress ratio of T7 growth plates was as follows:in addition to the concave/convex side of the upper surface of T7 growth plates,the concave/convex ratio of the lower surface of T7,the concave/convex ratio of the upper and lower surface of T7,and the anteriorly/anteriorly ratio were as follows:Group A>before correction>group B.Study Ⅳ:Imaging parameters,surface EMG RMS ratio and quality of life scores before and after treatment in the two groups were as follows.(1)Intra-group comparison between the two groups:intra-group comparison between coronal global balance(C7PL-CSVL),sagittal balance(SVA)and regional balance(RSH,LPT)groups had statistical significance(P<0.05);It was suggested that the brace intervention could improve the coronal balance and pelvic tilt,but the shoulder imbalance was found in both groups.SVA measurements were lower than before bracing,but still within the normal range.After wearing the brace for 6 months,the two groups were re-examined 24 hours after the brace was removed.Compared with before the brace,the measurement parameters of coronal global balance(C7PL-CSVL),sagittal plane balance(SVA)and regional balance(shoulder height)were statistically significant(P<0.05),suggesting that the overall coronal balance was improved in both groups.However,the difference of shoulder height was still greater than that before the brace,and the SVA measurements were in the normal range despite the differences.Other regional imbalance parameters(LPT)were improved in the treatment group.The coronal global balance(C7PL-CSVL)parameters were improved,the shoulder imbalance was improved,and the pelvic imbalance parameters were slightly increased,but they were still better than before the brace,the differences were statistically significant(P<0.05).Comparison between the two groups:before and within the brace,there was no statistically significant difference in the balance parameters between the two groups(P>0.05),suggesting that the baseline characteristics of the two groups were comparable.After 24 hours of debuttment,the global balance parameters(C7PL-CSVL)and regional balance parameters(RSH)of the experimental group were better than those of the control group,the difference was statistically significant(P<0.05).(2)Comparison of local balance parameters between the two groups:After wearing the brace,the initial correction rate of the brace Cobb Angle in both groups was>50%,which could be considered as the ideal correction value.After 6 months,all debraced devices showed corrective rebound,and there was no statistical significance between groups(P>0.05).(3)Comparison of the surface electromyography RMS ratio between the two groups before and after wearing the brace:There was no statistically significant difference in the RMS ratio of each marker point between the groups(P>0.05),suggesting that the RMS ratio of the two groups of patients is comparable.①Intra-group comparison of the RMS ratio of each marker point in the two groups:the RMS ratio of the T2 marker points after wearing the brace and 24 hours after debranching in the two groups was greater than that before the brace,and the difference was statistically significant Significance(P<0.05),suggesting that T2 imbalance occurred in both groups after wearing the brace;there was no significant difference in the RMS ratio of L2 markers after wearing the brace and before the brace(P>0.05);6month reexamination and Compared with before/after wearing the brace,the RMS ratio of T8 and L5 markers showed better performance after 6 months than before/after wearing the brace,suggesting that it was more balanced after 6 months(the ratio was closer to 1)(P<0.05).②Comparison of RMS ratio between the two groups after wearing the brace:24hour reexamination after 6 months of debranching,the RMS ratio of the experimental group at T2 and T8 marker points was smaller than that of the control group(the ratio was closer to 1)(P<0.05),the RMS ratio of the L5 marker point in the experimental group was greater than that in the control group(the ratio was closer to 1)(P<0.05),and the difference was statistically significant.It suggests that compared with the control group,the activation of the paravertebral muscles in the experimental group combined with acupuncture treatment is more balanced(the ratio is closer to 1)(4)There was no significant difference in C-BrQ scores between the two groups after wearing(P>0.05),suggesting that the two groups were comparable.After 24 hours of reexamination,the C-BrQ score of the two groups was increased compared with that at the beginning of wearing the brace,and the difference was statistically significant(P<0.05).The C-BrQ score of the experimental group was higher than that of the control group,suggesting that acupuncture and moxibustion treatment improved the quality of life of the patients wearing the brace.Conclusion(1)The research reveals the muscle activation characteristics of paravertebral muscle in Lenke Ⅰ AIS patients and its correlation with spine-pelvis 3D parameters.In this group,the T8 marker corresponds to the convex side>the concave side of the main thoracic curve,while the L5 marker corresponds to the concave side>the convex side of the lumbar compensatory curve.The concave/convex Ratio(T8Ratio)was correlated with AVRMT、C7PL-CSVL、TK、and PLT,while the concave/convex ratio(L5 Ratio)was correlated with AVTL and AVRL.(2)This study effectively established Lenke type I AIS tensionic integral finite element model,including bone,growth plate,muscle and soft tissue,etc.,which could provide numerical simulation for "jin-gu imbalance" and bracing correction.(3)Under the condition of pelvic stability,both the clinical correction force and the correction force combination with the upper limit of the threshold were improved with certain imaging parameters,specifically,the improvement of Cobb Angle and AVT.Although the Cobb Angle correction rate was higher with the clinical correction force combination,the Cobb Angle increased slightly and the TK decreased near the thoracic curve,showing that the concatene-convex ratio of the mechanical response values of the muscle and growth plate was not better than that before the correction and the other correction force combination.And adopting the combination of limited threshold limit corrective force show Cobb Angle correction rate is relatively low,but in the muscle concave and convex axial force balance and ratio before and after the growth plate is concave and convex and more hasten is reasonable.The results of this study are helpful to optimize the brace treatment strategy of major thoracic curvature and improve the Cobb correction rate.At the same time,attention should be paid to the bump ratio of mechanical response between muscle and growth plate.The von Mises stress distribution analysis of growth plates is helpful to understand the trend of spine growth guided by brace correction.(4)After 6 months of intervention combined with acupuncture and brace treatment,the correction rate of Cobb Angle was not improved,but the "gu imbalance" was better than the control group.The improvement of coronal balance and shoulder balance;In terms of functional evaluation parameters of "jin imbalance",RMS ratios of T2 and T8 markers in the experimental group tended to be more balanced in the control group. |
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