| Lumbar disc herniation(LDH) is a common disease,in which the degeneration of intervertebral disc is the key point.The pathomechanics of the disease include the rupture of annulus fibrous,the bulging or protrusion of nucleus pulposus,and nerve roots compression or stimulation.The patients will present various symptoms caused by irritating nerve roots,such as low back pain,sciatica,muscle paralysis,cauda equina syndrome and so on.The treatments of LDH could be roughly divided into two main parts,the operative treatment and the other conservative treatment.The later is composed by numerous treatments and therapies.Spinal manipulative therapy is one of the conservative therapies which aroused academic ambiguity most.Since the pathomechanism of LDH was discovered in 1934,the nucleus pulposus is immediately absorbed concentration by healthcare workers worldwide,no exception of the doctors who favors conservative treatment.They try by all means to adjust their manipulative skills to affect the protruded nucleus pulposus but failed to push it back or change its size by any chance after all efforts of constant try.They do not find any changes at all after a successful conservative treatment by the recheck of CT or MRI,which proved the size and shape of protruded nucleus pulposus has no relation to the releasing of clinical symptoms and signs of the patients.The clinical situation reminds us of reconsidering the therapeutic principle of traditional Chinese spinal manipulation which focus only on the balance disturbance of spinal column,which seems very much correlated to the recovering progress of the patients.The study,therefore,put forwards the topic of a clinical research to reconsider the principle of restoring biomechanical balance of spinal column in manipulative treatment.It is well known that the traditional Chinese spinal manipulative therapy has been integrated with modern medicine for 40 years in China and successfully applied in the conservative treatment of LDH patient by restoring the mechanical balance of spinal column with a typical skill of correcting vertebral subluxation.It is always believed there are some correlation between the clinical symptom and deformation of spinal column in LDH patient from the views of manipulative therapists according their clinical experiences,which is leading the widely recognizing of spinal manipulative treatment in LDH patient worldwide and especially in China.How to objectively evaluate,however,the curative effect of spinal manipulative treatment by way of restoring the mechanical balance of spinal column will be the key point to improve the conservative treatment and clarify its mechanism of spinal manipulative treatment.There is an urgent need for clinicians then to have a sensitive,objective and quantitative index for curative effect estimation,which has restricted the study of manipulative mechanism for decades.It is just at this moment we find that projection grating profilometry on human back applied widely in the evaluation of the patient with spinal scoliolosis will meet the demand.Computer assisted projection grating profilometry(PGP) on human back will objectively record the asymmetry of human trunk reflecting the spinal deformation before and after the treatment.The record could be analyzed as a quantitative index for objective evaluation of spinal deformation which will be of clinical significance in the evaluation of curative effect of a conservative therapy.We,therefore,conduct a clinical experiment in this study to prove this method of detection,which will not only provide a objective index to evaluate the clinical significance of spinal disorder but also provide an example in TCM diagnosis as an objective "observation".The study make full use of PGP technique to evaluate the spinal deformation of LDH patients before and after Feng' Spinal Manipulative therapy(FSM) and try to prove its clinical significance of objective recording.Brief introduction of PGP techniqueSimilar to molté,projection grating profilometry(PGP) is another noninvasive image analyzing system by applied structured light methods.The technique has been applied in analyzing rachis deformities of the patient with spinal scoliosis or deformation.By projecting a grid over the patients' back,the system could immediately produce a topographic image of the back in a color or gray scale by software in three dimensions.Visual inspection of the topographic images by the system will instantly provides quantified indexes of back deformity of the patient.The study is aimed at providing a sensitive,objective and quantitative index for the evaluation on LDH patients after a conservative therapy.We record image of PGP on the back of LDH patient in position of both standing and lateral bending reflecting static and dynamic balance of spinal column.ObjectiveThe purpose of the study is to analyze if any correlation existed between the asymmetrical recordings of PGP image detected from the back of LDH patient by a specially designed device and the clinical manifestation of the patients;and hopefully,it will become one of most objective index in evaluating the result of conservative treatment on LDH patient.The study is divided into three parts as following.1) the reproducibility of PGP image detected by the device will be tested;2) the difference of PGP image between LDH patients and normal subjects will be statistically analyzed both at static and dynamic state;and 3) to figure out if any correlation between the improvement of asymmetry indexes detected from PGP image and reducing of the quantified indexes for clinical manifestation of the patients before and after FSM therapy.Clinical researchesTest 1.The reproducibility testing of the recorded PGP image for analyzing the asymmetry of spinal column detected by a specially designed PGP system.1.1 Objective:This part of the research is to analyze if symmetrical indexes of spinal column (SISC) collected from the recorded PGO images(LR,M,H,S,HA as following) is reproducible in normal subjects based on repeated detections in different times.1.2 Samples and methods1.2.1 Samples20 normal subjects were tested in the study.1.2.2 Positioning:20 normal subjects were fixed on a specially designed frame.They were imaged in neutral position,left bending position and right lateral bending position by the PGP system.1.2.3 MethodsEach subject was imaged 3 times.The 2ed record was imaged 2 hours after the 1st image and the 3rd image was conducted 20days later.1.3 symmetrical indexes of spinal column(SISC) collected from the recorded PGO imagesM:the angle between topical line of spinal column line and vertical line representing the a quantified asymmetry of spine list at a static position.LR,the ratio of the ranges of motion between the left and right lateral bending of the spine representing a quantified asymmetry of the spine in a dynamical state.H,the ratio of the heights at a certain paraspinal point between left and right representing a quantified rotation of spinal column.S,ratio of the cross section plane between the left and right from middle line of spine also representing a quantified rotation of spinal columnHA,hump angle representing again a quantified rotation of spinal column.1.4 Statistic analysisThe reproducibility was statistically analyzed with repeated measurement by SAS9.0.Test 2.The analysis on the difference of SISC between LDH patients and normal subjects based on recorded PGP image2.1 ObjectiveDuring the test we analyzed the difference of SISC between LDH patients and normal subjects based on recorded PGP image and try to find out if the LDH patients has more deformed spine or not.2.2 Samples and Methods2.2.1 Samples70 LDH patients were selected and 40 normal subjects were also selected at mean time as a control in the test.2.2.2 Positioning:The same as in test 1 above.2.2.3 Methods1) Comparing the SISC and general state of LDH patients before the treatment with that of normal subjects;2) comparing SISC and general state of LDH patients again 20 days after the treatment with that of normal subjects at same time.3) The similar indexes above were compared between the patients and the normal subjects with the same degree of spine list.2.2.4 TreatmentThe LDH patients were accepted FSM therapy twice a week and some adjacent medical cares,such as hot compress of Chinese herbal medicine for 20 days. Test 3.Correlation study between SISC and the quantified clinical manifestation of LDH patients.3.1 ObjectiveTest 3 conducted a correlation study between the SISC and some quantified indexes for the clinical manifestation of the patients,such as VAS(visual analogue scale), JOA(Japanese orthopedic association scale),and SLR(straight leg raising test) before and after FSM therapy.The study also analyze the correlation between the changes of SISC and that of the quantified clinical indexes of LDH patients,which might show us if the SISC could be of any clinical significance to objectively reflect the clinical manifestation of the patients.3.2 Samples and Methods3.2.1 Samples70 LDH patients were selected in this part of study according to criteria settled by the study.3.2.2 Positioning:The same as in test 1 above.3.2.3 Method1) Statistic correlation study was conducted between the SISC and VAS,JOA, and SLR before and after FSM therapy.The study also analyze correlation between the changes of SISC and that of the quantified clinical indexes of LDH patients,which might show us if the SISC could be of any clinical significance to objectively reflect the clinical manifestation of the patients.2) Radiograph of lumbar spine was imaged in neutral,left and right lateral position with the Cobb's angle in neutral and the range of motion(ROM) in lateral bending recorded,which was compared with those of SISC recorded from PGP image to find if there some differences.3) CT and/or MRI were scanned with the size and position of the protruded nucleus pulposus recorded by way of a special measurement..3.2.4 Treatment:The same as in test 2 above.Results 1.The reproducibility testing of the recorded PGP image for analyzing the asymmetry of spinal column detected by a specially designed PGP system.The study compared three recordings detected at different times statistically by SAS9.0 for reproducibility analysis and find no significant differences among them (M,LR,S,H,HA) with the p＞0.05.2.The analysis on the difference of SISC between LDH patients and normal subjects based on recorded PGP image and the difference of SISC on LDH patient before and after the treatment.2.1 The comparison analysis showed that there is a very significant difference of SISC between LDH patients and normal subjects by SAS9.0 with P＜0.01 at all analysis.2.2 The paired T test shows that there is a significant difference of SISC before and after 20days of FSM therapy in the LDH patients.2.3.The results shows that there is a significant difference of SISC between the LDH patients and normal subjects with the same degree of spine list by SAS9.0.The patient group shows more asymmetry of ROM in lateral bending than normal subjects with the P＜0.01 in all analysis.3.Correlation study between SISC and the quantified clinical manifestation of LDH patients.3.1 Correlation study between the quantified indexes of clinical manifestation(SLR, VAS and JOA) and SISC before and after the treatment shows that there is no significant correlation with r=0.4076,P＜0.05.3.2 A further study shows a significant correlation between the changes of SISC after FSM therapy and changes of the SLR,VAS and JOA with r=0.878251,and P＜.0001 by Wilks' Lambda test.The coefficient of DLR is much higher(r=0.8731) then the others.DLR and HA put the most weight on the correlation according to the statistic analysis.3.3 There are no significant changes in the shape and size of protrude nucleus pulposus after 20 days of FSM therapy by CT or MR recheck.3.4 The study proves that the radiograph image has a very significant correlation with PGP image in measuring the angle of spine list and ROM of lateral spending to the left and right of spine.Conclusion1.Symmetrical indexes of spinal column(SISC) collected from the recorded PGP images are statistically proved reproducible,which proves great clinical significance.2.There are significant differences of SISC between normal subjects and LDH patients with the later significantly higher.The study also shows that there is a significant difference of SISC between the LDH patients and normal subjects with the same degree of spine list and the patient shows more asymmetry of ROM in lateral bending than normal subjects..3.The study proved that SISC collected from the recorded PGP images is significantly correlated with the quantified indexes of clinical manifestation of the patients(SLR,VAL,JOA) before the conservative treatment.And further more,the improving changes of SISC(LR,M,HA especially LR) after the treatment is significantly correlated with the improving changes of the quantified indexes of clinical manifestation at the same time,which indicate that that the SISC collected from the recorded PGP images could stand for a sensitive and quantified index to evaluate the clinical state of LDH patient and therapeutic effect of a certain treatment.The result of the experiment reminds us that we should put more weight on the balance disorder of spinal column in the manipulative therapy to LDH patients.4.The study proves again that the shape and size of protrude nucleus pulposus has no paralleled relation with the patient's clinical manifestation,which is demonstrated by the recheck of CT or MR after a successful spinal manipulative treatment in the study.5.The study proves that the radiograph image has a very significant correlation with PGP image in measuring the angle of spine list and ROM of lateral spending to the left and right of spine but the later has no radiation at all as a side effect and more accurate analyzing ways. |
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