| 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 headacheObjective: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 manipulationsIn 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 manipulationObjective: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.
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