| Cervical radiculopathy is the most common type of cervical spondylosis.The disease often manifests as neck pain,dyskinesia,pain in the upper limbs,numbness,paresthesia,and so on.Those who have suffered for a long time may even have muscle atrophy.The results of several statistical research reports have shown that cervical radiculopathy has been at the forefront of non-lethal diseases that endanger people's health.Due to the huge population in China and the increasing aging of the population,the disease is more serious in our country,which seriously affects the lives of individuals and also places a heavy burden on society.Therefore,it is especially necessary to find an effective,simple and suitable treatment.At present,conservative treatment is the first choice for cervical radiculopathy.Exercise as one of the treatment measures,its clinical effectiveness has been confirmed in many studies.The cervical spine is composed of a dynamic system and a static system.The dynamic system mainly refers to the neck muscles,and the static system mainly refers to the cervical vertebra.The onset of cervical spondylosis can be characterized as"dynamic imbalance first,static imbalance mainly",that is,the abnormalities of the"Jin" of the cervical spine cause the occurrence of "bone dislocation",and eventually"Jin and bone are dysfunctional together ",which causes this disease.Studies have also shown that the onset of cervical radiculopathy is associated with increased muscle tone in the neck muscles.Increased cervical muscle tension,that is,the occurrence of "muscle urgency",which causes abnormal stress,which causes the cervical vertebra to stretch,leading to the occurrence of "skeletal misalignment".Long-term skeletal maladjustment will cause stress osteophytes and intervertebral discs degeneration.These can stimulate the cervical nerve root,leading to the occurrence of cervical radiculopathy.The pathogenesis of cervical radiculopathy can be summarized as "the Jin first,Jin and bone are dysfunctional together".According to "Lingshu · Weiqi Shichang","the Jin have no yin and no yang,no left,no right,the sickness is in itself." Therefore,for the treatment of this disease,it is necessary to intervene in the "Jin" of the neck,adjust the state of the neck muscles,"treat the bones through the Jin," and finally reach the physiological states of "Jin and bone are normal."Cervical rehabilitation exercise is a set of cervical spine exercise methods created by Professor Liguo Zhu based on the anatomy,physiological status of cervical spine and the characteristics of cervical disease.This cervical rehabilitation exercise has been included in the cervical radiculopathy guideline compiled by the Chinese Association of Chinese Medicine.The cervical rehabilitation exercise has won many awards,such as the Li Shizhen Innovation Award of the Chinese Association of Chinese Medicine and the Beijing Science and Technology Progress Award,and it is also a promotion project of the Beijing Administration of Traditional Chinese Medicine.Cervical rehabilitation exercise is a direct intervention to the neck "Jin",which is in line with the above principle—"treating bones through Jin".Our team's previous researches found that cervical rehabilitation exercises combined with other therapies can better improve clinical efficacy and reduce the recurrence rate for treating cervical radiculopathy.However,the specific mechanism of cervical rehabilitation exercise therapy for cervical radiculopathy is unclear.Based on this,we propose a hypothesis:cervical rehabilitation exercises can play a therapeutic role in treating cervical radiculopathy by reducing muscle tone and then improving neck function and cervical spine mobility.This study expounds the effects of cervical rehabilitation exercise on cervical radiculopathy through the literature research,clinical research,applied basic research and basic research.1.Literature researchThe effect of exercise on cervical radiculopathy:A systematic review and Meta-analysis1.1 ObjectiveRandomized controlled trial of exercise in treating cervical radiculopathy at home and abroad was retrieved,and the objective was to analyze the effects of exercise for treating patients with cervical radiculopathy.1.2 MethodsThe computer retrieved 7 databases including the Medline database(via Pubmed),the Web of Science database,the Embase database,the Cochrane Library,CNKI,the Wanfang database,and the VIP database.Randomized controlled trials involving exercise for cervical radiculopathy were enrolled.Data were pooled after trials quality assessment for meta-analysis.Then the studies meeting the inclusion criteria were used for data extraction,and Revman5.3 software was used for meta-analysis data analysis and graphic production.Use the funnel plot to evaluate publication bias.If the heterogeneity is high,a sensitivity analysis should be performed to determine the robustness of the results,and a subgroup analysis also can be used to identify the source of heterogeneity.GRADE classification for each outcome make a strength recommendation.1.3 ResultsTen studies involving 871 participants with cervical radiculopathy were included.Meta-analysis revealed that compared with control group,there was a reduction in VAS[SMD=-0.89;95%CI:(-1.34,-0.44),P<0.0001].There was also an improvement of NDI[MD=-3.60;95%CI:(-6.27,-0.94);Z=2.65,P=0.008<0.05].Because there are no reports of two indicators—SF-12 and SF-36,so analysis cannot be performed.The funnel plots show that the symmetry is slightly worse,and there may be some publication bias.However,the pooled results were verified to be stable by sensitivity analyses.Subgroup analysis showed that sources of high heterogeneity may be related to the time of intervention,language of publication,and year of publication.Besides,the result of GRADE is low for each outcome.1.4 ConclusionExercise alone or exercise plus other treatment may be helpful to patients with cervical radiculopathy.However,Large-scale studies using proper methodology are recommended.2.Clinical researchThe effects of cervical rehabilitation exercise on cervical radiculopathy:A pilot study2.1 ObjectiveThis study initially explored the clinical efficacy and safety of cervical rehabilitation exercises for cervical radiculopathy,and strengthened the clinical evidence of cervical rehabilitation exercise.2.2 MethodsAccording to the inclusion and exclusion criteria,60 patients cervical radiculopathy(non-acute phase)were selected from September 2018 to November 2019 in Wangjing hospital,Institute of Orthopaedics,Xiyuan hospital,Beijing Dongyang Community Health Service Center.All the included cases were divided into a treatment group and a control group,with 30 cases in each group.The control group was given cervical health guidance,and the treatment group was given cervical rehabilitation exercise+cervical health guidance.The VAS score,NDI index,SF-12 PCS score,and SF-12 MCS score were recorded before the intervention,1 week,2 weeks,3 weeks,4 weeks,2 months,and 3 months after intervention.SPSS 17.0 and GraphPad Prism 8.0.2 software were used for statistical analysis and graph drawing of the recorded data.2.3 ResultsThere was no significant difference in gender,age,course of disease,condition of the affected limb,VAS score before intervention,NDI index,SF-12 PCS score,and SF-12 MCS score between the two groups(P>0.05).So,the two groups are comparable.The results of comparison of related indicators are as follows:(1)NDI index:the difference between the two groups of patients is statistically significant.The reduction of NDI index in the treatment group was more significant than that in the control group(P<0.05),and there were statistical differences at each observation time point(P<0.05).This shows that cervical spine rehabilitation exercises can better improve the NDI index of patients,and the effect is more obvious with the extension of exercise time.(2)VAS score:The decrease in the VAS score of patients in the treatment group was similar to that in the control group(P>0.05),and there was no significant difference between the three months after the intervention and the two months after the intervention(P>0.05).There were statistical differences at all other time points(P<0.05),indicating that the cervical rehabilitation exercise was not effective in reducing the pain of patients,but the pain could be better with time,and the effect could be extended to 2 months after the intervention.(3)SF-12 PCS score:The SF-12 PCS score of patients in the treatment group was significantly higher than that in the control group(P<0.05),and the differences between each observation time point were statistically significant(P<0.05),indicating that cervical rehabilitation exercise can effectively improve the patient's body function within 3 months,and the better the effect over time.(4)SF-12 MCS score:The SF-12 MCS score of patients in the treatment group increased significantly,and the difference with the control group was statistically significant(P<0.05).Besides,the differences at each time point were statistically significant(P<0.05).This shows that cervical rehabilitation exercises can better improve the psychological state of patients with cervical radiculopathy,and the effect is more significant with time.(5)Adverse reactions:One patient in the treatment group had symptoms of sore neck and shoulders after exercise.We asked patients to apply heat to the neck and shoulders to reduce the number of exercises.Then,these symptoms disappeared.Another patient had a soreness and numbness in the affected arm during the Chuniaoqifei exercise.After instructing him to reduce the angle of arm extension,the symptoms disappeared.No abnormalities were seen in the rest.2.4 ConclusionCervical rehabilitation exercise can better improve the cervical spine function status of patients suffering from non-acute stage of cervical radiculopathy,improve the quality of life of patients.Additionally,the longer the treatment time,the better the effect.And the safety of cervical rehabilitation exercise is also good.Although cervical rehabilitation exercise has no obvious effect in improving pain,it still maintains certain advantages.The insignificant reduction in pain may be related to the non-acute phase of the disease or small sample size and observation time points.3.Applied basic researchEffect of cervical rehabilitation exercise on muscle tension and cervical spine mobility of patients with cervical radiculopathy3.1 ObjectiveThe effects of cervical rehabilitation exercise on wide muscle tone and cervical range of motion in patients with cervical radiculopathy were analyzed based on the theory of " Jin bound bones".Thus,the effects of cervical rehabilitation exercise on the "Jin" of the neck and the effects of "Jin" on the "bone" are clarified.This will clarify the possible mechanism for cervical rehabilitation exercise for treatmentof cervical radiculopathy,which lays the foundation for its clinical application.3.2 Methods3.2.1 Muscle tension The soft tissue tone test analysis system(M_tone JZL-?)was used to measure the wide neck muscle tone of patients with cervical radiculopathy.The displacement corresponding to the analysis system of soft tissue tension at 200g pressure is recorded as the muscle tone.Multi-point muscle tone data were recorded including before intervention,1 week,2 weeks,3 weeks,and 4 weeks after the intervention of cervical rehabilitation exercise.The recorded data was processed to draw the muscle tone cloud map using MATLAB R2015a software,and then performed a comparativeanalysis.3.2.2 Cervical Spine Mobility OptiTrack-V120:Duo&Trio instrument was used to measure cervical range of motion of patients with cervical radiculopathy before intervention,1 week,2 weeks,3 weeks,and 4 weeks after intervention.Optitrack Motive software and Visual3D V5software are used to record data.SPSS 17.0 software was used for statistical analysis.And GraphPad Prism 8.0.2 software was used for graphic drawing.3.3 Results3.3.1 Muscle tension With the continuous exercise,muscle tone has gradually decreased since beforeintervention,1 week,2 weeks,3 weeks,and 4 weeks after intervention.3.3.1.1 Before the intervention Generally speaking,the patients' neck muscle tone was slightly less symmetrical,and the right muscle tone is higher than the left.The low muscle tone area is mainly concentrated in the muscles on both sides of the C3-C6 cervical spine,and the muscle tone from the C6-T1 area is higher than that of the neck.3.3.1.2 One week after the interventionThe symmetry of the distribution of the cloud map is better than that before the intervention,and the area of increased muscle tone is reduced,especially in the areas of C6-7.3.3.1.3 Two weeks after the interventionThe muscle tone distribution in the "clump area" of the neck gradually spread into a "strip-like" area similar to the anatomical shape,and the symmetry on both sides of the image was better than before.3.3.1.4 Three weeks after the interventionThe overall neck muscles tone has a downward trend.And the symmetry is better in both the cervical and scapular regions.The muscle tone of the neck and scapular region is basically distributed according to the anatomical shape.3.3.1.5 Four weeks after the interventionThe overall decrease in muscle tone is obvious,and the area of low muscle tone gradually increases.The left and right tone maps are symmetrical.3.3.2 Cervical spine mobility3.3.2.1 FlexionThe difference of cervical flexion angles at different time points were statistically significant(P<0.05).After comparison multiple time points,there was no significant improvement in cervical spine activity before and during the first week of intervention(P>0.05),but there were statistically significant differences in other time periods(P<0.05).3.3.2.2 ExtensionCervical extension angles at different time points were statistically significant(P<0.05).After comparison multiple time points,although the extension angles were increased in before the intervention,one week,three weeks and four weeks after the intervention,the differences were not statistically significant(P>0.05),the differences in the other time periods were statistically significant(P<0.05).3.3.2.3 Left lateral bendingThe differences of the left lateral bending angle were statistically significant(P<0.05).Compared with the results of third week after the intervention and the second week after the intervention,the left lateral bending of the cervical spine increased,but the difference was not statistically significant(P>0.05),and the differences at other observation time points were statistically significant(P<0.05).3.3.2.4 Right lateral bendingThe differences in the right lateral bending angle of the cervical spine at different time points were statistically significant(P<0.05).The differences in each time period are statistically significant.(P<0.05).3.3.2.5 Left rotationThe differences in the left rotation angle of the cervical spine at different time points were statistically significant(P<0.05).The differences in each time period are statistically significant.(P<0.05).(6)Right rotation:The differences in the right rotation angle of the cervical spine at different time points were statistically significant(P<0.05).The differences in each time period are statistically significant.(P<0.05).3.4 ConclusionCervical rehabilitation exercise can effectively reduce the cervical muscles tone in patients with cervical radiculopathy,which regulates the neck force balance,and change from "Jin urgent" to "Jin soft".Through the index of cervical vertebra activity,we can see that after "soft tendons",we can intervene "bones dislocation" to improve it in the direction of "bone alignment".It is suggested that the treatment of cervical radiculopathy by cervical rehabilitation exercise may be achieved by improving the stress of the bone and adjusting the stress balance of the cervical spine.After "soft tendon",it can improve the "bones dislocation" and achieve the purpose of "bones alignment".It is suggested that cervical rehabilitation exercise for treating cervical radiculopathy by improving the stress of the bone and adjusting the stress balance of the cervical spine.4.Basic researchBiomechanical study of cervical rehabilitation exercise for treatment of cervical radiculopathy4.1 ObjectiveAfter quantifying the movement of cervical rehabilitation exercise,the three-dimensional finite element model of cervical vertebra was loaded to analyze the biomechanical mechanism of each movement,which can provide support for the development of exercise prescription.The relationship between bone and Jin after the cervical muscles tone reduction was analyzed based on the relationship between Jin and bones.Then its therapy mechanism was explored.4.2 Methods4.2.1 Quantification of cervical rehabilitation exerciseEach movement of the cervical spine rehabilitation exercise was quantifiably split.Twenty volunteers were selected to complete the cervical spine rehabilitation exercise.The Optitrack motion capture system and force-measuring gloves were used to perform trajectory capture and subsequent data processing on each movement.4.2.2 Construction of finite element model of cervical vertebra and loading of cervical rehabilitation exerciseCT was used to scan neck of normal human.Construction of finite element model included the geometric reconstruction,reverse engineering,mesh division,material assignment and other processes,a three-dimensional finite element model of cervical vertebra with complete structure including vertebral body(C0-T1),intervertebral disc(C2-C7),ligament,articular cartilage,muscle and so on.After verifying its effectiveness,the quantified cervical rehabilitation parameters are loaded on the model,and the stress of the vertebral body,intervertebral disc,ligament,and muscle strain of each movement is analyzed.4.2.3 Effect of different muscle tension on cervical radiculopathyThrough the simulation of the degeneration of cervical intervertebral disc,the disease model which accords with the characteristics of cervical radiculopathy is constructed.Then,the stiffness parameters are used to simulate the muscle tone of cervical muscles.Three finite element models of cervical radiculopathy are constructed,which are the increase of muscle tone,the normal of muscle tone and the decrease of muscle tone.Three models were loaded with four working conditions of flexion,extension,rotation and lateral bending to analyze the influence of cervical vertebra Jin and bones after the reduction of muscle tension caused by cervical rehabilitation exercise,which further explores the mechanism of cervical rehabilitation exercise.4.3 Results4.3.1 Quantification of cervical rehabilitation exerciseMotion split and parameter measurement of cervical rehabilitation exercise were carried out.The Qianquhoushen exercise was divided into two movements:flexion and extension.The measurement results were as follows:flexion 63.31°,extension 62.15°.Xuanjingwangzhong exercise was divided into cervical rotation and flexion.The measurement results were left rotation for 81.2°,right rotation for 79.3°,left flexion for 15.66°,right flexion for 19.06°.The movement of Huitouwangyue was divided into rotation and extension of 45°.The measured results were 81.2°for left rotation and 79.3°for right rotation.The Chuniaoqifei exercise can be divided into three parts:cervical extension,upper limb extension,and pull-down force of the upper limb.extension of the cervical spine was measured at 62.15°,the angle between the upper limb extension and the torso was 38.18°,and the upper limb pull-down force was 77.36N.The Yaozhuanshaungjian exercise can be divided into four motions of the shoulder joint:upward,forward,downward,and backward.The measured displacement parameters were 83.82mm upward,96.83mm forward,48.03mm downward,and 50.46mm backward.4.3.2 Construction of finite element model of cervical vertebra and loading of cervical rehabilitation exerciseThe finite element model of all vertebrae and discs,10 ligaments and 14 muscles of the cervical spine was constructed,and compared with the results reported in the relevant literature,the result showed that the simulation of the model is good.And then each movement of cervical rehabilitation exercise was loaded on the model.4.3.2.1 Qianquhoushen exerciseWhen the cervical spine is flexed,the entire force area of the cervical spine includes under the occipital bone,all vertebral bodies,intervertebral disc,among which the anterior and posterior arch of the atlas was the most stressed area.The vertebral stress gradually increased from C2 to C4 and decreased from C4 to C7.The maximum stress of the intervertebral disc was in the C4-5,and the maximum stress was mainly concentrated in the front of the intervertebral disc.Splenius cervicis and levator scapulae were the most strained muscles.The stress of the posterior longitudinal ligament,the ligamentum flavum,the interspinous,and the supraspinous ligament all increased with the process of neck flexion,and the the greatest stress was located at ligamentum flavum.The cervical finite element model was loaded with the extension motion.The areas with greater stress were mainly concentrated in the facet joint and the Luschka joint.The area with the greatest stress in the atlas was the anterior and posterior arches.The maximum stress vertebral was C2.The larger stress in disc mainly occurred on both sides,with C3-4 being the most stressed disc.Sternocleidomastoid was the muscle that produces the greatest deformation,and the anterior longitudinal ligament underwent the greatest stress.4.3.2.2 Xuanjingwangzhong exerciseC4 and C5 vertebrae were subjected to the most stress after loading this motion.The maximum stress area of the atlas was in the anterior and posterior arches.From C2 vertebra to C6 vertebra,the maximum stress area was mainly concentrated on the left superior articular process and the inferior articular surface.The larger stress area of the vertebral body was transferred from the left to the upper right outer side of the vertebral body.The larger stress area of the vertebral was transferred from the left side to the right side of the vertebral body from top to bottom,until the maximum stress area of the C7 was transferred to the right vertebral body.The most stressed intervertebral disc were located at C3-4 and C4-5 segments.The muscle that produces the largest deformation was splenius cervicis.During rotation,the stress of each ligament increased,and the maximum stress was in the ligamentum flavum.During flexion process,the stress of the anterior longitudinal ligament gradually decreased,and the other ligament stress increased significantly.4.3.2.3 Huitouwangyue exerciseThe C3 bearing the maximum stress when this motion was loaded on the cervical spine finite element model.The maximum stress of C3 to C6 vertebrae was distributed in the area of Luschka joint,left superior articular process and inferior articular surface,At the C7 vertebra,the area of significant stress shifted to Luschka joint.The maximum stress among dics occurred at the C3-4 segment.Longissimus Capitis was the muscle with the largest strain.During the rotation,the stress of each ligament gradually increased.The ligamentum flavum was the most stressed ligament.After the extension,the stress of the ligaments decreased except for the anterior longitudinal ligament.4.3.2.4 Chuniaoqifei exerciseChuniaoqifei exercise was loaded to the cervical model.the obvious stress was mainly concentrated in the vertebra,the superior articular process and inferior articular surface.The C2 is subjected to the maximum stress in the vertebra.The maximum stress of the atlas was still in the anterior and posterior arch,and the obvious stress areas in the other vertebrae appear at the joints of vertebral bodies.The C3-4 disc was most stressed.The sternocleidomastoid muscle was the most deformed.The anterior longitudinal ligament was the greatest stress among ligaments.4.3.2.5 Yaozhuanshuangjian exerciseWhen the humeral head in the model was loaded with upward,forward,downward,and backward,the stress distribution of the cervical spine was approximately the same.The stress changes of the anterior and posterior arches of atlas were obvious,but the stress changes of the rest vertebrae were not obvious.The stress change of intervertebral disc was not obvious.The maximum stress was found in C4 vertebra,and the obvious position of vertebra stress was in Luschka joint.From the top to the bottom,the stress of the intervertebral disc gradually increased,and the obvious area of stress gradually moved from the two sides to the posterolateral area.In terms of muscles,the upward and forward movements were the largest deformations of splenius cervicis and longissimus Capitis,while the downward and backward movements were levator scapulae.In the aspect of ligament stress,except for the anterior longitudinal ligament,the stress of other ligaments increased gradually in the upward movement,of which the ligamentum flavum was the most obvious.In the forward movement,the stress of each ligament increase first and then decreased.in the downward movement,the stress of the anterior longitudinal ligament increased continuously,while the stress of the other three ligaments decreased gradually.When moving backward,the anterior longitudinal ligament also raised slightly and then descends,showing a parabolic shape.4.3.3 Effect of different muscle tension on cervical radiculopathy4.3.3.1 Flexion conditionIn the three finite element models of cervical radiculopathy with increased muscular tension,normal muscular tension and decreased muscular tension,loading was performed in the flexion condition,the stress of the vertebral body was found to be greater at the junction of the vertebral body and the vertebral body,while the stress of the lamina and spinous process was less scattered.Among them,the atlas vertebrae suffered the most stress.The maximum stresses of the atlas vertebrae were increased in muscle tension,normal muscle tension,and decreased muscle tension,which were 42.17Mpa,38.81Mpa,and 35.22Mpa.The main stress areas of intervertebral disc were anterior and anterolateral.With the decrease of muscle tension,the stress of vertebrae gradually decreased.The stress trend of each cervical intervertebral disc was basically similar to that of the vertebral body,but in C2-3 and C5-6 discs,with the decreased of muscle tone,the stress tends to increased slightly.4.3.3.2 Extension conditionThe stress distribution of the three disease models was similar.The greater stress areas were mainly concentrated in Luschka joint,the superior articular process and the inferior articular surface,and the atlas in the anterior and posterior arch.The most stressed vertebra is the C2.From the top to the bottom,the stress distribution of the intervertebral disc changed from anterolateral to posterolateral.4.3.3.3 Rotating conditionLoading of rotation conditions to three finite element models,the stress distribution areas were almost the same.The most stress area of atlas is mainly located in the anterior and posterior arches.And the most stress area of the rest vertebra is mainly located in the Luschka joint and the right articular process.The stress area of intervertebral disc is mainly on both sides.The most stressed vertebra is C5,and the stress of each vertebra is not much different.C3-4 segment of the intervertebral disc is the most stressed.4.3.3.4 Lateral bending conditionAfter lateral flexion loading,the maximum stress distribution of the vertebral body is mainly concentrated in the left pedicle and left vertebral body,the maximum stress of the atlas is still in the anterior and posterior arches,the most stressed vertebral body is C4.The most stressful locations of the intervertebral discs are on both sides,of which the right side is the main part,and the C3-4 segment is the most stressed disc.The regions of maximum stress distribution for the three models are approximately the same.4.4 ConclusionDifferent motions of cervical rehabilitation exercise have different biomechanical effects on the cervical spine,and appropriate exercise prescriptions can be formulated according to their respective characteristics.The mechanism of cervical rehabilitation exercise in the treatment of cervical radiculopathy may be to reduce the cervical muscle tone,which further reduces the stress of cervical vertebra and intervertebral disc.For areas with cervical stress concentration,the stress balance of the cervical spine can be adjusted by improving the cushioning capacity of the intervertebral disc and dispersing the stress to other vertebrae. |
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