Clinical observation of thoracolumbar segment small joint disorder treated by orthopedic manipulation Fan Zhiyong Huang Weichang Instruction: Cha He Ping Rehabilitation Clinic, Guangdong Hospital of Integrative Medicine (Nanhai, Guangdong 528200) [Abstract] Objective: To investigate the clinical efficacy of orthopedic manipulation in the treatment of thoracolumbar segment small joint disorder. METHODS: Seventy-six patients with small joint disorders of the thoracolumbar segment were randomly divided into 38 cases treated with orthopedic manipulation (observation group) and 38 cases treated with physiotherapy (control group). RESULTS: The immediate analgesia rate after 1 treatment was 89.47% in the observation group and 52.63% in the control group, and the difference between the 2 groups was significant (P<0.01). The total effective rate in the observation group was 94.74%, and the total effective rate in the control group was 81.57%, and the difference between the two groups was significant (P<0.05). CONCLUSION: The clinical efficacy of manipulation in the treatment of small joint disorders of the thoracic spine is better than that of physiotherapy treatment. The thoracolumbar small joint disorder belongs to the category of spinal small joint disorder, also known as vertebral misalignment, which refers to the slight change of the microscopic anatomical position of the small joints of the thoracolumbar segment caused by the external force on the small joints of the vertebrae of the spine, resulting in a series of clinical symptoms. This group of cases mainly occurred in the small joints of the thoracolumbar segment, that is, between the 12 thoracic and 1 lumbar vertebrae. In this study, from January 2008 to December 2009, the four-person extraction and extension under impact palm pressure method (hereinafter referred to as Cha's orthopedic manipulation) of Professor Cha and Ping was used to treat this disease with satisfactory results. 1. Data and methods 1.1 General data: There were 76 cases in this group, all of them were patients who came to our rehabilitation clinic, including 49 male cases and 27 female cases; their ages ranged from 16 to 60 years old, of which 65 cases were aged 20-46 years old; the duration of the disease ranged from 1 hour to 10 months, with a history of obvious sprain in 56 cases and no obvious sprain in 20 cases. The patients with small joint disorders in the thoracolumbar segment were divided into 2 groups according to the randomized grouping method: observation group (orthopedic manipulation group) and control group (physiotherapy group), 38 cases in each group. The gender, age, disease duration and disease nature of the 2 groups were compared, and the differences were statistically not significant (P > 0.05) and were comparable. 1.2 Diagnostic criteria and inclusion criteria Diagnostic criteria were formulated with reference to the relevant literature [1-4]: history of trauma or long-term history of poor posture, mostly complaining of back pain with impaired movement after trauma or lifting, which was aggravated when holding the chest or rotating or deep breathing, and even involving the intercostal area. Physical examination reveals that there is often a thoracic deformity, the affected vertebra (T12-L1) spinous process is skewed or posteriorly protruding, interspinous paraspinous pressure pain, palpable tense spinal muscles or striated fibrous tissue, clinical manifestations and X-ray suggests that the thoracolumbar (T12-L1) vertebral spinous process is asymmetrical, the physiological curvature of the spine can be diagnosed. Exclusion criteria: subjects without previous organic lesions of thoracic spine disease such as osteoporosis and fracture dislocation were excluded. Inclusion criteria: those who meet the above diagnosis and can cooperate with the treatment are all included in the observation subjects of this group 1.3 Treatment method The observation group adopts Cha’s orthopedic manipulation treatment, the specific operations are as follows: ① Relaxation technique: mainly using the meridian pointing and plucking technique, the patient is lying prone, the whole body is relaxed, the doctor uses one thumb to point and roll along the muscles around the spinous process of the thoracic 12-lumbar 1 vertebra to relax, when touching the painful point and When touching the painful points and nodal points, the thumb flicks the surrounding strips of hard nodules for 1-2 min; ② four people pulling and stretching under the impact palm pressure method: the end of the relaxation technique, two assistants with a towel from the patient’s two armpits, two assistants pulling the towel, two assistants against pulling the double lower limbs, while shaking the double lower limbs, the operator’s center of gravity is placed on the lesion for impact palm pressure method, the doctor with the root of the palm of one hand positioned at the affected area, the other hand superimposed on it, first uniform The pressure is applied evenly, and at the end of the patient’s exhalation, the patient’s chest is suddenly pushed and pressed with force, and the click of resetting the spinous process can be heard, indicating the success of the technique. Note that the operation must be used with the patient’s breathing, and the doctor should exert a moderate amount of force evenly, not necessarily forcing the sound of clicking, as long as the feeling of sliding under the pressed spinous process can be felt. In the control group, low frequency wave therapy was used once a day for one week, and the efficacy was determined after one course of treatment. 1.4 Efficacy evaluation criteria: Cured: lateral spinal deviations were reset, back pain disappeared, function returned to normal, and no recurrence in 1 month follow-up; Improved: lateral spinal deviations were improved, pain was reduced, and function was not completely restored; Invalid: no change in signs and symptoms before and after treatment. 1.5 Statistical methods: SPSS13.0 statistical software was applied to the measured test data for statistical analysis, chi-square test, ANOVA, etc. 2 Results 2.1 The efficacy of immediate analgesia for 1 treatment: 23 cases were cured, 11 cases were improved and 4 cases were invalid in the observation group, 9 cases were cured, 11 cases were improved and 18 cases were invalid in the control group. l comparison of the efficacy of immediate analgesia in the 2 groups, the difference was significant (P<0.01), and the efficacy of the treatment group was better than that of the control group. 2.2 Efficacy after 1 course of treatment: 32 cases were cured, 4 cases were improved and 2 cases were invalid in the observation group, 18 cases were cured, 13 cases were improved and 7 cases were invalid in the control group. After 1 course of treatment efficacy, the difference was significant (P<0.05), and the efficacy of the treatment group was better than that of the control group. 2.3 Relationship between clicking sound and efficacy: After 1 course of treatment, 38 patients in the observation group cooperated with the doctor to complete the joint repositioning massage technique, among which 35 patients showed clicking sound every time they pressed, and 3 patients did not show clicking sound for 1 or 2 times, but there was a clear sense of spine misalignment after pressing, and the patients all felt a sense of relief at the lesion site immediately. There was no significant difference between the efficacy of the group with and without sound. 3 discussion: 3.1 anatomical basis of thoracolumbar segment small joint disorder: thoracolumbar segment small joint disorder belongs to the category of tendon injury in Chinese medicine, also known as vertebral misalignment, thoracolumbar segment small joint in the combination of thoracic and lumbar vertebrae, thoracic vertebrae from the anatomical point of view by the upper 10 thoracic vertebrae and ribs, sternum together constitute a cage-like structure, increasing the stability of the thoracic vertebrae within the structure, the thoracic vertebrae in the cage is restricted, which is why the onset of thoracic vertebrae than the cervical and This is why the thoracic spine is less common than the cervical and lumbar spine, compared with the cervical and lumbar spine is more stable, but outside the cage-like structure of the thoracolumbar segment combined with greater mobility, because the thoracolumbar segment is more mobile than the upper thoracic spine, so the thoracolumbar segment combined with the cervical and lumbar spine as easy to cause a variety of injuries, but also easy to cause small joint disorders, once the thoracolumbar segment combined with joint disorders, easy to produce local inflammation, stimulation of the corresponding nerve, blood vessels Once the joint disorder occurs in the thoracolumbar segment, it is easy to produce local inflammation, stimulate and pull the corresponding nerves and blood vessels, and cause pain and functional disorders in the corresponding parts and the organs they are innervated [5]. Therefore, the key to the treatment of this disease is to correct the small joint disorders caused by spinal instability, restore the internal and external balance of the spine and the coordination of spinal joints, muscles and ligaments. If small joint misalignment occurs repeatedly in this area must waist attention to the presence of compression fractures and the possibility of disc herniation in the thoracolumbar segment. From the general information, it can be seen that this group of patients have a history of acute injury, the treatment of this disease is also diverse, oral painkillers, acupuncture, physical therapy, manipulation, closure, small acupuncture, scraping and cupping, external ointment, etc., although with some effect, but the key to a good solution lies in grasping the essence of the disease, as the saying goes: the treatment of the disease to seek the root, the key is to restore the mechanical balance of the spine. Therefore, manipulation is the first choice, and manipulation is easy for patients to accept, without injections and drugs, less side effects, as long as the force can not be too rigid, generally can achieve good results. 3.2 Manipulation characteristics: At present, there are various techniques for thoracic spine repositioning, such as two-handed stacking method, shoulder support pushing top method, shoulder trigger pushing chest method [6], rotational repositioning method, oblique trigger method spinal fine-tuning technique, reverse pressure repositioning technique, elbow pressure rib spine joint repositioning method, chest expansion traction trigger method, etc., but there are different situations from person to person, the thoracic spine has a total of 12 segments, and the rectification of different segments is not the same, the use of four people pulling The combination of the thoracic and lumbar vertebrae is a complex area, and the characteristic of this technique is that by increasing the strength of traction, the rehabilitation of the thoracic vertebrae which is not easy to be completed in the conventional position can be well achieved. This technique is characterized by the fact that, by increasing the strength of traction, we can achieve a good orthopedic reset of the correction that is not easily accomplished in conventional positions. This technique is characterized by the following: the first step is to activate blood circulation, remove blood stasis, and relieve pain, which can relieve muscle tension or spasm in the affected area and promote the excretion of inflammatory and pain-causing substances; the second is to increase the strength of traction; the third is to press the wrong suture point in the traction state, and then cooperate with the thinking assistant's traction shaking, often in the process of traction shaking the wrong suture has been reset; the fourth is the impact palm pressure. This technique requires gradual pressure under traction shaking, with the end of the patient's exhalation is to add an explosive force to lift the embedding and restore the original anatomical position of the original spine in the patient's natural thoracic movement, interrupting the vicious circle of swelling - pain - muscle spasm It also eliminates a series of symptoms and signs of spinal nerve and sympathetic nerve stimulation caused by small joint disorders. 3.3 Awareness of the clicking sound and its therapeutic effect: The clicking sound is a common physical phenomenon that occurs during spinal manipulation. Therefore, some scholars think that the appearance of the clicking sound is meaningless because some joints in the human body also emit a clicking sound under normal circumstances, and the appearance of the sound only represents the separation of the joint surface; some scholars think that the clicking sound is essential for successful resetting techniques It is considered to be a sign of successful joint repositioning[7] . The efficacy of the present study shows that it is not necessary for a click to occur during the repositioning process, but the key to the treatment is whether there is a sense of misalignment of the spinous processes during the repositioning process, and there is no direct relationship between the occurrence of a click and the efficacy of spinal repositioning techniques. In other words, the force used in pushing is sufficient to overcome the frictional force that prevents the joint from resetting, so that the joint is reset and the passive activity is controlled within the physiological range, which is a more ideal rehabilitation [8]. In addition, we analyzed the two invalid patients in the observation group: both patients did not make a clicking sound in each revision, although they had a misalignment of the spinous process during the revision, and further CT of the thoracic spine showed hypertrophy of the ligamentum flavum leading to thoracic spinal stenosis. This also indicates whether patients with ligamentum flavum hypertrophy and spinal canal stenosis are not prone to clicking sounds during the revision, which needs to be further investigated. In summary, this treatment technique has good immediate analgesic efficacy, fast onset of action, easy for patients to accept, and has certain therapeutic advantages. At present, the diagnostic criteria for this disease are not yet strictly mastered, and the criteria for evaluating the efficacy are mostly based on comparing the improvement of symptoms before and after treatment, lacking strict objective indicators; in clinical practice, we have also noticed that some patients whose pain has stopped after treatment, but whose symptoms recur again after a period of time Subluxation-rectification, rectification-subluxation, which suggests that there are many problems in our diagnosis and treatment, and if to solidify the efficacy is the current urgent need to solve the problem of spine and spine-related diseases, our assessment of this disease needs more diagnostic indicators to make objective conclusions and improve the clinical cure rate. References: [1] Yu L, Li YM, Lin WF. Clinical observation of thoracic small joint disorder treated by orthopedic manipulation of Professor Lin Yingqiang. Guangdong Medicine, 2008, 9(7): 1225-1226 [2] State Administration of Traditional Chinese Medicine. Diagnostic and efficacy criteria for Chinese medicine illnesses [M]. Nanjing: Nanjing University Press, 1994, 198. [3] Yan Juntao. Tui Na [M] . Beijing: China Chinese Medicine Publishing House, 2003.138. [4] Sun Shuchun. Color Atlas of Practical Tui Na Manipulation [M] . Beijing: China Medical Science and Technology Press, 1994.9. [5] Wei Guikang. Tendon Injuries in Chinese Medicine [M]. Shanghai: Shanghai Science and Technology Publishing House, 1997:164. [6] Wang Qiang Zeng Qingyun Wang Guocai's clinical observation of thoracic spine small joint disorder by manipulation and rehabilitation. Chinese Journal of Rehabilitation Medicine 2005.20(9):708 [7] Li Yikai,Zhao Weidong,Zhong Shizhen. A comparative study of the "click" sound of two neck rotation techniques [J]. Chinese medicine orthopedics, 1998,10(6):9-10. [8] Cha and Ping, Fan Zhiyong, Zhang Ruifang, et al. The quantitative-effect relationship between the clicking sound and the maximum pressing pressure caused by thoracic spine palm press[J]. Chinese Journal of Rehabilitation Medicine,2009,24(2):126-128