Operational and Intervention Effects of Targeted Tuina in Lumbar Intervertebral Disc Degeneration Model Rabbits

Summary

The finger tactile measurement system quantifies tactile pressure on the finger using a highly sensitive electrosurgical pressure sensor, with software displaying and accurately recording the pressure data and video in real time. Two analysis modules unify the data processing for thumb tracking and conditioning during Tuina.

Abstract

Tui Na or massage therapy alleviates symptoms related to intervertebral disc degeneration (IDD). However, precise, repeatable, standardized instructions for Tuina manipulation are lacking. This study establishes IDD model rabbits induced by fibrous ring puncture, creates targeted Tuina stimulation protocols at the acupuncture points in the lumbar region, and describes in detail the operation methods and requirements of kneading, pointing, and flicking. New Zealand male white rabbits (n = 15) were selected and randomly divided into a blank group, a model group, and a Tuina group. The rabbits in the model group and the Tuina group were molded by fibrous ring puncture; the rabbits in the model group were only immobilized on the operating table without treatment. In contrast, the Tuina group used the "8N/10N, 30 cycles/min" prescription for kneading, pointing, and flicking to perform the intervention, using tactile sensory aids to monitor and regulate the intensity of the Tuina operation. Imaging diagnosis and pathological tests were used to assess the effect of Tuina in rabbits, and the results showed improved imaging features and significantly lowered pathology scores of lumbar disc degeneration in the Tuina group compared to the model group (P < 0.01). Targeted Tuina in the lumbar region may be beneficial in the alleviation of lumbar disc degeneration, but further verification is needed. By regularly performing Tuina and recording the mechanical information involved enables reproducible manipulation prescriptions and helps to observe the basic features of the underlying mechanism of Tuina for IDD.

Introduction

The age of onset of intervertebral disc degeneration (IDD) is becoming increasingly younger, with studies showing¹ that the prevalence of IDD is approximately 35% of subjects aged 20 to 39 years involving at least one lumbar level, and all individuals aged 60 to 80 years have IDD. The deleterious effects associated with IDD are widespread, and the disability is found to be positively associated with the degree of IDD in magnetic resonance imaging (MRI) studies^2,3. Although conventional treatments such as bed rest, functional exercise, non-steroidal anti-inflammatory drugs (NSAIDs), and surgery are widely used, they have had limited success in relieving pain⁴. Therefore, we emphasize the need for new treatment strategies to prevent and treat this disease and its co-morbid symptoms. Complementary and alternative medicine approaches (CAM) have been welcomed by a wide variety of patients with IDD, for instance⁵, in the United States alone, 44% of the population used at least one CAM in 1997, the most common symptom being low back pain with IDD and its associated pathology as the main cause. In fact, patients who are dissatisfied with the use of conventional treatment for IDD often turn to CAM such as Tui Na or Tuina.

Tuina therapy has a long history and is widely accepted as an effective method for restoring tissue function, relieving pain and tissue stress, and promoting overall health. According to Wu⁶, the first step in treating IDD disease is to use conservative approaches such as chiropractic and acupuncture treatments. Chiropractic or massage (60% of CAM) is a licensed treatment and is the most commonly used of the many CAM therapeutic options in the United States. A growing body of evidence⁷ has confirmed the considerable clinical benefits of chiropractic or massage for the treatment of lower back pain, not only in terms of safety but also in terms of significantly reducing costs after initial treatment compared to other CAM options such as acupuncture. The 2007 guidelines of the American College of Physicians (ACP) and the American Pain Society (APS)⁸, as well as related systematic evaluations and reviews^9,10, recommended chiropractic as a nonpharmacologic therapy option for acute, subacute, or chronic low back pain. The findings of a 2017 retrospective study on the benefits and harms of nonpharmacologic therapy for lower back pain¹¹ were also consistent with previous guidelines recommendations. The review found no serious harm and some evidence of high-quality, low-risk bias for the efficacy of chiropractic and massage for lower back pain. A recent study¹² found that US adults with disc herniation receiving chiropractic spinal manipulation were less likely to undergo discectomy compared to those receiving other cares. Tuina or massage as the primary therapy for IDD can reduce pain and improve skeletal muscles function in the short term by relaxing spastic muscles in the lower back, improving the abnormal anatomical position of the lumbar spine, reducing symptoms of nerve compression and lumbar disc pressure, and increasing internal spine stability¹³, and can also show good benefits in terms of improving symptoms, signs, and pain scores¹⁴.

Physical stimulation therapies, such as Tuina, can alleviate symptoms related to IDD, but one of the most significant challenges in conducting research is the lack of reproducible prescriptions for Tuina and the absence of uniform normative standards for Tuina treatment, which limits progress in the field and is not conducive to scientifically assessing the effects of Tuina therapies. More importantly, the lack of standardized treatment is also less conducive to studying the type and properties of Tuina in relation to the principles of therapeutic activity and mechanism. Some studies have reported intervention frequency but have ignored the possibility of a dose-response relationship for Tuina therapy; that is, there may be an optimal amplitude, duration, and frequency of Tuina that produces maximum recovery of muscle and joint function¹⁵. As a result, treatment parameters should include the type of massage, duration, and intensity or level of pressure or depth attained¹⁶. To address these issues, we used a tactile force measuring finger guard to quantify and monitor the magnitude and frequency of force during Tuina manipulation in this study. The measuring systems and software (see Table of Materials) originated from the Humanoid Robotics Research Laboratory at Harvard University and were developed with the support of the Defense Advanced Research Projects Agency (DARPA), the Army Research Laboratory, and the National Institutes of Health (NIH), and are currently the most accurate devices for quantifying human touch. Depending on the needs of the field environment, the user can choose to communicate data, observe and record tactile changes either wired or wirelessly.

TCM offers an alternative treatment and thought process for patients affected by IDD. We based the protocol presented here on the traditional Chinese medicine (TCM) meridian theory¹⁷, which states that proximal acupuncture points have a therapeutic effect on the affected area. TCM also indicates that the bladder meridian is located mainly on both sides of the paraspinal column, and its circulation location is closely related to the lumbar region, which is also closely related to the symptoms of lumbar pain, leg numbness, and leg pain that occur in patients with IDD. The bladder meridian is often used as the preferred meridian for the treatment of IDD in Chinese medicine clinics. Ying¹⁸ examined 240 patients with IDD who met the criteria for the exploration of force-sensitive acupuncture points¹⁹, and then determined whether these were force-sensitive points based on the presence or absence of the sensitization characteristics of the point. The force-sensitive acupuncture points in IDD were primarily distributed in the bladder meridian (41.37%). According to the findings of a data mining study²⁰, acupuncture points are mostly distributed in meridians that follow the areas of the pain-prone areas of the lower back and legs, i.e., primarily on the bladder meridian. As a result, in this study, we limited the treatment range by selecting three points near the lumbar vertebrae, Pishu (BL20), Sanjiaoshu (BL22), and Shenshu (BL23), as the operation sites for the stimulation focus in conjunction with the distribution of acupuncture points in rabbits with reference to the guidelines of the experimental acupuncture²¹.

Protocol

The Animal Experimental Ethics Committee at Chengdu University of Traditional Chinese Medicine reviewed and authorized all study protocols (approval number CUTCM-2021-23), and all operations of this protocol followed the committee's guidelines. 6-month-old New Zealand white rabbits (n = 15) weighing 2.5 ± 0.2 kg were selected, provided by Chengdu Dashuo Experimental Animal Co., Ltd., experimental animal license number: SCXK (Su) 2017-0002. Standard animal housing conditions were 20-26 °C, 50%-70% humidity, alternating 12-h light and dark cycles, free diet, and water intake. The blank group included rabbits without any processing (no surgical incision and puncture of the IVD).

1. Establishment of the IDD rabbit model

NOTE: The following protocols were used to establish the IDD model.

1. Anesthetize the rabbits intravenously at the ear margins using 3% pentobarbital sodium solution at a rate of 1.2 mL/kg, depending on their body weight. Pay attention to the rabbit's respiratory rate and eye pupil changes during anesthesia and push the drug as slowly as possible. Administer meloxicam via subcutaneous injection into the operative area for analgesia at a dosage of 0.35 mg/kg.
2. Ensure the rabbits in the model and Tuina groups were fixed on an operating table and restrained in a prone position. Shave the right lower lumbar spine (the surgical area and prepare for skin treatment.
3. Place the anesthetized rabbit onto the sterile operating table in a prone position with the spine squared and the right side of the rabbit facing the operator.
4. After shaving, disinfect the surgical area with chlorhexidine solution in the first round for 3-5 min. After drying, use iodophor for the second round of disinfection for 1-3 min. After drying, use 70% alcohol for a third round of disinfection. Each round of disinfection covers the surrounding area of skin at least 5-10 cm. After alcohol drying, use a sterile surgical towel to cover the surgical area to keep it sterile until the procedure begins. Then, use a scalpel to make an incision 3 cm from the median spine line, approximately 5 cm in length. Pluck away the skin, fascia, and muscles, avoid obvious blood vessels, and feel the fingers in the direction of the spine to reach the lumbar vertebral segments.
5. Visualize the right segment of the lumbar spine with the aid of a light source. If any oozing blood obscures the view, remove it with a sterile dry cotton ball. Select a 16 G bone puncture needle (see Table of Materials). After removing the stylet of the puncture needle, wrap the end of the needle of the outer needle with a folded sterile gauze block and place it against the palm of the puncturing surgeon's hand.
6. Hold the needle in place by pinching the body with five fingers, and then vertically puncture the right side of the disc in the L3/L4, L4/L5, and L5/L6 lumbar segment, respectively.
7. After the successful puncture, rotate the needle in a circle once, leave for 10 s, and then withdraw. After inserting the stylet back into the puncture needle, push out a white gelatinous nucleus pulposus tissue.
8. Suture the fascial and cortical layers. Then, cover the incision with sterile gauze. Administer meloxicam via subcutaneous injection at the operative area for postoperative pain management in animals at a dose of 0.35 mg/kg once daily for seven days.
9. On the second day after modelling, rabbits were anesthetized by intravenous injection of 3% pentobarbital sodium solution. Perform magnetic resonance imaging (MRI) and obtain images to determine whether the model is successful. Perform magnetic resonance imaging (MRI) examinations using a SPEC 0.35-T imager. Acquire T2-weighted images (T2WIs) in the sagittal plane with the following settings: fast spin echo (SE) sequence with time to repetition (TR) of 3100 ms, time to echo (TE) of 115 ms, section thickness of 3 mm, and gap of 0.8 mm.

2. Using the finger guard

1. Sterilize the operator's hand and carefully place the finger guard on the right hand. Adjust the gloves so that the sensor hidden in the finger belly of the finger guard can face the operator's finger belly for better information acquisition.
2. Insert the end of the sensor on the finger guard into the interface of the circuit board and make sure that the connection is stable so as not to interrupt the transmission of information during operation.
3. Use the universal serial bus (USB)-C type cable to connect the computer to the input port of the circuit board of the finger sleeve and adjust the position of the transmission cable so that it will not break away from the contact during operation or the operator will not get tied up.
4. Open the software on the computer system. Ensure to connect the finger guard to the computer before opening the software.
5. In the Sensor Range (N) selection box on the left-hand side of the software interface, click on the Down button and 10N to limit the sensor's measurement range. When it is ready, it is possible to see a certain force on the dynamic monitoring chart: the contact pressure between the operator's finger and the finger guard. Click on Tare on the system to zero the force.
6. Keep the operator's force constant so the force curve remains at the desired value.
7. Monitor the force curve and adjust the force level according to the curve change.
8. At the end of the operation, click on the Export Chart Date on the software to export the information table, which reflects the force levels for each time period.

3. Tuina operation methods

1. In order to avoid errors caused by differences in proficiency, accuracy, and intensity of the acupuncture points, appoint the same person for all Tuina interventions.
   NOTE: The operator must be a trained practitioner who has been practicing Tuina for at least 5 years.
2. Gently place the operator's left hand on the back of the rabbit's dorsal and hold it in place to prevent the rabbit's torso from struggling and moving during the procedure.
   1. Use the right hand to operate, trying to keep the shoulders, waist, and wrists as relaxed as possible.
      NOTE: The operator's shoulders should hang naturally, the elbows should be naturally flexed, and the wrists should be flexible and not tense and stiff.
3. Kneading and pointing of the acupuncture points. Knead the Pishu (BL20), Sanjiaoshu (BL22), and Shenshu (BL23) points on the left side of the spine. Place the belly of the thumb on the acupuncture point and the remaining fingers naturally on the contralateral muscular skin to anchor the thumb and the remaining four fingers in the gesture.
   NOTE: Positioning of acupuncture points ("Cun" is a unit of measurement for the location of acupoints in traditional acupuncture theory):
   BL20: 1.5 cun(approximately 15 mm) lateral to the posterior midline on the lower border of the spinous process of the 11^th thoracic vertebra.
   BL22: 1.5 cun (approximately 15 mm) lateral to the posterior midline on the lower border of the spinous process of the 1^st lumbar vertebra.
   ​BL23: 1.5 cun (approximately 15 mm) lateral to the posterior midline on the lower border of the spinous process of the 2^nd lumbar vertebra.
4. Press the point once and knead it 3 times for one cycle. During the kneading operation, suspend and flex the wrist, with the forearm actively applying force, driving the thumb to apply rhythmic, circular pressure to the acupuncture point with a force of 8 N and a frequency of 30 cycles/min.
5. For the point-pressing operation, place the thumb perpendicular to the skin of the acupuncture point and slowly increase the force to 10 N. Then press until the skin of the white rabbit is depressed by 0.5 cm before slowly decreasing the pressure. Perform this action on each acupuncture point for 1 min.
6. Flick the erector spinae muscles.
   1. Flick the vertical spinal muscles on the left lower dorsal of the rabbit. Place the fingers on the lateral aspect of the erector spinae muscles, and place the remaining four fingers s naturally on the opposite side, with appropriate pressure applied vertically to a depth of approximately 0.5 cm.
7. Relax the wrist and wrist joints, and use the force of the swinging arm to drive the thumb to the inner side of the muscle in a lateral plucking motion perpendicular to the direction of the muscle fibers, as if plucking a string. Pluck a muscle three times in a cycle, slowly moving the position from top to bottom. Ensure that the force is 10 N, and the frequency is 30 cycles/min, with 2 min for each side.
   NOTE: Plucking one muscle for a long time is not allowed.
8. Knead each side of the rabbit at the three acupuncture points and flick for 5 min, for a total of 10 min on both sides, once a day, 5 times a week for 4 weeks. Take care to avoid the surgical incision when operating on the right side.
9. Be precise when searching for acupuncture points, preferably according to bony markings.
   NOTE: It is important to note that, unlike humans, the white rabbit has 7 lumbar vertebrae, and the position of the lumbar vertebrae segments can be viewed on the basis of the images, and that the lumbar vertebrae are different from the thoracic vertebrae to the touch. In addition, there is a distinct indentation at the acupuncture point of touch. Observing the white rabbit's condition during manipulation will also be helpful, as this will help when searching for the acupuncture point. When the correct acupuncture point is touched, the white rabbit's muscles will appear in a tense state.

Results

Basic characteristics of the mechanical curve of Tuina operation
Figure 1 depicts the software screenshots recording in real-time the graphs of pressure data over time for the kneading, pointing, and flicking methods with corresponding first-order velocity characteristics during the Tuina intervention IDD model rabbits. The curve is not completely straight or conforms to a certain functional relationship because of the change in the reaction force of the rabbit's lumbar ...

Discussion

Considering the structural and functional complexity of IVD, we chose rabbits as a constructive model for IDD disease, which is characterized by an abnormal cell-mediated response to progressive structural damage. Animal models of various species, such as rabbits, rats, and dogs, have been used to study changes in structural, biological, and biochemical properties during degeneration^23,24,25. However, when comparing the results ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
0.3 T Veterinary Maenetic Resonance lmaging(MRI)	NINGBO CHUANSHANJIA	CSJ-MR
Alcohol medical	LIRCON	20230107
Benzylpenicillin potassium	Jiangxi Keda Animal Pharmaceutical	140051251
FingerTPS Finger Tactile Measurement System	TPS
FingerTPS guard	TPS	CSU8-10N
Haemostatic forceps	SHINVA	20211239
Injection syringe	CONPUVON	20153151307	1 mL, 5 mL, 10 mL
Knife blades	Hons Medincal	20210615
Medical absorbent cotton ball	Cofoe	20210006
Medical suture needle	Shanghai Xiaoyi Medical Devices	20192020430
Medullo-puncture needle	Yangzhou Jiangzhou Medical Devices	20190902	Used to puncture lumbar disc
Physiological saline	NeilMed	C1210504D2
Povidone iodine solution	Sichuan IJIS Medical Technology	20221209
PPS Chameleon TVR software	TPS
Quasi-microbalance	Explorer
Rabbit dissection operating table	Zhenhua Biomedical	ZH-BXT-3Z	Used to immobilize rabbits
Shaver	AUX
Sterile gauze	Cofoe	20202140675
Surgical gloves	DR.LERSH	20172140028
Surgical knife	Hons Medincal	20210019
Surgical tweezers	SHINVA	20210233
USB-C data transmission line	KINI
White light photography microscope	Nikon	Eclipse Ci-L