Xu Xu-jie (许旭杰), Wang Wen-li (王文丽)

1 Jiaxing Second Hospital of Zhejiang Province, Jiaxing 314000, China

2 Jiaxing Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University, Jiaxing 314001, China

Lumbar myofascitis, also known as myofascial pain syndrome (MPS) is a common clinical condition and the main course of low back pain. It is characterized by diffuse dull pain, localized pain, coldness, skin numbness, muscle spasms and impaired movement.The pain is worse in the morning, mild during the day and aggravated in the evening. The pain is often triggered by physical inactivity or too much activity. This condition has a long duration and is often triggered by fatigue or weather changes. It can affect the patients’quality of life. It is pathologically featured by chronic soft tissue pain in multiple myofascial trigger points[1-2].Pressing these trigger points may produce referred pain.

The concept of trigger point was first proposed by Travell JG[3]in 1952. Till 1981, Simons DG,et al[4-5]confirmed the existence of trigger point and proposed the diagnosis of MPS in 1990. Modern Chinese scholars did some research on the mechanism of fasciitis. Wang YS,et al[6]held that release of 5-HT and histamine caused by soft tissue injury can produce ischemia and neurological sensitization, consequently resulting in shortening of muscle fibers, and inflammatory pain and the corresponding clinical symptoms. According to clinical data, Zhou XG,et al[7]found that myofascitis is closely related to work and lifestyle. It is more common in long-term desk work groups (such as teachers,accountants, designers and engineers). The body maintaining a fixed position for a long time will keep the back muscles in a continuous state of high tension, and it will make the muscles release inflammatory substances, causing ion imbalances. For example, hightension muscles will over-release calcium. High concentrations of calcium ions will in turn lead to sustained muscle contraction. When muscle pressure continues to rise, interstitial vessels are compressed,blocking the blood circulation and increasing tissue ischemia. Finally, there forms up a vicious cycle of pain-contraction-aggravated pain[8].

In order to explore an effective treatment of lumbar myofascitis, this research was to observe the clinical effect of acupuncture plus moving cupping with white mustard oil in treating lumbar myofascitis, and the report is given as follows.

1 Clinical Materials

1.1 Diagnostic criteria

The diagnostic criteria were according to the diagnosis of lumbar myofascitis inCriteria of Diagnosis and Therapeutic Effect of Diseases and Syndromes in Traditional Chinese Medicine[1]: trauma after improper treatment, a history of strain or exposure to cold; more in the elderly, especially manual labors; back pain, stiff muscle, a weight-bearing sensation, often associated with weather changes, e.g. overcast and rainy weather may aggravate the symptoms; the back with a fixed tenderness or extensive tender points; back muscle stiffness, and nodule-like changes often can be palpated,along the lines of the sacrospinalis, with limited range of motion of the back; no positive findings by X-ray.

1.2 Inclusion criteria

Conforming to the above diagnostic criteria; over 18 years old; no abnormality in serum human leukocyte antigen B27 (HLA-B27) and four coagulation indicators,namely, prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and fibrinogen (FIB) screening. All patients signed the informed consent.

1.3 Exclusion criteria

Those with severe life-threatening or infectious diseases; with abrasions and bleeding tendency;pregnant women or those who cannot tolerate acupuncture or moving cupping treatment; those with a history of lumbar surgery or severe lumbar deformity;those who can’t understand the scales or judge their own degree of pain; those with fracture, osteoporosis,lumbar spinal stenosis, spondylolisthesis or spinal tumor or infections.

1.4 Statistical methods

The SPSS 22.0 version software was used for statistical analysis. Chi-square test was adopted for gender data; age data in normal distribution with homogeneity of variance were expressed as mean ±standard deviation (x±s), and analyzed byt-test. Visual analog scale (VAS) score and Chinese version of Roland-Morris disability questionnaire (RMDQ) were grading data, and were analyzed by rank-sum test.P＜0.05 indicated a statistically significant difference.

1.5 General data

A total of 90 patients were enrolled in this study, and all visited Jiaxing Second Hospital of Zhejiang Province for low back pain between January 2016 and December 2016. According to the order of treatment, they were divided into an observation group and a control group,45 cases in each group. There were no significant differences in gender and age between the two groups(bothP＞0.05), indicating the comparability between the two groups (Table 1).

Table 1. Comparison of general data between the two groups

2 Treatment Methods

2.1 Observation group

2.1.1 Acupuncture therapy

Points: Dazhui (GV 14), Yaoyangguan (GV 3), Ashi points and bilateral Weizhong (BL 40), Yanglingquan(GB 34) and Shenshu (BL 23).

Method: The tender points were found and taken as Ashi points. After routine disinfection, needles of 0.30 mm in diameter and 40 mm in length were selected to puncture. After arrival of qi, even reinforcing-reducing manipulation was conducted to make patients to feel soreness, numbness or distention.The needles were retained for 30 min.

2.1.2 Moving cupping method

Moving cupping was used after acupuncture therapy.

Compound white mustard oil configuration: 40%mustard oil, 40% sesame oil, 10% wintergreen oil, and turpentine 10%.

Method: The patient was coated with white mustard oil on the back. The doctor took a special glass cup of a 45 mm in outer diameter, 38 mm in inner diameter of and 70 mm in depth, used flash-fire method to make the cup adsorb onto Dazhui (GV 14), and then moved the cup to slide down along the Governor Vessel [from Dazhui (GV 14) to Yaoyangguan (GV 3)], the first side line [from Dazhu (BL 11) to Qihaishu (BL 24)] and the second side line [from Fufen (BL 41) to Zhishi (BL 52)] of the Bladder Meridian, from top to bottom (single palm held the cup, made the cup body perpendicular to the skin, and pulled the cup to make it slide gently from top to bottom). Repeated the above operation until the local skin was significantly flushing or purple black petechia appeared.

2.2 Control group

Points: Same as those used in the observation group.

Methods: The acupuncture method was same as that in the observation group. The moxa stick was cut into small segments of about 2.5 cm in length. Made a hole in the center with a cotton swab and then fixed one moxa segment onto the needle tail, and lit it from the bottom. A paper pad was placed on the skin to prevent burn by falling ash. Paramedics removed ash regularly during the treatment. Three segments for each point,totally lasting about 30 min.

The two groups were treated twice a week. The effect was observed after 4 weeks of treatment in both groups.

3 Observation of Efficacy

3.1 Observation items

Patients of the two groups were assessed with VAS and Chinese version of RMDQ before treatment, and respectively after 1-week and 4-week treatment.

3.1.1 VAS[8]

With a straight line of 10 cm in length, the leftmost mark is 0 cm and the rightmost mark is 10 cm,explained as that 0 cm means no pain, while 10 cm means severe unbearable pain. Patients were asked to point out his pain intensity on the line. The corresponding calibration line pointed by the patient was considered as the score of VAS. The scale must be determined by the patient himself and the researcher should not suspect or have any suggestive behaviors.

3.1.2 Chinese version of RMDQ[2]

There are 24 items in the Chinese version of RMDQ,including walking, standing, bending, work, bed rest,wearing clothes, and self-care ability in many aspects of daily life. Each question entry is calculated as 1 point.The answer to ‘yes’ is 1 point, and the answer to ‘no’ is 0 point. The total score is the sum of all points to ‘yes’.The lowest score is 0 and the highest score is 24. The higher the score, the worse the dysfunction.

3.2 Criteria of therapeutic effect

The efficacy was evaluated according to the therapeutic effect criteria of PMS in theCriteria of Diagnosis and Therapeutic Effect of Diseases and Syndromes in Traditional Chinese Medicine[1].

Cure: Back pain disappeared, mobility free, and no recurrence during the treatment.

Improvement: Back pain reduced, but a little discomfort during activity.

Failure: No improvement in symptoms.

3.3 Results

3.3.1 Clinical efficacy

After 4 weeks of treatment, the overall clinical efficacy of the two groups was compared using rank-sum test (Z=-3.715,P=0.000), suggesting that acupuncture plus moving cupping is better than acupuncture plus warm needling for PMS (Table 2).

3.3.2 VAS score

There was no significant difference in VAS score between the two groups before the treatment (P＜0.05).After one week of treatment, the VAS scores of the two groups were lower than those before the treatment(bothP＜0.01), but there was no significant difference between the two groups (P＞0.05). These results suggested that both treatment protocols were effective.After 4-week treatment, compared with those after 1-week treatment, the VAS scores of the two groups continued to decline, there were significant intra-group differences in the two groups (bothP＜0.01); the VAS score in the observation group was significantly lower than that in the control group (P＜0.01). These results suggested that acupuncture plus moving cupping can relieve pain better than acupuncture plus warm needling (Table 3).

3.3.3 Chinese version of RMDQ score

Before the treatment, the difference in Chinese version of RMDQ score between the two groups was not statistically significant according to rank-sum test(P＞0.05). After 1-week treatment, the Chinese version of RMDQ scores of both groups were lower than those before the treatment (bothP＜0.01), but there was no significant difference between the two groups (P＞0.05).These results suggested that both treatment protocols can improve patient’s dysfunction. After 4 weeks of treatment, the Chinese version of RMDQ scores of both groups continued to decline, with a statistical intragroup difference in each group compared with the score after 1-week treatment (bothP＜0.01). The Chinese version of RMDQ score in the observation group was significantly lower than that in the control group(P＜0.05). These results suggested that acupuncture plus moving cupping can improve the dysfunction better than acupuncture plus warm needling (Table 4).

Table 2. Comparison of clinical efficacy between the two groups (case)

Table 3. Comparisons of VAS scores before and after the treatment (average rank)

Table 4. Comparisons of Chinese version RMDQ scores before and after the treatment (average rank)

4 Discussion

Lumbar myofascitis falls under the category of‘Bi-impediment syndrome’ and ‘low back pain’ in Chinese medicine. As far as internal factors are concerned, it is caused by deficiency of the liver and kidney and stagnation of qi and blood. As far as exogenous factors are concerned, it is caused by wind,cold and dampness or inappropriately treated or untreated traumatic injuries. Internal and external etiological factors either cause obstruction or malnourishment, both resulting in pain[9-10].

Modern medicine considers that it is majorly caused by soft tissue strain of the back. The aseptic inflammation of the local soft tissue and the peripheral nerve micro-vascular permeability are the main pathological changes[11]. The main purpose of treatment is to relieve pain[12-15]. Acupuncture plus warm needling is a routine and effective method for myofascitis[16].Moving cupping therapy, a TCM treatment, is based on the cupping therapy[17]. Moving cupping method was first seen in an article entitled ‘Cupping therapy’ in 1956,which was published inShanghai Zhongyiyao Zazhi(Shanghai Journal of Traditional Chinese Medicine)[18],with the function of dilating local microvessels.Governor Vessel, the sea of yang, can unblock yang in the whole body; the Bladder Meridian, from top to bottom, can link the qi movements of Zang-fu organs.So, moving cupping along the Governor Vessel and Bladder Meridian pathways can induct yang to the surface of the human body, adjust qi movement, and improve human immunity[19].

Ashi points can circulate the local qi and blood to stop pain. Weizhong (BL 40) is the He-Sea point of the Bladder Meridian, and belongs to the earth in five elements. The Bladder Meridian passes the back, so puncturing Weizhong (BL 40) can relax sinews and activate collaterals. Yanglingquan (GB 34), the tendon influential point of the Eight Influential Points, can fortify tendons and bones, dispel wind and resolve dampness. Shenshu (BL 23), as the Back-Shu point of the kidney, can tonify the liver and kidney, strengthen bones, and warm kidney to dispel cold; at the same time, as a local point, it can dredge the local qi and blood, relax sinews and activate collaterals.Yaoyangguan (GV 3) can strengthen tendons and bones,as well as dispel cold and dampness. Dazhui (GV 14) is a crossing point of all yang meridians, can dredge qi and unblock blood of the Governor Vessel, dispel cold and resolve dampness. To combine those points above can unlock the meridians and warm yang to relieve pain.

Bai Jie Zi(Semen Sinapis Albae) can warm the lung to resolve phlegm, regulate qi to resolve stasis, and dredge collaterals to kill pain. It is commonly used in treating cough and asthma due to cold and phlegm, chest and hypochondrium distention and fullness, joint numbness or pain caused by phlegm stagnation, or furuncle/mass due to phlegm and dampness[20-21]. White mustard oil can make the skin hot, and promote deep blood circulation, and has a strong anti-inflammatory analgesic effect[22]. Patients with back pain often have cold back feeling, and feel comfortable after treated with mustard oil. Wintergreen oil, also known as methyl salicylate, is good at releasing swelling to kill pain;turpentine can relax tendons[23-24], dredge collaterals,and promote the penetration of salicylic acid[20]. The combination of the two has a better efficacy. Sesame oil plays a role in lubricating and protecting the skin.

From the results of this study, it was shown that after 1 week of treatment, the back pain of both groups was significantly relieved, and the functional improvement of the observation group was more significant than that of the control group. After 4 weeks of treatment, the improvements in pain and activity disorder in the observation group were more significant than those in the control group, and the recovery rate of the observation group was higher than that of the control group. Acupuncture plus moving cupping with white mustard oil has curative effect in treatment of lumbar myofascitis. It can relieve back pain and improve the activity of the back. Therefore, it can be used as a kind of simple and effective treatment for myofascitis.

Conflict of Interest

There was no potential conflict of interest in this article.

This work was supported by Special Department Fund of Jiaxing Second Hospital of Zhejiang Province (浙江省嘉兴市第二医院特色科室基金).

Statement of Informed Consent

Informed consent was obtained from all individual participants in this study.

[1] State Administration of Traditional Chinese Medicine.Criteria of Diagnosis and Therapeutic Effect of Diseases and Syndromes in Traditional Chinese Medicine. Nanjing:Nanjing University Press, 1994: 200.

[2] He G. Development of Chinese Version of the Roland-Morris Disability Questionnaire for Patients with Low Back Pain. Hefei: Master Thesis of Anhui Medical University, 2005.

[3] Travell JG. Myofascial trigger points: clinical view//Nonlca JJ, Albe Fessard D. Advances in Pain Research and Therapy. New York: Raven Press, 1976: 919-926.

[4] Simons DG, Travell J. Myofascial trigger points, a possible explanation. Pain, 1981, 10(1): 106-109.

[5] Simons DG, Hong CZ, Simons LS. Endplate potentials are common to midfiber myofacial trigger points. Am J Phys Med Rehabil, 2002, 81(3): 212-222.

[6] Wang YS, Yao M. Research progress on myofascial trigger points. Harbin Yike Daxue Xuebao, 2001, 35(3): 230-231.

[7] Zhou XG, Zhong Q, Yang C, Yang LX, Zhang Y. Study on the TCM pathogenesis and syndrome differentiation of myofascitis cluster analysis. Zhongyi Zazhi, 2008, 49(10):924-926.

[8] Zhang Y. Clinical Efficacy Observation of Sliver-needle Acupuncture for Myofascial Pain Syndrome. Beijing:Master Thesis of Beijing University of Chinese Medicine,2015.

[9] Wu XS. Clinical Observation on Acupuncture plus TDP for Myofascitis of the Back Region. Beijing: Master Thesis of Beijing University of Chinese Medicine, 2007.

[10] Yuan YL. Clinical observation on moving cupping plus moxibustion for 40 cases with back cold and pain.Neimenggu Zhongyiyao, 2015, 34(7): 91-92.

[11] Sun SC, Fei YR, Peng HD. Acupuncture, acupressure and moving cupping for 98 cases with back cold and pain.Shanghai Zhenjiu Zazhi, 2001, 20(4): 30.

[12] Liu Q. Clinical study on ultrasonic drug penetration therapy for myofascial pain of neck and back. Zhonghua Wuli Yixue Yu Kangfu Zazhi, 2008, 30(3): 193-194.

[13] Zhang W, Yu JM, Han GJ, Liu CS, Wang MY. Efficacy of ultrasonophoresis with diclofenac diethylamine emulgel in the treatment of primary fibromyalgia syndrome. Shiyong Tengtongxue Zazhi, 2011, 7(4): 264-266.

[14] Li XH, Zhao WC, Yang CX. Clinical observation on tizanidine for myofascial pain syndrome. Zhongguo Kangfu Yixue Zazhi, 2008, 23(5): 434-435.

[15] Li YK, Mu WH, Wang AH. Medications for myofascial pain syndrome. Jingyaotong Zazhi, 2002, 23(2): 170-171.

[16] Wu BD. Clinical Efficacy Observation on Jingjin Needling Combined with Acupuncture Therapy for Lumbar myofascitis. Harbin: Master Thesis of Heilongjiang University of Chinese Medicine, 2013.

[17] Yu NN, Chen ZL, Chen B, Liu PD, Guo Y. Elucidation of moving cupping method based on heaven-human-earth theory. Shanghai Zhenjiu Zazhi, 2015, 34(3): 260-264.

[18] Tian CQ. Cupping therapy. Shanghai Zhongyiyao Zazhi,1956, 2(5): 21-23.

[19] Chinese Pharmacopoeia Commission. Chinese Pharmacopoeia (Part One). Beijing: Chemical Industry Press, 2005: 134.

[20] He SQ. Experience of Zhu Liang-chun in usingBai Jie Zi(Semen Sinapis Albae). Zhongguo Zhongyiyao Xinxi Zazhi,2001, 8(2): 74-75.

[21] Li XL, Zhang YQ, Huang TH. Study on anti-inflammatory and analgesic effects of extract ofBrassica alba. Xiandai Zhongyao Yanjiu Yu Shijian, 2007, 21(6): 28-30.

[22] Zhou SQ. Experience of using tuina media. Hangzhou:Proceedings of the Fourth National Tuina Symposium,1995: 92-93.

[23] Lü XM. The fourth lesson: auxiliary elements for tuina therapy. Zhongguo Xiangcun Yiyao, 2015, 22(19): 40-41.

[24] Li HY, Yang WZ, Mi HT, Sun HL, Zhao YY. Effect of different penetration enhancers on the permeation of salicylic acid. Hebei Daxue Xuebao (Ziran Kexue Ban),2007, 27(3): 279-282.