Kai Zhang,Xin Wu

1Department of Acupuncture and Moxibustion,Tianjin Public Security Hospital,Tianjin,China.2Tianjin Nankai District Chinese Medicine Hospital,Tianjin,China.

Background

Cervical disease is a common clinical disease.Symptoms are the pain in the head,neck,shoulder,upper limb,interscapular region,and chest,high blood pressure,excessive sweating,and irritability,resulting in clinical complications affecting upper and/or lower limb functional activity[1-2].Presently,the treatment of cervical diseases is mainly based on oral muscle relaxants,nonsteroidalanti-inflammatory drugs,and Chinese medicine for activating blood circulation and relieving pain.Non-drug therapy based on traditional Chinese medicine(TCM),including acupuncture,cupping,and massage,is prevalent in clinical practice and widely used due to its direct effect on the affected part.

Cervical spondylosis falls in the category of Bizheng in TCM.According to the records ofSuWen·BiLun(B.C.220~211,Han Dynasty of China),Bizheng is caused by the combination of wind,cold,and dampness.Ge Hong of the Jin Dynasty of China recorded“chiropractic manipulation”in the bookZhouHouBeiJiFang(B.C.341,Jin Dynasty of China)as a treatment for Bizheng.Lingshu·Zhoubi(B.C.475~221,Han Dynasty)believes that treatment with acupuncture for this disease should be continued,even when the pain has been relieved,to avoid relapses.Zhao Xuemin of the Qing Dynasty,in the bookBencaogangmu(A.D.1578,Ming Dynasty of China)described the application of cupping therapy for Bizheng.In recent years,studies have found that the use of a three-step therapy (including balance needle,electroacupuncture,and puncture cupping)for cervical spondylosis,both nerve root and vertebral artery types,and other cervical diseases has an effective clinical rate of more than 80%,and the effect of acupuncture plus cupping therapy is significant[3-14].Sun Wuquanet al.found that the clinical efficacy and improvement of symptoms in patients who underwent spine fine-tuning manipulation for cervical spondylosis were better than that in the traction control group[16].

In this review,we propose a new approach in cervical diseases regarding the co-treatment for the neck,chest,and waist,which not only improves clinical efficiency but also achieves better long-term efficacy (decrease recurrence rate).This paper expounds the scientific nature of “co-treatment of neck,chest,and waist”from the perspective of TCM theory and modern medical research and summarizes the methods of non-drug therapy under the guidance of this theory.

From the basic theory of Chinese medicine,“the neck,chest,and waistare treated together”

From the perspective of syndrome differentiation and treatment,the feasibility of“neck,chest and waist co-treatment"

The concept of“cervical diseases”is most relevant to that of“Bizheng”in TCM.The pathogenesis of the disease is trauma,chronic strain,emotional internal injuries,feeling of wind,cold,dampness,and other factors,which can cause meridian block.From the perspective of syndrome differentiation,cervical diseases are divided into different syndrome types [17]. According to syndrome differentiation and treatment,as well as the use of herb or acupuncture points,cervical,thoracic,and lumbar spondyloses belong to the category of “Bizheng”.The focus of TCM treatment lies in the essence of its syndrome,not on the “disease”.On the basis of symptom differentiation,according to the lesion on different parts,it is supplemented by corresponding herb or acupuncture points.This also reflects the concept of treating different diseases that use the same method[18].For example,in the classic prescription ofTCM,Duhuo Jisheng Decoction is a famous prescription for the therapy of spinal joint disease.It is used to treat Bizheng,the deficiency of liver and kidney as well as deficiency of Qi and blood due to its beneficial effects on removing wind and dampness,activating meridians to stop pain,replenishing liver and kidney,as well as regulating Qi and blood[19].Clinically,cervical spondylosis,thoracic spondylosis,lumbar vertebrae disease,chronic arthritis,rheumatoid arthritis, and sciatica belong to the abovementioned syndromes,which embody the idea of treating different diseases with the same therapy in TCM.It can be seen that TCM understands the disease from the perspective of holistic concepts as well as syndrome differentiation and treatment,providing a basis for the concept of“chest,neck,and waist co-treatment.”

From the perspective of “prevention of disease”,the advanced nature of “neck, chest, and waist co-treatment”

TCM has obvious advantages in the prevention of disease,and the connotation of treatment is preventing the occurrence,progress and relapse ofdisease [20].Therefore,from the perspective of“prevention of disease,”the method of “co-treatment of the neck,chest,and waist”can prevent the development and progression of thoracic and lumbar diseases,and the advantage of TCM treatment is better reflected.Early prevention is the early intervention in a population with the spine of sub-healthy to slow the progression of the spinal disease.In treating cervical lesions,attention is paid to early intervention in the thoracolumbar spine to prevent the progressofthe disease.During the treatmentof thoracolumbar disease,the cervical vertebra can also be treated at the same time.This treatment method is based on preventing the progression of diseases and aggravation of the existing condition and also reflects the guidance of TCM diagnostic methods.In cervical lesions,not only can the positive pressure points be found in the neck,but also the thoracic and lumbar vertebrae should be palpated,often in the spine.Positive pressure points such as tender areas,nodules,and cords are always found on the spine midline and both sides of the spinous process.Therefore,attention should be paid to the palpation of the entire spine.According to the Wuzang theory in Chinese medicine that includes liver,heart,spleen,lung and kidney,the dysfunction of liver,spleen,and kidney are the basis for the development of cervical diseases,because they are considered as being responsible for the function of the tendon,muscle and bone respectively.Moreover,the deficiency of kidneys often causes bone weakness.The corresponding back shu points are located in the thoracic vertebrae and lumbar spinous processes[3].Through acupuncture and massage,the treatment method is applied to the back shu points.It is fundamentally regulating cervical lesions from the perspective of conditioning the organs,making them resistant to disease[20-21].

Seeing the rationality of“co-treatment of the neck,chest,and waist”from the Du Meridian

Adjusting the Du meridian plays an important role in the treatment of spinal diseases.The Du meridian is the sea of the Yang meridian and whole-body meridians[3].Regarding the circulation of the Du meridian,in theNeiJing(B.C.220~211,Han Dynasty)andNanJing(B.C.475~221,Zhanguo Dynasty),the terms such as“cross spine”and “assist in spine”are mentioned on many occasions,and it is concluded that the relationship between the Du meridian and spine is the closest.The Du meridian is closely connected to the twelve meridians,especially overlapping with thefoot-taiyangmeridian of the foot and interacting with the meridians to run through Qi and blood of whole body,exerting the governor’s role[3].Therefore,the Du meridian is closely related to visceral Qi and blood function[3].The study found that,in pathological condition,the propagation of sensation along channels is prone to occurred.Ma Chaoet al.studied the conduction of the longissimus dorsi muscle located in the dorsal bladder meridian of rats and found that myoelectric activity and propegated sensation along channels were closely related,and the direction of myoelectric transmission is similar to that of the bladder distribution[22].TheTuotianzhuangis the essence of the internal work(exercise to benefit the internal organs)of the South ShaolinYijinjing(A.D.1624,Ming Dynasty).Dou Sidonget al.also found that theTuotianzhuanginspired the infrared radiation trajectory of Du meridian on the back,making it more continuous and regular.Then the temperature of the area where Dazhui point located,Du meridian distributed and neck is increased,which play a role in the treatment of cervical spondylosis[23].It has proved again that the treatment of the Du meridian and bladder meridian has the potentials to be used in the therapy of the cervical.Therefore,from the aspects of the function of Du meridian,the relationships of Du meridian with the twelve meridians and the relationships of Du meridian and Zangfu,Qi and blood,spinal disease should be adjusted from the perspective of the Du meridian.

From theperspective of western medicine,the scientificity of“co-treatment of the neck,chest,and waist”

The static balance of the spine

The internal balance system(called static balance)which contains vertebral bodies and intervertebraldiscs aswell as the dynamic system which was regulated by muscle and ligament maintain the spinal stabilization[24].The spine is the mainstay of the human body.The spine has four physiological curvatures,like a flexible curved bar.A change in the cervical curvature will also change the lumbar curvature.The theory of spinal dynamic balance reveals that the lateral curvature of the cervical vertebra can also cause the kompensatorisch reverse curvature of the thoracic vertebra and lumbar vertebra,to maintain mechanicalbalance.Among these,the relationship between the neck and waist curvatures is the closest,which is a constant adaptation in functional activities during human evolution[25].The change in cervical physiology curvature is an important structural basis of the cervical lesions.The physiological morphology of the cervical spine and lumbar vertebrae resembles a bow,and its function is interrelated with the principle of bow action principle[25].Whether the function of the spine is strong is directly related to the normal structure of its physiological curvature or not.The ability of the“spinal arch”to store and release energy,that is,the structure of the spinal curvature,determines the incidence of spinal disease.This suggests that lumbar disease and cervical disease are mutually causative pathogenesis.Clinical studies have also found that the curvatures of the cervical and lumbar vertebrae are linearly correlated.Moreover,the lumbar curvature is straightened,and through the effect of thoracic curvature seesaw magnifies effector,causes the cervical curvature passively straightened.Therefore,from the system of spine static balance,it showed the importance of co-treatment on the neck,chest,and waist.

The spine is the backbone of life,like the steel bar,carrying the gravity of the human body,moreover,the muscles,ligaments,and blood vessels stabilize the spine,like the concrete,together building the bridge of life[26-27].The spine is not only the central axis and pillar but also the chain and hub of various movements of the human body.It is not only a kind of static stability to maintain the normal operation of various life activities of the human body but also a dynamic balance to participate in the majority of human movement[28].The morbidity of the cervical and lumbar vertebrae is the dislocation of the spine intervertebral joints and the substance in the intervertebral disc exceeds the original limit,and then compression the blood vessels or nerves cause different degrees of pain,numbness,dizziness,and other symptoms[29-30].It is fundamentally related to breaking the biomechanical structure and losing the original stability of the spine.

The ligament of the neck is interconnected to the supraspinous and thoracolumbar ligament.The superficial muscles of the back include the trapezius,latissimus dorsi,scapular levator muscle,and rhomboid muscle[25].The trapezius muscle is the key muscle group in the treatment of cervical spondylosis.It has a triangular shape on one side,and the two sides make up a rhombus.It extends from the outer occipital protuberance of the neck to T12,as shown in Figure 1A.The yellow shaded part represents the right side of the trapezius.It can be seen by running through the trapezius that the neck and shoulder muscles are closely related,and found the anatomical basis of co-treatment of the neck,chest,and waist[30].Similarly,the latissimus dorsi is located on the underpart of back,waist,and chest sidewalls.It is starting from the sixth thoracic vertebrae and covering all spinous processes and posterior part of the crista iliaca.The trend was showed thatthe thoracic and lumbarmusclesare closely connected(Figure 1B).The semi-spine muscles of the inner layer are also almost parallel to the spine,its located on the deep side of the trapezius muscle and shallow side of the suboccipital muscle group.The semi-spine muscles startfrom the C4-C6 zygopophysisand C7-T10 transverse process,stop at between the upper and lower occipital lines and C2-T4 spinous processes.The yellow shaded parts in Figures 1C and D are the right side of semispinalis capitis and semispinalis thoracic,respectively.In addition,the starting point of splenius capitis was located in the C7 and T1-T4 crest which under the ligamentum nuchae.The musculi splenius cervicis originate from the T3-T6 spinous processes,ending in node which located in C1-C3 processus transversus,and itparticipate in the linkage and movement of the cervical and thoracic vertebrae.The erector spinae of the deep muscle group is the longest muscle behind the spine.It starts from the back of the sacrum,spinous processes of lumbar spine,back of the iliac crest,and thoracolumbar fascia.It consists of three parts:the lateral side is the iliocostalis muscle,ending at the costal angle;the middle is the longest muscle,ending in the transverse process and its adjacent ribs;the inner side is the spine muscle,ending in the spinous process[30].The yellow shaded parts in Figures 1E,F,and G are the right thoracic spine muscle,longest chest muscle,and lumbosacral rib muscle,respectively.The simultaneous contraction of both sides of the erector spinae allows the spine to extend backward,which is an important structure in maintaining the upright posture of the human body[30].Therefore,from the perspective of the spine muscle trend,the co-treatments of the neck,chest,and waist are more scientific.lumbosacral rib muscle

Figure 1 The related muscles of the neck,chest,and waist

Epidemiological evidence

In recentliterature,Jacobs showed thatcervical spondylosis was associated with a higher incidence of lumbar disc abnormalities[31].Wei Chundeet al.studied the relationship between cervical and lumbar curvatures in cervical spondylosis and found that patients with cervicalspondylosisalso had differentdegreesof reduction(98.63%)in the lumbar curvature,suggesting that the change in lumbar curvature is the important etiology of the cervical curvature change and cervical spondylosis[32].Wei Yizonget al.studied the effect of lumbar curvature on cervical curvature and explored the etiology and pathology of cervical spondylosis and cervical and lumbar syndrome in spine anatomy and physiology and exercise mechanics[33].A total of 27 healthy adolescent men and women were selected to stand and sit for one hour,respectively.Standard lateral radiographs of the lumbar and cervical vertebrae were obtained,and the arcuate area of the neck,lumbar curvature station,and the front and back X-ray films were measured by the mathematical geometry arch area calculation method.The results showed that,after one hour of sitting,in the radiograph of the cervical and lumbar spine,the area of the lumbar arch was reduced by 53.14%compared with that in the standing position,and the area of the cervical arch was also reduced by 48.33%;the difference was significant(P<0.05).It is concluded that the change in lumbar curvature affects the cervical curvature,and the pathological changes are related to sedentary lifestyle.Lumbar curvature change is an important cause of pathological change in cervical spondylosis and cervical and lumbar syndrome.Sun Yongzhanget al.observed cervical and thoracic X-ray measurements of 448 cases and found that there is more than 5°of thoracic vertebrae scoliosis in 87%cervical spondylosis due to the abnormal cervical curvature.After the thoracic vertebra rotates to the behind position of the hinge of cervical and thoracic joints,the cervical spine rotates in the opposite direction,indicating that thoracic scoliosis is an important cause of secondary cervical instability[34].This reason is closely related to work at desk and single upper limb movement and may also have a certain relationship with habitual side sleeping.Chest and back injuries are one of the worthy reasons of attention in cervical spondylosis.

Biochemical evidence

The pathological changes in cervical,thoracic,and lumbar lesions are all caused by chemical substances and biologically active medium produced by prominent nucleus pulposus,including matrix metalloproteinase-3,tumor necrosis factor-α, interleukin 1β, vascular endothelialgrowth factor,etal,which motivate autoimmune and inflammatory reactions and then result in pain on the nerve roots.The expression imbalance of the two enzyme,matrix metalloproteinase-3 and tissue inhibitor of metalloproteinase-1,cause the decomposition ofelastic fibersofthe flavum and lead to the intervertebraldisc in differentdegreesofbulging,protrusion,and prolapse[35-36].Tumor necrosis factor alpha and interleukin 1β are important inflammatory mediators during the degeneration of the intervertebral disc,both ofthem can affectthemetabolism of intervertebral disc matrix,thereby make the imbalance in the intervertebral disc,increased accumulation of related metabolitesand capillary permeability,and further development of the inflammatory response[37-38].Vascular endothelial growth factor and angiotensin II are involved in osteogenesis and osteolysis,which affect the body’s estrogen levels and the stability of the cervical and lumbar spine[39-40].The vascular endothelial growth factor and angiotensin II provided a biochemical basis for the theory of“co-treatment of neck,chest,and waist”.

Non-drug therapy under theguidance of the theory of“co-treatment of the neck,chest,and waist”

External treatment in TCM under the guidance of“co-treatment of the neck,chest,and waist”

Massage In TCM non-drug therapy,massage has an independent treatment system for spinal diseases,the treatment methods were the comprehensive application of push,take,press,rub,pull,shake,knead and carry,merely different in the combination and weight of the techniques[41-46].Tendon and boneco-treatment,local plus distal acupoint treatment are performed to achieve the effects of dredging meridians,removing blood stasis,co-treatment of liver,spleen and kidney,preventing disease,and emphasizing the palpation of the spine in TCM.In the spinal three-finger palpation,the middle finger is placed in the midline of the spinous process,and the index and ring fingers are placed on both sides of the spinous process,from the top to the bottom,from the cervical to lumbar vertebrae[44].Palpation is looking for positive pressure points such as pressing pain,nodules,and streaks.Under the guidance of the theory of“co-treatment of the neck,chest,and waist,”patients with cervicalspondylosis should pay attention to the adjustment of the mechanical balance of the thoracolumbar spine and lumbar vertebra. The combination of techniques is flexible,and the two single techniques can be combined into one composite technique. Several composite techniques can be combined into a set of manual treatments for a certain patient.Manipulative treatmenthas the following advantages:1.Comprehensively relieves muscle spasm of the neck and shoulders of the patient and improves blood circulation.2.Increases the pressure on the outside of vertebral disc,improves the position of the prominent nucleus pulposus,and reduces the compression of the nerve root.3.Reduces the pressure on the intervertebral disc and reduces the oppress of protrusion on nerve root.4.Effectively releases the adhesion.

AcupunctureAcupuncture refers to the use of needles or non-needle tools to stimulate special parts of the human body(acupoints)and methods such as lifting and twisting to prevent or treat diseases.There are many clinical reports on acupuncture in the treatment of spinal diseases.Many meta-analyses have shown that acupuncture is safe and effective in the treatment of cervical spondylosis and cervical,thoracic,and lumbar diseases[47-53].The downside is that higher-quality clinical research evidence is needed.In addition to the separate application of acupuncture,there are also some studies on the use of acupuncture combined with cupping and massage techniques,which achieved better results.Yang Minet al.used mesh meta-analysis to evaluate the clinical efficacy of acupuncture alone or in combination with cupping and massage on lumbar disc herniation,and a total of 30 studies(2589 patients)were included[54].The mesh meta-analysis showed that combination therapy was superior to acupuncture alone in improving pain and curative effect,and the recurrence rate was lower than that of acupuncture alone(P<0.05).However,the ranking results showed that different interventions for various indications have different effects.Consistent with the meta-analysis results of Chen Xinyonget al.,there may be a superposition effect of TCM combination therapy[55].Moreover,Wu Xi reported the effects of three treatment programs (electroacupuncture,electroacupuncture + traction,electroacupuncture +traction+Western medicine)on sciatica caused by lumbar disc herniation and found that the effects of the three programs are equivalent and electroacupuncture may be a more cost-effective therapy compared to combination therapy[56].Studies by Kimet al.have confirmed that acupuncture is a cost-effective treatment[57].The systematic review by Ambrosio also shows that acupuncture has the advantages of low cost and good effect in treating chronic pain[58].

Modern medical treatment under the guidance of“co-treatment of the neck,chest,and waist”

Autonomic therapyDuring work,the head and neck position is changed regularly,and the heightor inclination of the table is adjusted.The physiological curve of the head and neck is maintained during sleep.Sufficient sleep can alleviate the pain caused by cervical muscle spasm;reduce the stimulation of the herniated disc to the spinal cord,nerve roots,and blood vessels,and delay degeneration[59].The exercise of neck,shoulder,and back muscles could increase the stability of the biomechanical structure of the spine,promotes blood circulation,and benefits the health of the spine.

Traction and brakingRadiography showed that the patient’s intervertebral space or the longitudinal diameter of the intervertebral foramen was turned narrow,so traction therapy should be applied.Usually,it is pulled by the occipital band,and the effective physiological braking position of the head and neck is taken.It is suitable for long-term traction of 2 to 3 weeks(1.5 to 2 kg).It should not be overloaded and in the short term to prevent excessive traction.Cervical traction can improve the narrow of the vertebral space or longitudinal diameter of the intervertebral foramen,the good rate is 93.55%,and the effective rate is 96.77%[60].Some studies have suggested that cervical vertebral fixed-point traction is superior to cervical traction in the treatment of cervical spondylosis,mainly to relieve pain and reduce nerve root compression [61].At the same time of treatment,attention should be paid to the change of the lumbar intervertebral space,and proceed traction.

Shockwave treatmentIn the treatment of cervical spondylosis,emphasis strike on the neck muscle group should focus on the strike on the thoracolumbar muscles at the same time[62].As a strong stimulus,shock wave can be provided not only according to the principle of soft tissue balance but also under the guidance of TCM meridians,thereby achieving the purpose of adjusting the balance of the whole body.When the shock wave acts on the diseased tissue, it can improve the local microcirculation and accelerate the absorption of metabolites and pain-causing substances.The strong stimulation caused by the shock wave can obviously inhibit the spinal nerve cells,thereby blocking the upward conduction of pain,increase the pain threshold,and increase the threshold of the nerve receptor for injective stimulation,moreover,shock waves can cause damage and closure of the neurosensory receptors[63].

Conclusion

Thoracic and lumbar spine lesions cause spinal instability,and the physiological function of the cervical spine is also affected by it.The neck and thoracic and lumbar spine have their own dynamic and static balance.Therefore,we believe that the study on cervical lesions should not be limited to the local part of the cervical spine but should extend to the restoration of stability of the spine,to achieve the co-treatment in the neck,chest,and waist.However,in the clinical research of TCM,the methods,stimuli,and treatment courses of the acupoints used in the research are not the same,and there are differences with respect to the intervention period,measurement index,and interval time of each study.There is also a distinction between syndrome differentiation and addition or subtraction in one study.Moreover,the quality of the research is generally not high,most of which do not describe the random method in detail,without blind method and allocation concealment,and there is the possibility of bias in many stages of the experiment.Future clinical trials in TCM should be designed as multicenter and with large-scale samples and implemented and described in strict accordance with the methods of randomized controlled research.Furthermore,a new concept should be put forward to provide a reference for further studies and clinical research.

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