Clinical study of Tuina combined with functional training to improve the clinical symptoms and balance function in patients with meniscus injury

SU Xiaojie (苏小杰), XING Hua (邢华), ZHU Xiaojun (竺潇骏), WANG Siyu (汪思宇), ZHANG Guangyuan (张广渊),LI Jianhua (李建华), GONG Li (龚利)

1 Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine,Shanghai 200437, China

2 Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China

Abstract

Keywords: Tuina; Massage; Exercise Therapy; Meniscus Injuries; Balance Function

The meniscus is an important structure of the knee joint, acting to stabilize the joint, bear pressure, and nourish articular cartilage[1].At the same time, the meniscus is also one of the most common injury sites in knee joint injuries, accounting for about 12%-14% of the total knee joint injury[2].Meniscus injury is mostly caused by strong straightening of the knee joint during flexion and rotation, and the meniscus is impacted and squeezed by a mechanical force[3], mostly manifested as joint pain, swelling, joint interlocking, and activity limitation.It will affect joint stability, cause lower limb line of force deviation, accelerate joint degeneration,and increase the risk of osteoarthritis, greatly affecting joint function and the quality of life of patients[4-5].

Current studies have shown that meniscus injury can cause proprioception impairment of the knee joint,resulting in decreased joint stability and affecting motor function[6-8].Functional training has a good effect on improving the lower limb muscle strength, balance function, and motor function area of patients with meniscus injury[9].However, clinical practice has found that patients do not have a high degree of cooperation with functional training, and they have a certain fear of pain and discomfort during exercise[10].

As a traditional non-drug therapy, Tuina (Chinese therapeutic massage) has a good analgesic effect and can alleviate joint pain and movement limitation[11],effectively improving the balance function and proprioception of the knee joint[12].It also has obvious advantages in the treatment of knee joint diseases.In recent years, our team has carried out a clinical study on Tuina combined with functional training in the treatment of meniscus injury, and the results are reported as follows.

1 Clinical Materials

1.1 Sample size calculation

The sample size was estimated according to the sample size calculation formula for comparison of means of multiple samples in Medical Statistics(Figure 1)[13].

In the formula, n represents the required sample content of each group, g is the number of groups, Siis the standard deviation of each group,¯Xiis the mean of each group, and¯X is the overall mean.According to our group’s previous research results, the pain and symptom subscale scores of the knee injury and osteoarthritis outcome score (KOOS) were used as indicators.As estimated by the previous research results of our study, the standard deviation of the combination (Tuina combined with functional training)group was 5.22, the standard deviation of the Tuina group was 9.85, and the standard deviation of the functional training group was 9.55.The average value of the combination group was 87.88, the average value of the Tuina group was 78.29, and the average value of the functional training group was 85.15.By applying the numerical value to the above formula, it was calculated that 26 cases were needed in each group.Considering the sample dropout rate as 15% and the ratio of three groups was 1:1:1, the sample content of each group was calculated to be 31 cases, and the total sample content was 93 cases.

1.2 Trial design and randomization

This research adopted the randomized controlled method.The subjects were divided into a Tuina group, a functional training group, and a combination group.

The randomization method used was the random number method, in which random numbers were generated by SPSS 26.0 random number generator, and subjects were allocated to the Tuina group, the functional training group, or the combination group at a ratio of 1:1:1, with 31 cases in each group.Patients who met the criteria were given a random number in the order of consultation and allocated to the group to which the random number belonged.

This study passed the ethical review of Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine (Approval No.2020105).

1.3 Source of cases

In this study, 93 patients with meniscus injury who met the inclusion criteria were selected from the Outpatient Department of Tuina in Yueyang Hospital of Integrated Traditional Chinese and Western Medicine,Shanghai University of Traditional Chinese Medicine between January 2021 and December 2021.

1.4 Diagnostic criteria

According to the Knee Pain and Mobility: Meniscal and Articular Cartilage Lesions Revision 2018: Using the Evidence to Guide Physical Therapist Practice[14]to establish the diagnostic criteria for meniscus injury.1)history of knee sprain; 2) joint interlocking, “locking”; 3)joint swelling; 4) pathological score of the meniscus:joint locking, pain in hyperextension, pain in passive knee flexion, and positive Macgregor’s sign.Meniscus injury could be diagnosed if clinically meeting 1) + 2) +3)and meeting 3 or more symptoms in 4).

1.5 Classification of meniscus injury

With reference to Campbell's Operative Orthopaedics[15]for knee in MRI description of meniscus injury grading, the grading criteria are as follows.GradeⅠ: focal punctate or round high signal in the meniscus;grade Ⅱ: horizontal linear, oblique strip of high signal but not reaching the meniscus joint surface; grade Ⅲ:linear or irregular high signal in the meniscus extending to the articular surface of the meniscus, which may be accompanied by changes in meniscus morphology.

1.6 Inclusion criteria

Those who met the clinical diagnostic criteria for meniscus injury; grade Ⅱ or below meniscus injury according to MRI examination; aged 20 to 40 years; had not received drug therapy or physical therapy such as acupuncture and massage in the latest one month;volunteered to participate in the trial and provided written informed consent.

1.7 Exclusion criteria

Those with tissue tears and/or ruptures of the anterior cruciate ligament, lateral collateral ligaments,etc.; with acute injuries, redness, and swelling of the joints that are not suitable for exercise therapy; with skin damage of the knee, tumors, tuberculosis,osteomyelitis, severe cardiovascular diseases or mental illnesses.

1.8 Criteria for elimination and dropout

Those who withdrew during the course of the study;had poor compliance during the course of the study and did not adhere to the study protocol; needed to interrupt treatment due to uncontrollable factors such as trauma or pregnancy.

1.9 Statistical analysis

Data were processed using SPSS version 26.0 statistical software.Measurement data that met normal distribution were described as mean ± standard deviation (, and measurement data that did not meet normal distribution were described as median(interquartile range) [M (IQR)]; count data were expressed as frequency, rate, or constitutive ratio; and rank data were expressed as rank order.One-way analysis of variance was used for between-group comparisons of measurement data at baseline; Chisquare test was used for between-group comparisons of count data; and rank-sum test was used for betweengroup comparisons of rank data.Repeated measurement parameters with normality and homogeneity of variance were analyzed by repeated measures analysis of variance.Non-conforming repeated measurement parameters were analyzed using generalized estimating equations.The test criterion was α=0.05.P＜0.05 was considered statistically significant.

Missing data generated by dropout cases were processed as follows: when the cause of dropout was not related to the study, the direct exclusion method was used, i.e., missing data were directly deleted; when the cause of dropout was related to the study, the data were processed using the last observation carried forward method.

2 Treatment Methods

2.1 Tuina group

The Tuina manipulation was formulated according to the Tuina treatment of meniscus injury in Science of Tuina[16]and the common clinical manipulations.

Yi Zhi Chan pushing and rolling manipulations were applied around the knee joint for about 3 min; pointpressing manipulation, pressing-kneading manipulation,and Yi Zhi Chan pushing were applied to Neixiyan(EX-LE4), Dubi (ST35), Xuehai (SP10), Liangqiu (ST34),Yanglingquan (GB34), Yinlingquan (SP9), Zusanli (ST36),Futu (ST32), Fengshi (GB31), Weizhong (BL40), and Chengshan (BL57), 10-30 s for each point; rolling,grasping, and pressing-kneading manipulations were applied to the quadriceps muscle for about 3 min;kneaded patella for 1 min; rolling manipulation was applied to the biceps femoris, semitendinosus, and semimembranosus muscles for 3-5 min, with flexion and extension of the knee joint; elbow point-pressing manipulation was applied to Juliao (GB29), Huantiao(GB30), and Biguan (ST31) for 30 s each; rolling manipulation was applied to the iliotibial fascia for 1 min; and linear rubbing manipulation was applied to the knee joint for 1 min, in order to penetrate heat.Tuina therapy was carried out twice a week for 8 weeks.

2.2 Functional training group

Referred to the content of the exercise therapy in Sports Injury Rehabilitation Therapy[1]to make the training plan.

Phase 1 (Figure 2): Straight leg raising training, hip adduction and abduction training, and ankle dorsiflexion training.Each set of 8 repetitions, 3-5 sets each time, for a total of 4 weeks.

Phase 2 (Figure 3): Elastic-band-resistance straight leg raising training; elastic-band-resistance hip adduction and abduction training; elastic-band-resistance static squatting against the wall; tandem walking; one leg standing.Each set of 8 repetitions, 3 to 5 sets each time,for a total of 4 weeks.

Figure 3 Phase 2 functional training

2.3 Combination group

Functional training was carried out concurrently during Tuina therapy, with the same Tuina technique as in the Tuina group and the same functional training method as in the functional training group, for a total of 8 weeks.

3 Outcome Observation

3.1 Observation items and methods

3.1.1 KOOS

The KOOS was evaluated before intervention and after 4 weeks, and 8 weeks of interventions.The KOOS consists of 5 subscales: pain, symptoms, ability to perform activities of daily living, sports and recreation,and quality of life.Higher scores indicate less severe symptoms and better functioning of the joints.

3.1.2 Y-balance test (YBT)

The functional movement test YBT apparatus produced by FMS Corporation of the United States was used for testing.The length of the lower limb (the distance from the anterior superior iliac spine to the midpoint of the medial ankle of the ipsilateral crus) and the maximum distance to push the test plate anteriorly,posteromedially, and posterolaterally were recorded.The tests were repeated twice, and the average value was taken.

Calculation method: The distance of the moving foot(test side) to push the slider anteriorly, posteromedially,and posterolaterally was recorded as a, b, and c,respectively.

YBT balance coefficient = (a + b + c) ÷ (Length of leg ×3) × 100%.

3.2 Efficacy assessment

The efficacy was evaluated according to the Criteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[17], and the pain and symptom subscale scores of the KOOS were used as the assessment criteria.

Cured: Pain and other symptoms disappeared, joint motion was normal, and the KOOS reduced by ≥95%.

Markedly effective: Pain and other symptoms disappeared, joint motion was not limited, and the KOOS reduced by ≥70% but ＜95%.

Effective: Pain and other symptoms basically disappeared, joint motion was mildly limited, and the KOOS reduced by ≥30% but ＜70%.

Invalid: No significant improvement in pain and other symptoms and joint motion, and the reduction of the KOOS was less than 30%.

3.3 Comparisons of results

3.3.1 Trial completion and baseline comparisons

During the trial period, 4 cases dropped out from the Tuina group, all of whom lost their visits.In the functional training group, 5 people dropped out, of whom 3 did not complete the functional training on time in violation of the trial protocol, 1 was unable to cooperate due to trauma, and 1 was lost to visit.In the combination group, 1 dropped out due to recurrent illness.The final completion of the trial was 27 cases in the Tuina group, 26 cases in the functional training group, and 30 cases in the combination group.The flow of the trial is shown in Figure 4.

The general information of the three groups was statistically processed, and the differences were not statistically significant, indicating that the three groups were comparable (P＞0.05).See Table 1.

3.3.2 Comparison of the clinical efficacy

The total response rates of the Tuina group,functional training group, and combination group were 85.2%, 84.6%, and 90.0%, respectively, and there was no significant difference in the total response rate among the three groups (P＞0.05).See Table 2.

3.3.3 Comparison of the KOOS

After 4 weeks and 8 weeks of interventions, the total score and each subscale score of KOOS in the three groups were significantly increased compared with those before intervention (P＜0.05).The comparison between two groups showed that after 4 weeks and 8 weeks of interventions, there was a statistically significant difference in the score of sports and recreation function between the Tuina group and the combination group (P＜0.05).After 4 weeks of interventions, there was a statistically significant difference in the total score of KOOS between the functional training group and the combination group(P＜0.05).After 8 weeks of interventions, there were statistically significant differences in the score of daily living ability and sports and recreation function between the functional training group and the combination group (P＜0.05).However, there was no significant difference in the quality of life score between the two groups (P＞0.05).See Table 3 and Table 4.

3.3.4 Changes in balance function

The YBT balance coefficients of the affected and non-affected lower limbs of the patients in all three groups after 4 and 8 weeks of interventions were significantly higher than those before intervention(P＜0.05), but the differences among the three groups were not statistically significant (P＞0.05).See Table 5.

Group n Age/year(Degree of meniscus injury/case x ±s)Gender/case BMI/(kg·m-2)(x ±s)Course/month[M (IQR)]Male Female Grade I Grade II Tuina 31 28.5±4.2 12 19 21.8±2.3 12 (20) 19 12 Functional training 31 27.5±4.1 12 19 22.3±3.1 12 (26) 23 8 Combination 31 30.3±4.9 11 20 22.8±2.8 18 (24) 18 13 Statistical value 2.5871) 0.0882) 1.4531) 0.2321) 1.9523)P-value 0.081 0.957 0.239 0.793 0.377

4 Discussion

Meniscus injury belongs to the category of “tendon dislocation” in Chinese medicine, mostly caused by indirect violence or chronic strain injury resulting in abnormal tendon position or tendon fracture injury.Its pathogenesis lies in the imbalance of tendons and bones.The joints are surrounded by poor Qi and blood circulation, the tendons are not moistened, and the blood stasis blocks, which affects the function of the tendons in restraining the bones and gliding the joints,resulting in joint pain, stiffness, and impaired movements[18].“The bone is regular, and the tendon is soft”, which is the key to the normal function of the knee joint[19], from which the theory of “tendon and bone imbalance” has been gradually developed in recent times, referring to the imbalance between joint dynamics and statics as tendon and bone dislocation.It is believed that the imbalance of tendon and bone will affect the muscle recruitment pattern and cause abnormal function of the meridians and tendons around the knee, thus causing a series of symptoms[19-20].Accordingly, Professor FANG Min’s team put forward the concept that “tendon is the first to be affected in tendon and bone imbalance”, which suggests that malfunction of the tendons is the first and foremost factor in knee joint diseases[21].This concept emphasizes that tendon disease is the first and bone disease is the second, i.e.in the order of onset, the tendon is the first to suffer from the pathogen on behalf of the knee, and then the bone is injured; secondly, the role of the tendon should be emphasized in the treatment, and the spasm of the local tendon should be released through tendon manipulations, and then the bone dislocation should be adjusted, so that the balance of the tendon and bone can be restored more effectively to alleviate pain and dysfunction of the joints[21-22].

Modern research has found that Tuina combined with functional training can effectively inhibit the secretion of inflammatory factors such as interleukin-1β and tumor necrosis factor-α[23], and has good efficacy for pain and functional activity limitation[24-25].Tuina manipulation can effectively reduce joint cavity effusion and inhibit the production of inflammatory mediators[11]; it can reduce the spasm and adhesion of periarticular muscles, exert analgesic and antispasmodic effects, and promote the restoration of knee joint motor function[26-28].Therefore, this study took tendons as the focus of treatment and adopted Tuina therapy based on tendon regulation manipulation to dredge the meridians, dispel stasis, and benefit joints.In functional training, the training of muscle strength was the main focus, considering that the guidelines clearly stated that muscle strength training and neuromuscular control training around the hip and knee should be provided in a timely manner after meniscus injury[14]; therefore, targeted functional training was used to enhance the muscle strength around the hip and knee to help improve motor function[29].

This study found that the three intervention methods of Tuina, functional training, and Tuina combined with functional training can improve the clinical symptoms and joint function of patients.According to the change in KOOS, the treatment effect of the combination group was better than that of the functional training group(P＜0.05), but there was no significant difference between the combination group and the Tuina group(P＞0.05).In the improvement of activities of daily living and sports and recreation function, the treatment effect of the combination group was better than that of the functional training group (P＜0.05).It shows that compared with functional training alone, Tuina combined with functional exercise has a better improvement effect on joint pain and dysfunction caused by knee meniscus injury.

In the evaluation of clinical efficacy, the total effective rate of the combination group was 90.0%, which was higher than 85.2% of the Tuina group and 84.6% of the functional training group, but there was no statistically significant difference among the three groups (P＞0.05).

Compared with the results of previous studies, the efficacy of Tuina combined with functional training in this study did not show significant advantages, which may be related to the following reasons.First, this study used the KOOS pain and symptom subscale scores as the basis for efficacy evaluation and ignored the influence of daily life function and life recreation ability on efficacy.Thus, the three intervention methods had significant effects, but there was no statistically significant difference in the efficacy among the groups.Second, this study did not limit the course of disease of patients.Although the baseline was unified and the disease of the participating population was limited to grade Ⅰ-Ⅱ, the symptoms of patients with a long disease course and patients with a new disease are often different, and the same treatment method may affect the results of efficacy evaluation.

The YBT of lower limbs is an effective method to measure the postural control ability and dynamic balance ability of lower limbs.It can be used to evaluate the risk level of sports injury, evaluate the degree of recovery, and predict the safe return to sports[30].Meniscus injury can cause changes in muscle tone around the knee, such as decreased quadriceps strength and hamstring tension.Tuina can improve the balance of tension of the lower limbs, repair the function of ligament and cartilage, improve the static homeostasis of the knee joint, and thus enhance the balance function of the lower limbs[30].Tandem walking and one-leg standing training in functional training can effectively improve balance function[31-32].This study found that all three treatments could effectively improve the balance function of the lower limbs.Although the difference among the groups was not statistically significant, in the test of the Tuina group, we found that the balance function of the non-affected lower limb that was not trained was also improved,which may be related to the regulation effect of Tuina on the center.The mechanical force of Tuina acts on the body, and the body will transmit perceived signals to the central, thereby enhancing the readjustment of the central to local muscles[33-34]and improving the ability of bilateral lower limb muscle control, namely improving the function of balance.At the same time,Tuina can improve the proprioception of the affected knee[35], improve the movement stability of the joint,and reduce the load of the healthy knee joint, thus improving the stability of both lower limbs.

In conclusion, functional training, Tuina, and Tuina combined with functional training can improve the clinical symptoms and balance function in patients with meniscus injury, and Tuina combined with functional training has a significant improvement effect on the ability of daily living and sports and recreation function.

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Acknowledgments

This work was supported by Shanghai Clinical Key Specialty Construction Project (上海市临床重点专科建设项目, No.Shslczdzk04001); Three-year Development Projects for Promoting Clinical Skills and Clinical Innovation in Municipal Hospitals ( 促 进 市 级 医院临床技能与临床创新三年行动计划,No.SHDC2020CR6018-003, No.SHDC2020CR3096B);Project Within the Budget of Shanghai University of Traditional Chinese Medicine (上海中医药大学预算内项目, No.2021LK091); SHEN Guoquan Shanghai Famous Old Chinese Medicine Academic Experience Research Studio (沈国权上海市名老中医学术经验研究工作室,No.SHGZS -202225).

Statement of Informed Consent

The protocol and informed consent were approved by the Medical Ethics Committee of Yueyang Hospital of Integrated Traditional Chinese and Western Medicine,Shanghai University of Traditional Chinese Medicine(Approval No.2020105).Informed consent was obtained from all individual participants.

Received: 21 August 2022/Accepted: 15 February 2023