Juan-Juan Mao,Bo-Yu Zhu,Hao-Shuo Wang

1Tianjin University of Traditional Chinese Medicine,Tianjin 301617,China.

Abstract Cervical spondylosis of vertebral artery type is one of the chief patterns of cervical spondylosis.It is often described as neck pain accompanied with radiating pain and neurologic symptoms, such as sudden dizziness,blurred vision,tinnitus,nausea,vomiting, memory loss,and sudden fainting.The incidence of cervical spondylosis increases and patients with cervical spondylosis become progressively younger.Acupuncture in the cervical spondylosis of vertebral artery type treatment has a local positive reaction “Liuhe point”, in order to dredge the local Qi and blood.More and more evidences into the effectiveness and safety of cervical spine acupuncture for cervical spondylosis,specific neck pain,cervical radiculopathy,etc.This article summarizes the recent literature on acupuncture and acupuncture combined with other therapies for cervical spondylosis of vertebral artery type treatment and provides a comprehensive review from the perspectives of acupuncture therapy, warm needle moxibustion therapy, electroacupuncture, and acupuncture combined with other therapies, in order to provide reference and reference for clinical treatment.

Keywords: Cervical spondylosis, Cervical spondylosis of vertebral artery type, Traditional non-drug therapy,Acupuncture,Research progress

Background

Cervical spondylosis (CS) is the most common progressive disorder in the aging cervical spine [1].Even though age-related degeneration is the primary cause of degeneration, in younger patients injuries to the cervical disc can affect this degenerative process.The incidence of CS increases and patients with CS become progressively younger[2,3].

Cervical spondylosis of vertebral artery type (CSA)are the most common types of cervical spondylosis,which causes a disorder of blood flow in the vertebral arteries, resulting in an inadequate blood supply to the brain.The clinical manifestations of this disease include sudden dizziness, blurred vision, tinnitus,nausea, vomiting, memory loss, and sudden fainting[2].CSA treatment is often managed through conservative therapies, which includes oral analgesics,oral steroids, cervical traction, manual therapy, and various combinations of these.But treatments are subject to some limitations owing to the quality of evidence and adverse drug reaction.

In the world, many patients with cervical radiculopathy are increasingly turning to acupuncture,including cervical spine manipulation, to relieve their symptoms and reduce the side effects of medications[4].Acupuncture in the CSA treatment has a local positive reaction “Liuhe point”, in order to dredge the local Qi and blood.More and more evidences into the effectiveness and safety of cervical spine acupuncture for CS, specific neck pain, cervical radiculopathy, etc.Therefore, the purpose of this review is to summarize the literature regarding the effectiveness and safety of using cervical spine acupuncture in the treatment of CSA.

Acupuncture or moxibustion therapy

Acupuncture is one of the important parts of oriental medicine.It refers to a therapeutic method that stimulates specific parts with acupuncture instruments to achieve the purpose of treatment.These specific parts are called acupoints.In the treatment of CSA,acupoints mainly include Fengchi (GB20), Dazhui(GV14), Tianzhu (BL10), Jiaji (EX-B2) and so on.According to the theory of traditional Chinese medicine (TCM), acupuncture has the function of dredging channels and collaterals, reconciling yin and yang, strengthening the upright and dispelling evil.In the clinical treatment of CSA, acupuncture,moxibustion and electroacupuncture are often used,and a good effect has been obtained, which is discussed below.

Acupuncture therapy

Acupuncture is easy to administer and is widely used worldwide [5].Clinical studies have demonstrated the safety and effectiveness of acupuncture.Chen et al.[6]recruited 110 patients with CSA and randomly divided them into the treatment group and control group.The treatment group received acupuncture at the acupoints of Fengchi (GB20), Jiaji (EX-B2), Neiguan (PC6) and Dazhui (GV14), while the control group received Chinese massage.The study found that the effectiveness rate of the treatment group (94.87%) was significantly higher than that of the control group(76.92%).In other clinical studies [7-9], patients with CSA were enrolled and randomly divided into the acupuncture group and the western medicine group.All these researches results showed the advantages of acupuncture over the common western medicine treatments, especially in the hemodynamic parameters,such as systolic velocity,mean velocity et al.

Warm-needle moxibustion therapy

Moxibustion has effects of warming the meridians and expelling the coldness, restoring yang from collapse,removing the blood stasis and dispersing the stagnation and preventing diseases and keeping healthy.Warm-needle moxibustion therapy combines acupuncture and moxibustion, so it has their dual efficacy.The therapy could not only warm the meridians and expel the coldness, but also promote blood circulation to remove meridian obstruction.In compared with acupuncture,warm-needle moxibustion can reduce muscle spasms and promote the recovery of motor functions[10].

Warm-needle moxibustion therapy has been shown effective.Dao et al.[11] recruited 200 patients with CSA.In the observation group, patients received acupuncture on Fengchi (GB20) and Jiaji (EX-B2),meanwhile, light moxa moxibustion warm moxibustion on the needle handle for 20 minutes.At the same time, they were treated with seated stretching therapy.In terms of the control group, patients received oral flunarizine hydrochloride capsule(Country Medicine Accurate Character Number:H31020418).The total effective rate of treatment in the observation group was 91.0%, which was higher than that of the control group 76%.Therefore,warm-needle moxibustion therapy can improve the efficacy.In the other two studies [12, 13], patients were divided into a control group and a warm acupuncture combined with physical therapy group.The control group was treated with traction.As for the warm acupuncture group, it adopted the warm acupuncture, focusing on_Tianzhu (BL10), Fengchi(GB20),and Fengfu(GV16),et al.It was found that the pain score, total efficiency, and vertebral artery mean velocity of the warm acupuncture group was better than that of the conventional treatment group (P＜0.05).

Electroacupuncture

Electroacupuncture therapy is the application of electrical stimulation to acupuncture needles [14].The needle will insert into the acupuncture point to obtain Qi and a small electric current close to the body’s bioelectricity will be used for stimulation.In clinical practice or acupunc-ture research, electroacupuncture is the commonest form of acupuncture that is used to manage neck pain[15].It is believed to have 2 distinct advantages: (i) the therapy can be applied consistently and (ii) electrical stimu-lation can be performed and thus the traditional acupuncture can be combined with modern theory of neuromodulation [16].A study has demonstrated that electroacupuncture was more effective than simple acupuncture in treating neck pain caused by CSA [17].Concerning the treatment with electroacupuncture for liver and blood regulation,Zhang [18] used electroacupuncture to regulate liver and nourish blood for treatment.X-rays revealed significant improvement in the patient’s cervical function.Symptoms such as dizziness, headache, and neck and shoulder pain are also significantly reduced.Ou[19]was treated with plexiform electroacupuncture.The blood flow velocity of vertebral artery and basilar artery was significantly higher in the observation group than in the control group (P＜ 0.05),Electroacupuncture therapy for CSA is effective in improving many of the patient’s clinical symptoms and increasing blood flow to the vertebral and basilar arteries.

Acupuncture combined with other therapies

Acupuncture combined with Tuina

Tuina is a typical external medical therapy of TCM and includes many modalities such as soft tissue relaxation, acupoint, traction and other therapies.Treatment with Tuina can significantly expand periphery bloodvessels, improve cerebral blood flow and promote the circulation to alleviate the blood stagnation.The combination of acupuncture and Tuina can further improve the patient’s condition.It has been reported that, combination of acupuncture with Tuina has a more effective results of hemodynamics than acupuncture only.It has been proved that the blood flow velocity and adverse reaction incidence of right vertebral artery,left vertebral artery,basilar artery were significantly better than those in the control group (P＜0.05) [20].The effects also could see in the symptoms improvements.Yang et al.[21] found that the scores of symptoms and function assessment scale(the evaluation scales of cervical vertigo) and clinical assessment scale (cervical spondylosis clinical evaluation scale) of cervical vertigo were significantly higher in the treatment group than in the control group.Similarly, Zhou [22] found that combination of acupuncture with message had a greater advantage over the control group in terms of scores in vertigo,headache, neck pain, the neck and shoulder movement function,and ability to work normally.

Acupuncture combined with laser irradiation

Laser irradiation therapy is a treatment method guided by TCM meridian theory.It combines modern laser technology, microelectronic technology and traditional acupuncture techniques to enhance the therapeutic effect [23].Laser irradiation therapy through low power laser irradiation local organization, make local organization vasodilation, improve blood circulation and lymphatic circulation, enhance body metabolism,promote inflammation absorption, adjust the function of vegetative nerve, so that the sick body gets faster recovery.Zhang [24] selected 94 patients with CSA and randomly divided them into two groups.In the control group, 47 patients were treated with laser irradiation at the stellate ganglia.And in the study group, 47 patients were treated with acupuncture combined with laser irradiation.The results showed that the visual analogue scale score of the study group was lower than that of the control group (P＜0.05).And the cervical function scores of the study group were higher than those of the control group(P＜0.05).In another study [25], 120 patients with CSA were enrolled and randomly divided into a control group and a study group of 60.The control group was treated with conventional electroacupuncture, while the study group was treated with electroacupuncture and laser irradiation.The infrared meter was used to detect the change/variation in temperature of the patient’s head and face.The temperature variation is used to evaluate the efficacy.In the study group, the effective rate was 100%.In the control group, it has a total effective rate of 88.3%.These studies provide the evidence for the efficacy of acupuncture combined with laser irradiation in improving therapeutic efficacy.

Acupuncture combined with herbal moist and hot compresses

Herbal hot and moist compress therapy could promote the different kinds of TCM herbs entering organs through meridians.This therapy could also transport them throughout the body.It has the effect of wet meridian disperses cold, promotes blood circulation,disperses blood stasis, dispels wind and dehumidifies the effect of dredging collaterals.Liu et al [26]recruited 80 patients with CVS.The control group received acupuncture and massage treatment.Except acupuncture and massage, patients in the study group also received Chuanxiong (Cinnamomi Ramulus),Honghua (Croci Stigma), Sanqi (Notoginseng Radix et Rhizoma)and other traditional Chinese medicines with yellow wine and aged vinegar, brought them to a boil,and immersed a towel in the liquid.This towel was then applied to the patient’s shoulder and neck alternately for 30 minutes each time, once a day for 10 days.The results showed that the total effective rate was better in the study group (97.5%) than in the control group (80%).Tang [27] used acupuncture and massage combined with Chinese herbal moist and hot compresses to treat patients.The treatment results showed that the average systolic blood flow velocity of the combined group was significantly faster than that of the single group (P＜0.05), which had a better therapeutic effect.Li [28] studied 120 patients with vertebral visual analogue score and also found that acupuncture combined with herbal hot compresses could positively affect the patients’ blood flow velocity.

Acupuncture combined with acupoint injection

Compared to traditional acupuncture, acupoint injection is an innovation that injects a small amount of drug at acupuncture points [29].The drugs used have been extended to almost all kinds of traditional Chinese and western medicine that can be used for injection.Acupoint injection is widely used in clinic because of its small dosage, quick effect, little side effect and long retention time at acupoint.Xiang [30]and others used a mixture of acupoint injection of Danshen injection (manufacturer: Sichuan Shenghe Pharmaceutical Co.Ltd.approval No.: Guohua Z51021303) and 5% Licadoin 1 mL (manufacturer:Hubei Tian Sheng Kangdi Pharmaceutical Co.Ltd.approval No.: Guohua H42021839) as well as acupuncture treatment and found that the total effective rate of the clinical treatment in the study group was higher than that of the acupuncture group.In the control group, the improvement of plasma concentration of et-1 and calcitonin gene-related peptide are greater than that in the control group, and the length of hospitalization was shorter than that in the control group, and the difference was statistically significant(P＜0.05).Che[31]used acupuncture point injections of vitamin B12 combined with acupuncture to treat patients with CSA.It was found that the patients in the study group had a better prognosis than those in the control group after treatment.

Acupuncture combined with herbal packets therapy

Herbal packets therapy combines the external treatment of TCM with modern drug transdermal techniques.It combines the effects of infrared and magnetic fields.Thus, it improves the conversion rate of active substances in Chinese herbs.At the same time,Chinese herbs can penetrate through the skin and act straight on the affected area.Through these two effects,clinical efficacy can be improved.As a result, this therapy has significant advantages in clinical applications.Yang [32] treated the control group by acupuncture of Baihui (GV20), Dazhui (GV14),Fengchi(GB20),Tianzhu(BL10),etc.As for the study group, he/she used acupuncture combined with herbal packets.During the acupuncture treatment, the selection of acupuncture points and the method of acupuncture were the same as those in the control group.In herbal packets therapy, Chinese medicine ingredients such as Chuanxiong (Chuanxiong Rhizoma), Xuduan (Dipsaci Radix), Duhuo (Angelicae PubescentisRadix), Honghua (Croci Stigma) and other herbs are used to make a powder, and then mix it with rice wine to make a paste.Later,put the paste into a 10 cm ×10 cm cotton bag and tie the bag, and apply heat to the affected area.It was found that evaluation scales of cervical vertigo score of the study group was significantly higher than that of the control group, and the difference was statistically significant (P＜0.01).These studies indicate that the combined application of acupuncture therapy and herbal packet therapy can improve the efficacy.

Acupuncture combined with oral Chinese herbal medicine

Chinese medicine focuses on the role of both acupuncture and medicine in the treatment of diseases.According to different syndrome types, traditional Chinese medicine will give different prescriptions, of which Tongluo Huoxue decoction and Gualou Xiebai Baijiu decoction are typical prescriptions.Xue [33]and others treated the patients with Tongluo Huoxue decoction which is an empirical formula clinically combined with acupuncture and massage for 4 weeks.By studying the clinical efficacy, blood flow parameters of vertebrobasilar artery, and changes in cervical spine mobility, the patients treated with TCM combined with acupuncture and tui-na had significant clinical efficacy and the cervical spine mobility angle improved significantly compared with the control group.In addition, a related study [34] showed that Gualou Xiebai Baijiu decoction which is fromSynopsis of Golden Chamber(an ancient Chinese medical book written by Zhongjing Zhang about during the Eastern Han Dynasty (25 C.E.-220C.E.))combined with blood-letting puncture for CS could first significantly reduce serum endothelin levels.The systolic flow velocity, diastolic flow velocity, mean peak flow velocity and serum nitric oxide levels of the left and right vertebral arteries were significantly higher than those of the control group (P＜0.05),which promoted blood circulation in the neck and thus significantly improved the patients’ symptoms,suggesting that acupuncture combined with traditional Chinese medicine is effective in patients with CSA.

Other therapies

Needle-knife therapy

Needle-knife is traditional Chinese acupuncture developed from the advantages of modern western medical scalpels [35].It not only has the role of TCM acupuncture to regulate the balance of Yin and Yang,dredge the Qi and blood meridians, but also has the function of western medical scalpels: cutting and decompression.It is clinically effective in the treatment of vertebral artery type cervical spondylitis.Yao [36] used needle and knife combined with supine(fixed-point) retractor repositioning maneuver to treat the observation group, while the control group was treated with acupuncture for 30 minutes, with 250 mL of 0.9% saline and 40 mL of compoundSalvia deliriuminjection intravenously,one time per day.The treatment results showed that the physiological curvature of the cervical spine improved better in the observation group than in the control group.Tian et al.[37] chose needle and knife combined with extraction and extension traction to treat patients with CSA.They found that the positive rate of neck rotation test,cervical physiological curvature, the visual analogue score of pain, and clinical outcomes and recurrence were better in the observation group than in the control group after treatment.In addition, needle knife with supine stretching [38], needle knife matched with herbal pillow [39], drug injection and needle knife combination [40], etc., all have a better therapeutic effect on the patients with CSA.

Acupoint embedding therapy

Under the guidance of acupuncture and moxibustion theory,combined with modern physical medicine,with the aid of needles buried in absorbable surgical sutures,a series of therapeutic effects of continuous stimulation of human acupuncture can produce a series of treatment methods.TCM believes that acupuncture embedding therapy produces a more intense acupuncture effect than general acupuncture, with“pass its meridians,transfer its Qi and blood”.Lin et al.[41] used acupuncture embedding and simple hammer blows for chiropractic treatment, and acupuncture for the control group.The clinical efficacy and the changes of the indicators of transcutaneous Doppler ultrasound showed that the treatment group was better than the control group after 1 month of treatment, and the difference was statistically significant(P＜0.05).

Conclusion

CSA is often caused by cervical degenerative disc changes, segmental instability of the cervical spine,reduced vascular elasticity, and vertebral artery sclerosis.Many studies have shown that acupuncture has significant advantages in treating CSA, reducing serum levels of inflammatory factors [42].It has the effects of sedation, anti-inflammatory, and improving microcirculation.Through our review, we obtained the following summarized results based on the available relevant studies that we searched through literature:(1)local acupuncture points such as Baihui (GV20),Fengchi (GB20), and Jiaji (EXB2) are mainly used,among which the Jiaji(EXB2)is most commonly used;(2) electroacupuncture, warm acupuncture and other applications can correct vertebral artery hemodynamic disturbances in CSA patients; (3) acupuncture combined with other therapies, such as massage therapy, herbal packets, herbal moist and hot compresses,laser irradiation,and combination of TCM,are innovative and the advantages of stable action,obvious efficacy and short duration of treatment are worthy of further promotion.Meanwhile, there are many other therapies have significant effects, such as needle-knife therapy,acupoint embedding therapy,etc.,which are innovative and worth learning.