Research progress of non-specific neck pain in traditional Chinese medicine and western medicine

Chang-Long Qin,Yue-Li Sun,Yu-Song Jia,Zeng-Bin Ma,Qiao-Mei Yuan,Xue-Shi Di,Shui-Wen Long,Yu Ran,Chao Zhang,Zhong-Ze Li,Yong-Jun Wang,Jiang Chen＊

1Beijing University of Chinese Medicine,Beijing 100029,China;2Longhua Hospital,Shanghai University of Traditional Chinese Medicine,Shanghai 200032,China;3Dongzhimen Hospital of Beijing University of Chinese Medicine,Beijing 100700,China;4Department of Acupuncture and Massage,Beijing Hospital/National Center of Gerontology/Institute of Geriatric Medicine,Chinese Academy of Medical Sciences,Beijing 100730,China;5Heilongjiang University of Chinese Medicine,Harbin 150040;6Institute of Spinal Diseases,Shanghai University of Traditional Chinese Medicine,Shanghai 200032,China.

#Chang-Long Qin and Yue-Li Sun are the co-first authors of this paper.

Abstract

Keywords:Non-specific neck pain,Pathogenesis,Traditional Chinese medicine treatment,Western medicine treatment,Summarization

Background

Non-specific neck pain (NSNP) is defined as unexplained neck pain or discomfort accompanied by stiffness or limitation of movement without specific structuraland pathologicalchanges in imaging examination,and exclude infection,trauma,fracture,tumor and other factors[1].The neck pain persists more than 3 months is called chronic non-specific neck pain(CNSNP)[2].The cause of the disease is not clear.In recent years,with the change of people’s living and working habits and the emergence of intelligent devices,the incidence rate of NSNP is increasing year by year showing a younger trend[3].Office workers,students,drivers,workers are more likely to suffer from NSNP,obesity is also one of the high risk factors[4–6].Work and study pressure increases,long-term bow or improper posture,anxiety and depression,lack of exercise,etc.[7],more and more people are troubled by NSNP,people are not only affected their physical and mental health,the quality of life is declining, and therefore bear greater economic pressure[8].The treatment of NSNP abroad is mainly based on patient education,exercise,manipulation,medicine or injection therapy[9],while in our country it is mainly treated by acupuncture and massage and other external treatment of traditional Chinese medicine(TCM).The research progress of TCM and western medicine in the treatment of NSNP is presented as follows.

Study on modern pathogenesis

At present,there are more and more studies on the mechanism of pain,but there is still a lack of clinical evidence related to the mechanism of pain in patients with NSNP[10].Some scholars believe that long-term strain can change the muscle movement pattern and produce chronic and persistent pain in the neck.Electromyography and ultrasound have verified this abnormal movement pattern:The activation of the deep muscles of the neck was inhibited,while the compensatory activation of the superficial muscles increased[11–14].Some studies have shown that the imbalance of spinal biomechanics caused by the weakening of neck muscle strength and elasticity and ligament injury can also lead to neck pain,limited movement and other symptoms[15–17].In addition,the increase of inflammatory factors such as Interleukin-1β (IL-1β)and Tumor Necrosis Factor-α(TNF α)and central sensitization may exist in patients with chronic neck pain[18,19].These mechanisms can occur at the same time,but one mechanism may play a dominant role in clinical.Scholars have studied the mechanism of nonspecific neck pain from different angles such as muscle,mechanics and nerve.The author believes that in clinic,these mechanisms exist in patients with nonspecific neck pain at the same time,but one mechanism may occupy a dominant position.

Etiology and pathogenesis of TCM

From the point of view of TCM,NSNP belongs to the category of “neck arthralgia”,“stiff neck”,“neck and shoulder pain”and so on[20].It is written in Suwen that“wind,cold and dampness pathogen are mixed together and become arthralgia.If the wind pathogen is strongest called migratory arthralgia,if the cold pathogen is strongest called arthralgia aggravated by cold,If the dampness pathogen is strongest called fixed arthralgia[21]”.Wind-cold-dampness pathogens invade externally,stay in the joints,muscles,bones,lead to blockage of meridians and Qi and blood,“cold having property ofcontraction,characteristic of dampness being heavy and turbid”,so there is neck discomfort,pain,stiffness,limited movement and so on.According to Shanghan Lun,“Taiyang syndrome,stiff neck and back,sweating and aversion to wind,Guizhi Jia Gegen decoction governs.”It also points out that exogenous pathogen invades the Taiyang meridians,the neck meridians are blocked,and the malnutrition of meridians leads to stiff neck and neck pain[22].

Pain can be divided into three categories:excess syndrome,deficiency syndrome,and syndrome of intermingled deficiency and excess[23].It is written in Suwen that“cold pathogen invade the meridians and collaterals leads to slow pulse.If it stays outside of the vessel,the blood flow will be limited;if it stays inside the vessel,the Qi flow will be bloked,therefore cause pain suddenly”[24].Stagnation leading to pain.If the exogenous pathogen invades and blocks the Qi and blood or phlegm and static blood block the meridians,it will lead to pain with excess syndrome.Deficiency leading to pain.Deficiency of Qi and blood,or poor circulation of Qi and blood,causes malnutrition of meridians,resulting in pain with deficiency syndrome.If the course of the disease is long, the wind-cold-dampness-heat pathogens will injure Qi and blood and Yin and Yang.Where pathogen is gathered,its Qi will be deficient.Some people are susceptible to exogenous pathogen due to deficiency.Some people are unable to push the blood because of Qi deficiency,then the blood and channels will be blocked.Spleen deficiency generating phlegm also lead to blocakege of blood and channels.All of these are syndrome of intermingled deficiency and excess,which are common clinically.

TCM treatment

Internal treatment

By TCM pattern classification,neck pain can be accordingly classified into five types:wind-cold invasion pattern,pattern of blood stasis and Qi stagnation,pattern of phlegm-dampness obstructing collateral,qi-blood deficiency pattern and liver-kidney deficiency pattern[25].The pattern of wind-cold invasion is the most common,followed by the pattern of blood stasis and Qi stagnation,and the latter three syndrome types are relatively rare and often coexist with the first two syndrome types.

Neck pain with wind-cold invasion pattern is characterized by obvious pain,stiff neck,aversion to wind and cold,thin and white fur,stringy and tight pulse and so on.Guizhi Jia Gegen decoction can be used for treatment.According to statistics,Guizhi Jia Gegen decoction is the most frequently used prescription[26],which is composed of Ge Gen(Radix Puerariae),Gui Zhi(Ramulus Cinnamomi),Bai Shao(Radix Paeoniae Alba),Sheng Jiang(Rhizoma Zingiberis Recens),Da Zao(Fructus Jujubae),Gan Cao(Radix Glycyrrhizae).Among them,Ge Gen is the most important medicine,which can promote fluid production,relieve rigidity of muscles,ascend Yang and expel pathogenic factors from muscles.In the treatment of neck pain,Ge Gen is used most frequently[27].In addition,the combination of Bai Shao and Gan Cao can relieve pain effectively,and at the same time,some Qiang Huo(Rhizomaet Radix Notopterygii)and Wei Ling Xian(Radix Clematidis)can be added to increase the effect of dispelling pathogenic wind for relieving pain.

Most of the patients with neck pain of blood stasis and Qi stagnation have a history of trauma or chronic strain,the pain site is fixed,the tongue is dark and purple,petechia and ecchymosis can be seen on the tongue,or sublingual varices,hesitant pulse and so on.The main treatment is Shentong Zhuyu decoction.Dang Gui(Radix Angelicae Sinensis),Chuan Xiong(Rhizoma Ligustici Chuanxiong),Chi Shao(Radix Paeoniae Rubra),Hong Hua(Flos Carthami),Tao Ren(Semen Persicae)and Wu Ling Zhi(Faeces Togopteri)all have good effect of promoting blood circulation for removing blood stasis and relieving pain,we can also add Ji Xue Teng(Caulis Spatholobi)and Dan Shen (Radix Salviae Miltiorrhizae)to enhance the effect of promoting blood circulation for removing blood stasis.

If the patient has the syndrome of phlegm-dampness blocking collaterals,there will be neck discomfort with heavy sensation of head,white and greasy fur,slippery and rapid pulse and so on.We often use Banxia Baizhu Tianma decoction for promoting diuresis and dissipating phlegm.Ifthe patientappears pale complexion,shortness of breath and weakness,limb numbness,pale tongue,thready and weak pulse and other symptoms of Qi-blood deficiency pattern,you can use Bazhen decoction plus Huang Qi(Radix Astragaliseu Hedysari),Chen Pi(Pericarpium Citri Reticulatae)tobenefit Qi and nourish blood.If the patient has the symptoms of soreness and weakness of waist and knees,tinnitus and deafness,weakness of ulnar pulse,etc.,then Liuwei Dihuang decoction is used to nourish the liver and kidney.

Acupuncture and massage

Acupuncture and massage are traditional treatment methods in China,which have a long clinical history.They have the advantages of simple operation,low cost,good curative effect and less side effects in the treatment of neck pain[28,29].From the point of view of TCM,acupuncture and massage has the functions of relieving rigidity of muscle and activating collateral,harmonizing Yin and Yang,strengthening vital Qi to eliminate pathogenic factor,promoting Qi and activating blood,and so on[30].These treatments act on the neck,can dredge the neck meridians,activate Qi and blood,eliminate pathogens,and nourish muscles,so that neck stiffness and pain can be relieved.Modern studies have shown that acupuncture and massage can improve microcirculation,promote the absorption of inflammatory substances,relieve spastic muscles,enhance muscle strength,and make the bones and tissues around the neck tend to mechanical balance[31–34],thus relieving the clinical symptoms of patients with neck pain and enhancing the movement function of cervical vertebrae.

Acupuncture.A study[35]randomly divided 60 patients with neck pain into two groups.The treatment group was treated with acupuncture at Tianzhu(BL 10),Fengchi(GB 20),Jianjing(GB 21),Houxi(SI 3)and Lieque(LU7)points.After retaining needle 30 min,electroacupuncture was used to stimulate Fengchi(GB 20)and Jianjing(GB 21)points.After treatment,it was found that acupuncture was superior to sports patch in relieving neck pain.Acupuncture site is not only limited to specific points,but also acupuncture myofascial trigger point or Jiaji point,Ashi point,etc.,to relieve pain in patients[36,37].Of course,if combined with neck strength training or neck exercise,the effect will be much better than acupuncture alone.

Massage and bonesetting.There are various forms of massage in the treatment of CNSNP,and most scholars have adopted this set of operations:push and press the governor channel,push and press Jiaji point;push and press the gallbladder channel;rub the neck and back,and intermittently pull out the cervical vertebra.After the completion of massage operation,combined with Chinese traditional exercise,the pain of patients was effectively reduced and the range of motion of cervical vertebra was improved[38–41].

In addition,creative techniques such as Caihong Huang’s Tai Chi Tuina and Jingjing Wu’s Long’s bone-setting “four steps and ten methods”have certain advantages in the treatment of CNSNP[20,42,43].The author believes that whether it is a general technique or a special technique,the curative effect depends to a large extent on the level of the operator.

Derivative acupuncture method.

Internal hot acupuncture.Internal hot acupuncture therapy is developed from Chinese traditional warm acupuncture therapy,which has the advantages of constant temperature,smokeless and no skin damage.modern studies have shown that internal hot acupuncture can improve local blood circulation and promote the absorption of inflammatory substances,speed up the recovery of damaged tissue and muscle,relieve muscle tension,spasm and so on[44].

Ping Zhou[45]randomly divided 60 patients with CNSNP into two groups.The treatment group was treated with acupuncture on both sides of the vertebral lamina and transverse process of C4-T1 under local anesthesia,and the internal hot acupuncture was heated,while the control group was treated with local heating with magnetic vibration thermotherapy apparatus.Two weeks and 3 months after treatment,the visual analogue scale and neck disability index scores of the internal hot acupuncture group were better than those of the thermal magnetic group,and the follow-up results showed that the internal hot acupuncture treatmenthad a betterlong-term effect.Using ultrasonic elastography to study,it is found that internal hot acupuncture therapy can also increase the elasticity of neck muscles[46].

Intradermal needle.Intradermal needle uses the theoretical content of the twelve cutaneous regions in the meridian theory,through the long-term effect of skin stimulus,to harmonize yin and yang,activate Qi and blood,balance functions of Zang-Fu organs and relieve rigidity of muscle and activate collateral[47].Although Juan Huang[48]used intradermal needle combined with percutaneous nerve electrical stimulation to effectively improve the muscle tension and spasm of patients with CNSNP,the author believes that intradermal needle should be used as an adjuvant therapy and should be combined with other therapies to play a role.

Electro-acupuncture.The research of Rong Mu[49]shows that the effect of electro-acupuncture combined with cupping therapy in relieving pain symptoms in patients with CNSNP is higher than thatof non-steroidal anti-inflammatory drugs.Internal hot acupuncture is a combination of acupuncture and heating stimulation, electro-acupuncture is a combination of acupuncture and electrical stimulation,the two acupuncture methods are the associate combination of acupuncture and physical stimulation.The author believes that internal heat acupuncture and electro-acupuncture cannot replace traditional acupuncture,although they have many advantages and indications,but in many cases they are not suitable for use.

Comprehensive therapy

Zhongbo Wang[50]used acupuncture combined with exercise massage to treat 30 patients with NSNP,and compared with physical therapy group(n=30)and blank group(n= 30).After treatment,the total effective rate,the improvement of neck pain,the recovery of neck function and the quality of life of patients in the experimental group were better than those in the physical treatment group and the blank group. Combined therapy may achieve better short-term and long-term effects[51],but whether the complex treatment process can be promoted in clinic remains to be discussed.

Traditional Chinese exercise.

The traditional exercise of TCM has the advantages of various forms,simple and easy to learn,physical and mentalregulation,remarkable effect and so on.According to Exercise TherapyforNeck Pain:Consensus from Chinese Experts,the traditional Chinese exercise such as Tai Chi,Baduanjin and Qigong can not only improve neck pain and activity function,but also improve patients’psychological and emotional problems[52].Traditional exercise like Tai Chi,compared with general sports,not only play the role of exercise,but also can recuperate the heart and spirit of patients,in addition,the quality of life of patients can also be improved[53].

Western medicine treatment

Education

The implementation of education programs seems to be ineffective in the prevention and treatment of neck pain,and there is no significant effect in pain education for patients with neck pain,such as stress adjustment skills,self-care strategies and so on[54,55].Studies have shown that pain education combined with neck and shoulder exercise,balance and aerobic training is more effective than pain education alone[56,57].Taken together,it may be neck and shoulder exercise,balance and aerobic training that play a therapeutic role rather than pain education.The author believes that the effectiveness of education depends on the medical compliance of patients and personalization of the education program.

Exercise

There are many types of exercise for the treatment of nonspecific neck pain in clinic.Although there is a lack of high-quality evidence,exercise seems to be effective in relieving neck pain.Due to the lack of comparative studies on different types of exercise,therefore,it is difficult to judge whether one form of exercise is more effective than another form of exercise[57].Martin-Gomez[58]reported exercise control can treat patients with CNSNP.Khan[59]treated CNSNP with isometric exercise.Two methods have achieved good results.Clinicalstudies by Andersen et al have shown that scapular function training can reduce the degree of chronic non-specific neck and shoulder pain in adults and increase the range of motion of the shoulder[60].Otherexercise therapies,such ascervicalstabilization exercise,proprioceptive exercise,deep cervical flexor training,active and passive neck movement,global posture re-education,yoga,etc.,have been proved to be effective in clinical trials[61–65].

Compared with the use of a single exercise therapy,the combination of different exercise therapy is more effective.At present,due to the lack of evidence,it is impossible to provide clinical guidance on the exercise dose needed to maximize the effectiveness of exercise therapy[66].The author believes that exercise therapy should be combined with other therapies to maximize the curative effect,and different exercise forms and doses should be decided according to the situation of patients.

Manual therapy

Manual therapy is commonly used in the treatment of NSNP,which can be divided into manipulation and mobilization.There is low to moderate quality evidence shows that manipulation and mobilization can relieve pain and improve patients'cervical vertebra function compared with other interventions,but whether it is more effective than routine nursing or other treatment has not been determined [67].Manipulation and mobilization are rarely used as independent therapies in clinic,and most patients have received combined therapy[68].The combination of different forms of manual therapy with exercise is superior to manual or exercise alone in the treatment of NSNP [69–71].Therefore,similarto the above recommendations of exercise therapy,manual therapy also promotes combination and individualization.

Psychology

Anxiety and depression are associated with a high incidence of neck pain[72].Lack of awareness of pain,fear,anxiety and depression may be risk factors for acute conversion to chronic neck pain[73].Cognitive behavioral therapy is one of the most common psychotherapies used to treat chronic pain.Cognitive behavioraltherapy leads to gradualchanges in cognitive behaviorand disease by changing the thinking and improving mood of neck pain maladjustmentand cervicalvertebra dysfunction.Clinical studies by Linton[74]have shown that increased cognitive behavioral intervention and prophylactic physiotherapy can enhance the prevention of long-term cervical dysfunction.It is not clear whether psychotherapy alone is effective for neck pain.Combined psychotherapy on the basisofother treatments may be more effective,but further research is needed to demonstrate that it may be more effective to provide patients with well-targeted and personalized psychotherapy[57].

Other therapies

Dry needling is similar to acupuncture in TCM,while dry needling is mainly used in the trigger point of myofascial pain.The results of Cerezo-T é llez[75]support the application of deep dry needling in the treatment of myofascial pain syndrome in patients with CNSNP.

There are few reports on the treatment of acute nonspecific neck pain.Ibuprofen is an option,but intradermal injection of local anesthetics(lidocaine and bupivacaine)and steroids(methylprednisolone)may be a better option[76].

Conclusion

With the development of the times,the incidence of NSNP is increasing year by year.Long-term neck pain,discomfort and stiffness have brought great harm to people’s physical and mental health.NSNP is similar to cervical spondylosis of cervical type,but some domestic scholars think that NSNP is equivalent to cervical spondylosis of cervical type.NSNP and cervical spondylosis of cervical type should be distinguished according to whether there are organic lesions in imaging.

The author thinks that NSNP and cervical spondylosis of cervical type should be distinguished according to whether there are specific signs in imaging examination.The treatment of this disease by TCM and western medicine is rich and combined with many methods,and it is widely used in clinic.How to better use a variety of treatment methods in order to achieve the best effect remains to be further discussed.However,the clinical observation of the disease is too much,the discussion on the treatment mechanism is scarce,and many clinical studies lack long-term follow-up[23]and high-quality evidence.We made a table to show the clinical trials and outcomes of different interventions(Table 1).

Table 1 Trials of various interventions

Table 1 Trials of various interventions(Continued)

Therefore,in the future clinicalresearch and practice,we should standardize the treatment means and strengthen the research on the pathogenesis and treatment mechanism with the help of modern science and technology.With regard to the research on the mechanism,the results can not only open up some ideas for clinical exploration,but also promote the invention of specific medicine or instruments,and ultimately benefitpatients.Atpresent,syndrome differentiation and treatment of TCM has been widely used in clinical trials of cervical spondylosis,and external treatment methods such as Chinese medicine pillow,hot-packed Chinese medicine therapy,Chinese medicine application and so on have also been proved to have a good effect in the clinical trials of cervical spondylosis.I hope to see more reports about this kind of treatment in the future research of NSNP.