ZHU Binye (祝斌野), LI Xue (李雪)?

Shaanxi University of Chinese Medicine, Xianyang 712000, China

Abstract

Keywords: Tuina; Massage; Pediatric Tuina; Tui-Pushing Manipulation; Point, Danzhong (CV17); Point, Feishu (BL13); Cough Variant Asthma; Child, Preschool

Cough variant asthma (CVA) is a special type of asthma with chronic cough as the predominant or only symptom and often is the heralding symptom of typical asthma[1-2]. CVA mainly manifests as irritable dry coughing, especially in the early morning and evening. It does not respond to anti-infectious treatments and can be triggered or aggravated by cold air, dust mites,pollens, or fumes and gases[3]. CVA is one of the main causes of chronic cough in kids but is often misdiagnosed as recurrent respiratory infection or bronchitis[4]. If not treated properly, it may develop into typical asthma in 30%-50% of the affected kids[5]. We adopted LIU’s pediatric Tuina (Chinese therapeutic massage), Tui-Pushing chest-back manipulation,together with the conventional treatment protocol to treat CVA in children, and achieved satisfactory results with a high safety rating.

1 Clinical Materials

1.1 Diagnostic criteria

It conformed to the diagnosis in theGuideline for Clinical Diagnosis and Treatment of Pediatrics of Traditional Chinese Medicine:Cough Variant Asthma in Children(Formulation)[6]. Recurrent cough lasted for over one month, more often in the early morning and evening, with few or no phlegm, induced or worsened when there was cold or hot air or a strange odor, or when speaking loud or exercising; presented any one of the following accompanied symptoms: coarse rales,itchy pharynx, and changes in the pattern of food intake,sleep, perspiration, or defecation.

1.2 Inclusion criteria

Met the diagnostic criteria; aged 2-6 years old; the family members or guardians signed the informed consent form and permitted the kids to receive the treatment.

1.3 Exclusion criteria

Chronic cough caused by other illnesses or with infectious symptoms; those unable to cooperate or complete the study; those coupled with other severe systemic diseases.

1.4 Statistical methods

The SPSS version 20.0 statistical analysis software was adopted. The enumeration data were checked by the Chi-square test. The measurement data were expressed as mean ± standard deviation (comparisons; the rank-sum test was used for those not satisfying homogeneity of variance. Statistical significance was recognized whenP＜0.05.

1.5 General data

The subjects were 72 CVA kids who visited the Pediatric Tuina or Pediatrics Outpatients of the Affiliated Hospital of Shaanxi University of Chinese Medicine between September 2019 and December 2020. They were divided into a control group and an observation group using the random number table method, with 36 cases in each group.

During the study, three kids withdrew due to an exacerbated condition, and one kid lost to visit in the control group. In the observation group, one kid withdrew due to an exacerbated condition, and two kids lost to visit. Consequently, 65 cases (32 cases in the control group and 33 cases in the observation group)completed the study. The two groups were statistically equal comparing the gender, age, average disease duration, and disease stage (P＞0.05), indicating the comparability (Table 1).±s) when satisfying homogeneity of variance, processed by the independent samplest-test in between-group comparisons and the pairedt-test in intra-group

Group n Gender (case) Average age(Disease stage (case)images/BZ_7_1311_2835_1350_2881.png±s, year)Average disease duration(images/BZ_7_1311_2835_1350_2881.png±s, month)Male Female Acute attack Chronic attack Observation 33 18 15 3.9±1.2 2.4±0.1 12 21 Control 32 15 17 4.0±1.2 2.3±0.3 11 21

2 Treatment Methods

2.1 Control group

Kids in the control group received the conventional pediatric Tuina treatment to cease cough, resolve phlegm, and relieve asthma[7]: Kai-Opening orifices 24 times [Kai-Opening Tianmen, Tui-Pushing Kangong,Tui-Pushing Taiyang (EX-HN5), An-Pressing and Rou-Kneading Zongjin, and Fen-Parting Yinyang, 24 times each], Bu-Reinforcing Pijing 200 times, Qing-Clearing Ganjing 250 times, Qing-Clearing Xinjing 150 times,Bu-Reinforcing Feijing 300 times, Bu-Reinforcing Shenjing 100 times, Rou-Kneading Wailaogong 60 times,Tui-Pushing Sanguan 150 times, Tui-Retreating Liufu 50 times, Rou-Kneading Erhougaogu 24 times, Rou-Kneading Dingchuan (EX-B1) 100 times, and Rou-Kneading Chuangxin (a unique pediatric Tuina point of LIU’s school of pediatric Tuina, located bilaterally to the spine, two finger widths away from the first thoracic spinal process) 100 times, Nie-Pinching the spine 6 times, An-Pressing and Rou-Kneading Jianjing (GB21)3 times. The treatment was performed once a day for three consecutive courses with one month as one treatment course.

2.2 Observation group

The observation group additionally received Tui-Pushing chest-back manipulation.

Operation of Tui-Pushing chest-back manipulation:Rou-Kneaded Danzhong (CV17) 100 times with the index and middle fingers at 200 times/min; separately Tui-Pushed Danzhong (CV17) 500 times with two thumbs at 150 times/min; straightly Tui-Pushed Danzhong (CV17) 50 times with the index and middle fingers of the right hand from the upper end of the sternal manubrium till the xiphoid process at 150 times/min; Anya-Pressed from the first intercostal space one by one till the fourth intercostal space with the index and middle fingers of the right hand, 5 times each; An-Pressed and Rou-Kneaded Feishu (BL13) with the thumbs at 200 times/min, followed by Tui-pushing manipulation in a “介”-like pattern 100 times at 150 times/min; consequently, Ca-Scrubbed Feishu (BL13)in a “八”-like pattern with two thumbs after dipping some water and salt as the medium till the inner edge of the scapular area turned red[8-9]. The details are illustrated in Figure 1.

The treatment was offered once a day for three successive treatment courses, with a one-day rest after six consecutive days and one month as a course.

3 Efficacy Observation

3.1 Items

The scales were filled in before and one month after treatment.

3.1.1 Symptoms rating scale of traditional Chinese medicine for CVA in kids[10]

The number of cough: Frequent paroxysmal cough,6 points; paroxysmal cough but less often, 4 points;intermittent cough not lasting long, 2 points; no cough,0 point.

The intensity of cough: Persistent paroxysmal cough through day and night, affecting sleep and study,6 points; frequent cough, more likely at night or in the early morning, slightly affecting sleep and study,4 points; occasional cough, more often at night or in the early morning, but not affecting sleep or study, 2 points;no cough, 0 point.

The nature of cough: Spasmodic cough, 6 points;bucking, 4 points; dry cough, 2 points; no cough, 0 point.

3.1.2 Safety rating

Any adverse reactions that occurred during or following the treatment were recorded, such as allergies,wounds, and pain.

3.2 Efficacy criteria

We referred to the efficacy criteria for the treatment of chronic cough in theGuiding Principles for Clinical Study of New Chinese Medicines[11]and calculated the reduction rate of the cough symptoms scale score using the Nimodipine method. The reduction rate of the cough symptoms scale score = (Cough symptoms scale score before treatment - Cough symptoms scale score after treatment) ÷ Cough symptoms scale score before treatment × 100%.

Markedly effective: The cough symptoms scale score reduction rate ≥70.0%.

Effective: The cough symptoms scale score reduction rate ≥30.0% but ＜70.0%.

Invalid: The cough symptoms scale score reduction rate ＜30.0%.

3.3 Treatment results

3.3.1 Comparison of the efficacy

After three treatment courses, the total effective rate in the observation group was superior to that in the control group (P＜0.05). At the one-month follow-up,there was no significant difference in the total effective rate between the two groups (P＞0.05), (Table 2).

3.3.2 Comparison of the cough symptoms scale score before treatment

Before treatment, there were no significant differences in the scores of the number, intensity of cough or nature of cough between the two groups(P＞0.05), indicating the comparability (Table 3).

3.3.3 Comparison of the cough symptoms scale score after treatment

After three treatment courses, the number, intensity,and nature of cough scores were compared again. The scores all showed a significant decline in both groups(P＜0.05), and the efficacy in the observation group was superior to that in the control group (P＜0.05),(Table 4-Table 6).

3.3.4 Comparison of the cough symptoms scale score at the follow-up

The number, intensity, and nature of cough were scored again one month after treatment, and there were no significant differences between the two groups(P＞0.05), (Table 7).

Group n After treatment Follow-up ME Effective Invalid TER (%) ME Effective Invalid TER (%)Observation 33 12 18 3 90.91) 16 14 3 90.9 Control 32 5 18 9 71.9 8 19 5 84.4

Table 3. Comparison of the symptoms scale score between the two groups before treatment (±s, point)

Group n Number of cough Intensity of cough Nature of cough Observation 33 3.49±1.34 3.19±1.23 3.52±1.21 Control 32 3.57±1.12 3.26±1.07 3.21±1.25 Z-value -0.498 -0.031 -0.342 P-value 0.602 0.983 0.785

Intensity of cough Nature of cough 3.19±1.23 3.52±1.21 1.15±0.82 1.07±0.57-3.433 -4.269 0.000 0.000

Intensity of cough Nature of cough 3.26±1.07 3.21±1.25 1.64±1.01 1.99±0.46-3.045 -3.231 0.000 0.001

Intensity of cough Nature of cough 1.15±0.82 1.07±0.57 1.64±1.01 1.99±0.46-2.087 -1.635 0.027 0.008

Intensity of cough Nature of cough 1.48±1.05 1.51±0.65 1.29±0.79 1.32±0.95-1.053 -0.257 0.112 0.237

3.3.5 Adverse reactions

No kids showed any treatment-related discomforts during the treatment or at the follow-up.

4 Discussion

We can find no proper term for CVA in the ancient TCM classics but only classify it under the categories of“cough”, “l(fā)ung Bi-Impediment”, or “wind cough”[12]. The pathogenesis of cough is principally related to the external pathogens attacking the lung or the dysfunction of Zang-Fu organs damaging the lung,where the lung Qi fails to disperse or descend and rush up to the pharynx and throat. Therefore, the treatment of cough should target the lung[13-14].

LIU’s pediatric Tuina has been awarded the fourth batch of intangible cultural heritage issued by the Hunan Provincial Department of Culture. Till today it has been passed down through six generations. Its unique Tui-Pushing back manipulation and Tui-Pushing chest manipulation are essential in treating respiratory diseases and have been proven significantly effective[15].Current clinical practice has standardized the two manipulations and combined them into Tui-Pushing chest-back manipulation to achieve better treatment results[16].

The Tui-Pushing chest-back manipulation operates on the projections of the lungs on both the back and the chest. Danzhong (CV17) is the major point in the Tui-Pushing chest manipulation. Located in the chest and regarded as the Influential Point for Qi in the Eight Influential Points, it can regulate Qi and relieve the depression in the chest. Thus it has been commonly used to treat respiratory disorders[17-19]. Modern research has noted that first Rou-Kneading and then Tui-Pushing Danzhong (CV17) can descend Qi to relieve asthma and bring down the counterflow to cease coughing. Further, An-Pressing the intercostal spaces can boost nerve impulses to go up to the brain through intercostal nerves and influence the regulation center of cardiovascular nerves by stimulating the reticular system of the brainstem, encouraging the reattribution of blood in the body, and improving the local blood flow[20-21]. The Tui-Pushing back manipulation chiefly operates on Feishu (BL13) and the surrounding cutaneous region of the Bladder Meridian[22-23]. Feishu(BL13) coordinates with the lung interiorly and is where the Qi of the lung infuses. Stimulating this point can regulate the function of the lung and help maintain the dynamic balance of the Qi activities of the lung and between Yin and Yang[22]. LIU’s Tui-Pushing chest-back manipulation performs Rou-Kneading, Tui-Pushing, and Ca-Scrubbing manipulations at Feishu (BL13) till the skin turns red, which can produce a durable, deep, and safe stimulation to this point. The Tui-Pushing manipulation in a “ 介”-like pattern and the Ca-Scrubbing manipulation with salt in a “八”-like pattern also involve the cutaneous region of the Bladder Meridian around Feishu (BL13)[24]. This area is the main projection of the lungs and tracheas on the back. Stimulating this area can harmonize Qi and blood, descend lung Qi, and promote the expulsion of phlegm to finally regulate the function of the lung organ. Besides, this is a part of the cutaneous region of the Bladder Meridian, which not only is the outer defense of the human body but also governs skin and hair in cooperation with the lung.Therefore, when the lung organ is sick, especially from the external contraction, stimulating the cutaneous region of the Bladder Meridian can achieve satisfactory clinical efficacy[25-26]. LIU’s Tui-Pushing back manipulation, selecting the cutaneous region of the Bladder Meridian to treat diseases like cough, wheezing,and fever, shares a common mind with ZHANG Zhongjing’s treatment of external contraction with the Bladder Meridian.

Children’s CVA is a lung disease, manifesting as a number of Qi-related symptoms such as cough, chest tightness, shortness of breath, and panting. We treated it with the Tui-Pushing back manipulation [it takes Feishu (BL13) as the chief point] and the Tui-Pushing chest manipulation [it takes Danzhong (CV17) as the chief point], in order to regulate Qi and lung function and descend the reverse Qi flow to cease coughing. This treatment is concise in point selection and significantly effective. Moreover, the two manipulations both work on the “pathway of thoracic Qi” and thus are suitable to treat lung-pertinent diseases. In this study, the Tui-Pushing chest-back manipulation used based on the conventional pediatric Tuina method for ceasing cough,resolving phlegm, and relieving asthma effectively reduced the number and intensity of cough and improved the nature of cough with a high safety rating.Hence, this combination method is safe and effective and deserves a promotion.

Conflict of Interest

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

Acknowledgments

This work was supported by the Scientific Research Project of Education Department of Shaanxi Provincial Government (陜西省教育廳科研項(xiàng)目, No. 19JK0231).

Statement of Informed Consent

Informed consent was obtained from the guardians of the recruited children in this study.

Received: 5 March 2021/Accepted: 28 July 2021