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00007632-201007010-0000200007632_2010_35_1415_xin_counterpulsation_15miscellaneous-article< 104_0_14_8 >Spine© 2010 Lippincott Williams & Wilkins, Inc.Volume 35(15)1 July 2010pp 1415-1422Enhanced External Counterpulsation and Traction Therapy Ameliorates Rotational Vertebral Artery Flow Insufficiency Resulting From Cervical Spondylosis[Randomized Trial]Xin, Wang MD, PhD*; Fangjian, Guo MD*; Hua, Wang MD, PhD*; Jiangtao, Xie MD, PhD*; Shouyi, Wang MM*; Yingchun, Zhao MM*; Xiong, Li MD, PhD†From the Departments of *Orthopedics, and †Sonograhy, Zhongnan Hospital of Wuhan University, Wuchang, Wuhan, People's Republic of China.Acknowledgment date: May 21, 2009. First revision date: August 4, 2009. Second revision date: September 9, 2009. Acceptance date: September 11, 2009.The manuscript submitted does not contain information about medical device(s)/drug(s).Institutional funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.Supported by Health Department of Hubei Province, JX3C17 (to W.X.).Informed consent has been signed by each patient.The protocol has been approved by Zhongnan Hospital of Wuhan University, and all experimentation was conducted in conformity with ethical and humane principles of research.Address correspondence and reprint requests to Wang Xin, MD, PhD, Department of Orthopedics, Zhongnan Hospital of Wuhan University, Donghu Rd 169, Zhongnan Hospital of Wuhan University, Wuchang, Wuhan 430071, People's Republic of China; E-mail: whuwangxin@yahoo.com.cn.AbstractStudy Design. Clinical trial of patients with rotational vertebrobasilar insufficiency (VBI) resulting from cervical spondylosis.Objective. To investigate the effectiveness of enhanced external counterpulsation (EECP) and traction therapy for these patients.Summary of Background Data. EECP would reduce arterial stiffness and vascular resistance, and increase regional blood flow of vertebral arteries, thus may ameliorate symptoms in these patients.Methods. One hundred sixty-three patients who were clinically suspected rotational VBI caused by cervical spondylosis were enrolled in this study. They were randomly allocated into 3 groups: EECP + traction, EECP, and traction group. All patients and 50 healthy volunteers received transcranial color Doppler examination of the vertebral artery and basilar artery in both a neutral cervical spine position and a rotational position.Results. Within 3 days after treatment, 47 (84%) patients in EECP + traction group, 32 (61%) patients in EECP group, and 8 (15%) patients in traction group achieved successful outcomes, while at 3 months' follow-up, 45 (80%) patients in EECP + traction group, 34 (64%) in EECP group, and 3 (6%) in traction group achieved successful outcomes. With head rotation, the percentage of reduction of blood flow velocities of the vertebrobasilar artery (VBA) in patients was much greater than that of the healthy volunteers (P < 0.01). After treatment, rotational blood flow velocity reduction percentage of VBA in each treatment group was much lower than that of each group before treatment. EECP + traction group experienced the greatest decrease of rotational blood flow velocity reduction percentage of VBA, while EECP group experienced second greatest.Conclusion. EECP and traction therapy can relieve the symptoms of rotational VBI, improve the rotational reduction of vertebrobasilar blood flow, and reduce the increased arterial impedance.Vertebrobasilar insufficiency (VBI) is a condition in which decreased blood volume of the vertebral artery (VA) and basilar artery (BA) results in insufficient blood supply to certain parts of the brain.1 This will lead to a wide range of syndromes, including vertigo, dizziness, headache, impaired vision, position related nystagmus, disequilibrium, gait disturbances, difficulty talking, and weakness or numbness on one or both sides of the body,2,3 with vertigo being the most characteristic symptom.4 The close anatomic contact between the vertebral arteries and the cervical spine leaves the posterior circulation vulnerable to ischemia, and VA is most susceptible to compression with rotation at C1–C2 and C5–C6.5 VBI secondary to cervical spondylotic osteophytes has been described6,7; extreme neck turning can compromise VA flow, especially at the C5 and C6 levels.1,8 Symptoms may be exacerbated with extension of the cervical spine or rotation of the neck. With head rotation, significant stenosis of VA may be caused by spondylotic osteophytes projecting from the vertebral joints adjacent to the foramen transversarium,9 segmental instability, fibrous thickening of the tendons from the longus colli, and anterior scalenus muscles,10 and herniated cervical discs1,8; the first 2 are the most common causes. Osteophytes at the unco-apophyseal joints compress VA with head rotation, whereas those that occur at the facet joints seem to cause compression with neck extension.11 An anterior approach12 and a posterior approach13 to decompress VA secondary to cervical spondylosis have been documented; in some cases, angioplasty or bypass procedures for occluded portions of VA may be necessary.14 However, these invasive surgical procedures are reserved for the medication-resistant patients with hemodynamically significant lesions of the posterior circulation and high risk of stroke.15 All these procedures have serious risks and could precipitate degeneration of the cervical spine; hence, conservative therapies are advocated. Actually, conservative therapies, such as traction,16 tuina, and pharmaceutical treatment17 have relatively small effects in relieving the symptoms of these patients, thus calling for a novel effective treatment. Enhanced external counterpulsation (EECP) is a safe, highly beneficial, low-cost, noninvasive treatment for patients with angina and heart failure18 and various other vascular diseases, such as restless leg syndrome, sudden deafness, hepatorenal syndrome, and erectile dysfunction.19 EECP therapy consists of electrocardiogram-gated rapid, sequential compression of the lower extremities taking place during diastole, followed by simultaneous decompression during systole, which augments diastolic blood flow, improves endothelial function, and exerts clear arterial effects on large and small vessels by reducing arterial stiffness and vascular resistance and increasing regional blood flow.20 Our hypothesis is that EECP would reduce arterial stiffness and vascular resistance, and increase regional blood flow of vertebral arteries, thus may ameliorate symptoms in these patients. We designed a clinical trial to evaluate the efficacy of EECP and traction therapy for these patients.Materials and MethodsWe undertook a randomized, controlled, clinical trial to evaluate the efficacy of EECP and traction therapy for rotational VBI resulting from cervical spondylosis. The trial was carried out in the orthopedic outpatient section of a large teaching hospital in China. Patients who complained of vertigo and drop attacks were advised to have radiograph examinations of the cervical spine and transcranial color Doppler (TCD) evaluations. Subsequently, those with positive findings, satisfying the inclusion and exclusion criteria (Table 1), and willing to participate in this trial were recruited. All patients gave written informed consent after full explanation of the purpose, nature, and risk of procedures, and were randomly allocated to 1 treatment. From March 2006 to November 2007, 163 patients (76 men, 87women) who were clinically suspected rotational VBI caused by cervical spondylosis were enrolled in this study. Mean age was 53 ± 18 years. They were randomly allocated into 3 groups: EECP + traction, 56 patients (25 men, 31 women) with mean age at 55 ± 16, receiving EECP therapy and traction therapy; EECP, 53 patients (26 men, 27 women) with mean age at 52 ± 19, receiving EECP therapy; traction, 54 patients (25 men, 29 women) with mean age at 52 ± 17, receiving traction therapy. There were some withdraws who were not included in the 163 patients and the data analysis: withdraw on the day of randomization (EECP + traction group, n = 1); withdraw from treatment and follow-up assessments (EECP + traction group, n = 1; EECP group, n = 3; traction group, n = 5). The EECP equipment (WFB-V, Guangzhou, China) was used and the pressure applied to the cuffs during EECP was set at 300 mm Hg. Detailed illustration of EECP procedure is shown in Figure 1. The traction therapy used a traction device (AKRON-8908, England). Continuous traction was performed with the patient in supine, and the angle of pull was set to 15 degree of flexion. Each session included 2 sub sessions of approximately 30 minutes each. The average force of pull for this study was 5.1 ± 1.3 kg. Traction procedure is described in Figure 2. Subjects who received EECP/traction therapy completed 35 sessions administered 1 session (1 hour) per day over 35 consecutive days. Ultrasound evaluation was performed with a color-coded duplex scanner (EME-4040, German). The equipment was calibrated by the manufacturers, assuring instrument reliability and validity. All patients underwent Doppler ultrasound evaluation by the same radiologist blinded to treatment type. TCD evaluations of the distal part of the VA and the proximal part of the BA were performed with a 2-MHz probe via the sub occipital window. This recording was made initially with the patient's head in neutral position. Later the subject turned his/her head slowly to the left at the angle of approximately 60° and extended at the angle of 30°. The head was fixed in this position and TCD evaluations of VA and BA were performed for at least 30 seconds. The same procedure was repeated in the opposite direction. Before treatment and after 35 sessions of EECP and/or traction, all patients received TCD examination of VA and BA both in a neutral cervical spine position and a rotational position. Fifty healthy volunteers from January 1, 2006 to February 28, 2006 also received TCD examination; their data are referred to as control. Peak velocity (Vp) and mean velocity (Vm) of blood flow and pulsatility index (PI) and resistance index (RI) of VA and BA were obtained. PI and RI can reflect arterial impedance.21Table 1. The Inclusion Criteria and Exclusion Criteria of This StudyFigure 1. Technique of EECP: a set of cuffs is wrapped around the calves, thighs, and buttocks. The cuffs are inflated sequentially during diastole, calves up. The pressure is released at the onset of systole. Inflation and deflation are timed according to the R wave on the patient's cardiac monitor.Figure 2. Technique of traction: continuous traction is performed. Patient is in supine and the angle of pull is set to 15° of flexion. The initial pull force is set to 3 kg, then incrementally adjusted upwards (up to 7 kg) to optimally reduce the patient's symptoms.Outcome EvaluationFollow-up was conducted by the same investigator blinded to treatment type within 3 days after completion of treatment and after 3 months. Outcome was determined by symptom- and sign-alleviated levels based on perceived recovery according to the global rating of change, which is a 15-point global rating scale ranging from −7 (a very great deal worse) to zero (about the same) to +7 (A very great deal better).22 Intermittent descriptors of worsening or improving symptoms are assigned values from −1 to −6 and +1 to +6, respectively.23 Patients who achieved a favorable change more than 6 (“A great deal better” or “A very great deal better”) were classified as having a successful outcome. Patients were required to report any adverse event they experienced.StatisticsWe used a paired t test to compare continuous variables between the patients and the volunteers, 1-way ANOVA tests to compare continuous variables between the 3 treatment groups and the healthy volunteers with Student-Newman-Keuls analysis for pairwise comparisons, and a χ2 test to compare categorical variables, as appropriate. All parametric results were expressed as mean ± SD for each group. A P value less than 0.05 was considered significant. SPSS 13.0 (Chicago, IL) was used to perform all the data analyses.ResultsBaseline InformationNo significant differences were seen in clinical characteristics or VA hemodynamics at baseline between treatment groups (Tables 2, 3, Figure 3). The mean age of the patients was 56 while that of the healthy volunteers was 58. Rotational reduction percentage of Vp of left VA in the patients is greater than that of the healthy volunteers (38 ± 11 vs. 14 ± 5, P < 0.01). Vm, PI, and RI of left VA, and all these parameters of right VA and BA showed the same tendency between patients and volunteers. All 163 patients had experienced drop attacks and vertigo; 93 patients experienced moderate to severe headache (33 in EECP + traction group, 29 in EECP group, 31 in traction group). Twenty patients had tinnitus (5 in EECP + traction group, 8 in EECP group, 7 in traction group), while 74 had nausea/vomiting (28 in EECP + traction group, 20 in EECP group, 24 in traction group).Table 2. Doppler Measurements of Vertebral Artery and Basilar Artery in Patients and Volunteers, at BaselineTable 3. Doppler Measurements of Vertebral Artery and Basilar Artery in Treatment Groups, at BaselineFigure 3. Rotational reduction percentage of blood flow velocity (Vp, Vm) and increased percentage of PI and RI of LVA in treatment groups and volunteers at baseline, 3 days follow-up and 3 months follow-up. Significant differences were seen between treatment groups both at 3 days and 3 months follow-up (P < 0.01). A, Vp, Rotational reduction percentage of Vp; (B) Vm, Rotational reduction percentage of Vm; (C) PI, Rotational increased percentage of PI; (D) RI, Rotational increased percentage of RI.Outcome of Follow-up Within 3 DaysIn the EECP + traction group, 47 (84%) patients had a successful outcome. In the EECP group, 32 (61%) patients achieved a successful outcome, whereas in the traction group, only 8 (15%) patients had a successful outcome. Significant differences were seen between treatment groups (P < 0.01).In the EECP + traction and EECP groups, left VA, right VA, and BA hemodynamics showed significant improvement, while in traction group little improvement was seen (P > 0.05, vs. pretreatment). In the EECP + traction group, the improved levels of rotational reduction percentage of blood flow velocity (Vp, Vm) of left VA (32%–20%, 32%–21%), right VA (30%–19%, 30%–20%), and BA (29%–19%, 30%–19%) were more significant than those of patients in the EECP group (29%–24%, 29%–25%), (31%–25%, 30%–24%), (30%–24%, 29%–24%); increased percentage of PI and RI was brought down more than that in the EECP group. The improved levels of hemodynamic parameters in EECP group were significantly more than that in traction group (P < 0.01). Compared with 50 healthy volunteers, patients in EECP + traction group still showed impaired rotational flow velocity (Vp, Vm) and increased arterial impedance (PI, RI) (P < 0.01). (Table 4, Figure 3).Table 4. Doppler Measurements of Vertebral Artery and Basilar Artery in Treatment Groups, at Follow-up Within 3 DaysOutcome of 3-Month Follow-upIn the EECP + traction group, 43 of 47 patients who achieved successful outcome at follow-up within 3 days still reported successful outcome, and 2 of 9 patients who failed the treatment reported favorable change more than 6, whereas in the EECP group 2 patients did not retain successful outcome and 4 patients experienced a new favorable change more than 6. However, in traction group, only 3 patients still reported successful outcome, and no new successful outcome cases were reported. In sum, 45 (80%) patients in the EECP + traction group, 34 (64%) in the EECP group, and 3 (6%) in the traction group achieved successful outcome. Significant differences were also seen between treatment groups (P < 0.01).In the EECP + traction and EECP groups, left VA, right VA, and BA hemodynamics still showed significant improvement, while in the traction group no significant improvement was seen (vs. pretreatment). In the EECP + traction group, the improved levels of rotational reduction percentage of Vp and Vm of left VA (32%–21%, 32%–21%), right VA (30%–19%, 30%–19%), and BA (29%–20%, 30%–20%) were more significant than those of patients in the EECP group (29%–25%, 29%–25%), (31%–25%, 30%–26%), (30%–24%, 29%–24%); decline of increase percentage of PI and RI was greater than that in EECP group (P < 0.01). Similar differences were also seen between EECP group and traction group (P < 0.01). Patients in the EECP + traction and EECP groups still showed rotational flow velocity impairment and arterial impedance increase compared with healthy volunteers (P < 0.01). Results are shown in Table 5 and Figure 3.Table 5. Doppler Measurements of Vertebral Artery and Basilar Artery in Treatment Groups, at 3-Month Follow-upAdverse EventsIn each group, no major adverse events were reported. EECP treatment and traction treatment were well tolerated. Five patients in the EECP + traction group and 4 patients in the EECP group developed minor skin eruption (contact dermatitis), which were cured by topical steroid cream. Two patients in the EECP + traction group and 3 patients in the EECP group experienced mild leg pain, while 3 patients in the EECP + traction group and 5 patients in the traction group experienced mild toothache. Pain was well tolerated and relieved spontaneously with passage of time.DiscussionIn this study, we found that EECP and traction therapy can increase rotational VA blood flow and relieve symptoms in patients with rotational VBI secondary to cervical spondylosis. The efficacy of EECP + traction therapy is far better than EECP or traction therapy individually. With head rotation, the percentage of reduction of blood flow velocities of vertebrobasilar artery in patients is much greater than that in healthy volunteers. After treatment, rotational blood flow velocity was partly restored in each treatment group.No similar clinical trials regarding the efficacy of EECP on rotational VBI secondary to cervical spondylosis or on cervical spondylosis have been performed. EECP is generally selected as a treatment of choice for patients with ischemic vascular diseases. In a review article, Manchanda and Soran proved that EECP is safe and effective for patients with refractory angina, with a clinical response rate averaging 70% to 80%, which is sustained up to 5 years, and for patients with coexisting heart failure, by improving quality of life, exercise capacity and left ventricular function long-term.24 Our study shows a little higher clinical response rate in patients with rotational VBI secondary to cervical spondylosis, with approximately 85% patients who received EECP + traction therapy reporting excellent to good satisfaction of symptom relief and about 65% patients receiving EECP treatment experiencing excellent to good satisfaction. We reported only relatively immediate outcomes of EECP treatment, so long-term outcomes are not available to compare. Due to limited funds and some other reasons, we still could not take out 2 year or longer follow-up. Further multicenter long-term randomized clinical trials are needed to confirm our results. The mechanism of the benefits of EECP may be due to reducing arterial stiffness and improving wave reflection characteristics.25 Werner et al reported that during EECP the posterior tibial artery showed a second early diastolic antegrade flow and a reverse end-diastolic flow caused by the cuff inflation and deflation respectively, and these flow changes caused a 4-fold increase of the PI, thus increasing shear-stress-related improvement of endothelial function.26 EECP augments diastolic and reduces systolic blood pressures and improves blood flow in various organ systems.27 On average, EECP decreased systolic blood pressure (baseline systolic blood pressure >110 mm Hg), but for patients with low baseline systolic blood pressure (<110 mm Hg), EECP increased systolic blood pressure,28 which may produce favorable effects for patients. EECP increases blood atrial natriuretic peptide,29 and the cGMP production, which regulates vascular smooth muscle tone and this increase, may improve arterial function by activating the nitric oxide-dependent pathways.30 Casey et al reported that 35 sessions of EECP decreased circulating levels of proinflammatory biomarkers, including plasma tumor necrosis factor-alpha, monocyte chemoattractant protein-1, and soluble vascular cell adhesion molecule-1.31 Marthol et al reported that EECP does not compromise cerebral auto regulation and, therefore, bears no cerebrovascular risks,32 whereas Alexandrov et al demonstrated that EECP induced marked changes in cerebral arterial waveforms and augmented peak diastolic and mean middle cerebral artery flow velocities on TCD.33 According to our findings, EECP actually benefits cerebral blood flow greatly. The compression of the lower-extremity vascular bed would increase diastolic pressure and flow and increase venous return, creating a strong retrograde counter pulse in the arterial system, forcing freshly oxygenated blood toward the heart. EECP increases blood flow velocity and decreases PI and RI of the vertebrobasilar artery, and improves symptoms via improvement in endothelial function, enhancement of ventricular function, and improvement in oxygen consumption.Cervical traction is a conservative intervention frequently used for the treatment of cervical spondylosis, though the efficacy and mechanisms are not well known.34 In a retrospective study of 58 outpatients, Swezey et al reported that seated cervical traction using an over-the-door pulley support with attached weights provided symptomatic relief in 81% of patients with mild to moderately severe cervical spondylosis syndromes.35 However, Graham et al recently reviewed 7 selected randomized controlled trials (total participants = 958), but found no clear evidence to support or refute the efficacy or effectiveness of continuous or intermittent traction for pain reduction, improved function, or global perceived effect in patients with chronic neck disorders.36 We noted less than 15% of patients in the traction group with a successful outcome, which may be attributed to a high threshold for defining “success” and our selected subgroup of patients. In the EECP + traction group, 84% of patients reported successful outcomes, whereas in the EECP group, 61% patients achieved successful outcomes, which implies that EECP therapy has synergistic effects with traction therapy. We found that in EECP + traction group, 8 out of 11 patients (73%) who did not improve at the 3-month follow-up had large spondylotic osteophytes projecting from the vertebral joints adjacent to the foramen transversarium compressing VA, whereas 3 of 45 successful patients (7%) had these kinds of spondylotic osteophytes (P < 0.01); 9 of 11 patients (82%) with failure outcomes had severe baseline rotational VA blood flow reduction (>40%), whereas 5 of 45 successful patients (11%) had over 40% baseline rotational VA blood flow reduction (P < 0.01). These may be 2 factors that contribute to failure of treatment of these patients. We suspect that other factors, such as comorbidity, anomaly of VA courses, may also be responsible, however, more studies should be taken out to determine whether these factors involved. Physiologic effects of cervical traction may involve the increase of the intervertebral disc space, widening of the intervertebral foramen, the relaxation of the back musculature, distraction and gliding of the facet joints, and stretching of the spinal ligaments.37,38 A transitory increase in physiologic range of motion of the cervical spine occurs following the application of intermittent cervical traction.39 An in vivo imaging study reveals that there was an average increase of 5.81%, 16.56%, and 18.9% in the foraminal area and an average increase of 3.75%, 8.67%, and 10.43% in foraminal height in healthy volunteers after cervical traction at 5, 10, and 15 kg, respectively, according to studying the cervical magnetic resonance images taken at the neutral position.40 Vertebral separation and intervertebral foramen widening could remove direct pressure or contact forces from compromised vertebral arteries and thus bring the partial relief of VBI symptoms. These physiologic effects of cervical traction may enhance the effects of EECP, thus making EECP + traction so effective. However, to reveal the exact mechanism why combination of the cervical traction and EECP is so much more effective, further studies, such as using dynamic computed tomography angiography or magnetic resonance angiography to study VA courses and blood flow, and lab experiments to examine the biologic effects of this therapy are needed.ConclusionIn conclusion, we found solid evidence to recommend the routine use of EECP therapy on patients with rotational VBI resulting from cervical spondylosis to increase rotational VA blood flow and to relieve symptoms. Those patients may further benefit from combined traction therapy. For those patients who react favorably to EECP therapy should consider extra courses of EECP, and those who react negatively should be referred to further investigation or invasive procedures. Further long-term investigations should be taken out to confirm these results.Key Points * EECP and traction therapy can relieve the symptoms of rotational vertebrobasilar insufficiency, improve the rotational reduction of vertebrobasilar blood flow, and reduce the increased arterial impedance. * EECP and traction therapy proves to be an effective noninvasive therapy to treat rotational vertebrobasilar insufficiency caused by cervical spondylosis. * EECP therapy should be used routinely on patients with rotational VBI resulting from cervical spondylosis to increase rotational vertebral artery blood flow and to relieve symptoms.References1. Tatlow WF, Bammer HG. Syndrome of vertebral artery compression. Neurology 1957;7:331–40. [Context Link]2. Cloud GC, Markus HS. Diagnosis and management of vertebral artery stenosis. QJM 2003;96:27–34. [CrossRef] [Full Text] [Medline Link] [Context Link]3. Vilela MD, Goodkin R, Lundin DA, et al. 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Link]3914085ovid.com:/bib/ovftdb/00007632-201007010-0000200151592_2008_8_619_liu_quantitative_|00007632-201007010-00002#xpointer(id(R40-2))|11065213||ovftdb|SL001515922008861911065213P93[CrossRef]10.1016%2Fj.spinee.2007.04.016ovid.com:/bib/ovftdb/00007632-201007010-0000200151592_2008_8_619_liu_quantitative_|00007632-201007010-00002#xpointer(id(R40-2))|11065405||ovftdb|SL001515922008861911065405P93[Medline Link]17697801Enhanced external counterpulsation (EECP) and traction therapy can relieve the symptoms of rotational vertebrobasilar insufficiency, improve the rotational reduction of vertebrobasilar blood flow, and reduce the increased arterial impedance. The efficacy of EECP + traction therapy is far better than EECP or traction therapy individually, and proves to be effective treatment.Enhanced External Counterpulsation and Traction Therapy Ameliorates Rotational Vertebral Artery Flow Insufficiency Resulting From Cervical SpondylosisXin, Wang MD, PhD; Fangjian, Guo MD; Hua, Wang MD, PhD; Jiangtao, Xie MD, PhD; Shouyi, Wang MM; Yingchun, Zhao MM; Xiong, Li MD, PhDRandomized Trial1535