滚法推拿作用的动态压力特征研究
摘要
研究背景
推拿是中医临床学科中的一门古老的传统外治法,也是人类最早的自然治疗方法之一。因具有简便、舒适、有效、安全的特性和独特的疗效正日益引起临床的重视。推拿具有疏通经络、行气活血,理筋整复、滑利关节,调整脏腑功能、增强抗病能力等作用。其临床应用范围广泛,有骨伤科、内科、妇科、外科、儿科、神经科等科病症。临床上,进行推拿治疗时,医生多是根据患者的反应以及自己的临床经验进行推拿治疗,使得手法的临床使用存在着一定的盲目性和随意性。虽然推拿临床应用范围广泛,但它毕竟是一种外力作用于人体,如果操作不当,则有可能造成伤害。因此,对推拿手法进行研究,以规范推拿手法的安全操作,提高疗效,是推拿学科所面临的紧迫问题。
众所周知,推拿手法刺激量是影响临床疗效的关键因素之一。为了揭示推拿手法的本质和特点,在20世纪50年代到60年代,相继开展了推拿生理作用及治疗机制的初步研究。20世纪80年代以来,推拿学科在与各个相关学科相互交叉、相互渗透,研究范围不断扩大。推拿手法力的研究大都围绕着力的大小、方向和作用点这三个要素展开。这些研究为推拿手法量化、规范化及标准化的研究奠定了理论基础。对手法的要求在教材中只是定性的提出了“有力、均匀、柔和、持久、深透”这十个字,没有提出各类推拿手法操作的具体参数。作为一种物理的力学刺激,推拿手法具有推拿强度、持续时间和频率与速度等的要素。手法直接作用于体表的力只有达到一定强度才会产生有效的反应即临床疗效。因此,手法有力是操作者必须具备的条件之一。术者要根据治疗对象、施术部位、手法性质和病证虚实以及患者的体质而变化应用,并借以调整力的大小,施加恰当的手法力。故用力的基本原则是既保持疗效,又要避免产生不良反应。周信义教授依据手法的力度,并估计手法所能达到的大体层次,将手法分为5类：轻度手法、较轻手法、中度手法、重度手法、特重手法。有作者将治疗部位的皮肤到骨骼的距离分为10层,皮肤表面为0层,骨骼为10层,其间分别为1-9层,将每种手法的操作力度用层数来表示,即所谓的“分层理论”。但这些分类没有具体的量化标准,实施起来难以把握。因此,更多的研究集中在推拿手法刺激量参数测定和推拿手法刺激量等方面。
为完成推拿数据的采集和分析,从上世纪80年代初起国内开始了推拿手法刺激量参数采集设备的研制。最早王国才等研制开发了推拿手法力学信息测录系统。在此基础,建立了中医推拿力学信息计算机处理系统。而与此同时,上海中医学院与同济大学合作研制出推拿手法测定仪。许世雄等在原推拿手法测定仪的结构基础上进一步改进,研制了FZ-1型中医推拿手法测力分析仪,利用手法操作时作用力三维显示的实时描述对手法的技术特征从力学的角度进行了描述。随后的推拿手法测定仪研制,其信号输出线与二道生理记录仪相连,它借助二道生理仪,可直观地看到手法电信号的强弱波形图谱,可对手法的力量、速度、频率的变化,通过波形的特征加以分析。后续研究设计出测力平台与测力手套相结合的在体手法测量系统。该系统应用电子万能测试机对传感器进行标定,使得测量精度可精确到1mg,能在手法治疗的同时将手法施力不同部位的力的大小、形态做一记录,并可真实、客观地应用数字及图形表示,同时可对治疗过程进行累计定量。此外,还可得到一定时间内各点作用力的时序、频率及能量累积量。近些年,国外一些高科技的压力传感器检测系统陆续被引入以及国内的一些科研开发创新,使得推拿手法的检测内容更为丰富和精确。这些技术设备使推拿手法从单纯被感知,发展到具体可视,不同维度的力的动态波形描述以及实时显示,从而实现了手法操作过程的客观监测和手法质量优劣的客观评价。通过研究分析,可以提示被测手法特定式的动力学参数,如频率和手法的动力学参数的最佳组合模式以及最佳推拿时间等。了解产生手法动作形式的动作结构,使手法动力学研究从定性向定量化和直观化方面迈进了一大步,对推动推拿手法动力学研究进程大有裨益,也为探索推拿手法标准化提供了新的研究方法和途径。
通过研究得出推拿手法科学施力应包括：(1)最佳着力点部位的选择；(2)腧穴或治疗部位应有足够“强”的峰值力；(3)相关组织周围足够多的冲量值；(4)所选腧穴间距离的长短及其所处解剖部位的差异；(5)最佳手法频率；(6)治病所需最佳冲量值；(7)旋转手法操作的关键力学参数包括作用力、加速度、作用时间、位移及扳动冲量及其相互关系等。研究均指出推拿手法刺激量与手法的作用部位、手法的着力面、作用力的大小、方向及持续时间等因素相关。近年来手法的规范化研究大多根据手法运动生物力学的研究成果,以揭示手法动作的运动学、动力学规律和原理,再结合应用人体运动的“动作结构”原理来构建手法技术规范的标准和内涵。
但推拿手法刺激量研究尚存在不完善之处：第一,目前研究推拿手法刺激量参数的规律只是局限于滚法等少数几个手法上,对这样采集的数据进行分析与处理的结果,并不能全面地说明问题。第二,推拿手法测定大多数都是对手法进行电信号解释,以波形图谱的方式来对手法的力量、节奏、频率、周期等要素进行综合测评,而且至今这种综合测评也没有一个统一、权威的标准,即什么样的电信号和波形图谱才是正确的电信号和波形图谱。第三,利用手法测定仪器测试手法刺激量参数时,大部分是脱离病人进行手法测试,忽视了被操作对象的体质、病症、部位等临床因素,加之影响推拿手法频率范围因素还有手法运动的特异性、操作者的生理条件及治疗目的等。因此,较难具体指出推拿手法刺激量参数的大小范围。所得出的结论有些就显得欠缺临床意义。
推拿手法的种类繁多,但无论何种手法,都是以力的形式表现出来的,其最终是要作用于人体,以适宜的手法刺激量作用于患者的体表局部而达到治疗目的。而适宜手法的界定,以往是以“有力、均匀、柔和、持久、深透”来要求的,缺乏推拿力学和刺激量等方面的确切参数,也缺少来自被推拿者方面的客观评价指标。
滚法是丁季峰先生在继承家传一指禅推拿手法的基础上所创的推拿法[3,4],以其科学的操作方法、广泛的适应性及良好的临床效果,既继承了一指禅手法均匀柔和的特性,又增加了治疗面积大、刺激力量强的优点。滚法是用手掌尺侧面的背部及掌指关节背侧突起处,在操作部位做来回翻掌、旋转的动作。其具有体表接触面积大、刺激力量强而且又十分柔和的特征,主要用于治疗运动系统和周围神经系统疾病。
多年来由于对手法量效关系研究匮乏,缺乏实验研究的客观量化的操作标准作指导,滚法操作方式呈现多样性,临床滚法使用存在盲目性、随意性。并且滚法连最基本特征都较少有客观量化的可信研究。操作者多根据患者的反应以及自己的临床经验大致判断手法的量与操作时间,长此以往严重地影响了医者对手法的深入了解和使用,妨碍了疗效的进一步提高。临床上盲目加大手法力量、延长治疗时间,以寻求提高疗效的现象极为普遍。揭示推拿手法的本质和特点,对其进行定性、定量的分析研究,观察手法操作过程中物理量的变化特点,建立量化、规范化的推拿手法实验研究已成为中医推拿界急需解决的重要课题。
Novel动态压力分布测量系统(Novel pliance mobile system, NPMS)是德国慕尼黑NOVELgmbh生产的库容传感器动态压力测试系统。该系统是专为医疗、人体工程学和生物力学等的测试而设计的。此系统能同步测量和实时显示动态压力分布,软件数据采集后几个测量过程能够在同一屏幕上比较,显示压力与时间、垂直方向力与时间和接触面积与时间的数值。我们使用pliance-M expert S2020,将其引入用于中医推拿滚法的压力测量,发现其是一个较理想的研究滚法的工具。本实验继承本教研室课题“滚法推拿作用的接触面积与图像研究”,进行滚法推拿作用的动态压力特征研究,以期为滚法刺激量的规范化和量化提供实验依据,为推拿学科提供新的研究方法。
目的
引入Novel动态压力分布测量系统来研究推拿滚法,以阐明滚法推拿作用的压力、压强、压力中心轨迹和压力峰型特征,并比较不同年资的推拿操作者滚法动态压力特征的异同,为临床应用和初学者学习滚法提供量化、规范化和客观化的实验依据。
方法
将推拿学生和医师(均接受过正规推拿手法培训)按推拿学习和工作年限分为3组。即A组：初年资者,即初学推拿的学生,学习并运用滚法少于3年者,并自认为滚法掌握一般或较差者；B组：中年资者,即学习和掌握并运用滚法3-8年者,并自认为滚法掌握较好、好；C组：高年资者,即学习和掌握并运用滚法8年以上者,主要是从事推拿临床和教学多年的老师,并自认为滚法掌握好、极好者。A组20人,B组10人,C组5人,共35人,均为男性。
将NPMS各端口联接紧密,打开Novel软件,进行压力感受器调整与校正,每次数据收集前进行Novel软件校正。部分设置如下：Scanning Rate为38.000frames/sec; Baud Rate为115200Baud;CUT-OFF/COLOR COPE为>0.200N/cm; X-edge为1.250；Y-edge为1.250；Area为1563cm2;Time/frame为13.333ms。
滚法操作者二天内不做剧烈运动、无大量饮酒,数据采集前先休息30分钟,期间用自制推拿操作者信息采集表收集操作者的相关信息。将内置有压力传感器的压力垫平放于硬质办公桌上,每位受试者先将滚法操作要领熟悉一遍,然后用利手(此35名操作者均为右侧利手)在压力垫上试滚法操作1分钟。然后分别操作2分钟,收集数据。手法的操作严格按照推拿专著中的要求进行。计算机实时显示操作者每次按压手法的最大压力、接触面积等信息。
结果
1操作者的基本情况A组均为在校研究生,本科专业为中医类,系统地正规学习过推拿。年龄22-26岁,平均23.95岁；身高162～180cm,平均169.70cm,体重50～70kg,平均61.35kg,学习并运用滚法时间为1～3年,平均为2.65年。B组为在校研究生、临床推拿与康复医师和部分年轻推拿教师,本科专业为中医类,系统地正规学习过推拿。年龄23～29岁,平均25.60岁；身高165～182cm,平均171.30cm,体重61～81kg,平均65.40kg,学习并运用滚法时间为3～7年,平均4.80年。C组为从事推拿临床和教学多年的教师,年龄31～47岁,平均39.50岁；身高167～178cm,平均171.80cm,体重70～78kg,平均72.80kg,学习并运用推拿时间为12～25年,平均18.40年。3组受试者基本情况行统计分析,行方差齐性检验,其中年龄、体重、从事时间方差不齐；其余身高、前臂长、第五掌指关节至腕横纹长、掌横纹处周径方差齐。三组间比较,A组和B组年龄差异无显著性,无统计学意义(P>0.05),A组和C组之间,B组和C组之间示差异具有显著性,有统计学意义(P<0.05)(Tamhane检验)。三组间体重比较,A组和C组差异无显著性,无统计学意义(P>0.05),A组和B组之间,B组和C组之间示差异具有显著性,有统计学意义(P<0.05)(L-SD检验)。三组间从事时间比较,A组和B组之间,B组和C组之间,A组和C组之间,示差异具有显著性,有统计学意义(P<0.05)(Tamhane检验)。其余指标三组之间比较示差异无统计学意义(P>0.05)。
2总体压力和压强平均最大/最小压力为各组中每位操作者出现的最大/最小压力值的和,再除以每组人数。平均最大压强为各组中每位操作者出现的最大压强值的和,再除以每组人数；平均压强为为各组中每位操作者的平均压强值的和,再除以每组人数。A组平均最大压力、平均最小压力、平均最大压强和平均压强分别为28.28±11.69N、3.89±6.58N、7.91±2.98N/cm2和2.93±1.95N/cm2;B组分别为29.15±9.96N、5.79±13.05、9.42±4.67N/cm2和3.35±2.87N/cm2;C组分别为38.43±5.97N、7.97±12.11N、8.61±4.78N/cm2和4.05±3.88N/cm2；全体分别为29.98±10.91N、5.02±9.42N、8.44±3.73N/cm2和3.21±2.50N/cm2。
3压力中心轨迹NPMS实时显示滚法动态压力分布的压力中心。各个时间点的压力中心叠合则形成压力中心轨迹。将各个组别、各个滚法操作者做一个比较,按压力中心轨迹的形态分为4种,即Ⅰ长条形、Ⅱ心形、Ⅲ椭圆形和Ⅳ不规则形。A组中Ⅰ、Ⅱ、Ⅲ和Ⅳ型例数分别为7、7、3和3；B组中Ⅰ、Ⅱ、Ⅲ和Ⅳ例数分别为3、2、3和2；C组中Ⅰ、Ⅱ、Ⅲ和Ⅳ型例数分别为2、3、0和0。A、B和C组中Ⅰ长条形和Ⅱ心形之和所占各组比例分别为70%、50%、100%。35人中,Ⅰ长条形12例,占34.29%；Ⅱ心形12例,占34.29%；Ⅲ椭圆形6例,占17.14%；Ⅳ不规则形5例,占14.29%。
4压力峰型按压力三维图像上显示的压力的峰的数量和类型分类,分为4型,即Ⅰ单主峰型、Ⅱ双主峰型、Ⅲ多主峰型和Ⅳ主峰不明显型。A组中Ⅰ、Ⅱ、Ⅲ和Ⅳ型例数分别为3、6、8和3；B组中Ⅰ、Ⅱ、Ⅲ和Ⅳ例数分别为1、2、3和4；C组中Ⅰ、Ⅱ、Ⅲ和Ⅳ例数分别为1、0、0和4。3组中Ⅰ单主峰型、Ⅱ双主峰型、Ⅲ多主峰型和Ⅳ主峰不明显型分别为5例、8例、11例、11例,比例分别为14.29%、22.86%、31.43%、31.43%。A、B和C组中Ⅰ单主峰型和Ⅳ主峰不明显型之和分别占各组的30%、50%、100%。
结论
Novel系统可很好显示滚法操作的图像和面积特征,是研究滚法较理想的量化依据和测试工具。实验为滚法的直观显示和标准化及量化提供了科学依据。
1滚法的压力和压强本试验中,ABC各组平均最大压力分别为28.28±11.69N、29.15±9.96N和38.43±5.97N,为A组 2压力中心轨迹和压力峰型(1)本试验将压力中心轨迹分为Ⅰ长条形、Ⅱ心形、Ⅲ椭圆形和Ⅳ不规则形,其中以Ⅰ和Ⅱ最多,并且C组全是Ⅰ和Ⅱ型。因此我们有理由认为Ⅰ长条形和Ⅱ心形是滚法操作较好的压力中心轨迹。(2)将压力峰型分为Ⅰ单主峰型、Ⅱ双主峰型、Ⅲ多主峰型和Ⅳ主峰不明显型,A、B和C组中Ⅰ单主峰型和Ⅳ主峰不明显型之和分别占各组的30%、50%、100%,依次增高。因此我们认为Ⅰ单主峰型和Ⅳ主峰不明显型是滚法操作较好的压力峰型。
Research background
Manipulation is a old external therapy of traditional Chinese medicine (TCM) in clinical disciplines, on which clinical workers are increasingly attracted attention at home and abroad for its unique efficacy and specialty of simplicity, comfort, effectiveness, safety. With the characteristics of dredging meridians, accelerating circulation of qi and blood, restoration of muscle, lubricating joints, adjusting internal organs function, enhancing disease resistance and so on, manipulation is widely applied in clinical disease such as orthopedic, internal medicine, gynecology, surgery, pediatrics, neurology and other subjects. As a natural therapy without drug side effects and invasiveness, it can emerge some abnormalities when there are operation mistake or patients are in inappropriate posture. And then these accidents can minor interference the effective of manipulation, or serious harm the human body or even threaten patients'life. So advancing the correctness and security is a key for teaching and clinical practice of manipulation. Experimental study has been very lagging behind in this field. Since1980s, the massage science got faster growth with the cross and penetration between the basic crossing subjects and it. And the study scope was expanded from human trials to animal experiments, from the clinical curative effect to the function mechanism of manipulation.
Rolling manipulation was created by Ding Ji-feng who inherited the basis of pushing manipulation with one finger, which inherited the softness and increased the advantages of large treatment area and strong stimulation. Rolling manipulation is to roll and rotate on operation place using ulnaris flank of palm back and back protuberance of metacarpophalangeal joints. And it is mainly used in the treatment of sports system and peripheral nervous system diseases.
For many years because of lack of research on dose-response relationship of manipulation and lack of objective quantification research for operating standards for guidance, the pattern of rolling manipulation presented diversity and clinical using exsisted blindness and arbitrariness. Even the most basic characteristics were lacking of creditable objective quantitative research. That doctor estimated the quantity and time of manipulation by patients'reaction and their clinical experiences has seriously impeded understanding and applying of the technique and has hampered further improveing of the curative effect. It is common to augmenting manipulation strength and prolonging treatment time blindly to enhance the curative effect. Revealing the essence and characteristics, analysing it qualitatively and quantitatively, surveying the characteristics of changing of physical quantity in operation, to establish the quantizing and normalized experiment research on manipulation, has proved to be an important issue that should be resolved immediately by massage/manipulation discipline of traditional Chinese medicine (TCM).
Novel pliance mobile system (NPMS) was manufactured by NOVELgmbh of Munich of Germany, which was dynamic stress test system of capacitative sensors. The pliance mobile is a dynamic pressure distribution measuring system for capacitative sensors. The system is designed for a variety of testing use including medical, ergonomics and biomechanics applications. NPMS was one of the three system (pliance, pedar emed) that was developed to measure the contact pressure of multiple ensemble surface.(1)Structure and working principle Novel was based upon calibration, accurate and reliable capacitive sensor. Every sensor was elastic and was arranged according to matrix, that can attached to the three-dimensional surface. Sensor array was connect to the Novel pliance electronic devices.(2)Analysis of data acquisition and processing Measurement and real-time display of dynamic stress can be synchronized. These data of stress, contact area and time can be displayed on the screen at the same comparison after data acquisition. Process includes the calculation of center of pressure, force and area of the curve derivation and so on. Stress analysis can be online or off offline by a computer or handheld computer to complete.(3)Applied range This system is used in recommended temperature0-40°C, humidity20-80%. Novel system can measure the relatively soft surface pressure mainly in these field such as aircraft and car seats, office chairs and wheelchairs. We used the pliance-M expert S2020, and introduced it to massage pressure measurements and found it was an ideal tool for rolling manipulation.
Objective
To introduce Novel pliance mobile system to research rolling manipulation to clarify the characteristics of the image and area of rolling manipulation. And to compare the similarities and differences of the image and area of different operators. To provide a quantitative standardized and objective-oriented basis for clinical doctors and beginners to learn rolling manipulation.
Methods
Medical students and physicians who had received formal training in manipulation of TCM were divided into3groups by learning and work experience of manipulation. Group A, the juniors, who are beginners of massage students, study and apply the rolling manipulation less than3years and grasp the rolling manipulation generally and inferiorly. Group B, the intermediates, who study and apply the rolling manipulation from3to8years, grasp the rolling manipulation well and superiorly. Group C, the seniors, who study and apply the rolling manipulation more than8years, grasp the rolling manipulation superiorly and were teachers who had been engaging in clinical manipulation physician and teaching massage for many years. There were20,10and5participants separately in group A, B and C, a total of35participants.
And then connected the ports of NPMS closely, turned on the software of Novel, adjusted and corrected the pressure sensors. The software of Novel should be adjusted before data collectiog every time. Parts of the setup were as follows. Scanning Rate was38.000frames/sec, Baud Rate was115200Baud, CUT-OFF/COLOR COPE was≥0.200N/cm, X-edge was1.250, Y-edge was1.250, Area was1.563cm2, Time/frame was13.333ms。
Manipulators who did not exercise strenuously and drink heavily within two days before experiment should have30-minute break before data collectiog. Their informations were collected when they were at rest by checksheet. Every manipulators, who then firstly were familiar with essentials again, manipulated tentatively on the mat for1minute which was on desk flatwise, and then manipulated for2minutes. The manipulating was in strict accordance with requirements on massage monograph. The maximum compression pressure, contact area and other informations for each operator were real-time display in computer. The collected data were processed and analysed by intrinsic software and SPSS13.0.
Results
1. Fundamental informations about manipulators Manipulators of group A were all graduate students in school, who were major in traditional Chinese medicine and systematically studied the regular massage from undergraduate school. They were22-26years old, averaging24.08years old,162-180cm height, averaging169.75cm, 50-70kg weight, averaging59.58kg, who had been studying and applying the rolling manipulation less than3years, averaging2.58years.Manipulators of group B were all graduate students in school and clinical manipulation and rehabilitation physicians or teachers, who were major in traditional Chinese medicine and systematically studied the regular massage from undergraduate school. They were23-29years old, averaging25.33years old,165-182cm height, averaging171.50cm,61-70kg weight, averaging66.33kg, who had been studying and applying the rolling manipulation from3to8years, averaging4.33years.And group C were all teachers who had been engaging in clinical manipulation physician and teaching massage from12to25years, averaging18.5years.. They were31-47years old, averaging39.5years old,167-178cm height, averaging171.75cm,70-78kg weight, averaging73.25kg.
2. Area of rolling manipulation The result of average total area was group B>group C>group A, the difference between the maximum and minimum area was group B>group A>group C, the average maximum area was group B>group C> group A, the average minimum area was group C>group A>group B. Minimum of area in group A and B was0, which meant there existed jump when they were manipulating.
3. The whole image of rolling manipulating The whole image was the overall image of the operation for2minutes, that was classified according to three kinds of methods:①the pressure uniformity,②the overall image morphology and③pressure image patterns over3N/cm2. Images can be classified to4types according to the pressure uniformity:the type I of very uneven pressure, the type II of uneven pressure, the type III of lack of uneven pressure, the type Ⅳ of even pressure.Images also can be classified to5types according to the overall image morphology:the type I of squareness, the type II of triangle, the type III of shape of q, the type IV of strip and the type V of irregular.Images can be classified to5 types according to pressure image patterns over3N/cm2:the type Ⅰ of a big monoblock, the type Ⅱ of a small monoblock, the type Ⅲ of2roughly equal block, the type Ⅳ of2unequal block and the type Ⅴ of multi-block. Ratio of the type Ⅰ of very uneven pressure, the type Ⅱ of uneven pressure were40%、70%and100%seperately in group A, B and C according to①the pressure uniformity. Majority was the type Ⅲ of shape of q in group A, the type Ⅰ of squareness and the type Ⅱ of triangle in group B, the type Ⅲ of shape of q and the type Ⅰ of squareness in group C seperately according to②the overall image morphology. Majority was the type Ⅰ of a big monoblock all in the3group according to pressure image patterns over3N/cm2that was40%、30%、60%in group A, B and C seperately.
4. The images of each stages of rolling manipulation The images of each stages of rolling manipulation was the pressure image collected by pressure sensors at intervals of every0.04seconds (adjustable), and these images composed a continuous rolling screen when playing. NPMS can instantly display dynamically the changes of the pressure and image of rolling manipulation. That richness of images transformation of group A was less than group B and C meant that action was blunt and lack of alternating in group A. Transformations of image, area and pressure in group B were bigger than in group A and C. Numerical value transformations of area and pressure were moderate in group C.
Conclusion
Novel system provided an ideal quantifying basis and testing tool to research rolling manipulation which can wonderfully display the characteristics of images and area of rolling manipulation. This experiment provided scientific basis for the visual displaying and standardization and quantification of rolling manipulation. The result of average total area was group B>group C>group A. The difference between the maximum and minimum area was group B> group A> group C. In a cycle the average maximum area was group B>group C>group A, the average minimum area was group C>group A>group B. But it can not concluded that the biger or the smaller was better as to average total area because of. multitudinous factors that can inflect the average total area. That minimum of area in group A and B was0, which meant there existed jump when they were manipulating, was a objectiveevidence that manipulaters in group A and B did not grasp manipulation masterly. NPMS can instantly display dynamically the images changes of rolling manipulation. Ratio of the type I of very uneven pressure, the type Ⅱ of uneven pressure were40%,70%and100%seperately in group A, B and C according to①the pressure uniformity. Majority was the type III of shape of q in group A, the type I of squareness and the type II of triangle in group B, the type III of shape of q and the type I of squareness in group C seperately according to②the overall image morphology. Majority was the type I of a big monoblock all in the3group according to pressure image patterns over3N/cm2that was40%、30%、60%in group A, B and C seperately. All of these meant that group A was worse than group B, and group B was worse than group C as to the proficiency and fluency of manipulation. The images in manipulating were different forms so all the images can be classified capitally. That richness of images transformation of group A was less than group B and C meant that action was blunt and lack of alternating in group A as to the images of each stages of rolling manipulation. Transformations of image, area and pressure in group B were bigger than in group A and C. Numerical value transformations of area and pressure were moderate in group C,which meant the manipulation in group C was better than in group B and C.
推拿是中医临床学科中的一门古老的传统外治法,也是人类最早的自然治疗方法之一。因具有简便、舒适、有效、安全的特性和独特的疗效正日益引起临床的重视。推拿具有疏通经络、行气活血,理筋整复、滑利关节,调整脏腑功能、增强抗病能力等作用。其临床应用范围广泛,有骨伤科、内科、妇科、外科、儿科、神经科等科病症。临床上,进行推拿治疗时,医生多是根据患者的反应以及自己的临床经验进行推拿治疗,使得手法的临床使用存在着一定的盲目性和随意性。虽然推拿临床应用范围广泛,但它毕竟是一种外力作用于人体,如果操作不当,则有可能造成伤害。因此,对推拿手法进行研究,以规范推拿手法的安全操作,提高疗效,是推拿学科所面临的紧迫问题。
众所周知,推拿手法刺激量是影响临床疗效的关键因素之一。为了揭示推拿手法的本质和特点,在20世纪50年代到60年代,相继开展了推拿生理作用及治疗机制的初步研究。20世纪80年代以来,推拿学科在与各个相关学科相互交叉、相互渗透,研究范围不断扩大。推拿手法力的研究大都围绕着力的大小、方向和作用点这三个要素展开。这些研究为推拿手法量化、规范化及标准化的研究奠定了理论基础。对手法的要求在教材中只是定性的提出了“有力、均匀、柔和、持久、深透”这十个字,没有提出各类推拿手法操作的具体参数。作为一种物理的力学刺激,推拿手法具有推拿强度、持续时间和频率与速度等的要素。手法直接作用于体表的力只有达到一定强度才会产生有效的反应即临床疗效。因此,手法有力是操作者必须具备的条件之一。术者要根据治疗对象、施术部位、手法性质和病证虚实以及患者的体质而变化应用,并借以调整力的大小,施加恰当的手法力。故用力的基本原则是既保持疗效,又要避免产生不良反应。周信义教授依据手法的力度,并估计手法所能达到的大体层次,将手法分为5类：轻度手法、较轻手法、中度手法、重度手法、特重手法。有作者将治疗部位的皮肤到骨骼的距离分为10层,皮肤表面为0层,骨骼为10层,其间分别为1-9层,将每种手法的操作力度用层数来表示,即所谓的“分层理论”。但这些分类没有具体的量化标准,实施起来难以把握。因此,更多的研究集中在推拿手法刺激量参数测定和推拿手法刺激量等方面。
为完成推拿数据的采集和分析,从上世纪80年代初起国内开始了推拿手法刺激量参数采集设备的研制。最早王国才等研制开发了推拿手法力学信息测录系统。在此基础,建立了中医推拿力学信息计算机处理系统。而与此同时,上海中医学院与同济大学合作研制出推拿手法测定仪。许世雄等在原推拿手法测定仪的结构基础上进一步改进,研制了FZ-1型中医推拿手法测力分析仪,利用手法操作时作用力三维显示的实时描述对手法的技术特征从力学的角度进行了描述。随后的推拿手法测定仪研制,其信号输出线与二道生理记录仪相连,它借助二道生理仪,可直观地看到手法电信号的强弱波形图谱,可对手法的力量、速度、频率的变化,通过波形的特征加以分析。后续研究设计出测力平台与测力手套相结合的在体手法测量系统。该系统应用电子万能测试机对传感器进行标定,使得测量精度可精确到1mg,能在手法治疗的同时将手法施力不同部位的力的大小、形态做一记录,并可真实、客观地应用数字及图形表示,同时可对治疗过程进行累计定量。此外,还可得到一定时间内各点作用力的时序、频率及能量累积量。近些年,国外一些高科技的压力传感器检测系统陆续被引入以及国内的一些科研开发创新,使得推拿手法的检测内容更为丰富和精确。这些技术设备使推拿手法从单纯被感知,发展到具体可视,不同维度的力的动态波形描述以及实时显示,从而实现了手法操作过程的客观监测和手法质量优劣的客观评价。通过研究分析,可以提示被测手法特定式的动力学参数,如频率和手法的动力学参数的最佳组合模式以及最佳推拿时间等。了解产生手法动作形式的动作结构,使手法动力学研究从定性向定量化和直观化方面迈进了一大步,对推动推拿手法动力学研究进程大有裨益,也为探索推拿手法标准化提供了新的研究方法和途径。
通过研究得出推拿手法科学施力应包括：(1)最佳着力点部位的选择；(2)腧穴或治疗部位应有足够“强”的峰值力；(3)相关组织周围足够多的冲量值；(4)所选腧穴间距离的长短及其所处解剖部位的差异；(5)最佳手法频率；(6)治病所需最佳冲量值；(7)旋转手法操作的关键力学参数包括作用力、加速度、作用时间、位移及扳动冲量及其相互关系等。研究均指出推拿手法刺激量与手法的作用部位、手法的着力面、作用力的大小、方向及持续时间等因素相关。近年来手法的规范化研究大多根据手法运动生物力学的研究成果,以揭示手法动作的运动学、动力学规律和原理,再结合应用人体运动的“动作结构”原理来构建手法技术规范的标准和内涵。
但推拿手法刺激量研究尚存在不完善之处：第一,目前研究推拿手法刺激量参数的规律只是局限于滚法等少数几个手法上,对这样采集的数据进行分析与处理的结果,并不能全面地说明问题。第二,推拿手法测定大多数都是对手法进行电信号解释,以波形图谱的方式来对手法的力量、节奏、频率、周期等要素进行综合测评,而且至今这种综合测评也没有一个统一、权威的标准,即什么样的电信号和波形图谱才是正确的电信号和波形图谱。第三,利用手法测定仪器测试手法刺激量参数时,大部分是脱离病人进行手法测试,忽视了被操作对象的体质、病症、部位等临床因素,加之影响推拿手法频率范围因素还有手法运动的特异性、操作者的生理条件及治疗目的等。因此,较难具体指出推拿手法刺激量参数的大小范围。所得出的结论有些就显得欠缺临床意义。
推拿手法的种类繁多,但无论何种手法,都是以力的形式表现出来的,其最终是要作用于人体,以适宜的手法刺激量作用于患者的体表局部而达到治疗目的。而适宜手法的界定,以往是以“有力、均匀、柔和、持久、深透”来要求的,缺乏推拿力学和刺激量等方面的确切参数,也缺少来自被推拿者方面的客观评价指标。
滚法是丁季峰先生在继承家传一指禅推拿手法的基础上所创的推拿法[3,4],以其科学的操作方法、广泛的适应性及良好的临床效果,既继承了一指禅手法均匀柔和的特性,又增加了治疗面积大、刺激力量强的优点。滚法是用手掌尺侧面的背部及掌指关节背侧突起处,在操作部位做来回翻掌、旋转的动作。其具有体表接触面积大、刺激力量强而且又十分柔和的特征,主要用于治疗运动系统和周围神经系统疾病。
多年来由于对手法量效关系研究匮乏,缺乏实验研究的客观量化的操作标准作指导,滚法操作方式呈现多样性,临床滚法使用存在盲目性、随意性。并且滚法连最基本特征都较少有客观量化的可信研究。操作者多根据患者的反应以及自己的临床经验大致判断手法的量与操作时间,长此以往严重地影响了医者对手法的深入了解和使用,妨碍了疗效的进一步提高。临床上盲目加大手法力量、延长治疗时间,以寻求提高疗效的现象极为普遍。揭示推拿手法的本质和特点,对其进行定性、定量的分析研究,观察手法操作过程中物理量的变化特点,建立量化、规范化的推拿手法实验研究已成为中医推拿界急需解决的重要课题。
Novel动态压力分布测量系统(Novel pliance mobile system, NPMS)是德国慕尼黑NOVELgmbh生产的库容传感器动态压力测试系统。该系统是专为医疗、人体工程学和生物力学等的测试而设计的。此系统能同步测量和实时显示动态压力分布,软件数据采集后几个测量过程能够在同一屏幕上比较,显示压力与时间、垂直方向力与时间和接触面积与时间的数值。我们使用pliance-M expert S2020,将其引入用于中医推拿滚法的压力测量,发现其是一个较理想的研究滚法的工具。本实验继承本教研室课题“滚法推拿作用的接触面积与图像研究”,进行滚法推拿作用的动态压力特征研究,以期为滚法刺激量的规范化和量化提供实验依据,为推拿学科提供新的研究方法。
目的
引入Novel动态压力分布测量系统来研究推拿滚法,以阐明滚法推拿作用的压力、压强、压力中心轨迹和压力峰型特征,并比较不同年资的推拿操作者滚法动态压力特征的异同,为临床应用和初学者学习滚法提供量化、规范化和客观化的实验依据。
方法
将推拿学生和医师(均接受过正规推拿手法培训)按推拿学习和工作年限分为3组。即A组：初年资者,即初学推拿的学生,学习并运用滚法少于3年者,并自认为滚法掌握一般或较差者；B组：中年资者,即学习和掌握并运用滚法3-8年者,并自认为滚法掌握较好、好；C组：高年资者,即学习和掌握并运用滚法8年以上者,主要是从事推拿临床和教学多年的老师,并自认为滚法掌握好、极好者。A组20人,B组10人,C组5人,共35人,均为男性。
将NPMS各端口联接紧密,打开Novel软件,进行压力感受器调整与校正,每次数据收集前进行Novel软件校正。部分设置如下：Scanning Rate为38.000frames/sec; Baud Rate为115200Baud;CUT-OFF/COLOR COPE为>0.200N/cm; X-edge为1.250；Y-edge为1.250；Area为1563cm2;Time/frame为13.333ms。
滚法操作者二天内不做剧烈运动、无大量饮酒,数据采集前先休息30分钟,期间用自制推拿操作者信息采集表收集操作者的相关信息。将内置有压力传感器的压力垫平放于硬质办公桌上,每位受试者先将滚法操作要领熟悉一遍,然后用利手(此35名操作者均为右侧利手)在压力垫上试滚法操作1分钟。然后分别操作2分钟,收集数据。手法的操作严格按照推拿专著中的要求进行。计算机实时显示操作者每次按压手法的最大压力、接触面积等信息。
结果
1操作者的基本情况A组均为在校研究生,本科专业为中医类,系统地正规学习过推拿。年龄22-26岁,平均23.95岁；身高162～180cm,平均169.70cm,体重50～70kg,平均61.35kg,学习并运用滚法时间为1～3年,平均为2.65年。B组为在校研究生、临床推拿与康复医师和部分年轻推拿教师,本科专业为中医类,系统地正规学习过推拿。年龄23～29岁,平均25.60岁；身高165～182cm,平均171.30cm,体重61～81kg,平均65.40kg,学习并运用滚法时间为3～7年,平均4.80年。C组为从事推拿临床和教学多年的教师,年龄31～47岁,平均39.50岁；身高167～178cm,平均171.80cm,体重70～78kg,平均72.80kg,学习并运用推拿时间为12～25年,平均18.40年。3组受试者基本情况行统计分析,行方差齐性检验,其中年龄、体重、从事时间方差不齐；其余身高、前臂长、第五掌指关节至腕横纹长、掌横纹处周径方差齐。三组间比较,A组和B组年龄差异无显著性,无统计学意义(P>0.05),A组和C组之间,B组和C组之间示差异具有显著性,有统计学意义(P<0.05)(Tamhane检验)。三组间体重比较,A组和C组差异无显著性,无统计学意义(P>0.05),A组和B组之间,B组和C组之间示差异具有显著性,有统计学意义(P<0.05)(L-SD检验)。三组间从事时间比较,A组和B组之间,B组和C组之间,A组和C组之间,示差异具有显著性,有统计学意义(P<0.05)(Tamhane检验)。其余指标三组之间比较示差异无统计学意义(P>0.05)。
2总体压力和压强平均最大/最小压力为各组中每位操作者出现的最大/最小压力值的和,再除以每组人数。平均最大压强为各组中每位操作者出现的最大压强值的和,再除以每组人数；平均压强为为各组中每位操作者的平均压强值的和,再除以每组人数。A组平均最大压力、平均最小压力、平均最大压强和平均压强分别为28.28±11.69N、3.89±6.58N、7.91±2.98N/cm2和2.93±1.95N/cm2;B组分别为29.15±9.96N、5.79±13.05、9.42±4.67N/cm2和3.35±2.87N/cm2;C组分别为38.43±5.97N、7.97±12.11N、8.61±4.78N/cm2和4.05±3.88N/cm2；全体分别为29.98±10.91N、5.02±9.42N、8.44±3.73N/cm2和3.21±2.50N/cm2。
3压力中心轨迹NPMS实时显示滚法动态压力分布的压力中心。各个时间点的压力中心叠合则形成压力中心轨迹。将各个组别、各个滚法操作者做一个比较,按压力中心轨迹的形态分为4种,即Ⅰ长条形、Ⅱ心形、Ⅲ椭圆形和Ⅳ不规则形。A组中Ⅰ、Ⅱ、Ⅲ和Ⅳ型例数分别为7、7、3和3；B组中Ⅰ、Ⅱ、Ⅲ和Ⅳ例数分别为3、2、3和2；C组中Ⅰ、Ⅱ、Ⅲ和Ⅳ型例数分别为2、3、0和0。A、B和C组中Ⅰ长条形和Ⅱ心形之和所占各组比例分别为70%、50%、100%。35人中,Ⅰ长条形12例,占34.29%；Ⅱ心形12例,占34.29%；Ⅲ椭圆形6例,占17.14%；Ⅳ不规则形5例,占14.29%。
4压力峰型按压力三维图像上显示的压力的峰的数量和类型分类,分为4型,即Ⅰ单主峰型、Ⅱ双主峰型、Ⅲ多主峰型和Ⅳ主峰不明显型。A组中Ⅰ、Ⅱ、Ⅲ和Ⅳ型例数分别为3、6、8和3；B组中Ⅰ、Ⅱ、Ⅲ和Ⅳ例数分别为1、2、3和4；C组中Ⅰ、Ⅱ、Ⅲ和Ⅳ例数分别为1、0、0和4。3组中Ⅰ单主峰型、Ⅱ双主峰型、Ⅲ多主峰型和Ⅳ主峰不明显型分别为5例、8例、11例、11例,比例分别为14.29%、22.86%、31.43%、31.43%。A、B和C组中Ⅰ单主峰型和Ⅳ主峰不明显型之和分别占各组的30%、50%、100%。
结论
Novel系统可很好显示滚法操作的图像和面积特征,是研究滚法较理想的量化依据和测试工具。实验为滚法的直观显示和标准化及量化提供了科学依据。
1滚法的压力和压强本试验中,ABC各组平均最大压力分别为28.28±11.69N、29.15±9.96N和38.43±5.97N,为A组
Research background
Manipulation is a old external therapy of traditional Chinese medicine (TCM) in clinical disciplines, on which clinical workers are increasingly attracted attention at home and abroad for its unique efficacy and specialty of simplicity, comfort, effectiveness, safety. With the characteristics of dredging meridians, accelerating circulation of qi and blood, restoration of muscle, lubricating joints, adjusting internal organs function, enhancing disease resistance and so on, manipulation is widely applied in clinical disease such as orthopedic, internal medicine, gynecology, surgery, pediatrics, neurology and other subjects. As a natural therapy without drug side effects and invasiveness, it can emerge some abnormalities when there are operation mistake or patients are in inappropriate posture. And then these accidents can minor interference the effective of manipulation, or serious harm the human body or even threaten patients'life. So advancing the correctness and security is a key for teaching and clinical practice of manipulation. Experimental study has been very lagging behind in this field. Since1980s, the massage science got faster growth with the cross and penetration between the basic crossing subjects and it. And the study scope was expanded from human trials to animal experiments, from the clinical curative effect to the function mechanism of manipulation.
Rolling manipulation was created by Ding Ji-feng who inherited the basis of pushing manipulation with one finger, which inherited the softness and increased the advantages of large treatment area and strong stimulation. Rolling manipulation is to roll and rotate on operation place using ulnaris flank of palm back and back protuberance of metacarpophalangeal joints. And it is mainly used in the treatment of sports system and peripheral nervous system diseases.
For many years because of lack of research on dose-response relationship of manipulation and lack of objective quantification research for operating standards for guidance, the pattern of rolling manipulation presented diversity and clinical using exsisted blindness and arbitrariness. Even the most basic characteristics were lacking of creditable objective quantitative research. That doctor estimated the quantity and time of manipulation by patients'reaction and their clinical experiences has seriously impeded understanding and applying of the technique and has hampered further improveing of the curative effect. It is common to augmenting manipulation strength and prolonging treatment time blindly to enhance the curative effect. Revealing the essence and characteristics, analysing it qualitatively and quantitatively, surveying the characteristics of changing of physical quantity in operation, to establish the quantizing and normalized experiment research on manipulation, has proved to be an important issue that should be resolved immediately by massage/manipulation discipline of traditional Chinese medicine (TCM).
Novel pliance mobile system (NPMS) was manufactured by NOVELgmbh of Munich of Germany, which was dynamic stress test system of capacitative sensors. The pliance mobile is a dynamic pressure distribution measuring system for capacitative sensors. The system is designed for a variety of testing use including medical, ergonomics and biomechanics applications. NPMS was one of the three system (pliance, pedar emed) that was developed to measure the contact pressure of multiple ensemble surface.(1)Structure and working principle Novel was based upon calibration, accurate and reliable capacitive sensor. Every sensor was elastic and was arranged according to matrix, that can attached to the three-dimensional surface. Sensor array was connect to the Novel pliance electronic devices.(2)Analysis of data acquisition and processing Measurement and real-time display of dynamic stress can be synchronized. These data of stress, contact area and time can be displayed on the screen at the same comparison after data acquisition. Process includes the calculation of center of pressure, force and area of the curve derivation and so on. Stress analysis can be online or off offline by a computer or handheld computer to complete.(3)Applied range This system is used in recommended temperature0-40°C, humidity20-80%. Novel system can measure the relatively soft surface pressure mainly in these field such as aircraft and car seats, office chairs and wheelchairs. We used the pliance-M expert S2020, and introduced it to massage pressure measurements and found it was an ideal tool for rolling manipulation.
Objective
To introduce Novel pliance mobile system to research rolling manipulation to clarify the characteristics of the image and area of rolling manipulation. And to compare the similarities and differences of the image and area of different operators. To provide a quantitative standardized and objective-oriented basis for clinical doctors and beginners to learn rolling manipulation.
Methods
Medical students and physicians who had received formal training in manipulation of TCM were divided into3groups by learning and work experience of manipulation. Group A, the juniors, who are beginners of massage students, study and apply the rolling manipulation less than3years and grasp the rolling manipulation generally and inferiorly. Group B, the intermediates, who study and apply the rolling manipulation from3to8years, grasp the rolling manipulation well and superiorly. Group C, the seniors, who study and apply the rolling manipulation more than8years, grasp the rolling manipulation superiorly and were teachers who had been engaging in clinical manipulation physician and teaching massage for many years. There were20,10and5participants separately in group A, B and C, a total of35participants.
And then connected the ports of NPMS closely, turned on the software of Novel, adjusted and corrected the pressure sensors. The software of Novel should be adjusted before data collectiog every time. Parts of the setup were as follows. Scanning Rate was38.000frames/sec, Baud Rate was115200Baud, CUT-OFF/COLOR COPE was≥0.200N/cm, X-edge was1.250, Y-edge was1.250, Area was1.563cm2, Time/frame was13.333ms。
Manipulators who did not exercise strenuously and drink heavily within two days before experiment should have30-minute break before data collectiog. Their informations were collected when they were at rest by checksheet. Every manipulators, who then firstly were familiar with essentials again, manipulated tentatively on the mat for1minute which was on desk flatwise, and then manipulated for2minutes. The manipulating was in strict accordance with requirements on massage monograph. The maximum compression pressure, contact area and other informations for each operator were real-time display in computer. The collected data were processed and analysed by intrinsic software and SPSS13.0.
Results
1. Fundamental informations about manipulators Manipulators of group A were all graduate students in school, who were major in traditional Chinese medicine and systematically studied the regular massage from undergraduate school. They were22-26years old, averaging24.08years old,162-180cm height, averaging169.75cm, 50-70kg weight, averaging59.58kg, who had been studying and applying the rolling manipulation less than3years, averaging2.58years.Manipulators of group B were all graduate students in school and clinical manipulation and rehabilitation physicians or teachers, who were major in traditional Chinese medicine and systematically studied the regular massage from undergraduate school. They were23-29years old, averaging25.33years old,165-182cm height, averaging171.50cm,61-70kg weight, averaging66.33kg, who had been studying and applying the rolling manipulation from3to8years, averaging4.33years.And group C were all teachers who had been engaging in clinical manipulation physician and teaching massage from12to25years, averaging18.5years.. They were31-47years old, averaging39.5years old,167-178cm height, averaging171.75cm,70-78kg weight, averaging73.25kg.
2. Area of rolling manipulation The result of average total area was group B>group C>group A, the difference between the maximum and minimum area was group B>group A>group C, the average maximum area was group B>group C> group A, the average minimum area was group C>group A>group B. Minimum of area in group A and B was0, which meant there existed jump when they were manipulating.
3. The whole image of rolling manipulating The whole image was the overall image of the operation for2minutes, that was classified according to three kinds of methods:①the pressure uniformity,②the overall image morphology and③pressure image patterns over3N/cm2. Images can be classified to4types according to the pressure uniformity:the type I of very uneven pressure, the type II of uneven pressure, the type III of lack of uneven pressure, the type Ⅳ of even pressure.Images also can be classified to5types according to the overall image morphology:the type I of squareness, the type II of triangle, the type III of shape of q, the type IV of strip and the type V of irregular.Images can be classified to5 types according to pressure image patterns over3N/cm2:the type Ⅰ of a big monoblock, the type Ⅱ of a small monoblock, the type Ⅲ of2roughly equal block, the type Ⅳ of2unequal block and the type Ⅴ of multi-block. Ratio of the type Ⅰ of very uneven pressure, the type Ⅱ of uneven pressure were40%、70%and100%seperately in group A, B and C according to①the pressure uniformity. Majority was the type Ⅲ of shape of q in group A, the type Ⅰ of squareness and the type Ⅱ of triangle in group B, the type Ⅲ of shape of q and the type Ⅰ of squareness in group C seperately according to②the overall image morphology. Majority was the type Ⅰ of a big monoblock all in the3group according to pressure image patterns over3N/cm2that was40%、30%、60%in group A, B and C seperately.
4. The images of each stages of rolling manipulation The images of each stages of rolling manipulation was the pressure image collected by pressure sensors at intervals of every0.04seconds (adjustable), and these images composed a continuous rolling screen when playing. NPMS can instantly display dynamically the changes of the pressure and image of rolling manipulation. That richness of images transformation of group A was less than group B and C meant that action was blunt and lack of alternating in group A. Transformations of image, area and pressure in group B were bigger than in group A and C. Numerical value transformations of area and pressure were moderate in group C.
Conclusion
Novel system provided an ideal quantifying basis and testing tool to research rolling manipulation which can wonderfully display the characteristics of images and area of rolling manipulation. This experiment provided scientific basis for the visual displaying and standardization and quantification of rolling manipulation. The result of average total area was group B>group C>group A. The difference between the maximum and minimum area was group B> group A> group C. In a cycle the average maximum area was group B>group C>group A, the average minimum area was group C>group A>group B. But it can not concluded that the biger or the smaller was better as to average total area because of. multitudinous factors that can inflect the average total area. That minimum of area in group A and B was0, which meant there existed jump when they were manipulating, was a objectiveevidence that manipulaters in group A and B did not grasp manipulation masterly. NPMS can instantly display dynamically the images changes of rolling manipulation. Ratio of the type I of very uneven pressure, the type Ⅱ of uneven pressure were40%,70%and100%seperately in group A, B and C according to①the pressure uniformity. Majority was the type III of shape of q in group A, the type I of squareness and the type II of triangle in group B, the type III of shape of q and the type I of squareness in group C seperately according to②the overall image morphology. Majority was the type I of a big monoblock all in the3group according to pressure image patterns over3N/cm2that was40%、30%、60%in group A, B and C seperately. All of these meant that group A was worse than group B, and group B was worse than group C as to the proficiency and fluency of manipulation. The images in manipulating were different forms so all the images can be classified capitally. That richness of images transformation of group A was less than group B and C meant that action was blunt and lack of alternating in group A as to the images of each stages of rolling manipulation. Transformations of image, area and pressure in group B were bigger than in group A and C. Numerical value transformations of area and pressure were moderate in group C,which meant the manipulation in group C was better than in group B and C.
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