【作者】 蒋丽；

【导师】 符文彬；

【作者基本信息】 广州中医药大学 ， 针灸推拿， 2012， 博士

【摘要】 目的：1.通过与针刺非经非穴及安慰针对照,评价针刺四关穴对肝郁型抑郁症的临床疗效。2.从胞内AC-cAMP-PKA信号通路的影响探讨针刺抗抑郁的作用机制。方法：1.临床研究将符合纳入标准的108例受试者随机分为四关穴组、非经非穴组、安慰针组。四关穴组：取四关穴(双合谷、双太冲)针刺,先针合谷穴后针太冲穴。常规消毒后,将带有可伸缩针管的泡沫圈垫粘于穴位皮肤上,以0.35×40mm毫针放入针管内,垂直进针,刺破泡沫圈垫并刺入皮下,采取均匀提插手法,以得气为度。针刺完后留针30分钟。期间每隔15分钟行提插手法一次。非经非穴组：选取①手背面3,4掌骨中点之间,②足背面3跖骨中点外侧,第3,4跖骨之间,两对非经非穴点。针刺操作方法、留针时间同四关穴组。安慰针组：取穴同四关穴组,操作过程同四关穴组,但是采用安慰针具,即一次性钝头针,将其放入针管内,垂直进针,穿破泡沫圈垫后仅能刺激表皮,不穿透皮肤,拿捏针柄使针随针管伸缩如同提插动作。留针时针尖由泡沫圈垫固定,针体由针管固定,以保持针立于穴位上。调节伸缩针管使针外露部分有如针刺入皮下。以上治疗均在留针时,配合深呼吸以调气。每周共治疗3次,每次治疗间隔时间>24h,共治疗6周。分别在治疗前、治疗后2周、治疗后4周及治疗后6周分别采用汉密尔顿抑郁量表(HAMD)、抑郁自评量表(SDS)、中医症状改善量表进行疗效评价,并在治疗结束后2周时采用HAMD量表进行随访,结合严重不良反应记录进行安全性评估,运用卡方检验、秩和检验、方差分析等统计方法进行三组间对照,探讨各组疗效差异。2.实验研究体重200-250g的成年SD雄性大鼠56只,随机分为7组：空白组、模型组、电针组(合谷+太冲)、药物组(氟西汀)、电针+盐水组、电针+H89组及氟西汀+H89组,每组8只。空白组不给予任何处理；模型组共接受42天各种不同的应激从而造成长期不可预见性温和刺激模型；电针组在应激21天起造模的同时选取四关穴(合谷、太冲),用G6805Ⅱ型电针治疗仪的疏密波(2-20HZ,强度以大鼠肢体微颤为度)进行治疗。每日针刺一次,每次30分钟,左右交替进行,持续3周。药物组在应激21天起造模的同时,每天灌胃给药(按照1.8mg/kg给予氟西汀)一次,持续3周。电针+盐水组,造模后取穴、电针操作、治疗时间及疗程与电针组一致,但于每日行电针前30min行侧脑室注射生理盐水(NS)；电针+H89组,造模后取穴、电针操作、治疗时间及疗程与电针组一致,但于每日电针前30min行侧脑室注射PKA阻滞剂H89。氟西汀+H89组,同氟西汀组,但在给药前予侧脑室注射H89。分别在实验开始前、实验第14天、21天、42天,观察大鼠Opnfield行为学、糖水消耗量,并在实验结束后对大鼠海马内的AC转化率,cAMP含量及PKA的活性进行检测。结果：1.1临床研究1.1.1基线比较三组患者在性别、年龄、病程、病情、合并用药及合并镇静催眠药用量方面,经统计分析,均无显著性差异(P>0.05)；三组患者在治疗前HAMD量表、抑郁自评量表(SDS)评分以及抑郁症中医证候量表评分组间比较,差异均无统计学意义(P>0.05),可认为三组基线水平一致,具有可比性。1.1.2总有效率及显效率治疗后四关穴组的显效率为44.74%,总有效率为84.21%；非经非穴的显效率为14.71%,总有效率为67.65%；安慰针组的显效率为5.56%,总有效率为38.89%。三组疗效构成比较,组间差异有统计学意义(X2=16.0375,P<0.0167)。三组总有效率比较,组间差异无统计学意义(P>0.05),四关穴组显著高于安慰针组(P<0.05),但与非经非穴组比较,差异无统计学意义(P>0.05)。安慰针组的显效率与总有效率和非经非穴组相比,均无统计学差异(P>0.05,P>0.05)。三组显效率比较,四关穴组均极显著高于非经非穴组和安慰针组(X2=4.1649, P<0.0167; X2=9.0925, P=P<0.0167);1.1.3HAMD抑郁量表各因子评分三组在治疗后各时段的HAMD的焦虑/躯体化因子、阻滞因子、睡眠障碍5个因子的评分均较治疗前上升,差异均有统计学意义(P<0.05)；四关穴组和非经非穴组对各时间段的焦虑/躯体化因子、睡眠障碍因子改善程度均优于安慰针组。四关穴组对各时间段的阻滞因子改善程度均优于非经非穴组和安慰针组。四关穴组在治疗后4,6周时对认知障碍因子改善程度优于安慰针组(P<0.0167),在治疗6周时对体重因子改善程度优于安慰针组(P<0.0167)。1.1.4抑郁自评量表(SDS)评分在以抑郁自评量表(SDS)评分为测量指标的评价中,在治疗4周及6周时,四关穴组的疗效均显著优于非经非穴组和安慰针组(P<0.0167,P<0.0167)；而在治疗各时点,非经非穴组优于安慰针组,但差异无统计学意义(P>0.05)。1.1.5抑郁症中医症候评定量表在以抑郁症中医证候量表评分为测量指标的评价中,在治疗6周时,四关穴组的疗效均显著优于非经非穴组和安慰针组(P<0.0167,P<0.0167)；在治疗各时点,非经非穴组和安慰针组比较均无显著性差异(P>0.05)。1.1.6三组随访HAMD评分比较：在治疗结束后2周时,以HAMD量表随访一次。三组组间比较,差异有统计学意义(P<0.05),四关穴组HAMD评分均优于非经非穴组和安慰针组(P<0.05,P<0.05),而后两组HAMD评分组间比较不存在统计学差异(p>0.05)。各组分别与治疗6周时评分相比,均无显著性差异(P>0.05)。1.2实验研究1.2.1openfield行为学变化各组水平及垂直运动的基础值均无明显差异(P>0.05),具有可比性。在接受3周慢性应激后,各组造模大鼠的水平及垂直运动次数均显著下降,与空白组相比有显著性差异(P<0.05)；各造模组大鼠组间比较没有显著性差异(P>0.05)。治疗3周后,模型组大鼠水平及垂直运动显著低于空白组(P<0.05)；电针组、药物组及电针+盐水组的运动次数分别与模型组比较均有显著升高(P<0.05,P<0.05,P<0.05)；电针组与电针+盐水组比较,无显著性差异；电针+H89组水平运动次数显著下降,与模型组比较没有显著性差异(P>0.05)。1.2.2糖水消耗量变化应激前各组之间大鼠的糖水消耗量没有显著性差异(P>0.05)；应激第22天后,糖水消耗量造模组大鼠的糖水消耗量显著下降,与空白组比较有显著性差异(P<0.05)；在治疗3周后(应激第42天),电针组、药物组糖水消耗量有所增加,均较应激3周时有显著改善(F=3.215,P=0.0156; F=5.167,P=0.0035);电针组与电针+NS组糖水消耗量之间没有统计学差异(P>0.05)；而电针+H89组糖水消耗量持续下降,与电针组比较,差异有统计学意义(F=4.321,P=0.0021)1.2.3海马AC转化率,cAMP含量及PKA活性检测在实验结束时,抑郁症模型大鼠海马组织AC转化率、cAMP含量及PKA活性均显著降低,与空白组比较,差异有统计学意义(P<0.05)。药物和电针均可增加抑郁症模型大鼠海马组织AC转化率、cAMP含量及PKA活性,基本达到空白组水平。结论：1.针刺四关穴、非经非穴、安慰针治疗肝郁型抑郁症在减轻抑郁程度上均有一定疗效,但四关穴针刺较其他两组疗效更为显著且持久。2.针刺四关穴对于抑郁症HAMD量表各因子的改善疗效优于非经非穴位与安慰针具组,随着治疗时间的延长疗效更为显著。3.针刺四关穴能显著改善抑郁症大鼠的行为学,显著上调海马AC、PKA活性及cAMP含量,PKA阻滞剂H89可阻断针刺抗抑郁的作用,提示AC-cAMP-PKA受体后信号转导通路可能是针刺抗抑郁的重要途径和作用靶点之一。更多还原

【Abstract】 Objectives1.From a randomized, single blind and controlled trial, we explore the effectiveness and safety of acupuncture treatment of "Siguan" acupoints on depression of stagnation of liver-Qi type.2. To explore the mechanism of acupuncture for antidepressive effect on AC-cAMP-PKA postreceptor signal transduction pathway.Methods1. Clinical study108cases were randomized into the following groups:Siguan acupoints group, non-acupoint group and Streitberger needle group groug.Siguan acupoints group:Siguan points (bilateral Hegu (LI4) and Taichong(LR3)) were selected to received acupuncture. After sterilizing,0.35×40mm acupuncture needles were put through the needle pipe and vertically inserted below to the skin through the foam tray which was stick to the surface of the points. Manipulated the needle until de-qi was felt by the patient. Retained the needle for30min with needle manipulation once per15min.Non-acupoint group:Two points that correspond to Siguan points were located①on the dorsum of hand and between the middle of the3th and4th metacarpal bone;②on the3th lateral metatarsal bone on dorsum pedis, between the3th and4th metatarsal bone. Needle manipulation and retaining were similar to Siguan points group.Streitberger needle group:The selected points and the needle insertion procedure were similar as Siguan acupoints group, except that the tip of the needle was blunt and could not puncture into the skin. During the needle retaining, the needle was hold by the foam tray and the needle pipe and adjust the stretching pipe to keep the appearance of the placebo needle look like as inserted into the skin as the verum needle in Siguan points group.All the patients in the three groups were asked to deep breath to regulating qi during needle retaining and received3sessions weekly with total6weeks of treatment.The effects were evaluated by the HAMD Scales, the SDS Scales, and the improvement Scales of symptoms of Traditional Chinese Medicine before the treatment and4time points (at the end of2week,4week and6week) during the treatment course. ITT analysis were used for all the data analysis.2. Animal studyAdult Sprague-Dawley male rats (200-250g) were used in the present experiment. Animals were divided randomly into7groups:the control group, the model group, the electroacupuncture(EA) group and drug group, EA plus normal saline (NS)group, EA plus H89group and Fluo plus H89group;8rats in each group. The chronic mild stress model(CMS) of depression was induced by various kinds of stress for42days. In the model group, rats were exposed to chronic mild unpredictable mild stress for6weeks. In the EA group, rats receive CMS procedure and electroacupuncture stimulation at Siguan points (bilateral Hegu (LI4) and Taichong(LR3)) once every other day for3weeks after CMS exposure. In the drug group, rats receive the same treatment as the CMS group and Fluoxetine treatment everyday for3weeks after CMS. The groups plus H89/NS were conditioned with the same as the EA or Fluoxetine group except for the intracerebroventricular injection of H89between CMS and EA. Changes of open-field behavior, sucrose consumption, AC activity, cAMP level and PKA activity in hippocampus of rats were observed in the study.Result1.Clinical study1.1BaselineThe difference in terms of age, height, weight, disease duration, sex, educational level, occupation, living habits, history of western medicine taking or acupuncture treatment receiving among3groups is no significant (P>0.05); And, the difference of scores of HAMD scale, SDS scale and TCM syndrome rating scale among the three groups of depressed patients on baseline was not statistically significant(P>0.05), baseline level can be considered the same among the three groups and comparability. 1.2Total effective rate and excellence rateAfter6weeks of treatment, the total effective rate and the excellence rate of the3groups respectively were84.21%and44.74%in Siguan acupoints group,67.65%and14.71%in non-acupoint group,38.89%and5.56%in the Streitberger needle group. Compare the total effective rate of the3groups, there was a significant difference among the3groups (P<0.0167).1.3HAMD ScaleThe gross effective rate was higher and the HAMD Scale score was better in the Siguan acupoints group than that of the non-acupoint group and sham-acupuncture group (P<.05). The improvement of score of anxiety/somatization factor, body weight factor, cognitive handicap factor, blockage factor and the sleeping disorder factor in Siguan acupoints group was started on the2week during the treatment, and which was lasted to the end of the treatment.1.4SDS scaleThe SDS Score was better in the both acupuncture groups than that in the non-acupoint group and Streitberger needle group (P<0.0167, P<0.0167), however, no significant difference was found between the non-acupoint group and Streitberger needle group.1.5Improvement Scales of symptoms of Traditional Chinese MedicineThe Improvement Scales of symptoms of TCM Score was better in the both acupuncture groups than that in the non-acupoint group and Streitberger needle group (P<0.0167,P<0.0167), again, no significant difference between the non-acupoint group and Streitberger needle group.2. Animal study2.1Changes of openfield behaviorThe behavior (horizontal and vertical motion) of the depression rats decreased significantly following stress, and EA treatment as well as EA+NS can effectively improve it, which is better than that of the drug (P<0.05, P<.0.05, P<0.05). Enhanced effects induced by EA were reversed by H89pretreatment.2.2Changes of sucrose consumptionSucrose intake in all stress groups decreased significantly in the3rd week and was much less than the control group (P<0.05). However, there was no remarkable difference among all stress groups. EA or Fluoxetine treatment leaded to increase in sucrose intake in the sixth week, however, not indicating significant difference with CMS group. H89pretreatment inhibited obviously increase in sucrose intake induced by EA.2.3AC activity, cAMP level and PKA activityAnimals exposed to stressors also showed a significant decrease in the ratio of AC transformation after the last week when the experiment ended. In the EA group and Fluxitine group, the ratio of AC transformation increased significantly after EA treatment for3weeks compared to the CMS group. EA and Fluxitine can improved the level of AC transformation ratio in the hippocampus of rats to a level as of normal rats. Changes in cAMP level and PKA activity were similar to AC (P<0.05, P<0.05, P<0.05)Conclusion1. Acupuncture treatment of Siguan acupoints was effective and safe in treating depression.2. Acupuncture treatment of Siguan acupoints regulating liver showed a more obviously curative effect on all factors of depression after treatment when compared to non-acupoint group and Streitberger needle groug.3. Acupuncture could improve signif ieantly changes of the behavior, sucrose consumption, AC activity, cAMP level and PKA activity in hippocamp of rats, therefore, AC-cAMP-PKA postreceptor signal transduction pathway is an important approach and target of acupuncture in treating depression.更多还原