【作者】 刘鉴慰；

【导师】 张家维；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2009， 博士

【摘要】 1文献研究针灸是祖国医学十分重要的组成部分,长期的临床实践证明了针灸治疗的有效性。针灸在中国的临床应用已有数千年,但在西方只是近些年才被逐渐接受。针灸临床疗效的报道可能吸引患者的就医,但其作用机制却一直不明,这限制了针灸被主流医学的接受。经络腧穴是针灸学的理论基础,由于其存在和作用机制一直未被实验医学所证实,因此在国外医学界也未得到广泛承认。近年来,可以实时反应脑功能区受到特定刺激时的活动状态的无创性的功能性磁共振成像(functional magnetic resonanceimaging,fMRI)的出现为这一研究提供了很有效的手段。脑功能研究是目前国际上研究的热点之一,现在对于人脑功能的研究主要集中在对人脑的高级认知功能的研究上。21世纪被许多科学家称为“生物科学、脑科学的百年”。在上一个世纪末欧美和日本的“脑十年”研究计划推动之下,对人脑认知功能及其神经机制进行多学科、多层次的综合研究已经成为当代科学发展的主流方向之一。西方几乎所有著名的大学都设有脑科学或认知科学研究机构,不少西方发达国家在各自的国家科学战略计划中对于脑、认知和行为的研究进行了重点部署。在人脑的认知功能研究当中,合理的设计实验、科学的对数据进行分析是取得可靠实验结果的保证。从上个世纪九十年代以来,应用于脑功能研究的脑功能成像技术得到了广泛的应用和长足发展。脑功能成像技术最大的优点就是无损伤,可以直接对人脑进行反复的非侵入性观察。不同的功能成像技术各有其优缺点,其中fMRI以其高空间分辨率的特点在人脑功能研究领域占据了重要的地位。随着近些年磁共振成像技术的不断发展,fMRI在人脑的功能研究领域中的应用越来越广泛,也越来越重要。血氧水平依赖性磁共振脑功能成像是目前应用最为广泛的神经成像方法。fMRI具有无创、无放射,时间、空间分辨率高、成像快速、造价相对较低,可在同一被试上多次重复等诸多优点,已成为脑功能成像的一个核心工具。该技术通过给被试一定的刺激,同时观察大脑皮层各个功能区的活动,结合功能和解剖成像,可以在活体上观察认知、情绪等心理过程。近十余年来,fMRI技术已被国内外广泛应用于视觉、听觉方面的研究,也被用于思维、情感等高级认知方面的研究,其研究结果已获得国际上普遍的认可。针灸的研究近年也逐渐增多。许多fMRI研究结果表明穴位的刺激激活的脑功能区与针灸文献所描述的相关。因此,应用fMRI研究针刺穴位的脑部反应就有可能阐释针灸的神经机制,从而促进针灸与现代医学的融合。2实验研究目的神门穴是手少阴心经的原穴,是临床治疗认知障碍的主要常用穴。中医理论认为,心主神。也就是说,神门穴在理论上和临床上都与认知密切相关。但其作用机制尚不明确。有很多fMRI论文讨论了针灸潜在的治疗效果,也有神门穴的相关研究。但fMRI目前还较少应用于捻转刺激和非捻转刺激的比较,以及同一解剖位置的穴位之间的比较。本研究通过观察fMRI,明确在针刺刺激相同解剖位置的不同经穴、假穴和不同刺激的脑功能激活。比较神门穴和养老穴,神门穴和假穴,捻转刺激与非捻转刺激神门穴所激活的脑功能区的不同。本研究旨在通过fMRI来研究刺激神门穴的特征性脑激活区,阐明刺激神门穴和脑激活的关系。较全面地反映针刺刺激神门穴影响脑功能区的作用。方法选取健康青年志愿者12例,男女各半。按随机区组原则,每个受试者按随机次序均给以针刺右侧的神门、养老穴、假穴,采用组块模式(静息阶段与刺激阶段交替出现、重复3次,分为3个组块)。刺激为手法捻转行针(捻转角度180°,频率1.5Hz)或不捻针。fMRI的主要参数为:TR/TE/FA=3560 ms/50ms/90°。采用VAS评价针刺的感觉。扫描后图像使用SPM2进行后处理,采用组分析,分别观察校正象的激活情况(FWE,0.05,K≥10),和非校正象的激活情况(None,0.001,K≥10)。结果(1)针刺捻转时,操作者指下均有得气感;所有受试者也均有“酸、麻、重、胀”的得气感。受试者的VAS评分各组差别无统计学意义(P＞0.05);(2)各穴功能像经过组分析后激活图见附录。根据各穴激活图、激活坐标的情况,非校正象的激活有可能增加了阳性结果;(3)各穴的激活区情况(组分析,corrected,0.05,K≥10)。神门穴主要激活了右侧额叶的中央后回BA2、BA1,左侧额下回BA47和中央后回BA43,其次为右侧顶叶的顶下小叶BA40,左侧颞叶的颞上回BA22,右侧脑岛BA40;养老穴主要激活了左顶叶的顶下小叶BA40,右侧额叶的额下回BA45、BA46,其次为左侧颞中回、颞下回BA37,左额上回BA10。(4)神门穴主要激活了右侧额叶的中央后回BA2、BA1,左侧额下回BA47和中央后回BA43,其次为右侧顶叶的顶下小叶BA40,左侧颞叶的颞上回BA22,右侧脑岛BA40;而假穴没有激活脑功能区。(5)刺激神门穴主要激活了右侧额叶的中央后回BA2、BA1,左侧额下回BA47和中央后回BA43,其次为右侧顶叶的顶下小叶BA40,左侧颞叶的颞上回BA22,右侧脑岛BA40;而非捻转刺激神门穴没有激活脑功能区。结论心经的神门穴和同水平的养老穴激活区明显不同,而假穴和非刺激神门穴没有激活脑功能区。而穴位的这种激活,是与本经的循行、本经属络脏腑以及本经络与他经经络、脏腑联系密切相关。揭示了针刺穴位可影响脑的功能而发挥作用。更多还原

【Abstract】 1 Literature researchAcupuncture is an important component of Traditional Chinese Medicine.Its validity has been proved by long-term clinical practices.Acupuncture have been used for thousands of years in China,but were accepted in the West only recently.Reports of patient improvement may be sufficient to persuade the health care consumer but failure to completely demonstrate mechanism which limits the acceptance of acupuncture in mainstream medicine.The meridian and acupoints are the foundation of acupuncture.It has not been widely accepted in the world because the existence and mechanisms of acupoint still need to be proved by completely laboratory and clinical experiments.In recent years, noninvasive functional magnetic resonance imaging(fMRI) that can provide detailed information in mapping of brain function in real time has been generally accepted for. acupuncture research as strong tools.The research of human brain function is one of the popular focuses internationally nowadays,which is mainly concentrated on the brain senior cognitive function presently. 21 centuries has been called as have been known as a century of bio-science or brain science by many scientists.In the last century,"brain decade" plans of Europe,the United States and Japan promote multi-disciplinary and multi-level research that has become the mainstream of the scientific development of contemporary one of cognitive function in the human brain and its neural mechanisms.There are cognitive brain sciences or scientific research institutions in almost all the well-known Western universities.Many western developed countries focused on the deployment of brain and cognitive and behavioral research in their national strategic plan for science.Within this research,the reasonable experimental design and scientific data analysis guarantee the reliable results.Since the 1990s,brain functional imaging techniques are widely applied and extensively developed.The best virtue of these techniques is non-invasive.Besides,It enable us to have direct looks into the brain repeatedly without physical damage.These techniques have their own prominence in the different aspects of temporal and spatial resolutions,but fMRI hold a very important station in brain functional study because of its high spatial resolution.The application of fMRI is more and more important in the research of human brain function with the constant development of magnetic resonance imaging.fMRI based on the BOLD(Blood Oxygenation Level Dependent) signal is currently the most widely used neuroimaging technique,fMRI is non-invasive,free of radioactive materials,with high spatial/temporal resolution and fast imaging acquisition,relatively less expensive,and can be applied on the same subject multiple times and has become one of the key tools in functional brain imaging.Through presenting participants with predefined stimuli,this technique allows observation of the activity in multiple brain areas simultaneously.It combines both functional imaging with anatomical imaging,making it possible to observe mental activity in cognitive and emotional processing in living systems.Inthe recent ten years,fMRI technology has been widely used in domestic and international visual,auditory research,and has also been used to thinking,emotion and other aspects of cognition research.Its findings have been recognized internationally.In recent years,research acupuncture has gradually increased.Many results obtained demonstrate the correlation between activation of specific areas of brain cortices and corresponding acupoint stimulation predicted by ancient acupuncture literature.Therefore, fMRI studies of brain response to acupuncture points may explain the neural mechanisms of acupuncture,and so as to promote the integration of modern medicine.2 Experimental studyObjectiveShenmen point(H7) that is often used to treat cognitive impairment is original point on the hand shao yin heart channel.Chinese medicine theory holds that heart govern spirit. In other words,Shenmen point is closely related with the cognitive in theory and clinical points.However,the physiological mechanisms of this application are still not clear.There are a lot of papers to discuss the mechanisms underlying the effects of acupuncture.There is also related research of Shenmen point.But to the best of our knowledge,fMRI has little been previously applied to study different stimulating such as twisting and non-twisting, and different point located in the same level of anatomy.In this study,we compared the brain activation on fMRI between Shenmen and Yanglao point(S16),Shenmen and nonpoint,and twisting and non-twisting in different meridian channels respectively at the same volunteer.It is the purposes of the present study to characterize the cerebral cortex activation by stimulating Shenmen using fMRI,and elucidate the relationship between stimulating Shenmen and the reaction of cerebral speech cortex.It will reflect comprehensively role of affecting the brain function by stimulating acupuncture Shenmen point.MethodsTwelve healthy young cases were enrolled in this research.According to the randomized block principle,each subject were given to the acupuncture at right Shenmen, Yanglao or nonpoint,based on the sequence of random number table.A block design including three blocks which baseline and stimulation appear alternately was adapted.In stimulation phase,the needle was twisted manually(1.5HZ,180°for 35.6ms) or not twisted. Main parameter in fMRI were TR/TE/FA=3560ms/50ms/90°.Acupuncture sensation was evaluated by means of visual analog scale(VAS).Scanned images were analyzed using SPM2.The result from Group analysis was corrected(FEW,0.05,K≥10) or uncorrected (None,0.001,K≥10).Results(1) There was a feeling of Deqi in operator and "sour,numbness,heavy,distend" in patient when needle was twisted.There was no difference in VAS score of the subjects in each group(P＞0.05);(2) Activation map from group analysis refer to appendix.According to the situation to activate map and coordinates the activation of,the activation of non-correction was likely to increase the positive results;(3) Result of activation domain(group analysis,corrected,0.05,K≥10).Right postcentral gyrus of frontal lobe(BA2,BA1),left inferior frontal gyrus(BA47),postcentral gyrus(BA43),right inferior parietal lobule(BA40),left superior temporal gyrus(BA22) and right insular(BA13) were evoked by twisting Shenmen point;Left inferior parietal lobule(BA40),right inferior frontal gyrus(BA45,BA46),left medial temporal gyrus and medial temporal gyrus(BA37) and left superior frontal gyrus(BA10) were evoked by twisting Yanglao point.(4) Right postcentral gyrus of frontal lobe(BA2,BA1),left inferior frontal gyrus (BA47),postcentral gyrus(BA43),right inferior parietal lobule(BA40),left superior temporal gyrus(BA22) and right insular(BA13) were evoked by twisting Shenmen point; But there were not evoked by acupuncture at nonpoint.(5) Right postcentral gyrus of frontal lobe(BA2,BA1),left inferior frontal gyrus (BA47),postcentral gyrus(BA43),right inferior parietal lobule(BA40),left superior temporal gyrus(BA22) and right insular(BA13) were evoked by twisting Shenmen point; But there were not evoked by nontwisting Shenmen.ConclusionThere were obviously different in area evoked by between twisting Shenmen point and Yanglao point.Besides,there were not evoked by nontwisting Shenmen or twisting nonpoint.Activation of twisting point is closely related with the internal organs as well as the course of the channels and collaterals.It revealed that acupuncture can play a role by means of affecting the function of the brain.更多还原