【作者】 甄俊平；

【导师】 柳澄；

【作者基本信息】 山东大学 ， 影像医学与核医学， 2007， 博士

【摘要】 目的利用磁共振成像（magnetic resonance imaging,MRI）平面回波序列（echo planar imaging,EPI）的血氧水平依赖（blood oxygenation leveldependent,BOLD）技术分别在开穴和闭穴时在足阳明胃经（stomachmeridian,ST）和足少阴。肾经（kidney meridian,KI）上取穴配伍刺激后进行脑功能成像实验研究,并于上述2条经脉所取穴位周围选取2个非穴位针刺点进行同样的实验作为对照,探讨不同时辰针刺不同经络后引起的脑功能变化及其各功能区在脑内定位的异同和分布规律,研究探讨时间针灸学的原理和依据,并寻找临床针灸不同经络可以治疗不同疾病的原因,寻找不同时辰针灸同一经络治疗效果差异的中枢原因。方法选择无任何中枢神经神经系统症状及体征的健康在校大学生、硕士研究生志愿者40名,其中男性22人,女性18人,年龄20～30岁,平均23岁。所有志愿者均为右利手,实验前1周内无任何服药史及针灸史,女性志愿者避免月经期实验。40名志愿者随机分为两组,其中一组在足阳明胃经开穴和闭穴时电针配伍针刺足三里与上巨虚两穴位后进行磁共振脑功能成像实验,并同时在开、闭穴时段内于上述所取穴位周围选取2个非穴位针刺点进行同样的实验作为对照。另一组在足少阴肾经开穴和闭穴时配伍电针针刺太溪与复溜两穴位后进行磁共振脑功能成像实验,并同时在开、闭穴时段内于上述所取穴位周围选取2个非穴位针刺点进行同样的实验作为对照。每个志愿者共进行4次实验,每人的实验顺序采用随机抽签的方式决定,同一志愿者的相邻2次实验之间至少间隔3天。磁共振成像设备使用Siemens公司产1.5 T 63 SP MagnetomSonata Maestro Class超导磁共振扫描仪,梯度场强度40 mT/m/s。四通道相控阵线圈。常规解剖像采用自旋回波（spin echo,SE）序列轴位T₁WI。扫描线平行于前连合与后连合之间的连线（AC-PC线）,扫描范围自额顶部头皮组织至颅底,覆盖整个大脑及小脑实质,共35层。成像参数TR=500 ms,TE=11 ms,层厚4 mm,层间隔0.4 mm,视野（FOV）200 mm,激励次数2,反转角度70°,矩阵192×75,带宽130 Hz/Px,成像时间4分54秒。采用与T₁WI完全相同的扫描方位、扫描角度、位置、范围、层厚、层间距、层数、视野进行场图（field mapping）扫描和磁共振脑功能成像（functional MRI,fMRI）。fMRI使用BOLD法,成像参数为TR=3000 ms,TE=50 ms,激励次数1,反转角度90°,矩阵64×100,带宽2604 Hz/Px,成像时间12分21秒,共采集245次。电针仪使用上海医疗器械高技术公司生产的G6805-2多功能治疗仪,连续波,频率2 Hz,电压6伏,电流0.8毫安～1.4毫安。针灸毫针使用苏州医疗用品有限公司生产的“华佗牌”针灸针,规格为Φ0.35 mm×40 mm。实验采用“OFF-ON-OFF”即“静息—针刺—静息”设计模式。功能成像BOLD序列采集245次,其中第1～85次为静息状态,第86次采集开始时扎针并同时通电刺激,第165次采集结束时拔针,随后的第166～245次采集为静息状态。严格控制所有实验的实施时间,统一选择时间进行实验,足阳明胃经开穴时（辰时,早7-9点）和闭穴时（戊时,晚7-9点）,足少阴肾经开穴时（申时,下午5-7点）和闭穴时（亥时,晚9-11点）。实验前分别测量每位受试者的血压、呼吸频率及脉搏。所有受试者选择统一的视听屏蔽环境。用棉球塞紧外耳道并佩戴耳机、眼罩,磁体室内仅保留微弱灯光,供针灸照明用。实验前保证每位志愿者静息15～30分钟。采用运行于Matlab平台的SPM99（SPM99,The WelcomeDepartment of Cognitive Neurology,University College London,UK）分析软件将实验所得数据进行处理。为减少实验开始时扫描序列转换、噪音变频及受试者心理因素对实验结果的影响,数据处理时将扫描初始的前5次采集得到的数据去除,共用240幅图像参加分析。图像经过对齐后,标准化到MNI（montreal neurologic institute,加拿大蒙特利尔神经研究所）空间,采用8×8×8 mm半高宽高斯核平滑。平滑后的数据按照广义线性模型进行估计,针刺期间数据减去第1个静息状态数据出现阳性脑功能信号者为脑区信号升高或激活;反之,第1个静息状态数据减去针刺期间数据出现阳性脑功能信号者为脑区信号减低或抑制。以P<0.001,k≥30作为阈值。结果叠加到标准脑上显示。所有脑激活区和抑制区均由实验数据进行组分析所得。脑功能区域的解剖位置、Broadmann区（BA）定位、中心坐标由平均脑功能图得出。结果足阳明胃经开穴组20名受试者20次实验都出现了不同程度的“得气”感觉和范围。闭穴组20次实验中4人各有1个穴位无“得气”感,其余受试者“得气”感觉与范围与实验组无明显差异。足阳明胃经开穴组结果显示有功能激活信号增高的脑区包括双侧中央前回（4,6区）、双侧中央前回（3-1-2区）、双侧额上回（9区）、双侧扣带回（24区）、双侧缰三角、左侧额下回（47区）、左舌回（19区）、右侧额中回（46区）、右侧楔前叶（7a）、右侧顶下小叶（7b）、右侧小脑。最大激活脑区位于右侧中央前回。出现信号减低的脑区包括双侧眶回（11区）、双侧颞极（38区）、双侧缘上回（40区）、双侧角回（39区）、右侧额下回（47区）、右侧颞叶（21区）、右侧楔叶（18区）、右侧额中回（46区）、右侧毯。最大抑制脑区位于右侧眶内侧回。足阳明胃经闭穴组结果显示有功能激活信号增高的脑区包括双侧中央前区（4,6区）、双侧中央前回（3-1-2区）、双侧扣带回（24区）、左侧额下回（47区）、左侧舌回（19区）、左侧顶上小叶（7区）、右侧小脑皮层。最大激活脑区位于右侧中央前回。出现信号减低的脑区包括双侧眶回（11区）、双侧颞极（38区）、左侧颞叶（21区）、右侧顶上小叶（7a）、右侧额下回（47区）、右侧角回（39区）。最大抑制脑区位于右侧直回。足少阴肾经开穴组20名受试者20次实验都出现了不同程度的“得气”感觉和范围。闭穴组20次实验中5人各有1个穴位无“得气”感。其余受试者“得气”感觉与范围与实验组无明显差异。足少阴肾经开穴组脑功能成像结果显示功能被激活信号增高的脑区主要位于双侧中央前回（4,6区）、双侧中央后回（3-1-2区）、双侧中央旁小叶、双侧扣带回（24区）、双侧舌回（19区）、双侧额下回（47区）、双侧小脑皮层、左侧岛叶（13区）、左侧丘脑、右侧顶上小叶（7区）。最大激活脑区位于双侧扣带回。信号减低的脑区为双侧眶回（11区）、双侧颞极（38区）、双侧额下回（47区）、双侧颞叶（22区）、左侧额中回（46区）、左侧海马旁回、右侧额上回（8区）、右侧枕叶（17区）、右侧枕颞内侧回（36区）。最大抑制脑区位于右侧眶内侧回。足少阴肾经闭穴组脑功能成像结果显示功能被激活信号增高的脑区主要位于双侧中央前回（4,6区）、双侧中央后回（3-1-2区）、双侧中央旁小叶、双侧扣带回峡（26区）、双侧小脑皮层、左侧额下回（47区）、左侧岛叶（13区）、左侧颞上回（22区）、右侧顶上小叶（7a区）。最大激活脑区位于左侧小脑。信号减低脑区为双侧眶回（11区）、双侧颞极（38区）、双侧海马旁回、左侧额下回（47区）、右侧枕叶（17区）、右侧枕颞内侧回（36区）、右侧扣带回（30区）、右侧小脑皮层。最大抑制脑区位于右侧眶内侧回。两实验组的非穴位对照组在开闭穴时段内得气感觉与激活区无差异,出现脑功能被激活的脑区包括左侧颞上回（22区）、左侧中央前回（6区后部）、双侧扣带回（24区、32区）、丘脑、小脑、左侧岛叶等。但脑功能活动区的数量、大小范围要比刺激穴位引起的功能活动区要少、范围要小。最大激活脑区位于右侧中央前回。刺激非穴位点出现的抑制脑区广泛分布于脑组织,无特异的功能抑制区。结论1.脑功能磁共振成像观察到的不同时辰针灸后中枢效应的差异,直观形象地证实了子午流注学说的客观存在。不同时辰针刺非穴点后,没有这种差异。2.不同时辰针刺足阳明胃经和足少阴肾经后,脑功能激活信号增高脑区和信号减低抑制脑区均有差异。开穴时段内两经络激活区和抑制区的数目和范围要比闭穴时段内多和广。这可能不同时辰针灸同一经络治疗效果差异的原因之一。3.开、闭穴不同时间配伍刺激足阳明胃经和足少阴肾经的两穴位后,激活与抑制的脑区既有相同之处,又有不同之别。而且开穴时可以形成完整的中枢激活与反射环路,闭穴时则无法形成完整的环路。依此我们可以解释临床上不同时间针灸同一经络的疗效有交叉重叠,也有明显区别的现象。4.开、闭穴配伍刺激足阳明胃经和足少阴肾经的2穴位后都可以不同程度地激活、抑制属于“内脏脑”的不同脑区。提示上述2条经络的止痛效果可能都是通过重新调节“内脏脑”的各个脑区的功能活动,使之达到新的功能激活与抑制平衡而实现的。这与中医治病阴阳平衡理论有一致性。而且,“内脏脑”的激活与抑制同一经络开、闭穴有重叠,这可能是不同时段治疗效应既相同又有差异的原因之一。5.开、闭穴时针刺足阳明胃经最大激活区均在右侧中央前回,而最大抑制脑区开穴时在右侧眶内侧回,闭穴时在右侧直回。针刺足少阴肾经开穴时最大激活区在双侧扣带回,而闭穴时在左侧小脑。最大抑制脑区均在右侧眶内侧回。不同时辰针灸同一经络最大激活和/或最大抑制脑区有差异,这可能不同时辰针灸同一经络治疗效果差异的原因之一。6.躯体运动区的7区在足阳明胃经开穴时针灸右侧是激活的,闭穴时左侧是激活的,而右侧是抑制的。这可能是足阳明胃经不同时辰治疗与肢体运动有关病症疗效差异的原因。足少阴肾经不论开闭穴时配伍刺激相关穴位躯体运动区的7区都是不激活的。这可能是不同穴位治疗疾病种类差异的原因之一。也表明子午流注在不同经络有不同的表现形式。更多还原

【Abstract】 Objective:To explore the functional localization and its distributing orderliness of the central nervous system（CNS）reaction on acupuncturing the two acupoints of stomach meridian of foot-yangming（ST）,two acupoints of kidney meridian of foot-Shaoyin（KI）,and two false acupoints near the acupoints of the meridians mentioned above respectively,using magnetic resonance imaging（MRI）,blood oxygenation level dependent（BOLD）of echo planar imaging（EPI）sequence,and to explore the exist and mechanism of the acupuncture of Zi-Wu-Liu-Zhu.Materials and methods:Forty right-handed volunteers without any symptom and sign of the central nervous system（male 22,female 18;age ranged 21 to 30 years old,average 23）who were studying on campus as students or postgraduates were selected in our studies.All of them had no history of taking drug and acupuncture within one week.Female volunteers were asked to avoid acupuncture test during menses.Every persion of these 40 volunteers was performed our acupuncture studied 4 times（160 totally）.20 persons was acupunctured Zusanli（ST36）and Shangjuxu（ST37）in the different time,and two false acupuncture as the compare.20 persons was acupunctured Taixi（KI3）and Fuliu（KI7）in the different time,and two false acupuncture as the compare,All acupuncture tests were performed on the right leg.The order of test was determined randomly.Images were required on a 1.5-T unit（63 SP Magnetom Sonata Maestro Class;Siemens Medical Systems;gradient strength,40 mT/m/s）. In each subject,after a sagittal scout sequence was performed,35 slices axial images of the entire area of the whole brain paralleled to the AC-PC line were obtained.Imaging sequences included spin echo（SE） T₁WI,gradient field mapping,and EPI（BOLD）were performed.The parameters of MR imaging included:slice thickness,3 mm;slice gap, 0.3 mm;FOV,200 mm.T₁WI:TR=600 ms,TE=15 ms;Matrix,256×256;FA,70°;Bandwidth,130Hz/Px;Scan time,4 minutes and 54 seconds.Gradient field map:TR=483 ms,TE=5.19 ms;NEX,1;FA, 60°;Matrix,64×100;Bandwidth,260 Hz/Px;Scan time,1 min and 4 seconds.T₂WI of BOLD:TR=3000 ms,TE=50 ms;NEX,1;FA,90°; Matrix,64×100;Bandwidth,2604 Hz/Px,Scan time,12 minutes and 21 seconds;Measurements,245.For acupuncture,a Multi-purpose Health Device G6805-2（made in Shanghai）was used.The parameters of it consisted of wave,continuous; frequency,2 Hz;voltage,6 volt;electric current,0.8 mAs-1.4 mAs.The stainless no-magnet acupuncture needles we used were brand of "Huatuo"（made in Suzhou,Φ0.35 mm×40 mm）.The experiments were designed as"rest-acupuncture-rest".From the first measurement to the 85th was called No.1 rest,the 86th to the 165th measurement was acupuncture period,and the 166th to the 245th was called the second rest.The stimulation with electric current were started at the 86th measurement and stopped at the end of the 165th measurement. Electric needles were taken out at the beginning of the 166th measurement.The blood pressure,frequency of breath,and pulse were measured before test for every volunteer.Data were analyzed by using Statistical Parametric Mapping software （SPM99;Wellcome Department of Cognitive Neurology,London,UK） implemented in Matlab 6.0（Mathworks Inc,Sherborn,MA）.The datasets were normalized to a standard space（Montreal Neurologic Institute space,MNI）within SPM99.This space was based on a template T1-weighted dataset,a close analog of Talairach space developed by the MNI.The temporal datasets were smoothed by using an isotropic Gaussian filter kernel having a full-width at half maximum of 8×8×8 mm the normalized voxel size.Statistical parametric maps were generated by using the general linear model to characterize regionally specific effects in the imaging data.Terms in the model included the activity condition（acupuncture）and the globle mean value of each temporal dataset.A boxcar reference waveform convolved with a kernel that approximates the hemodynamic response curve was used to test specific hypotheses,resulting in at value at each voxel.For all studies,statistical thresholding at significance level of p<0.001 and k≥30 was initially used to determine significant activation for each vexol.Results:In the"open" group of the ST,20 volunteers have the feeling of "De-Qi".In the"close" group of the ST,20 volunteers have the feeling of"De-Qi" except 4 volunteers felt no"De-Qi" in one acupoint.While the feeling of other haven’t the difference.The fMRI activation data of the ST are summarized as follows.In the"open" time of the Stomach meridian of foot-yangming（ST）: Signal increase elicited by acupuncture stimulating was demonstrated in Broadmann4,6,3-1-2,9,24,and habenular trigone,bilaterally;left Broadmann 47,19;right Broadmann 46,7,and cerebellum.Signal decrease was shown in Broadmann 11,38,39,and 40,bilaterally;and right Broadmann 47,21,18,46,and tapetum.In the"close" time of the Stomach meridian of foot-yangming（ST）: Signal increase elicited by acupuncture stimulating was demonstrated in Broadmann4,6,3-1-2,24,bilaterally;left Broadmann 47,19,7;right cerebellum.Signal decrease was shown in Broadmann 11,38,bilaterally; left Broadmann 21;and right Broadmann 47,39.In the"open" group of the KI,20 volunteers have the feeling of "De-Qi".In the"close" group of the ST,20 volunteers have the feeling of"De-Qi" except 5 volunteers felt no"De-Qi" in one acupoint.While the feeling of other haven’t the difference.The fMRI activation data of the KI are summarized as follows.In the"open" time of the Kideny meridian of foot-shaoyin（KI）: Signal increase elicited by acupuncture stimulating was demonstrated in Broadmann4,6,3-1-2,19,24,47,and paracentral lobule,bilaterally; left Broadmann 13,and thalamus;right Broadmann 7.Signal decrease was shown in Broadmann 11,22,38,and 47,bilaterally;and left Broadmann 46,and hippocampal gyrus;right Broadmann 8,17,36.In the"close" time of the Kideny meridian of foot-shaoyin（KI）: Signal increase elicited by acupuncture stimulating was demonstrated in Broadmann4,6,3-1-2,26,cerebellum and paracentral lobule,bilaterally; left Broadmann 47,13,22;right Broadmann7a.Signal decrease was shown in Broadmann 11,38,and hippocampal gyrus bilaterally;left Broadmann 47;right Broadmann 17,30,36,and cerebellum.In the control study,20 volunteers have the feeling of"De-Qi" both in the"open" and"close" group.While the feelings of them haven’t the differences.The fMRI activation data of the control group are summarized as follows.There aren’t different both the active and deactivate area when acupuncture the nonacupoint in the"open" and"close" time.Signal increase elicited by acupuncture stimulating was demonstrated in Broadmann 24,30,cerebellum,and thalamus bilaterally;left Broadmann 22,post of 6,and insula.Signal decrease was diffused.Conclusions1.fMRI can delineate the different reaction of the CNS.It testify exist of the acupuncture of Zi-Wu-Liu-Zhu objectively and directly.While it isn’t exist when you acupuncture the nonacupoint.2.The active,deactivate area（signal increase and decrease）the most active and deactivate area are different when acupuncture the meridian ST or KI.The number and extent of the active and deactivate area when acupuncture the meridian in the"open" time are more and wider then in the"close" time.These maybe one of the reason why it is different when acupuncture the meridian in the different time.3.There are both same and different when acupuncture the ST or KI in the different time.The whole active and reflect feedback routein can found when acupuncture in the"open" time,while the"close" time isn’t. These give us the answer of why the therapeutic effect is juxtaposition and obviously distinction.4.Multiple brain regions where were shown signal increase and signal decrease elicited by acupuncture stimulating are belonged to the "splanchnic brain".This result prompts that the clinical effect of ST and KI might be accomplished by adjusting the"splanchnic brain".The analgesia effect induced by acupuncturing the ST and KI may cause by the active and deactivate balance of"splanchnic brain".This is coincidence with the Chinese traditional medicine"yin" and"yang" balance.5.The most active and most deactivate are right precentral gyrus and right medial orbital gyri when acupuncture the ST in the"open" time, the most active when acupuncture in the"close" time is same as the "open" time.While the most deactivate is right gyrus rectus.The most active and most deactivate are bilateral cingulate gyrus and right medial orbital gyri when acupuncture the KI in the"open" time,The most active and most deactivate are left cerebellum and right medial orbital gyri when acupuncture the KI in the"close" time.The most active and deactivate area are different.These maybe one of the reason why it is different when acupuncture the same meridian in the different time.6.Right Broadmann 7 area is activated in the study when acupuncture the ST in the"open" time,while left Broadmann 7 is activated when acupuncture in the"close" time.Broadmann 7 areas aren’t activated in the study when acupuncture the KI both in the"open" and"close" time. These maybe one of the reason why it is different when acupuncture the same meridian in the different time.This maybe one of the reason why it is different when acupunctures the different meridian.These reflect of different meridian to the Zi-Wu-Liu-Zhu is different.更多还原