Design
A block design, neuroimaging study.
Time and setting
The experiment was performed at the MRI Center, Nanfang Hospital, China, from October 2008 to August 2010.
Subjects
Six right-handed healthy volunteers were recruited from the Southern Medical University in Guangzhou, China. The inclusion criteria were: (1) 21–28 years old undergraduate/postgraduate students; (2) non-smokers with regular eating habits without excessive consumption of liquid, tea or coffee, normal sleep, and normal body structure; (3) no acupuncture treatment in the one month prior to the experiment; (4) no metal in his/her body (such as heart stents); (5) no psychiatric history, such as claustrophobia; and (6) no contraindication for acupuncture, such as hemophilia. The subjects included three males and three females, with an average age of 23.33 ± 2.61 years (range 21–27 years).
Ten ischemic stroke patients were selected from the First Affiliated Hospital of Guangzhou University of Chinese Medicine. They were diagnosed according to diagnostic criteria in ICD-9 434 and ICD-8 433[17]. The inclusion criteria: (1) ischemic stroke in the left basal ganglia, with typical right hemiataxia (muscle strength of upper limb and lower limb less than four scores[18]) and sensory disability; (2) out of acute stage, with stable condition; (3) non-smokers with regular eating habits without excessive consumption of liquid, tea or coffee, normal sleep, and normal body structure; (4) treated with western medicine treatment within 1 month; (5) aged 40–65 years; and (6) right handed. Exclusion criteria: (1) course of disease longer than 1 year; (2) with acupuncture treatment within 1 month prior to the experiment; (3) with severe heart, liver, or kidney disease, or tumor; (4) severe aphasia or psychiatric history of dementia or claustrophobia; (5) pregnant women or those in lactation; (6) with metal in his/her body (such as heart stents); and (7) with contraindication for acupuncture, such as hemophilia. The patients included 9 males and one female, aged 56.10 ± 5.53 years (range 47–65 years), with course of disease of 5.30 ± 3.71 months (range 1–12 months). Chinese Stroke Scale scores[18] were 18.20 ± 4.02 points (range 15–27 points). In addition, nine patients had hypertension and two had diabetes mellitus. Informed consent was obtained from all participants.
Methods
Acupuncture
All subjects received acupuncture at Waiguan of the right side. The Waiguan acupoint was located on the forearm, 2 cun (a unit of length that refers to the width of the interphalangeal joint of the thumb) above the transverse crease of the dorsum of the wrist, between the radius and ulna (Figure 2)[19].
Acupuncture was performed by one physician, who had engaged in clinical acupuncture for more than three years. The tubes were purchased from Dongbang AcuPrime Co. (Exeter, England) and the 0.3 cm × 40 cm silver needles from Zhongyan Taihe Co. (Beijing, China). After routine sterilization, the physician held the tube using the left hand and tapped the end of the needle using the index finger of the right hand to insert its tip into the tube. The tube was then removed and the needle vertically punctured to a depth of 15 ± 2 mm. The handle of the needle was twirled to induce the needling sensation. Next, the physician manually applied an even reinforcing and reducing manipulation by twirling the needle ± 180°, at 60 times/min.
The acupuncture process was designed using a block method, with twirling and non-twirling stimulation alternated in 30-second blocks, and a total stimulation time of 6 minutes (Figure 3).
fMRI scan
fMRI scanning was performed with a 3.0 T whole-body MRI scanner (GE, Bethesda, MD, USA) and a standard head coil. The subjects used earplugs (Aearo Co., Hartford, CT, USA) and were blindfolded (Xinhua Tourism Co., Hangzhou, China). Each subject rested on the bed for 5–10 minutes before the scan. 3D anatomy images were collected with a T1-weighted 3D gradient echo-pulse fast spin sequence prior to acupuncture, with axial view T1 fluid-attenuated-inversion-recovery scan (repetition time, 2 300 ms; echo time, 21 ms; time of inversion, 920 ms; slice thickness, 6.0 mm; gap 1.0 mm for 20 layers for a total of 2 minutes 45 seconds; field of view, 24 cm × 18 cm; matrix, 320 × 256; number of excitations = 2; field of view echo train length, 9; and band width, 50).
Collection of blood oxygenation level-dependent functional images was conducted during acupuncture with a single provocation echo-planar imaging sequence with a gradient echo/echo-planar imaging/90 (90° pulse) (repetition time, 3 000 ms; echo time, 20 ms; flip angle, 90°; field of view, 24 cm × 24 cm; slice thickness, 6.0 mm; slice gap, 1.0 mm; matrix, 96 × 96; number of excitations = 1; phase per location, 130, 2 600 phases for 6 minutes and 30 seconds).
3D scanning was followed with an axial view 3D T1 fast spoiled gradient echo/20 T1 450 (repetition time, 4.6 ms; echo time, 3.3 ms; flip angle, 20°; field of view, 24 cm × 18 cm; slice thickness, 1.2–0.6 mm; band width, 25; matrix, 256 × 256; number of excitations = 1 for 248 layers in 6 minutes and 2 seconds).
Data analysis
The fMRI data were processed with the software SPM2 (http://www.fil.ion.ac.uk). (1) Slight movements of the head were corrected; (2) the images were normalized to the standard brain template of the Montreal Neurological Institute space; and then (3) smoothed spatially to reduce errors produced during imaging construction and eliminate tiny differences in brain structures among subjects; (4) The smoothed data were analyzed with a generalized linear model voxel by voxel. The t value of each voxel was calculated by two-sample t-tests, and statistical parametric mapping was based on the t values (P < 0.001, uncorrected, K > 30). Significant changes in different brain regions during stimulation and control conditions were identified and superimposed on the standard brain image mode of each subject’s anatomic images[20]; (5) the activated/deactivated con file of the model of stroke patients and normal controls was further analyzed using a two-independent sample t-test. The remaining procedures were the same as those reported in (4). Central coordinates from statistical parameters determined using SPM software package were reproduced and input in Talairach Client (download from http://www.talairach.org/client.html) to obtain the anatomical location and the BA range of the functional areas of the brain[21], which were corrected by a physician of the neurological medicine department according to anatomic knowledge and clinical experience.
