针灸对工作记忆和焦虑的作用研究
摘要
介绍
每个人都想提高记忆力。从滋补到运动,产品和服务不断向消费者推销并声称可以提高智力和记忆力,但很少见效。
工作记忆最初是由Baddeley和Hitch提出的。工作记忆被理解为短时记忆和控制注意力。它由三个系统组成：一个中央执行系统,管理着智力和注意力的分配；一个语音回路和一个视觉空间模板,把声音和图像分别保存在短时记忆中。
工作记忆被认为和阅读理解和运算推演相关联。被改进用来处理工作记忆的统计处理及分析任务已经有望涉及于各种能力：如记笔记、语言理解、玩桥牌、计算机语言学习、拼写学习、定向、建立词汇表,写作、综合学习和推理能力。工作记忆容量是决定人们在很多领域获得成功的一个主要因素。所以工作记忆是一个绝大多数人们想要提高的方面。
焦虑已被证实有损于工作记忆。研究显示它扰乱中央执行系统控制注意力的能力,这将有碍于中央执行系统排除外部刺激的能力,焦虑不仅有损于中央执行系统,它还损害工作记忆的所有方面。
焦虑已经显示出对运算表现工作记忆处理及分析任务测量的损害。焦虑还一样损害其他方面的成就,比如运动表现等。
针灸已被证实可以改善焦虑。研究显示针灸可以缓解一般性焦虑症郁闷型焦虑症外科手术焦虑症。可以参看Pilkington, Kirkwood, Rampes, Cummings和Richardson关于针灸和焦虑症的文献回顾。
如果焦虑症损害记忆并且针灸可以改善焦虑症,那么针灸可以提高记忆吗?一些研究已经用记忆遭受各种受创的老鼠、猴子和大老鼠进行了相关的研究。
还有一些研究已经也关注于验证针灸对认识受损的人类也一样有改善的功效至今为止,尚没有研究测试出针灸是否可以提高健康人群的记忆力。
这项研究旨在观察：针刺在焦虑状态和AOSPAN测试中的治疗作用。
方法
参与者
从当地的大学招募了90名受试者。国立健康科学大学机构审查委员会完全授权于这项研究。
所有受试者必须符合：18-30岁的大学在校生：愿意接受针灸治疗；在三个月前没有接受过针灸治疗；没有任何严重疾病；没有在接受任何精神治疗；非孕妇非哺乳期；英文流畅。任何受试者不符合上述条件都将被排除在该项研究之外。受试者为此获得10-20美元的报酬。
设备
该项研究在两所私人针灸门诊中实施。认可协议和个人资料表在休息室里完成。其他程序在一间8X10英尺,放置有一个按摩床,一个放有笔记本电脑的书桌和一把椅子的治疗室内完成。
工具和措施
Spielberger的焦虑状态特征量表(STAI)是一个被广泛运用的可以自测的焦虑症测量工具。它包含两个分别由20个子项构成的部分,测量个体特征(起始点)和焦虑的形式(状态)。Y-1表测量焦虑状态(SA)Y-2表测量焦虑个体特征(TA)。每个表包含20项陈述和主体级别,每个陈述反映在多大程度上体现他们的真实感受。最低得分为20分,最高位得分为80分
焦虑状态特征量表已显示很好的重复性和可信度。这是国际上被运用得最广泛的焦虑测试工具之一。一些专家甚至将焦虑状态特征量表称作焦虑测试工具中的“黄金标准”。
Unsworth等人的自动化跨度任务操作(AOSPAN)是一个已被证实具有良好的内部可信性和外部有效性的关于工作记忆的计算机测试,它可提供一系列数据以供分析。受试者被要求心算一项数学题,然后通过一个被显示的数字去记忆。接着还有另外的数学题和数字。在进行了一系列3-7项这样的数学题和数字组之后,受试者必须将显示出的数字按照正确的顺序排列出来。每次总计有75个数字和数学题。自动化跨度任务操作绝对的得分和总体正确得分共同反映出数字的回忆。总体正确得分计算所有正确的回答。绝对得分是在仅当一整组回忆正确的前提下给予得分。例如,有7组数学题和数字,如果受试者正确回忆了6个数字,总体正确得分将是6,绝对得分将是0。用自动化跨度任务操作(AOSPAN)测试记忆的研究最常比较的是总体正确得分。AOSPAN同时也关注数学问题中出现的精确度误差和运算速度差异。
用于针灸组的是DBC公司的不锈钢质的针灸针。这类针是单丝弹簧所制,体针用直径0.20毫米长度30毫米的针,头针用直径0.20毫米长度为15毫米的针。
自变量
自变量是躺在按摩床上20分钟的受试者,无论他们是否接受了四神聪、印堂、神庭、神门、内关和太溪穴位上的针灸。所有的针都是按相同的方法插入。四神聪穴上的针是平刺进针0.5寸,四根针互为垂直并共同指向百会穴。神庭穴位上的针是向下平刺0.5寸。印堂穴在两眉间横线上向下平刺0.3寸。神门穴垂直进针0.5寸。内关穴垂直进针1寸。太溪穴垂直进针并透昆仑穴。针灸全过程由一位有经验的专业针灸师实施。在对照组的受试者同样受到穴位按压和酒精消毒棉的擦拭,但不接受针灸。应变量
被测试出来的应变量是基于焦虑状态特征量表和自动化跨度任务操作的得分。
步骤
受试者们随机被分配进针灸组和对照组。所有受试者经过一次性测试,并且只有一次约见。在面试开始的时候,通过适当的方式让受试者们大致了解这项研究,然后他们填写个人自愿书和个人基本信息的表格。
接着,所有受试者被指导完成焦虑状态特征量表的表格Y-1和Y-2。经过初步的STAI之后,所有受试者被要求脱去鞋袜躺在按摩床上。治疗室灯光柔和并播放着舒缓的音乐。
针灸组的受试者接下来接受以下穴位的针灸：四神聪、神庭、印堂、神门、内关和太溪。所有穴位都按照同样的方法在两边同时针灸20分钟。
所有的穴位都是按照可舒缓情绪和提高精神注意力而进行选择。依照Peter Deadman等人的针灸手册：四神聪穴有益于视觉和听觉；舒缓情绪并有可能对记忆力有帮助。神庭穴有益于智力和舒缓情绪,此外,督脉是通向大脑的。印堂穴可以安神,有缓解焦虑和焦躁的可能。神庭穴可以舒缓情绪,调节和补养心脏,也可能对记忆力衰退,害怕和惊吓有帮助,此外,心脏主管精神及记忆。内关穴可能对记忆衰退、忧虑、害怕和惊吓有帮助。心包经主管心脏。选择太溪穴是因为肾脏连接大脑,还因为它位处身体下端,对身体上端所有的穴位起着平衡的作用。在这项治疗中,太溪穴是治本,并对受试者的意识有帮助。
受试者再一次完成Y-1表格。然后他们被引导至笔记本电脑那儿,在进行自动化跨度任务操作(AOSPAN)中接受自动指令。受试者被告知试验中出色的表现将直接影响到他们所获得的报酬,以此让他们尽力表现得更好。
必须尽力减少让对照组的受试者知道他们是在对照组的可能。关于这项研究的真实情况不可以如实地告知受试者们,只能告诉他们：“你们将填写一些个人评估的调查问卷,进行一些关于记忆的电脑测试,还可能接受一些穴位的针灸治疗。”当他们进行自动化跨度任务操作(AOSPAN)测试的时候,研究人员告诉他们：”现在我们将带你们进入第一项记忆测验。“这将有意地加大受试者们认为他们还可以在接受其他记忆测验之前接受针灸治疗的可能性。
研究人员要确保花费在每一组的时间,包括交谈和身体接触要按规定完全一样,以将安慰效果最小化。正如Finniss等人说明的那样,他证明这些不同可以影响到研究结果
统计分析
未配对T检验是用取自www.graphpad.com的在线软件,用作针灸组和对照组之间,以及STAI和焦虑状态特征量表小组间的平均值统计对比(资料)。回归分析用焦虑状态特征量表和自动化跨度任务操作的对应参数用在线软件www.easycalculation.Com9
结果
对照组有46人,其中男性为22人,女性为24人,平均年龄为21.28岁。针灸组有44人,其中男性为16人,女性为28人,平均年龄为20.53岁。两组间没有明显的性别和年龄结构上的差异。针灸组没有任何受试者报告有不良反应。结论由均数±标准差得出。
焦虑状态特征量表(STAI
STAI得出的数值：焦虑的起初状态,特质焦虑状态,和治疗期的焦虑状态(针灸或休息,SA2). SA1和SA2被计算和称为△SA。对比测试用来比较试验组和对照组及其小组里的成员。
两组间没有明显SA1或TA的不同。对照组里ASA的平均值是-6.35±7.49,针灸组里ASA的平均值是-7.61±5.65。对照组里SA2的平均值是29.63±8.2针灸组里SA2的平均值是26.13±4.5(p=0.0146,有意义)
TA系列获得的数值从23到63.取中间值,TA低于43的受试者被划入轻度焦虑(LA,n=62),TA大于等于43的受试者被划入重度焦虑(HA,n28)。在针灸组里,相对于LA(6.53±5.02,n=30)而言,作为严重焦虑症(9.93,±6.40,n=14)其SA的减少更加明显,但在统计学意义上并不能算是十分显著(p=0.0594)。
AOSPAN
AOSPAN提供的数据作为：绝对分值,正确得分总数,数学错误总数,数学精度误差,数学运算速度差异。
接受针灸治疗的受试者效果好于对照组。正确得分总数方面,针灸组的受试者得分9.5%,高于对照组(65.39±7.38相对于59.70±13.1,P=0.0134,明显)。与对照组相比,针灸组的正确百分比从79.6%上升为87.2%。平均AOSPAN的绝对得分,对照组是45.87±18.36(正确率61.2%),实验组是52.20±14.28(正确率69.6%)(p=0.072,接近有效)。男子组里,AOSPAN的绝对得分对照组是44.14±16.73,治疗组是55.13±15.01(n=16,p=.044,有效).在平均数学错误的总数方面,针灸组(2.68±2.31)比对照组低36%。(4.22±3.44,p=0.0153,有效)。对照组平均数学运算速度差异为1.24±1.59,实验组的对照组平均数学运算速度差异为0.80±1.3(p=0.153,无效).对照组的平均数学精确误差为2.98±2.52,实验组的平均数学精确误差为1.89±1.71(p=0.0188,有效)
经过回归分析显示在焦虑状态特征量表和自动化跨度任务操作的得分之间没有明显的相互关系。
总体上说,存在这样一种趋势,严重焦虑症的受试者在自动化跨度任务操作测试方面要比轻度焦虑症的受试者表现的差。当分成对照租和针灸组后,严重焦虑症受试者的表现在对照组中仍低于轻度焦虑症受试者；而在针灸组这种差异减少或消除了。
此外还有一个趋势是在针灸组中男性自动化跨度任务操作得分的提高比女性要明显。
讨论
在四神聪、神庭、印堂、神门、内关和太溪穴上持续针灸20分钟,可以在治疗后立即提高记忆力并减轻焦虑。然而,记忆的提高并非与SA和△SA有关。这并不能证明针灸是通过缓解焦虑而提高记忆力的。可能会有别的方法支撑这个假设。这项研究显示针灸可以通过不同的途径而不是仅通过缓解焦虑来提高记忆。
这个特殊的针灸疗法还显示出其疗效在减轻焦虑方面比单纯的休息更有效,不过两者差异并未具有统计学上的意义(相对于对照组的6.35点,针灸组不过是7.61点)。由于较大的标准偏差,这个趋势不具备统计学上的意义。如果仅仅比较最后一组焦虑,针灸组受试者的焦虑改善得比较明显(p<0.05)
这个研究还给出一个证据,即严重焦虑症个体并不能像轻度焦虑症个体在工作记忆测试中表现的那么好。在自动化跨度任务操作测试的所有类别中,严重焦虑症个体得分低于他们当中的在轻度焦虑症中的得分,尽管这并不很明显。如果从实验整体来看,严重焦虑症受试者绝对得分比其少于5.6%的总体正确得分要小11%,并且与他们的轻度焦虑症相比,其数学错误增加33%。用平均值去界定严重焦虑症和轻度焦虑症组已经遭到Conway等人的质疑,程序上确实存在一些实际的限制。但平均值仍旧被在此使用并产生出一些有意思的趋势。
针灸的使用降低了严重焦虑症的一些症状反应。当分成对照组和针灸组时,接受针灸的受试者其严重焦虑症的影响大大降低。
未接受针灸的受试者,其严重焦虑症受试者的绝对得分比轻度焦虑症受试者低12.5%,然而通过针灸治疗,严重焦虑症受试者显示仅有7.6%的受损。与轻度焦虑症对照组的受试者相比,严重焦虑症受试者的正确得份总数低于其对照组8.6%,但与轻度焦虑症针灸组相比严重焦虑症针灸组的得分仅减少1.5%。严重焦虑症受试者未接受针灸的形成数学错误比轻度焦虑症受试者未接受针灸的高52.2%,但严重焦虑症受试者接受针灸的比轻度焦虑症接受针灸的在数学错误方面少13.2%。事实上,严重焦虑症那些接受过针灸治疗的受试者在自动化跨度任务操作的所有测试中的得分都要高于轻度焦虑症的对照组受试者。然而这些发现并不具备统计学上的意义,尽管这趋势很明显,但这可能由于其小群体规模的原因,更大一些规模的研究可能会形成意义。未经治疗,严重焦虑症有损于工作记忆的表现。针灸减缓或消除了这种损害。
但是并不仅仅是严重焦虑症受试者见效。轻度焦虑症对照组和轻度焦虑症治疗组相比,治疗组在除了数率错误之外的所有测试中都表现得比对照组好。
其他研究设计
这项研究的另一种设计方式可能是请受试者在治疗期前后进行两次自动化跨度任务操作测试。这样的设计不适合这项研究,因为觉得与其让受试者们在测试中两次利用测试结果不如让他们进行记忆方面的测试。此外,自动化跨度任务操作测试要求受试者们经过漫长的练习阶段并在此间检测他们的反应(当时受试者们不知情),并以此为基础确定真正的实验时机。第二次测试时,受试者们将会知道他们回答问题是会用来进行测试的,因而可能会在真正的试验阶段用时更长一些。如果有可能改变自动化跨度任务操作,那么第一轮练习时期的测量可用于第二轮测试,并且从第二轮开始可以省去练习阶段,这样这项研究就可能按照如此运作。然而,在如此短的时间间隔内实行两次自动化跨度任务操作的测试,其可靠性和有效性尚未得到检测。
另一种这项研究的设计是让受试者做自动化跨度任务操作测试,接着做六到十二周的治疗,之后再进行自动化跨度任务操作测试。这可以给受试者们予足够的时间去忘记这个步骤,从而使第二次自动化跨度任务操作测试有效。
一次性方案和6-12周的方案都可以使用不同的穴位去实施。这项研究关注于心经、心包经、肾经、督脉经和头部的经外奇穴。脾也与认知有关,尤其是与大致可以翻译成的“意”有一定联系。加入三阴交或脾经上的其他穴位是值得进一步观察的。没有道理认为其他方案不会有更好的疗效。针灸穴位上的针灸或针压法也可以进行观察。针压法可以与针灸法相比较。
百会穴有类似于四神聪的功能。可以验证用百会代替四神聪穴并检测是否一个头针可以像四个一样有效。事实上,这个研究可以用任何穴位或取消数个穴位进行验证来观察怎样用最小的介入获得同样的效果。也许用针数目少才是必要的。
这个实验也可以在不同的人群进行。没有理由假设这项研究中显示的疗效局限在30以下的受试群里。今后的研究可以检测更大的年龄跨度比如18-65岁,或仅仅针对老年人(65岁或以上),或任何群体。
为什么没有安慰针灸组
安慰针灸组根本不存在。它不是一个没有反应的介入。两个最常见的安慰针灸实施方法是皮肤刺激或浅表针刺,或者针刺点偏离主要的(规范的)针灸穴位。
不过浅表针刺也影响经脉中的能量流。浅表针刺已经被显示可以在大脑边缘系统引起生理改变,但那些改变会因人而异。例如,浅针刺在无疼痛的受试者中可活跃大脑边缘系统,但在有疼痛的患者中效果减弱,一些研究已经显示安慰针灸也像真正的针灸一样有效,两者都比安慰药物更加有效。一些研究显示真正的针灸和安慰针灸同时辅助药物可以比单独使用药物更能提高疗效,并且真正的针灸要比安慰针灸更有效。还有一些研究显示,常规针灸和安慰针灸两者都可以通过不同的途径产生疗效
其次,身体上没有一个地方你插入针它没有反应。那些规范的针灸穴位,乃至经络上的每一个点都会对受试者主体能量流产生一定的影响。一些研究得出一个结果,安慰剂(或未接受治疗)有一些不同程度的效果,安慰针灸效果稍好,真正的针灸效果更加明显。
Lundeberg等人提出一个关于所谓“安慰”针灸的著名观点。他们说明,通过功能性磁共振成像测试最小化的针灸可以引起身生理改变。他们得出结论,安慰针灸不能用来解释针灸疗效,相反它还引入一些潜在偏见,阻碍了对针灸真实效果的认识。
治疗组的受试者们知道他们在治疗组吗?是的。那些在对照组的受试者们知道他们在对照组吗?不知道。有没有可能那些治疗组的受试者们知道他们被期望表现得更好而因此在自动化跨度任务操作测试中努力表现呢?有可能。所有受试者都被告知在自动化跨度任务操作测试中出色的表现将会直接和他们获取的报酬挂钩,因此可以设想所有受试者都会尽力。知道他们已经接受过了治疗,这可能会给针灸组的受试者们更大的信心和关注。出于这个原因,将来的研究可以给对照组一个奖励。有了这个辅助,每个人在进行自动化跨度任务操作测试之前都会认为他们已经接受了一些类型的治疗。
针灸已经被证实是一个对焦虑症有效的治疗手段。这个研究显示了它对焦虑状态的疗效,但并未满足特质焦虑。通常对焦虑症的长期治疗是药物和精神疗法。针灸很明显是一个比抗焦虑药物更好的选择,因为它的副作用很小并且已经过足够的研究确定其作为一个长期疗法的安全性。针灸疗法可以被用来配合精神疗法。
最后,全球老年人口正面临记忆衰退的严重问题。将来的研究应该着眼于使用这种治疗和不同的穴位组合去改善和提高老年人的记忆功能和认知功能。
Introduction
Memory is an area that everyone would like to improve. From supplements to exercises, products and services have been marketed to people with claims of helping boost mental capacity and memory; but few have been shown to be effective.
Working Memory (WM) was originally described by Baddeley and Hitch. WM is understood as short-term memory (STM) plus attentional control. It consists of three constituent systems:a Central Executive (CE), which is in charge of allocating mental resources and attention; a Phonologic Loop; and a Visual Sketchpad where audio or visual data are kept in STM respectively.
WM has been associated with reading comprehension and arithmetic calculation. The Span Tasks that have been developed to measure WM have been associated with predicting such diverse capabilities as:Note taking, language comprehension, playing bridge, learning a computer language, learning to spell, following directions, building vocabulary, writing, complex learning, and reasoning ability. Working memory capacity (WMC) can be a major factor in determining one's success in many areas. So WM is an area that most, if not all, people would want to improve.
Anxiety has been shown to disrupt WM. Studies show it disrupts the ability of the CE to focus attention; and that it limits the ability of the CE to ignore extraneous stimuli; and that anxiety may impair all facets of WM and not just the CE.
Anxiety has been shown to impair performance in math, reading and OSPAN task measures of working memory. Anxiety can also impair achievement in other areas as well, such as athletic performance.
Acupuncture has been shown to reduce anxiety. Studies have shown that acupuncture can reduce generalized anxiety, depressive anxiety, and pre-operative anxiety. See Pilkington, Kirkwood, Rampes, Cummings, and Richardson for a review of the literature regarding acupuncture and anxiety.
If anxiety impairs memory and acupuncture can reduce anxiety, can acupuncture improve memory? Some research has been done with mice, gerbils, monkeys, and rats who suffered cognitive impairment for a variety of reasons. Some research has also been directed at examining acupuncture's ability to help cognitively-impaired humans as well. But to date, no study has examined whether acupuncture can improve memory in healthy human subjects.
This study examines the effect of one acupuncture treatment on State-Anxiety (SA) and performance on the Automated Operation Span Task (AOSPAN).
Method
Participants90Subjects were recruited from local universities. The Institutional Review Board of the National University of Health Sciences granted full approval for the study.
Inclusion criteria was that all subjects must:Be undergraduate university students aged18-30; be wiling to receive acupuncture; have not received acupuncture in the past three months; be free of any serious medical problems; not be taking any psychoactive medication; not be pregnant or breastfeeding; and be fluent in English. All subjects who did not meet the inclusion criteria were excluded from the study. Subjects were compensated between$10-$20for their participation.
Setting
The study was conducted at two private acupuncture clinics around Chicago, Illinois, USA. Consent and demographic questionnaires were filled out in the waiting room. The remainder of the procedures was performed in an8x10foot treatment room with a massage table, a laptop computer on a desk, and one chair.
Instruments and Measures The State-Trait Anxiety Inventory (STAI) by Spielberger is a widely-used self-report anxiety instrument. It contains two separate20-item subscales that measure trait (baseline) and state (situational) anxiety. Form Y-1measures State Anxiety (SA) and form Y-2measures Trait Anxiety (TA). Each form contains20statements and subjects rate how much each statement reflects their true feelings. Twenty is the minimum score and80is the maximum. The STAI has shown test-retest reliability and external validity. It is one of the most widely-used anxiety measurement instruments in the world. Some authors even refer to the STAI as being the "gold standard" of anxiety measurement instruments.
The Automated Operation Span Task (AOSPAN) by Unsworth et al is a computerized test of working memory that has shown good internal reliability and external validity. It provides several pieces of data to analyze. Subjects are presented with a math problem to perform in their head and then are shown a letter to remember. Then there is another math problem and another letter. After a series of between three and seven of these math-letter pairs, subjects must recall the letters they were shown in the correct order. There are a total number of75letters and math problems each. The AOSPAN Absolute Score and the Total Correct Score both reflect the recall of the letters. The Total Correct score counts all correct responses. Absolute Score only gives credit for letters recalled correctly when the entire set is recalled correctly. For example, in a set of seven math problems and letters, if a subject correctly recalls six of the letters, the Total Correct score would be six and the Absolute score would be zero. Studies that use the AOSPAN to measure memory most often compare the Total Correct Score. The AOSPAN also tracks performance on the math questions broken down into accuracy and speed errors.
Stainless steel acupuncture needles from the DBC company were used for the Acupuncture group. The type of needle were Spring Singles, size0.20mm width by30mm length for body points; and0.20mm diameter by15mm length for points on the head.
Independent Variable
The independent variable was whether or not the subject received acupuncture for20minutes at Sishencong (EX-HN1), Yintang (EX-HN3), Shenting (Du24), Shenmen (Ht7), Neiguan (PC6), and Taixi (Kd3) while they lay on a massage table for20minutes. All needles were inserted with even method. Sishencong (EX-HN1), was needled transversely with all needles pointing towards Baihui (Du20) at a depth of0.5cun. Shenting (Du24) was needled in an inferior direction to a depth of0.5cun. Yintang (EX-HN3) was needled transversely with an inferior direction to a depth of0.3cun. Shenmen (Ht7) was needled perpendicularly to a depth of0.5cun. Neiguan (PC6) was needled perpendicularly to a depth of1cun. Taixi was needled perpendicularly to join with Kunlun (UB60). Acupuncture was administered by an experienced, professional acupuncturist. Subjects in the control group had the same points touched and swabbed with alcohol but were not needled.
Dependent Variables
The dependent variables that were measured were the scores on the STAI and the AOSPAN.
Procedure
Subjects were randomized by computer ahead of time into either Acupuncture or Control groups. All subjects were tested one at a time and had only one appointment to keep. At the start of the appointment, subjects had the study design partially explained to them and then they completed the Demographic Questionnaire and Informed Consent Forms.
Next, all subjects were administered the STAI forms Y-1and Y-2. After the initial administration of the STAI, all subjects were instructed to remove their shoes and socks and lay on a treatment table. The treatment room employed soft lighting and relaxing music.
Subjects in the Acupuncture Group then received acupuncture, at:Sishencong (EX-HN1), Shenting (Du24), Yintang (EX-HN3), Shenmen (Ht7), Neiguan (PC6), and Taixi (Kd3). All points were be needled bilaterally with even method and needles were retained for20minutes.
Acupoints were chosen in an effort to calm the spirit and improve mental function. According to the Manual of Acupuncture by Peter Deadman et al.: Sishencong (EX-HN1), benefits the eyes and ears; calms the spirit; and is indicated for poor memory. Shenting (Du24) benefits the brain and calms the spirit. Additionally, the Du channel goes to the brain. Yintang (EX-HN3) calms the Shen and is indicated to calm anxiety and agitation. Shenmen (Ht7) calms the spirit, regulates and tonifies the Heart; and is indicated for poor memory, fear and fright. Additionally, the Heart organ houses the mind. Neiguan (PC6) is indicated for poor memory, apprehension, fear and fright. The Pericardium is the Heart Master and also benefits the Heart. Taixi (Kd3) was chosen because the kidney is associated with the brain and because its low position on the body balances the effect of all the points on the upper body. In this treatment, Taixi (Kd3) helps to ground the treatment and the subjects'consciousness.
Subjects in the Control Group were laid on the same table for20minutes and had the acupoints touched and swabbed with alcohol, but were not needled. After this variable period, all subjects followed the same protocol.
Subjects completed the Y-1form again. Then they were directed to a laptop computer where they received automated instructions in performing the AOSPAN. Subjects were informed that a strong performance on the test would enter them into a drawing for a cash prize and were encouraged to do their best.
Care was taken to reduce the likelihood that subjects in the control group would realize that they were in the control group. Subjects were not told the order of events of the study. They were told,"You will fill out some self-evaluation questionnaires, take some computerized tests of memory, and may receive acupuncture at some point." When they were administered the AOSPAN, the researcher told them,"Now we will have you take the first memory test." This was intended to raise the possibility in the subjects'mind that they could still receive acupuncture before taking another memory test.
The length of time that the researcher spent with each group and the amount of conversing and the amount of physical contact were kept uniform in order to minimize the placebo effect as described by Finniss et al, who showed that these differences can affect outcomes.
Statistical analysis
The unpaired T-test was utilized for statistical comparison of mean values between Acupuncture and Control Groups, and between subgroups for STAI and AOSPAN data using www.graphpad.com online software. Regression analysis was performed to examine interactions between all measured parameters of STAI and all measured parameters of the AOSPAN using online software from www.easycalculation.com.
Results
Control group had46subjects:22males,24females, and a mean age of21.28years. Acupuncture group had44subjects:16males,28females, and a mean age of20.53years. There were no significant differences in gender makeup or age between the two groups. There were no adverse reactions reported from any subjects in the acupuncture group. Results are reported as mean value±standard deviation.
STAI
The STAI yielded numeric values for:Initial State-level anxiety (SA1), Trait level anxiety (TA), and State-level anxiety after the variable period (acupuncture or rest, SA2). The difference between SA1and SA2was calculated and termed ASA. Unpaired t-tests were performed to compare Acupuncture and Control groups and subpopulations within groups.
There were no significant differences in SA1or TA between the two groups. The mean ΔSA was-6.35±7.49in the Control group and-7.61±5.65in the Acupuncture group (p=-0.33, not significant). The mean SA2was29.63±8.2in the Control group and26.14±4.5in the Acupuncture group (p=0.0146, significant).
The values obtained for TA ranged from23to63. Using a median split, subjects with TA below43were classified as Low-Anxious (LA, n=62) and those with TA at or above43were considered as High-Anxious (HA, n=28). Within the Acupuncture group, the reduction in SA was greater for those considered to be HA (9.93,±6.28, n=14) compared to those considered LA (6.64±5.11, n=30), but this was not quite statistically significant (p=0.0625).
AOSPAN
The AOSPAN provided numeric values for:Absolute Score, Total Correct Score, Total Math Errors, Math Accuracy Errors, and Math Speed Errors.
Subjects who received acupuncture performed better than control. For the Total Correct Score, subjects in the Acupuncture group scored9.5%higher than those in the Control group (65.39±7.38compared to59.70±13.1, p=0.0134, significant), raising the percentage correct to87.2%for the Acupuncture group from79.6%for the Control group. The mean AOSPAN Absolute score was45.87±18.36(61.2%correct) in the Control group and52.20±14.28(69.6%correct) in the Acupuncture group (p=0.072, approaching significance). For the subgroup of males, the AOSPAN Absolute score was44.14±16.73in the Control group (n=22) and55.13±15.01in the Acupuncture group (n=16, p=.044, significant). The mean total number of math errors was36%less in the Acupuncture group (2.68±2.31) than the Control group (4.22±3.44, p=0.0153, significant). Mean number of math speed errors was1.24±1.59in the Control group and was0.80±1.3in the Acupuncture group (p=0.153, not significant). The mean number of math accuracy errors was2.98±2.52in the Control group and1.89±1.71in the Acupuncture group (p=0.0188, significant).
Regression analysis was performed and no significant correlations were found between: STAI and AOSPAN scores.
Overall, there was a trend that subjects with HA performed worse on the AOSPAN than LA subjects. When broken down into Control and Acupuncture groups, HA subjects performed below the LA subjects in the Control group; but this detriment was reduced or eliminated in the acupuncture group.
There was also a trend noticed that the improvement in scores on the AOSPAN that was found in the acupuncture group was more pronounced for males than for females.
Discussion
20minute needle retention at points:Sishencong (EX-HN1), Shenting (Du24), Yintang (EX-HN3), Shenmen (Ht7), Neiguan (PC6) and Taixi (Kd3) improves memory and decreases anxiety immediately after administration. However, the improvement in memory was unrelated to both SA and ΔSA. This does not prove that acupuncture cannot improve memory through the reduction of anxiety. It is possible that another protocol could support such a hypothesis. This study shows that acupuncture may improve memory via a different mechanism than specifically through reduction of anxiety.
This particular acupuncture treatment also resulted in a reduction of anxiety that was greater than resulted from rest alone, but that difference was not quite statistically significant (7.61points for Acupuncture group compared to the Control group's6.35). Due to the large standard deviation, this trend was not statistically significant. If only the final state-level anxiety is compared, the subjects in the acupuncture group had lower anxiety (p<0.05).
This research also supports the existing evidence that HA individuals do not perform as well as LA on tests of working memory. In all categories that AOSPAN measures, HA individuals scored lower than their LA counterparts, although not significantly. When examined as a whole, HA subjects' Absolute score was11%less than HA's, the Total Correct Score was5.6%less, and they made33%more math errors compared to their LA counterparts. The use of the median split to define HA and LA groups has been questioned by Conway et al and it is true that there are some practical limitations to this procedure. The median split is still widely used though and in this case yields some interesting trends.
The administration of acupuncture negated some of the deleterious effects of HA. When broken down between Control group and Acupuncture group, the effect of HA was much less for those who received acupuncture.
Without acupuncture, HA subjects performed12.5%worse than LA on the Absolute Score, whereas with acupuncture the HA subjects performance was impaired by only7.6%. Total Correct Score for HA subjects was8.6%worse for Control subjects compared to LA Control, but for HA Acupuncture group the score was reduced by only1.5%compared to LA Acupuncture subjects. HA subjects without acupuncture made52.2%more math errors than LA without acupuncture, but HA subjects with acupuncture made13.2%fewer math errors than LA acupuncture subjects. In fact, HA subjects who received acupuncture scored higher on all measures of the AOSPAN than the LA subjects in the control group. While these findings are not statistically significant, this is likely due to the small sub-population size and may become significant in a larger study. The trend seems clear though. Untreated, HA impairs performance of WM. Acupuncture reduces or eliminates that impairment.
It is not just the HA subjects that benefit though. Comparing LA Control to LA Acupuncture groups, the treatment group outperformed the control group in all measures with the exception of Math Speed Errors.
Alternate research designs
Another way to design this study would be to have subjects take the AOSPAN before and after the variable period. For this study, this design was rejected because it was felt that taking the test twice resulted in measuring subjects' ability to learn a task rather than testing memory. Additionally, the AOSPAN requires subjects to go through a lengthy practice period where their response time is measured (unbeknownst to the subjects at the time) and then used as the basis for timing the actual measures of the test. In a second administration, subjects would know their response times were being measured and could manipulate them in order to give them more time during the actual test. If it were possible to alter the AOSPAN so that the first round practice time measurements could be used for the second round of testing; and that the second round could begin without the practice sessions, then it may be possible to run the study this way. However, no data exists testing the reliability nor validity of the AOSPAN's measurement when administered a twice in such a short time span.
Another way to design this study would be to have subjects take the AOSPAN, then receive six to twelve weeks of treatment, and then retake the AOSPAN. This may give subjects sufficient time to forget the procedure and yield valid measures on the second administration of the AOSPAN.
Both the one-time protocol and the6-or12-week protocols could be performed using different points. This study focused on the Heart, Pericardium, Kidney, Du channels and extra points on the scalp. The Spleen is also involved in cognition, particularly in its association with the Yi, which is roughly translated as the Will. The addition of Sanyinjiao (Sp6) or other points on the Spleen channel are worthy of investigation. There is no reason to believe that another protocol could not have a greater effect. Auricular points with acupuncture or acupressure could also be investigated. Acupressure could be compared with acupuncture.
Baihui (Du20) has similar functions and indications as Sishencong (EX-HN1). Replications could substitute Baihui for Sishencong (EX-HN1), and investigate whether one scalp needle would be as effective as four. In fact, this study could be replicated with any or several points eliminated to investigate how minimal an intervention could be used to gain the same result. Perhaps only a few needles are necessary.
This experiment could also be run using different populations. There is no reason to assume that the beneficial effects shown in this study are limited to subjects under the age of30. Future research could examine a broader age range such as18-65, or just look at seniors (65or older), or any subgroup.
Why no sham group? Sham acupuncture does not exist. It is not an inert intervention. The two most common methods for administering sham acupuncture are either cutaneous stimulation/superficial needling or needling points away from major (or indicated) acupuncture points.
Superficial needling still affects the flow of energy in the channels. Superficial needling has been shown to induce physiologic changes in the limbic system and those changes are different between different subject types. For example, superficial needling will increase activity within the limbic system in subjects who have no pain, but it will reduce it in those with pain. Some studies have shown that sham acupuncture is as effective as true acupuncture; and that both are more effective than placebo medication. Other studies have shown that the addition of both verum and sham acupuncture to standard medication provide superior benefit than standard medication alone, but that the addition of verum acupuncture is more beneficial than sham. Others have shown that, while both sham and verum may be beneficial, that they may work through different mechanisms. At least one study even concluded that sham was more effective than verum.
Secondly, there is no place on the body into which you can insert a needle that is energetically inert. There are the defined acupoints, but every spot on the body lies within an acupuncture meridian and will therefore have some effect on the energy flow of the subject. Studies have shown an effect where placebo (or no treatment) has some degree of effect, sham acupuncture has more effect, and true acupuncture has even more effect.
Lundeberg et al present an excellent review of the literature regarding so-called "placebo" acupuncture. They explained that minimal acupuncture does cause physiologic changes as measured by fMRI. They conclude that placebo acupuncture does not serve to elucidate the effects of acupuncture but rather introduce a potential bias, which interferes with understanding acupuncture's true effects. Did the subjects in the Acupuncture group know that they were in the treatment group? Yes. Did those in the Control group know that they were in the Control group? No. Is it possible that those in the treatment group knew that they were supposed to do better and therefore did perform better on the AOSPAN? Perhaps. All subjects were told that a strong performance on the AOSPAN would enter them into a drawing for a cash prize, so it is assumed that all subjects gave their best effort. It is possible that knowing they had received a treatment gave Acupuncture subjects greater confidence and focus. For this reason, future studies may incorporate a sugar pill for the control group. With this addition, everyone may think that they had received some sort of treatment prior to taking the AOSPAN.
Acupuncture has been shown to be an effective treatment for anxiety. This study showed its effect on state level anxiety, but does not address the trait anxiety. The common interventions for addressing anxiety in the long term are medications and psychotherapy. Acupuncture is clearly a better choice than anti-anxiety medications because it carries much less risk of side effects and has been studied long enough to ascertain its safety as a long-term therapy. Acupuncture may be used in conjunction with psychotherapy.
Lastly, the aging population of the world is experiencing profound problems with memory loss. Future study should focus on using this treatment and other point combinations to affect and improve memory and cognitive function in the elderly.
Acknowledgements:The author would like to thanks to my support team in China:Dr. Xu Nenggui for taking me on as a student and advising me with great patience and wisdom. Thanks to Dr. Li Min, our liason, friend and great helper. And thanks to the Guangzhou University of Chinese Medicine. Thanks also goes to the support team in the USA:Dr Hui Yan Cai, Dr. Patricia Rush, Jeanie Bussell, Christopher Martiniano, Judith Schlaeger, Tricia Miller, Melissa Lee Grein, Jia Xu, Long Huynh, and Julia Kravitz, in addition to my family. Thanks to National University of Health Science and Judy Pocious for their assistance with Institutional Board Review and approval.
每个人都想提高记忆力。从滋补到运动,产品和服务不断向消费者推销并声称可以提高智力和记忆力,但很少见效。
工作记忆最初是由Baddeley和Hitch提出的。工作记忆被理解为短时记忆和控制注意力。它由三个系统组成：一个中央执行系统,管理着智力和注意力的分配；一个语音回路和一个视觉空间模板,把声音和图像分别保存在短时记忆中。
工作记忆被认为和阅读理解和运算推演相关联。被改进用来处理工作记忆的统计处理及分析任务已经有望涉及于各种能力：如记笔记、语言理解、玩桥牌、计算机语言学习、拼写学习、定向、建立词汇表,写作、综合学习和推理能力。工作记忆容量是决定人们在很多领域获得成功的一个主要因素。所以工作记忆是一个绝大多数人们想要提高的方面。
焦虑已被证实有损于工作记忆。研究显示它扰乱中央执行系统控制注意力的能力,这将有碍于中央执行系统排除外部刺激的能力,焦虑不仅有损于中央执行系统,它还损害工作记忆的所有方面。
焦虑已经显示出对运算表现工作记忆处理及分析任务测量的损害。焦虑还一样损害其他方面的成就,比如运动表现等。
针灸已被证实可以改善焦虑。研究显示针灸可以缓解一般性焦虑症郁闷型焦虑症外科手术焦虑症。可以参看Pilkington, Kirkwood, Rampes, Cummings和Richardson关于针灸和焦虑症的文献回顾。
如果焦虑症损害记忆并且针灸可以改善焦虑症,那么针灸可以提高记忆吗?一些研究已经用记忆遭受各种受创的老鼠、猴子和大老鼠进行了相关的研究。
还有一些研究已经也关注于验证针灸对认识受损的人类也一样有改善的功效至今为止,尚没有研究测试出针灸是否可以提高健康人群的记忆力。
这项研究旨在观察：针刺在焦虑状态和AOSPAN测试中的治疗作用。
方法
参与者
从当地的大学招募了90名受试者。国立健康科学大学机构审查委员会完全授权于这项研究。
所有受试者必须符合：18-30岁的大学在校生：愿意接受针灸治疗；在三个月前没有接受过针灸治疗；没有任何严重疾病；没有在接受任何精神治疗；非孕妇非哺乳期；英文流畅。任何受试者不符合上述条件都将被排除在该项研究之外。受试者为此获得10-20美元的报酬。
设备
该项研究在两所私人针灸门诊中实施。认可协议和个人资料表在休息室里完成。其他程序在一间8X10英尺,放置有一个按摩床,一个放有笔记本电脑的书桌和一把椅子的治疗室内完成。
工具和措施
Spielberger的焦虑状态特征量表(STAI)是一个被广泛运用的可以自测的焦虑症测量工具。它包含两个分别由20个子项构成的部分,测量个体特征(起始点)和焦虑的形式(状态)。Y-1表测量焦虑状态(SA)Y-2表测量焦虑个体特征(TA)。每个表包含20项陈述和主体级别,每个陈述反映在多大程度上体现他们的真实感受。最低得分为20分,最高位得分为80分
焦虑状态特征量表已显示很好的重复性和可信度。这是国际上被运用得最广泛的焦虑测试工具之一。一些专家甚至将焦虑状态特征量表称作焦虑测试工具中的“黄金标准”。
Unsworth等人的自动化跨度任务操作(AOSPAN)是一个已被证实具有良好的内部可信性和外部有效性的关于工作记忆的计算机测试,它可提供一系列数据以供分析。受试者被要求心算一项数学题,然后通过一个被显示的数字去记忆。接着还有另外的数学题和数字。在进行了一系列3-7项这样的数学题和数字组之后,受试者必须将显示出的数字按照正确的顺序排列出来。每次总计有75个数字和数学题。自动化跨度任务操作绝对的得分和总体正确得分共同反映出数字的回忆。总体正确得分计算所有正确的回答。绝对得分是在仅当一整组回忆正确的前提下给予得分。例如,有7组数学题和数字,如果受试者正确回忆了6个数字,总体正确得分将是6,绝对得分将是0。用自动化跨度任务操作(AOSPAN)测试记忆的研究最常比较的是总体正确得分。AOSPAN同时也关注数学问题中出现的精确度误差和运算速度差异。
用于针灸组的是DBC公司的不锈钢质的针灸针。这类针是单丝弹簧所制,体针用直径0.20毫米长度30毫米的针,头针用直径0.20毫米长度为15毫米的针。
自变量
自变量是躺在按摩床上20分钟的受试者,无论他们是否接受了四神聪、印堂、神庭、神门、内关和太溪穴位上的针灸。所有的针都是按相同的方法插入。四神聪穴上的针是平刺进针0.5寸,四根针互为垂直并共同指向百会穴。神庭穴位上的针是向下平刺0.5寸。印堂穴在两眉间横线上向下平刺0.3寸。神门穴垂直进针0.5寸。内关穴垂直进针1寸。太溪穴垂直进针并透昆仑穴。针灸全过程由一位有经验的专业针灸师实施。在对照组的受试者同样受到穴位按压和酒精消毒棉的擦拭,但不接受针灸。应变量
被测试出来的应变量是基于焦虑状态特征量表和自动化跨度任务操作的得分。
步骤
受试者们随机被分配进针灸组和对照组。所有受试者经过一次性测试,并且只有一次约见。在面试开始的时候,通过适当的方式让受试者们大致了解这项研究,然后他们填写个人自愿书和个人基本信息的表格。
接着,所有受试者被指导完成焦虑状态特征量表的表格Y-1和Y-2。经过初步的STAI之后,所有受试者被要求脱去鞋袜躺在按摩床上。治疗室灯光柔和并播放着舒缓的音乐。
针灸组的受试者接下来接受以下穴位的针灸：四神聪、神庭、印堂、神门、内关和太溪。所有穴位都按照同样的方法在两边同时针灸20分钟。
所有的穴位都是按照可舒缓情绪和提高精神注意力而进行选择。依照Peter Deadman等人的针灸手册：四神聪穴有益于视觉和听觉；舒缓情绪并有可能对记忆力有帮助。神庭穴有益于智力和舒缓情绪,此外,督脉是通向大脑的。印堂穴可以安神,有缓解焦虑和焦躁的可能。神庭穴可以舒缓情绪,调节和补养心脏,也可能对记忆力衰退,害怕和惊吓有帮助,此外,心脏主管精神及记忆。内关穴可能对记忆衰退、忧虑、害怕和惊吓有帮助。心包经主管心脏。选择太溪穴是因为肾脏连接大脑,还因为它位处身体下端,对身体上端所有的穴位起着平衡的作用。在这项治疗中,太溪穴是治本,并对受试者的意识有帮助。
受试者再一次完成Y-1表格。然后他们被引导至笔记本电脑那儿,在进行自动化跨度任务操作(AOSPAN)中接受自动指令。受试者被告知试验中出色的表现将直接影响到他们所获得的报酬,以此让他们尽力表现得更好。
必须尽力减少让对照组的受试者知道他们是在对照组的可能。关于这项研究的真实情况不可以如实地告知受试者们,只能告诉他们：“你们将填写一些个人评估的调查问卷,进行一些关于记忆的电脑测试,还可能接受一些穴位的针灸治疗。”当他们进行自动化跨度任务操作(AOSPAN)测试的时候,研究人员告诉他们：”现在我们将带你们进入第一项记忆测验。“这将有意地加大受试者们认为他们还可以在接受其他记忆测验之前接受针灸治疗的可能性。
研究人员要确保花费在每一组的时间,包括交谈和身体接触要按规定完全一样,以将安慰效果最小化。正如Finniss等人说明的那样,他证明这些不同可以影响到研究结果
统计分析
未配对T检验是用取自www.graphpad.com的在线软件,用作针灸组和对照组之间,以及STAI和焦虑状态特征量表小组间的平均值统计对比(资料)。回归分析用焦虑状态特征量表和自动化跨度任务操作的对应参数用在线软件www.easycalculation.Com9
结果
对照组有46人,其中男性为22人,女性为24人,平均年龄为21.28岁。针灸组有44人,其中男性为16人,女性为28人,平均年龄为20.53岁。两组间没有明显的性别和年龄结构上的差异。针灸组没有任何受试者报告有不良反应。结论由均数±标准差得出。
焦虑状态特征量表(STAI
STAI得出的数值：焦虑的起初状态,特质焦虑状态,和治疗期的焦虑状态(针灸或休息,SA2). SA1和SA2被计算和称为△SA。对比测试用来比较试验组和对照组及其小组里的成员。
两组间没有明显SA1或TA的不同。对照组里ASA的平均值是-6.35±7.49,针灸组里ASA的平均值是-7.61±5.65。对照组里SA2的平均值是29.63±8.2针灸组里SA2的平均值是26.13±4.5(p=0.0146,有意义)
TA系列获得的数值从23到63.取中间值,TA低于43的受试者被划入轻度焦虑(LA,n=62),TA大于等于43的受试者被划入重度焦虑(HA,n28)。在针灸组里,相对于LA(6.53±5.02,n=30)而言,作为严重焦虑症(9.93,±6.40,n=14)其SA的减少更加明显,但在统计学意义上并不能算是十分显著(p=0.0594)。
AOSPAN
AOSPAN提供的数据作为：绝对分值,正确得分总数,数学错误总数,数学精度误差,数学运算速度差异。
接受针灸治疗的受试者效果好于对照组。正确得分总数方面,针灸组的受试者得分9.5%,高于对照组(65.39±7.38相对于59.70±13.1,P=0.0134,明显)。与对照组相比,针灸组的正确百分比从79.6%上升为87.2%。平均AOSPAN的绝对得分,对照组是45.87±18.36(正确率61.2%),实验组是52.20±14.28(正确率69.6%)(p=0.072,接近有效)。男子组里,AOSPAN的绝对得分对照组是44.14±16.73,治疗组是55.13±15.01(n=16,p=.044,有效).在平均数学错误的总数方面,针灸组(2.68±2.31)比对照组低36%。(4.22±3.44,p=0.0153,有效)。对照组平均数学运算速度差异为1.24±1.59,实验组的对照组平均数学运算速度差异为0.80±1.3(p=0.153,无效).对照组的平均数学精确误差为2.98±2.52,实验组的平均数学精确误差为1.89±1.71(p=0.0188,有效)
经过回归分析显示在焦虑状态特征量表和自动化跨度任务操作的得分之间没有明显的相互关系。
总体上说,存在这样一种趋势,严重焦虑症的受试者在自动化跨度任务操作测试方面要比轻度焦虑症的受试者表现的差。当分成对照租和针灸组后,严重焦虑症受试者的表现在对照组中仍低于轻度焦虑症受试者；而在针灸组这种差异减少或消除了。
此外还有一个趋势是在针灸组中男性自动化跨度任务操作得分的提高比女性要明显。
讨论
在四神聪、神庭、印堂、神门、内关和太溪穴上持续针灸20分钟,可以在治疗后立即提高记忆力并减轻焦虑。然而,记忆的提高并非与SA和△SA有关。这并不能证明针灸是通过缓解焦虑而提高记忆力的。可能会有别的方法支撑这个假设。这项研究显示针灸可以通过不同的途径而不是仅通过缓解焦虑来提高记忆。
这个特殊的针灸疗法还显示出其疗效在减轻焦虑方面比单纯的休息更有效,不过两者差异并未具有统计学上的意义(相对于对照组的6.35点,针灸组不过是7.61点)。由于较大的标准偏差,这个趋势不具备统计学上的意义。如果仅仅比较最后一组焦虑,针灸组受试者的焦虑改善得比较明显(p<0.05)
这个研究还给出一个证据,即严重焦虑症个体并不能像轻度焦虑症个体在工作记忆测试中表现的那么好。在自动化跨度任务操作测试的所有类别中,严重焦虑症个体得分低于他们当中的在轻度焦虑症中的得分,尽管这并不很明显。如果从实验整体来看,严重焦虑症受试者绝对得分比其少于5.6%的总体正确得分要小11%,并且与他们的轻度焦虑症相比,其数学错误增加33%。用平均值去界定严重焦虑症和轻度焦虑症组已经遭到Conway等人的质疑,程序上确实存在一些实际的限制。但平均值仍旧被在此使用并产生出一些有意思的趋势。
针灸的使用降低了严重焦虑症的一些症状反应。当分成对照组和针灸组时,接受针灸的受试者其严重焦虑症的影响大大降低。
未接受针灸的受试者,其严重焦虑症受试者的绝对得分比轻度焦虑症受试者低12.5%,然而通过针灸治疗,严重焦虑症受试者显示仅有7.6%的受损。与轻度焦虑症对照组的受试者相比,严重焦虑症受试者的正确得份总数低于其对照组8.6%,但与轻度焦虑症针灸组相比严重焦虑症针灸组的得分仅减少1.5%。严重焦虑症受试者未接受针灸的形成数学错误比轻度焦虑症受试者未接受针灸的高52.2%,但严重焦虑症受试者接受针灸的比轻度焦虑症接受针灸的在数学错误方面少13.2%。事实上,严重焦虑症那些接受过针灸治疗的受试者在自动化跨度任务操作的所有测试中的得分都要高于轻度焦虑症的对照组受试者。然而这些发现并不具备统计学上的意义,尽管这趋势很明显,但这可能由于其小群体规模的原因,更大一些规模的研究可能会形成意义。未经治疗,严重焦虑症有损于工作记忆的表现。针灸减缓或消除了这种损害。
但是并不仅仅是严重焦虑症受试者见效。轻度焦虑症对照组和轻度焦虑症治疗组相比,治疗组在除了数率错误之外的所有测试中都表现得比对照组好。
其他研究设计
这项研究的另一种设计方式可能是请受试者在治疗期前后进行两次自动化跨度任务操作测试。这样的设计不适合这项研究,因为觉得与其让受试者们在测试中两次利用测试结果不如让他们进行记忆方面的测试。此外,自动化跨度任务操作测试要求受试者们经过漫长的练习阶段并在此间检测他们的反应(当时受试者们不知情),并以此为基础确定真正的实验时机。第二次测试时,受试者们将会知道他们回答问题是会用来进行测试的,因而可能会在真正的试验阶段用时更长一些。如果有可能改变自动化跨度任务操作,那么第一轮练习时期的测量可用于第二轮测试,并且从第二轮开始可以省去练习阶段,这样这项研究就可能按照如此运作。然而,在如此短的时间间隔内实行两次自动化跨度任务操作的测试,其可靠性和有效性尚未得到检测。
另一种这项研究的设计是让受试者做自动化跨度任务操作测试,接着做六到十二周的治疗,之后再进行自动化跨度任务操作测试。这可以给受试者们予足够的时间去忘记这个步骤,从而使第二次自动化跨度任务操作测试有效。
一次性方案和6-12周的方案都可以使用不同的穴位去实施。这项研究关注于心经、心包经、肾经、督脉经和头部的经外奇穴。脾也与认知有关,尤其是与大致可以翻译成的“意”有一定联系。加入三阴交或脾经上的其他穴位是值得进一步观察的。没有道理认为其他方案不会有更好的疗效。针灸穴位上的针灸或针压法也可以进行观察。针压法可以与针灸法相比较。
百会穴有类似于四神聪的功能。可以验证用百会代替四神聪穴并检测是否一个头针可以像四个一样有效。事实上,这个研究可以用任何穴位或取消数个穴位进行验证来观察怎样用最小的介入获得同样的效果。也许用针数目少才是必要的。
这个实验也可以在不同的人群进行。没有理由假设这项研究中显示的疗效局限在30以下的受试群里。今后的研究可以检测更大的年龄跨度比如18-65岁,或仅仅针对老年人(65岁或以上),或任何群体。
为什么没有安慰针灸组
安慰针灸组根本不存在。它不是一个没有反应的介入。两个最常见的安慰针灸实施方法是皮肤刺激或浅表针刺,或者针刺点偏离主要的(规范的)针灸穴位。
不过浅表针刺也影响经脉中的能量流。浅表针刺已经被显示可以在大脑边缘系统引起生理改变,但那些改变会因人而异。例如,浅针刺在无疼痛的受试者中可活跃大脑边缘系统,但在有疼痛的患者中效果减弱,一些研究已经显示安慰针灸也像真正的针灸一样有效,两者都比安慰药物更加有效。一些研究显示真正的针灸和安慰针灸同时辅助药物可以比单独使用药物更能提高疗效,并且真正的针灸要比安慰针灸更有效。还有一些研究显示,常规针灸和安慰针灸两者都可以通过不同的途径产生疗效
其次,身体上没有一个地方你插入针它没有反应。那些规范的针灸穴位,乃至经络上的每一个点都会对受试者主体能量流产生一定的影响。一些研究得出一个结果,安慰剂(或未接受治疗)有一些不同程度的效果,安慰针灸效果稍好,真正的针灸效果更加明显。
Lundeberg等人提出一个关于所谓“安慰”针灸的著名观点。他们说明,通过功能性磁共振成像测试最小化的针灸可以引起身生理改变。他们得出结论,安慰针灸不能用来解释针灸疗效,相反它还引入一些潜在偏见,阻碍了对针灸真实效果的认识。
治疗组的受试者们知道他们在治疗组吗?是的。那些在对照组的受试者们知道他们在对照组吗?不知道。有没有可能那些治疗组的受试者们知道他们被期望表现得更好而因此在自动化跨度任务操作测试中努力表现呢?有可能。所有受试者都被告知在自动化跨度任务操作测试中出色的表现将会直接和他们获取的报酬挂钩,因此可以设想所有受试者都会尽力。知道他们已经接受过了治疗,这可能会给针灸组的受试者们更大的信心和关注。出于这个原因,将来的研究可以给对照组一个奖励。有了这个辅助,每个人在进行自动化跨度任务操作测试之前都会认为他们已经接受了一些类型的治疗。
针灸已经被证实是一个对焦虑症有效的治疗手段。这个研究显示了它对焦虑状态的疗效,但并未满足特质焦虑。通常对焦虑症的长期治疗是药物和精神疗法。针灸很明显是一个比抗焦虑药物更好的选择,因为它的副作用很小并且已经过足够的研究确定其作为一个长期疗法的安全性。针灸疗法可以被用来配合精神疗法。
最后,全球老年人口正面临记忆衰退的严重问题。将来的研究应该着眼于使用这种治疗和不同的穴位组合去改善和提高老年人的记忆功能和认知功能。
Introduction
Memory is an area that everyone would like to improve. From supplements to exercises, products and services have been marketed to people with claims of helping boost mental capacity and memory; but few have been shown to be effective.
Working Memory (WM) was originally described by Baddeley and Hitch. WM is understood as short-term memory (STM) plus attentional control. It consists of three constituent systems:a Central Executive (CE), which is in charge of allocating mental resources and attention; a Phonologic Loop; and a Visual Sketchpad where audio or visual data are kept in STM respectively.
WM has been associated with reading comprehension and arithmetic calculation. The Span Tasks that have been developed to measure WM have been associated with predicting such diverse capabilities as:Note taking, language comprehension, playing bridge, learning a computer language, learning to spell, following directions, building vocabulary, writing, complex learning, and reasoning ability. Working memory capacity (WMC) can be a major factor in determining one's success in many areas. So WM is an area that most, if not all, people would want to improve.
Anxiety has been shown to disrupt WM. Studies show it disrupts the ability of the CE to focus attention; and that it limits the ability of the CE to ignore extraneous stimuli; and that anxiety may impair all facets of WM and not just the CE.
Anxiety has been shown to impair performance in math, reading and OSPAN task measures of working memory. Anxiety can also impair achievement in other areas as well, such as athletic performance.
Acupuncture has been shown to reduce anxiety. Studies have shown that acupuncture can reduce generalized anxiety, depressive anxiety, and pre-operative anxiety. See Pilkington, Kirkwood, Rampes, Cummings, and Richardson for a review of the literature regarding acupuncture and anxiety.
If anxiety impairs memory and acupuncture can reduce anxiety, can acupuncture improve memory? Some research has been done with mice, gerbils, monkeys, and rats who suffered cognitive impairment for a variety of reasons. Some research has also been directed at examining acupuncture's ability to help cognitively-impaired humans as well. But to date, no study has examined whether acupuncture can improve memory in healthy human subjects.
This study examines the effect of one acupuncture treatment on State-Anxiety (SA) and performance on the Automated Operation Span Task (AOSPAN).
Method
Participants90Subjects were recruited from local universities. The Institutional Review Board of the National University of Health Sciences granted full approval for the study.
Inclusion criteria was that all subjects must:Be undergraduate university students aged18-30; be wiling to receive acupuncture; have not received acupuncture in the past three months; be free of any serious medical problems; not be taking any psychoactive medication; not be pregnant or breastfeeding; and be fluent in English. All subjects who did not meet the inclusion criteria were excluded from the study. Subjects were compensated between$10-$20for their participation.
Setting
The study was conducted at two private acupuncture clinics around Chicago, Illinois, USA. Consent and demographic questionnaires were filled out in the waiting room. The remainder of the procedures was performed in an8x10foot treatment room with a massage table, a laptop computer on a desk, and one chair.
Instruments and Measures The State-Trait Anxiety Inventory (STAI) by Spielberger is a widely-used self-report anxiety instrument. It contains two separate20-item subscales that measure trait (baseline) and state (situational) anxiety. Form Y-1measures State Anxiety (SA) and form Y-2measures Trait Anxiety (TA). Each form contains20statements and subjects rate how much each statement reflects their true feelings. Twenty is the minimum score and80is the maximum. The STAI has shown test-retest reliability and external validity. It is one of the most widely-used anxiety measurement instruments in the world. Some authors even refer to the STAI as being the "gold standard" of anxiety measurement instruments.
The Automated Operation Span Task (AOSPAN) by Unsworth et al is a computerized test of working memory that has shown good internal reliability and external validity. It provides several pieces of data to analyze. Subjects are presented with a math problem to perform in their head and then are shown a letter to remember. Then there is another math problem and another letter. After a series of between three and seven of these math-letter pairs, subjects must recall the letters they were shown in the correct order. There are a total number of75letters and math problems each. The AOSPAN Absolute Score and the Total Correct Score both reflect the recall of the letters. The Total Correct score counts all correct responses. Absolute Score only gives credit for letters recalled correctly when the entire set is recalled correctly. For example, in a set of seven math problems and letters, if a subject correctly recalls six of the letters, the Total Correct score would be six and the Absolute score would be zero. Studies that use the AOSPAN to measure memory most often compare the Total Correct Score. The AOSPAN also tracks performance on the math questions broken down into accuracy and speed errors.
Stainless steel acupuncture needles from the DBC company were used for the Acupuncture group. The type of needle were Spring Singles, size0.20mm width by30mm length for body points; and0.20mm diameter by15mm length for points on the head.
Independent Variable
The independent variable was whether or not the subject received acupuncture for20minutes at Sishencong (EX-HN1), Yintang (EX-HN3), Shenting (Du24), Shenmen (Ht7), Neiguan (PC6), and Taixi (Kd3) while they lay on a massage table for20minutes. All needles were inserted with even method. Sishencong (EX-HN1), was needled transversely with all needles pointing towards Baihui (Du20) at a depth of0.5cun. Shenting (Du24) was needled in an inferior direction to a depth of0.5cun. Yintang (EX-HN3) was needled transversely with an inferior direction to a depth of0.3cun. Shenmen (Ht7) was needled perpendicularly to a depth of0.5cun. Neiguan (PC6) was needled perpendicularly to a depth of1cun. Taixi was needled perpendicularly to join with Kunlun (UB60). Acupuncture was administered by an experienced, professional acupuncturist. Subjects in the control group had the same points touched and swabbed with alcohol but were not needled.
Dependent Variables
The dependent variables that were measured were the scores on the STAI and the AOSPAN.
Procedure
Subjects were randomized by computer ahead of time into either Acupuncture or Control groups. All subjects were tested one at a time and had only one appointment to keep. At the start of the appointment, subjects had the study design partially explained to them and then they completed the Demographic Questionnaire and Informed Consent Forms.
Next, all subjects were administered the STAI forms Y-1and Y-2. After the initial administration of the STAI, all subjects were instructed to remove their shoes and socks and lay on a treatment table. The treatment room employed soft lighting and relaxing music.
Subjects in the Acupuncture Group then received acupuncture, at:Sishencong (EX-HN1), Shenting (Du24), Yintang (EX-HN3), Shenmen (Ht7), Neiguan (PC6), and Taixi (Kd3). All points were be needled bilaterally with even method and needles were retained for20minutes.
Acupoints were chosen in an effort to calm the spirit and improve mental function. According to the Manual of Acupuncture by Peter Deadman et al.: Sishencong (EX-HN1), benefits the eyes and ears; calms the spirit; and is indicated for poor memory. Shenting (Du24) benefits the brain and calms the spirit. Additionally, the Du channel goes to the brain. Yintang (EX-HN3) calms the Shen and is indicated to calm anxiety and agitation. Shenmen (Ht7) calms the spirit, regulates and tonifies the Heart; and is indicated for poor memory, fear and fright. Additionally, the Heart organ houses the mind. Neiguan (PC6) is indicated for poor memory, apprehension, fear and fright. The Pericardium is the Heart Master and also benefits the Heart. Taixi (Kd3) was chosen because the kidney is associated with the brain and because its low position on the body balances the effect of all the points on the upper body. In this treatment, Taixi (Kd3) helps to ground the treatment and the subjects'consciousness.
Subjects in the Control Group were laid on the same table for20minutes and had the acupoints touched and swabbed with alcohol, but were not needled. After this variable period, all subjects followed the same protocol.
Subjects completed the Y-1form again. Then they were directed to a laptop computer where they received automated instructions in performing the AOSPAN. Subjects were informed that a strong performance on the test would enter them into a drawing for a cash prize and were encouraged to do their best.
Care was taken to reduce the likelihood that subjects in the control group would realize that they were in the control group. Subjects were not told the order of events of the study. They were told,"You will fill out some self-evaluation questionnaires, take some computerized tests of memory, and may receive acupuncture at some point." When they were administered the AOSPAN, the researcher told them,"Now we will have you take the first memory test." This was intended to raise the possibility in the subjects'mind that they could still receive acupuncture before taking another memory test.
The length of time that the researcher spent with each group and the amount of conversing and the amount of physical contact were kept uniform in order to minimize the placebo effect as described by Finniss et al, who showed that these differences can affect outcomes.
Statistical analysis
The unpaired T-test was utilized for statistical comparison of mean values between Acupuncture and Control Groups, and between subgroups for STAI and AOSPAN data using www.graphpad.com online software. Regression analysis was performed to examine interactions between all measured parameters of STAI and all measured parameters of the AOSPAN using online software from www.easycalculation.com.
Results
Control group had46subjects:22males,24females, and a mean age of21.28years. Acupuncture group had44subjects:16males,28females, and a mean age of20.53years. There were no significant differences in gender makeup or age between the two groups. There were no adverse reactions reported from any subjects in the acupuncture group. Results are reported as mean value±standard deviation.
STAI
The STAI yielded numeric values for:Initial State-level anxiety (SA1), Trait level anxiety (TA), and State-level anxiety after the variable period (acupuncture or rest, SA2). The difference between SA1and SA2was calculated and termed ASA. Unpaired t-tests were performed to compare Acupuncture and Control groups and subpopulations within groups.
There were no significant differences in SA1or TA between the two groups. The mean ΔSA was-6.35±7.49in the Control group and-7.61±5.65in the Acupuncture group (p=-0.33, not significant). The mean SA2was29.63±8.2in the Control group and26.14±4.5in the Acupuncture group (p=0.0146, significant).
The values obtained for TA ranged from23to63. Using a median split, subjects with TA below43were classified as Low-Anxious (LA, n=62) and those with TA at or above43were considered as High-Anxious (HA, n=28). Within the Acupuncture group, the reduction in SA was greater for those considered to be HA (9.93,±6.28, n=14) compared to those considered LA (6.64±5.11, n=30), but this was not quite statistically significant (p=0.0625).
AOSPAN
The AOSPAN provided numeric values for:Absolute Score, Total Correct Score, Total Math Errors, Math Accuracy Errors, and Math Speed Errors.
Subjects who received acupuncture performed better than control. For the Total Correct Score, subjects in the Acupuncture group scored9.5%higher than those in the Control group (65.39±7.38compared to59.70±13.1, p=0.0134, significant), raising the percentage correct to87.2%for the Acupuncture group from79.6%for the Control group. The mean AOSPAN Absolute score was45.87±18.36(61.2%correct) in the Control group and52.20±14.28(69.6%correct) in the Acupuncture group (p=0.072, approaching significance). For the subgroup of males, the AOSPAN Absolute score was44.14±16.73in the Control group (n=22) and55.13±15.01in the Acupuncture group (n=16, p=.044, significant). The mean total number of math errors was36%less in the Acupuncture group (2.68±2.31) than the Control group (4.22±3.44, p=0.0153, significant). Mean number of math speed errors was1.24±1.59in the Control group and was0.80±1.3in the Acupuncture group (p=0.153, not significant). The mean number of math accuracy errors was2.98±2.52in the Control group and1.89±1.71in the Acupuncture group (p=0.0188, significant).
Regression analysis was performed and no significant correlations were found between: STAI and AOSPAN scores.
Overall, there was a trend that subjects with HA performed worse on the AOSPAN than LA subjects. When broken down into Control and Acupuncture groups, HA subjects performed below the LA subjects in the Control group; but this detriment was reduced or eliminated in the acupuncture group.
There was also a trend noticed that the improvement in scores on the AOSPAN that was found in the acupuncture group was more pronounced for males than for females.
Discussion
20minute needle retention at points:Sishencong (EX-HN1), Shenting (Du24), Yintang (EX-HN3), Shenmen (Ht7), Neiguan (PC6) and Taixi (Kd3) improves memory and decreases anxiety immediately after administration. However, the improvement in memory was unrelated to both SA and ΔSA. This does not prove that acupuncture cannot improve memory through the reduction of anxiety. It is possible that another protocol could support such a hypothesis. This study shows that acupuncture may improve memory via a different mechanism than specifically through reduction of anxiety.
This particular acupuncture treatment also resulted in a reduction of anxiety that was greater than resulted from rest alone, but that difference was not quite statistically significant (7.61points for Acupuncture group compared to the Control group's6.35). Due to the large standard deviation, this trend was not statistically significant. If only the final state-level anxiety is compared, the subjects in the acupuncture group had lower anxiety (p<0.05).
This research also supports the existing evidence that HA individuals do not perform as well as LA on tests of working memory. In all categories that AOSPAN measures, HA individuals scored lower than their LA counterparts, although not significantly. When examined as a whole, HA subjects' Absolute score was11%less than HA's, the Total Correct Score was5.6%less, and they made33%more math errors compared to their LA counterparts. The use of the median split to define HA and LA groups has been questioned by Conway et al and it is true that there are some practical limitations to this procedure. The median split is still widely used though and in this case yields some interesting trends.
The administration of acupuncture negated some of the deleterious effects of HA. When broken down between Control group and Acupuncture group, the effect of HA was much less for those who received acupuncture.
Without acupuncture, HA subjects performed12.5%worse than LA on the Absolute Score, whereas with acupuncture the HA subjects performance was impaired by only7.6%. Total Correct Score for HA subjects was8.6%worse for Control subjects compared to LA Control, but for HA Acupuncture group the score was reduced by only1.5%compared to LA Acupuncture subjects. HA subjects without acupuncture made52.2%more math errors than LA without acupuncture, but HA subjects with acupuncture made13.2%fewer math errors than LA acupuncture subjects. In fact, HA subjects who received acupuncture scored higher on all measures of the AOSPAN than the LA subjects in the control group. While these findings are not statistically significant, this is likely due to the small sub-population size and may become significant in a larger study. The trend seems clear though. Untreated, HA impairs performance of WM. Acupuncture reduces or eliminates that impairment.
It is not just the HA subjects that benefit though. Comparing LA Control to LA Acupuncture groups, the treatment group outperformed the control group in all measures with the exception of Math Speed Errors.
Alternate research designs
Another way to design this study would be to have subjects take the AOSPAN before and after the variable period. For this study, this design was rejected because it was felt that taking the test twice resulted in measuring subjects' ability to learn a task rather than testing memory. Additionally, the AOSPAN requires subjects to go through a lengthy practice period where their response time is measured (unbeknownst to the subjects at the time) and then used as the basis for timing the actual measures of the test. In a second administration, subjects would know their response times were being measured and could manipulate them in order to give them more time during the actual test. If it were possible to alter the AOSPAN so that the first round practice time measurements could be used for the second round of testing; and that the second round could begin without the practice sessions, then it may be possible to run the study this way. However, no data exists testing the reliability nor validity of the AOSPAN's measurement when administered a twice in such a short time span.
Another way to design this study would be to have subjects take the AOSPAN, then receive six to twelve weeks of treatment, and then retake the AOSPAN. This may give subjects sufficient time to forget the procedure and yield valid measures on the second administration of the AOSPAN.
Both the one-time protocol and the6-or12-week protocols could be performed using different points. This study focused on the Heart, Pericardium, Kidney, Du channels and extra points on the scalp. The Spleen is also involved in cognition, particularly in its association with the Yi, which is roughly translated as the Will. The addition of Sanyinjiao (Sp6) or other points on the Spleen channel are worthy of investigation. There is no reason to believe that another protocol could not have a greater effect. Auricular points with acupuncture or acupressure could also be investigated. Acupressure could be compared with acupuncture.
Baihui (Du20) has similar functions and indications as Sishencong (EX-HN1). Replications could substitute Baihui for Sishencong (EX-HN1), and investigate whether one scalp needle would be as effective as four. In fact, this study could be replicated with any or several points eliminated to investigate how minimal an intervention could be used to gain the same result. Perhaps only a few needles are necessary.
This experiment could also be run using different populations. There is no reason to assume that the beneficial effects shown in this study are limited to subjects under the age of30. Future research could examine a broader age range such as18-65, or just look at seniors (65or older), or any subgroup.
Why no sham group? Sham acupuncture does not exist. It is not an inert intervention. The two most common methods for administering sham acupuncture are either cutaneous stimulation/superficial needling or needling points away from major (or indicated) acupuncture points.
Superficial needling still affects the flow of energy in the channels. Superficial needling has been shown to induce physiologic changes in the limbic system and those changes are different between different subject types. For example, superficial needling will increase activity within the limbic system in subjects who have no pain, but it will reduce it in those with pain. Some studies have shown that sham acupuncture is as effective as true acupuncture; and that both are more effective than placebo medication. Other studies have shown that the addition of both verum and sham acupuncture to standard medication provide superior benefit than standard medication alone, but that the addition of verum acupuncture is more beneficial than sham. Others have shown that, while both sham and verum may be beneficial, that they may work through different mechanisms. At least one study even concluded that sham was more effective than verum.
Secondly, there is no place on the body into which you can insert a needle that is energetically inert. There are the defined acupoints, but every spot on the body lies within an acupuncture meridian and will therefore have some effect on the energy flow of the subject. Studies have shown an effect where placebo (or no treatment) has some degree of effect, sham acupuncture has more effect, and true acupuncture has even more effect.
Lundeberg et al present an excellent review of the literature regarding so-called "placebo" acupuncture. They explained that minimal acupuncture does cause physiologic changes as measured by fMRI. They conclude that placebo acupuncture does not serve to elucidate the effects of acupuncture but rather introduce a potential bias, which interferes with understanding acupuncture's true effects. Did the subjects in the Acupuncture group know that they were in the treatment group? Yes. Did those in the Control group know that they were in the Control group? No. Is it possible that those in the treatment group knew that they were supposed to do better and therefore did perform better on the AOSPAN? Perhaps. All subjects were told that a strong performance on the AOSPAN would enter them into a drawing for a cash prize, so it is assumed that all subjects gave their best effort. It is possible that knowing they had received a treatment gave Acupuncture subjects greater confidence and focus. For this reason, future studies may incorporate a sugar pill for the control group. With this addition, everyone may think that they had received some sort of treatment prior to taking the AOSPAN.
Acupuncture has been shown to be an effective treatment for anxiety. This study showed its effect on state level anxiety, but does not address the trait anxiety. The common interventions for addressing anxiety in the long term are medications and psychotherapy. Acupuncture is clearly a better choice than anti-anxiety medications because it carries much less risk of side effects and has been studied long enough to ascertain its safety as a long-term therapy. Acupuncture may be used in conjunction with psychotherapy.
Lastly, the aging population of the world is experiencing profound problems with memory loss. Future study should focus on using this treatment and other point combinations to affect and improve memory and cognitive function in the elderly.
Acknowledgements:The author would like to thanks to my support team in China:Dr. Xu Nenggui for taking me on as a student and advising me with great patience and wisdom. Thanks to Dr. Li Min, our liason, friend and great helper. And thanks to the Guangzhou University of Chinese Medicine. Thanks also goes to the support team in the USA:Dr Hui Yan Cai, Dr. Patricia Rush, Jeanie Bussell, Christopher Martiniano, Judith Schlaeger, Tricia Miller, Melissa Lee Grein, Jia Xu, Long Huynh, and Julia Kravitz, in addition to my family. Thanks to National University of Health Science and Judy Pocious for their assistance with Institutional Board Review and approval.
引文
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