基于功能磁共振成像的针刺研究方法论探讨
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摘要
针刺这一有着几千年历史的传统中医疗法在当今世界范围内越来越得到普遍接受和认可。针刺作为一种绿色的补充替代疗法已被证实在众多疾病特别是功能性疾病上具有显著的治疗效果。然而针刺的机制仍不明确，这严重制约着对针刺认识水平的提高，从而使得针刺理论更新缓慢，进一步地制约着针刺临床疗效最大化的发展。因此，尽早阐明针刺的机制尤其是针刺中枢机制对整个针刺领域的发展起着至关重要的作用。基于功能磁共振成像（fMRI）的针刺研究已经发展了超过十五个年头，期间发布了上百篇高水平的国际期刊文章，为针刺中枢机制研究的发展起到了巨大的推动作用。然而，由于针刺自身的复杂性，以及fMRI技术手段在数据处理和统计分析上的精密性，前人基于fMRI的针刺研究中存在着许多致命的问题。越来越多的研究者开始谨慎的审视之前文章中研究目的和假设，实验设计，实验控制，数据处理，统计分析以及结果解释中存在的问题。然而，从方法论的高度，评价和解决针刺fMRI研究中方法有效性和结果可靠性方面的研究还非常有限。本文正是从这一角度来展开工作的。
本文主要工作和创新如下：
首先，较为全面的从研究思路，分析方法和结果解释三个方面论述了基于fMRI针刺研究中存在的主要问题。并提出了基于fMRI针刺研究的客观性框架。在研究思路方面，选取健康被试探索针刺有效性相关的响应模式，以及假设针刺响应符合“ON-OFF”模式这两个方面是针刺fMRI研究思路中存在的主要问题。我们认为，1）应选取针刺适应症患者，以临床疗效为基础探索针刺中枢调节机制；2）基于健康受试者的针刺fMRI研究应该重点关注针刺刺激本身的中枢加工机制；3）基于实时记录的被试主观感觉信息作为参考向量，探索针刺感觉依赖的中枢响应模式是针刺fMRI研究思路上的改进措施。在分析方法方面，1）需要采用随机效应分析或混合效应分析这些能够推广的总体的组分析方法，并加大对个体结果的关注力度；2）需要采用多重比较校正后的阈值作为结果，尽可能避免假阳性的干扰；3）需要采用足够大的样本量来保证结果的可靠性，并从主观行为学和评价个体差异程度两个方面来控制样本的一致性。在结果解释方面，1）关于针刺特异性的解释要基于针刺组和对照组的组间比较结果，而不能基于两个单组结果的视觉上的比较；2）要采用更有效的实验设计和实验控制，在结果讨论上尽量避免采用之前针刺fMRI研究中常用的逆向推断的方式；3）要更谨慎的对针刺fMRI研究结果中的负激活进行可靠性评判和解释，因为不合理的实验控制和数据预处理都会引入广泛的伪造的负激活。总之，针刺fMRI研究需要建立全新的以保证客观性为基本目标的全新研究框架。
其次，全面细致的讨论了全局信号标准化这样一个预处理步骤对针刺fMRI结果的影响。全局信号标准化是数据预处理时经常使用的一个步骤，用来去除无用信号。然而，一些认知和情绪任务已经表明，如果全局信号标准化违背了正交假设的话，此预处理步骤会严重的改变统计结果。本文在针刺fMRI领域讨论了这个问题。总共招募了30个被试，研究使用全局信号标准化对针刺诱发得气BOLD响应的影响以及对非痛表面刺激血氧依赖（BOLD）响应的影响。我们基于比例缩放模型比较了采用全局信号标准化（PSGS）与未采用全局信号标准化（NO PSGS）的结果。发现全局信号标准化违背了正交假设，采用全局信号标准化与未采用全局信号标准化相比大多数被试的BOLD响应有了显著的变化。针刺fMRI领域大量的负激活是错误使用全局信号标准化所带来的后果。针刺得气诱发的中枢响应是非特异性的躯体感觉相关网络的正激活，并且其统计力度会通过全局信号标准化增强。总之，针刺fMRI领域采用全局信号标准化是不合理的。是否采用全局信号标准化预处理可能部分的解释之前针刺fMRI研究中存在矛盾的结果和解释的原因。
第三，初步表明了，针刺引起的得气相关和锐痛相关BOLD响应模式的部分分离。目前，fMRI已经成为研究针刺中枢机理最重要的方式之一。在100多篇基于fMRI的针刺研究中，围绕躯体感觉相关大脑网络的正激活是最鲁棒的BOLD响应模式。但是由于针刺刺激时对被试主观感觉控制不够完善，因此这种鲁棒的正激活反映的是得气，锐痛还是混合（得气加尖锐痛）的响应模式仍然不清楚。此外得气相关BOLD响应与锐痛相关BOLD响应的关系也不清楚。在本章中，我们招募了50个被试，根据他们在针刺刺激时是否感受到了锐痛将他们分为得气组和混合组。本章主要研究两个问题：第一，得气相关BOLD响应是什么样的？是正激活主导还是负激活主导？第二，得气相关BOLD响应与锐痛相关BOLD响应的关系是怎样的？我们的结果表明对于第一个问题，针刺刺激足三里时与得气相关的BOLD响应是正激活主导的模式；对于第二个问题，得气感觉下BOLD响应与混合感觉下BOLD响应在数量和性质上都有显著的差异。在空间分布上，锐痛的响应与得气的响应可能是部分分离的。因此，我们认为，为了研究针刺的中枢机理，有尖锐痛的被试应该排除，而使用只有得气的被试。
最后，我们评价了针刺刺激即时中枢响应模式的个体差异程度，以及基于中枢响应模式定义的例外点对组分析结果的影响。我们对16个被试进行了针刺足三里和棋盘格视觉刺激。我们利用广义线性模型得到的β值计算平均距离，并且通过它检测异常值来研究组的同质性。通过计算平均距离，我们发现针刺刺激相对视觉刺激有更显著的个体差异。从组分析的角度，我们发现在同质组中正激活是更显著的。得气打分与针刺刺激的平均距离没有直接的相关性。异常值的得气打分落在正常的范围内并且与其他的没有明显的差异。我们认为未去掉异常值的传统组分析结果对于检测针刺的真正效应没有非常高的灵敏度。我们建议在以后的针刺研究中应当要考虑个体差异。而且，对于了解针刺的效应，组分析的结果与个体分析的结果是同等重要的。
总体来说，本文从预处理和统计分析两个方面讨论了针刺fMRI研究中存在的方法论问题。主要表明了全局信号标准化这样一步预处理不适用于针刺fMRI研究；需要从控制被试主观感觉一致性和中枢响应模式一致性方面保证组分析结果的可靠性。本文的主要发现可以提高我们对针刺fMRI研究领域当前存在问题的认识，为将来探索新的保证结果特异性和可靠性研究框架提供帮助。
Acupuncture, a traditional Chinese therapy with thousands of years of history, hasbeen universally accepted and recognized worldwide nowadays. As a greencomplementary and alternative therapy, acupuncture has been demonstrated to be ofsignificant effect on many diseases, especially on functional diseases. However, themechanism of acupuncture remains elusive, which greatly restricts the improvements ofthe understanding of acupuncture. As a result, acupuncture theories update slowly andfurther restrict the development of maximum clinical effects of acupuncture. Therefore,to clarify the mechanisms, especially the central mechanisms of acupuncture as soon aspossible play a vital role in the development of the entire acupuncture field. fMRI basedacupuncture studies have gone through more than fifteen years, during which hundredsof high-level international journal articles have been released, which play a significantrole in promoting the development of acupuncture central mechanisms. Owing to thecomplexity of acupuncture, as well as the precision of fMRI technology in dataprocessing and statistical analysis, many fatal questions exist in previous fMRI basedacupuncture studies. More researchers start to cautiously inspect the questions that existin study hypothesis, experimental design, experimental control, data processing,statistical analysis, and interpretation of results. However, studies that evaluate validityof the method and reliability of the results from the height of methodology are stilllimited. The article commences the work exactly from this standpoint.
The details of researches and the main innovations were listed as follows:
Firstly, this study comprehensively discusses the main questions in fMRI basedacupuncture studies from three aspects: Research ideas, analytical methods andinterpretation of results. This article also put forward an objective framework of fMRIbased acupuncture studies. In terms of research ideas, selecting healthy subjects toexplore the effectiveness-related BOLD responses pattern of acupuncture and assumingthe acupuncture response meets the "ON-OFF" mode are the two main problems in thefMRI based acupuncture studies. We believe that:1) we should select patients withdiseases, which are proved to be effective by acupuncture treatments and explore thecentral regulation mechanism of acupuncture based on the clinical efficacy;2) fMRIbased acupuncture studies on healthy subjects should focus on the central processingmechanism of acupuncture stimulation;3) We should base on real-time recordingsubjective sensory information as the reference vector to explore the needling sensationdependent central response pattern. In terms of analytical methods,1) we should use group analysis method that can be generalized to the population, such as random effectsor mixed effects, and increase the attention on the individual results;2) We need to usemultiple comparison correction threshold values as the reported results, which can avoidthe possible false positive interference;3) We need a large enough sample size to ensurethe reliability of the results and guarantee sample consistency from two aspects ofsubjective behavior and evaluation of individual differences degree on BOLD patterns.In terms of results interpretation,1) acupuncture specificity should be interpreted basedon the comparison results between the acupuncture group and the control group, andshould not be based on just the visual comparison between the two one sample results;2)We should use more effective experimental design and experimental control and try toavoid reverse inference discussions that are commonly used in previous fMRI basedacupuncture studies;3) We should be more cautious on the evaluation and interpretationof deactivations in fMRI based acupuncture results, as unreasonable experiment controland data preprocessing will introduce a wide range of false deactivations. All in all, weneed to create a brand-new fMRI based research framework to safeguard the objectivity.
Secondly, this study comprehensively and detailedly discuss the impact of globalnormalization, a preprocessing step, on the results of fMRI based acupuncture studies.Global normalization is often used as a preprocessing step for dispelling the “nuisanceeffects.” However, it has been shown in cognitive and emotion tasks that thispreprocessing step might greatly distort statistical results when the orthogonalityassumption of global normalization is violated. The present study examines this issue infMRI acupuncture studies. Thirty healthy subjects were recruited to evaluate theimpacts of the global normalization on the BOLD responses evoked by acupuncturestimulation during de-qi sensation and tactile stimulation during nonpainful sensations.To this end, we compared results by conducting global normalization (PSGS) and notconducting global normalization (NO PSGS) based on a proportional scaling model.The orthogonality assumption of global normalization was violated, and significantchanges between BOLD responses for NO PSGS and PSGS were shown in mostsubjects. Extensive deactivations of acupuncture in fMRI were the non-specificallypernicious consequences of global normalization. The central responses of acupunctureduring de-qi are non-specifically activation dominant at the somatosensory-related brainnetwork, whose statistical power is specifically enhanced by PSGS. In conclusion,PSGS should be unjustified for acupuncture studies in fMRI. The differences includingthe global normalization or not may partly contribute to conflicting results andinterpretations in previous fMRI acupuncture studies.
Thirdly, this study Initially indicate that the de-qi related and shap pain relatedBOLD response patterns are partly separated. Nowadays, functional magnetic resonanceimaging (fMRI) has become one of the most important ways to explore the centralmechanism of acupuncture. Among the hundred or so fMRI-based acupuncture studies,activations around the somatosensory related brain network had the most robust bloodoxygen level-dependent (BOLD) responses. However, due to the insufficient control ofthe subjective sensations during acupuncture stimulation, whether these robustactivations reflected the pattern of de-qi, sharp pain, or mixed (de-qi+sharp pain)sensations was largely unknown. Furthermore, the relationship between the de-qi relatedand the sharp pain related BOLD responses was also unclear. The current studyrecruited50subjects and grouped them into the de-qi group or the mixed groupaccording to whether he/she experienced sharp pain during acupuncture stimulation togive a definite answer to the following two questions. First, what are the de-qi relatedBOLD responses, that is, are they dominated by activation or deactivation? Second,what is the relationship between the de-qi related and the sharp pain related BOLDresponses? Our results indicated that for the first question, BOLD responses associatedwith de-qi during acupuncture stimulation at ST36were activation dominated. For thesecond question, both the quantitative and qualitative differences of BOLD responsesbetween de-qi and mixed sensations evoked by acupuncture stimulation were significant.The pattern of BOLD responses of sharp pain might be partly separated from that ofde-qi in the spatial distribution. Therefore, we proposed that in order to explore thespecific central mechanism of acupuncture, subjects with sharp pain should be excludedfrom those with only de-qi.
Finally, we evaluate the degree of individual differences of immediate centralresponse pattern during acupuncture stimulation, and evaluate the impact of outliers,defined based on central BOLD response pattern, on the group analysis results.Acupuncture at ST36and checkerboard stimulation was applied to16subjects. Wecalculated the mean distance using beta values in a generalized linear model (GLM)analysis and employed it to study the group homogeneity by detecting the outliers. Amore significant individual difference was presented in acupuncture stimulationcompared with visual stimulation through evaluation of the mean distance. From thegroup results, we found that the activations were more significant in the homogeneousgroup results. Combining the behavior and fMRI results, there was no direct correlationbetween deqi index and mean distance in acupuncture stimulation. The deqi index of theoutlier was in the normal range and did not differ significantly from others. Traditional group results without removing outliers were not sensitive enough to detect the realacupuncture effect. We suggest that individual difference should be taken intoconsideration for future acupuncture studies. Also, group analysis paralleled withindividual analysis is critical for a full understanding of acupuncture effects.
Overall, this article discusses the methodological problems existing in acupuncturefMRI studies from two aspects of data pre-processing and statistical analysis. Thearticle indicates that the preprocessing step of global normalization is not suitable forthe fMRI based acupuncture studies; We should assurance reliability of group analysisresults by controlling consistency of subjective feeling and central response pattern. Themain findings of this article can improve our understanding of the current problemsexisting in acupuncture fMRI studies and provide help for the exploration a newresearch framework that guarantee results specificity and reliability in the future.
本文主要工作和创新如下：
首先，较为全面的从研究思路，分析方法和结果解释三个方面论述了基于fMRI针刺研究中存在的主要问题。并提出了基于fMRI针刺研究的客观性框架。在研究思路方面，选取健康被试探索针刺有效性相关的响应模式，以及假设针刺响应符合“ON-OFF”模式这两个方面是针刺fMRI研究思路中存在的主要问题。我们认为，1）应选取针刺适应症患者，以临床疗效为基础探索针刺中枢调节机制；2）基于健康受试者的针刺fMRI研究应该重点关注针刺刺激本身的中枢加工机制；3）基于实时记录的被试主观感觉信息作为参考向量，探索针刺感觉依赖的中枢响应模式是针刺fMRI研究思路上的改进措施。在分析方法方面，1）需要采用随机效应分析或混合效应分析这些能够推广的总体的组分析方法，并加大对个体结果的关注力度；2）需要采用多重比较校正后的阈值作为结果，尽可能避免假阳性的干扰；3）需要采用足够大的样本量来保证结果的可靠性，并从主观行为学和评价个体差异程度两个方面来控制样本的一致性。在结果解释方面，1）关于针刺特异性的解释要基于针刺组和对照组的组间比较结果，而不能基于两个单组结果的视觉上的比较；2）要采用更有效的实验设计和实验控制，在结果讨论上尽量避免采用之前针刺fMRI研究中常用的逆向推断的方式；3）要更谨慎的对针刺fMRI研究结果中的负激活进行可靠性评判和解释，因为不合理的实验控制和数据预处理都会引入广泛的伪造的负激活。总之，针刺fMRI研究需要建立全新的以保证客观性为基本目标的全新研究框架。
其次，全面细致的讨论了全局信号标准化这样一个预处理步骤对针刺fMRI结果的影响。全局信号标准化是数据预处理时经常使用的一个步骤，用来去除无用信号。然而，一些认知和情绪任务已经表明，如果全局信号标准化违背了正交假设的话，此预处理步骤会严重的改变统计结果。本文在针刺fMRI领域讨论了这个问题。总共招募了30个被试，研究使用全局信号标准化对针刺诱发得气BOLD响应的影响以及对非痛表面刺激血氧依赖（BOLD）响应的影响。我们基于比例缩放模型比较了采用全局信号标准化（PSGS）与未采用全局信号标准化（NO PSGS）的结果。发现全局信号标准化违背了正交假设，采用全局信号标准化与未采用全局信号标准化相比大多数被试的BOLD响应有了显著的变化。针刺fMRI领域大量的负激活是错误使用全局信号标准化所带来的后果。针刺得气诱发的中枢响应是非特异性的躯体感觉相关网络的正激活，并且其统计力度会通过全局信号标准化增强。总之，针刺fMRI领域采用全局信号标准化是不合理的。是否采用全局信号标准化预处理可能部分的解释之前针刺fMRI研究中存在矛盾的结果和解释的原因。
第三，初步表明了，针刺引起的得气相关和锐痛相关BOLD响应模式的部分分离。目前，fMRI已经成为研究针刺中枢机理最重要的方式之一。在100多篇基于fMRI的针刺研究中，围绕躯体感觉相关大脑网络的正激活是最鲁棒的BOLD响应模式。但是由于针刺刺激时对被试主观感觉控制不够完善，因此这种鲁棒的正激活反映的是得气，锐痛还是混合（得气加尖锐痛）的响应模式仍然不清楚。此外得气相关BOLD响应与锐痛相关BOLD响应的关系也不清楚。在本章中，我们招募了50个被试，根据他们在针刺刺激时是否感受到了锐痛将他们分为得气组和混合组。本章主要研究两个问题：第一，得气相关BOLD响应是什么样的？是正激活主导还是负激活主导？第二，得气相关BOLD响应与锐痛相关BOLD响应的关系是怎样的？我们的结果表明对于第一个问题，针刺刺激足三里时与得气相关的BOLD响应是正激活主导的模式；对于第二个问题，得气感觉下BOLD响应与混合感觉下BOLD响应在数量和性质上都有显著的差异。在空间分布上，锐痛的响应与得气的响应可能是部分分离的。因此，我们认为，为了研究针刺的中枢机理，有尖锐痛的被试应该排除，而使用只有得气的被试。
最后，我们评价了针刺刺激即时中枢响应模式的个体差异程度，以及基于中枢响应模式定义的例外点对组分析结果的影响。我们对16个被试进行了针刺足三里和棋盘格视觉刺激。我们利用广义线性模型得到的β值计算平均距离，并且通过它检测异常值来研究组的同质性。通过计算平均距离，我们发现针刺刺激相对视觉刺激有更显著的个体差异。从组分析的角度，我们发现在同质组中正激活是更显著的。得气打分与针刺刺激的平均距离没有直接的相关性。异常值的得气打分落在正常的范围内并且与其他的没有明显的差异。我们认为未去掉异常值的传统组分析结果对于检测针刺的真正效应没有非常高的灵敏度。我们建议在以后的针刺研究中应当要考虑个体差异。而且，对于了解针刺的效应，组分析的结果与个体分析的结果是同等重要的。
总体来说，本文从预处理和统计分析两个方面讨论了针刺fMRI研究中存在的方法论问题。主要表明了全局信号标准化这样一步预处理不适用于针刺fMRI研究；需要从控制被试主观感觉一致性和中枢响应模式一致性方面保证组分析结果的可靠性。本文的主要发现可以提高我们对针刺fMRI研究领域当前存在问题的认识，为将来探索新的保证结果特异性和可靠性研究框架提供帮助。
Acupuncture, a traditional Chinese therapy with thousands of years of history, hasbeen universally accepted and recognized worldwide nowadays. As a greencomplementary and alternative therapy, acupuncture has been demonstrated to be ofsignificant effect on many diseases, especially on functional diseases. However, themechanism of acupuncture remains elusive, which greatly restricts the improvements ofthe understanding of acupuncture. As a result, acupuncture theories update slowly andfurther restrict the development of maximum clinical effects of acupuncture. Therefore,to clarify the mechanisms, especially the central mechanisms of acupuncture as soon aspossible play a vital role in the development of the entire acupuncture field. fMRI basedacupuncture studies have gone through more than fifteen years, during which hundredsof high-level international journal articles have been released, which play a significantrole in promoting the development of acupuncture central mechanisms. Owing to thecomplexity of acupuncture, as well as the precision of fMRI technology in dataprocessing and statistical analysis, many fatal questions exist in previous fMRI basedacupuncture studies. More researchers start to cautiously inspect the questions that existin study hypothesis, experimental design, experimental control, data processing,statistical analysis, and interpretation of results. However, studies that evaluate validityof the method and reliability of the results from the height of methodology are stilllimited. The article commences the work exactly from this standpoint.
The details of researches and the main innovations were listed as follows:
Firstly, this study comprehensively discusses the main questions in fMRI basedacupuncture studies from three aspects: Research ideas, analytical methods andinterpretation of results. This article also put forward an objective framework of fMRIbased acupuncture studies. In terms of research ideas, selecting healthy subjects toexplore the effectiveness-related BOLD responses pattern of acupuncture and assumingthe acupuncture response meets the "ON-OFF" mode are the two main problems in thefMRI based acupuncture studies. We believe that:1) we should select patients withdiseases, which are proved to be effective by acupuncture treatments and explore thecentral regulation mechanism of acupuncture based on the clinical efficacy;2) fMRIbased acupuncture studies on healthy subjects should focus on the central processingmechanism of acupuncture stimulation;3) We should base on real-time recordingsubjective sensory information as the reference vector to explore the needling sensationdependent central response pattern. In terms of analytical methods,1) we should use group analysis method that can be generalized to the population, such as random effectsor mixed effects, and increase the attention on the individual results;2) We need to usemultiple comparison correction threshold values as the reported results, which can avoidthe possible false positive interference;3) We need a large enough sample size to ensurethe reliability of the results and guarantee sample consistency from two aspects ofsubjective behavior and evaluation of individual differences degree on BOLD patterns.In terms of results interpretation,1) acupuncture specificity should be interpreted basedon the comparison results between the acupuncture group and the control group, andshould not be based on just the visual comparison between the two one sample results;2)We should use more effective experimental design and experimental control and try toavoid reverse inference discussions that are commonly used in previous fMRI basedacupuncture studies;3) We should be more cautious on the evaluation and interpretationof deactivations in fMRI based acupuncture results, as unreasonable experiment controland data preprocessing will introduce a wide range of false deactivations. All in all, weneed to create a brand-new fMRI based research framework to safeguard the objectivity.
Secondly, this study comprehensively and detailedly discuss the impact of globalnormalization, a preprocessing step, on the results of fMRI based acupuncture studies.Global normalization is often used as a preprocessing step for dispelling the “nuisanceeffects.” However, it has been shown in cognitive and emotion tasks that thispreprocessing step might greatly distort statistical results when the orthogonalityassumption of global normalization is violated. The present study examines this issue infMRI acupuncture studies. Thirty healthy subjects were recruited to evaluate theimpacts of the global normalization on the BOLD responses evoked by acupuncturestimulation during de-qi sensation and tactile stimulation during nonpainful sensations.To this end, we compared results by conducting global normalization (PSGS) and notconducting global normalization (NO PSGS) based on a proportional scaling model.The orthogonality assumption of global normalization was violated, and significantchanges between BOLD responses for NO PSGS and PSGS were shown in mostsubjects. Extensive deactivations of acupuncture in fMRI were the non-specificallypernicious consequences of global normalization. The central responses of acupunctureduring de-qi are non-specifically activation dominant at the somatosensory-related brainnetwork, whose statistical power is specifically enhanced by PSGS. In conclusion,PSGS should be unjustified for acupuncture studies in fMRI. The differences includingthe global normalization or not may partly contribute to conflicting results andinterpretations in previous fMRI acupuncture studies.
Thirdly, this study Initially indicate that the de-qi related and shap pain relatedBOLD response patterns are partly separated. Nowadays, functional magnetic resonanceimaging (fMRI) has become one of the most important ways to explore the centralmechanism of acupuncture. Among the hundred or so fMRI-based acupuncture studies,activations around the somatosensory related brain network had the most robust bloodoxygen level-dependent (BOLD) responses. However, due to the insufficient control ofthe subjective sensations during acupuncture stimulation, whether these robustactivations reflected the pattern of de-qi, sharp pain, or mixed (de-qi+sharp pain)sensations was largely unknown. Furthermore, the relationship between the de-qi relatedand the sharp pain related BOLD responses was also unclear. The current studyrecruited50subjects and grouped them into the de-qi group or the mixed groupaccording to whether he/she experienced sharp pain during acupuncture stimulation togive a definite answer to the following two questions. First, what are the de-qi relatedBOLD responses, that is, are they dominated by activation or deactivation? Second,what is the relationship between the de-qi related and the sharp pain related BOLDresponses? Our results indicated that for the first question, BOLD responses associatedwith de-qi during acupuncture stimulation at ST36were activation dominated. For thesecond question, both the quantitative and qualitative differences of BOLD responsesbetween de-qi and mixed sensations evoked by acupuncture stimulation were significant.The pattern of BOLD responses of sharp pain might be partly separated from that ofde-qi in the spatial distribution. Therefore, we proposed that in order to explore thespecific central mechanism of acupuncture, subjects with sharp pain should be excludedfrom those with only de-qi.
Finally, we evaluate the degree of individual differences of immediate centralresponse pattern during acupuncture stimulation, and evaluate the impact of outliers,defined based on central BOLD response pattern, on the group analysis results.Acupuncture at ST36and checkerboard stimulation was applied to16subjects. Wecalculated the mean distance using beta values in a generalized linear model (GLM)analysis and employed it to study the group homogeneity by detecting the outliers. Amore significant individual difference was presented in acupuncture stimulationcompared with visual stimulation through evaluation of the mean distance. From thegroup results, we found that the activations were more significant in the homogeneousgroup results. Combining the behavior and fMRI results, there was no direct correlationbetween deqi index and mean distance in acupuncture stimulation. The deqi index of theoutlier was in the normal range and did not differ significantly from others. Traditional group results without removing outliers were not sensitive enough to detect the realacupuncture effect. We suggest that individual difference should be taken intoconsideration for future acupuncture studies. Also, group analysis paralleled withindividual analysis is critical for a full understanding of acupuncture effects.
Overall, this article discusses the methodological problems existing in acupuncturefMRI studies from two aspects of data pre-processing and statistical analysis. Thearticle indicates that the preprocessing step of global normalization is not suitable forthe fMRI based acupuncture studies; We should assurance reliability of group analysisresults by controlling consistency of subjective feeling and central response pattern. Themain findings of this article can improve our understanding of the current problemsexisting in acupuncture fMRI studies and provide help for the exploration a newresearch framework that guarantee results specificity and reliability in the future.
引文
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