The Resting-State Functional Magnetic Resonance Imaging Study On Thread Embedding Acupuncture Therapy For Postmenopausal Osteoporosis

Objective:The incidence rate of Postmenopausal Osteoporosis（PMOP）is increasing.However,over half of the PMOP patients are reluctant to take medicine because of its side effects.This has seriously reduced the actual effect of early intervention on PMOP and brought a great burden to China’s health care system.The previous clinical trials of our research team preliminarily showed that PMOP patients had specific changes in the central nervous system,which needs further exploration.Therefore,as an extension of the previous study,based on preliminary results,we explored the specific neuroimaging markers of PMOP by rs-fMRI technology to provide indicators for the ultra-early screening and diagnosis of PMOP;Thread embedding acupuncture therapy（TEAT）as an intervention method conducting a randomized,positive drug control study to explore the central nervous system mechanism and effect target of the intervention method to provide evidence for optimizing the clinical management program of PMOP in the future.Methods:1.Methods of specific imaging markers of the central nervous system in PMOP:22 PMOP patients and 22 postmenopausal healthy volunteers（PMHV）were included.PMOP patients met the diagnostic criteria based on the Clinical diagnosis and treatment guidelines·volume of osteoporosis and bone mineral diseases presented by the Chinese Medical Association.After signing the corresponding informed consent,the demographic information such as gender,age,height,weight,and education level of all subjects was recorded;The subject’s current disease history,past history,allergy history,vaccination history,family history,combined diseases,and other medical record information was recorded.The bone mineral density（BMD）of the lumbar spine（L2-4）and femoral neck（g/cm2）were collected as the condition monitoring indexes of this study;The subjects’ SFMPQ and osteoporosis symptom score were collected as the clinical symptom indexes of this study;The rs-fMRI data were collected as neuroimaging indexes.The clinical data were analyzed by statistical software SPSS 24.0;The statistical analysis of neuroimaging data was calculated and analyzed by using the statistical analysis software in DPABI,which under the MATLAB 2014a platform,and the correlation between neuroimaging indexes,condition monitoring indexes,and clinical symptom indexes were analyzed by using SPSS 24.0.P<0.05 was considered the standard with a statistical difference,and P<0.01 was considered the standard with a significant statistical difference.After the above processing was completed,the statistical analysis software in DPABI was used to calculate the statistical analysis values between and within the groups of fALFF and ReHo;Firstly,the hypothalamus’s paraventricular nucleus（PVN）,arcuate nucleus（ARC）,and ventromedial nucleus（VMH）were selected as the regions of interest（ROI）for FC data processing.Defined as ROI1-6 respectively,R stands for right（R）,and 1 stands for left（L）.The mean time series of all voxels included in ROI was extracted by DPARSF software.The functional connection results of 6 ROIs were calculated and statistically analyzed.Based on the statistical analysis results of fALFF,ReHo,and FC,the following correlation analysis and visualization process were carried out.2.Study methods for rs-fMRI effect mechanism of TEAT in postmenopausal osteoporosis:Patients with PMOP who met the diagnostic and inclusion criteria were randomly divided into the TEAT and drug therapy（DT）groups by random number table methods.The diagnostic criteria of PMOP patients were the same as before.After signing the corresponding informed consent,the demographic information such as gender,age,height,weight,and education level of all subjects was recorded;The subject’s current disease history,past history,allergy history,vaccination history,family history,combined diseases,and other medical record information was recorded.The BMD of the lumbar spine（L2-4）and femoral neck（g/cm2）before intervention were collected as the condition monitoring indexes of this study;The subjects’ SF-MPQ and osteoporosis symptom score before intervention were collected as the clinical symptom indexes of this study;The rs-fMRI data before intervention were collected as neuroimaging indexes.The TEAT group was treated with thread embedding acupuncture therapy once a week for 3 months,a total of 12 times;the DT group was treated with Alendronate sodium and Vitamin D3 tablets（once a week,one tablet at a time）and Caltrate（Once a day,one capsule at a time）for 3 months.After the course of treatment,the condition monitoring data,clinical symptom data,and neuroimaging data were collected again.The statistical analysis methods of clinical data and neuroimaging data were the same as before.P<0.05 was considered the standard with a statistical difference,and P<0.01 was considered the standard with a significant statistical difference.Neuroimaging data preprocessing,ALFF,ReHo,FC data processing,and statistical processing methods were the same as before.Based on the statistical analysis results of fALFF,ReHo,and FC,the following correlation analysis and visualization process were carried out.Results:1.Results of specific imaging markers of the central nervous system in PMOP:A total of 44 eligible cases were included in the trial,22 in the PMOP group and 22 in the PMHV group.Finally,a total of 21 patients in the PMOP group and 20 patients in the PMHV group completed all data collection.The SF-MPQ score of the PMOP and PMHV groups selected the two independent samples rank-sum test in the statistical method,and the results showed that there were significant differences in PRI total score,PRI sensory item score,PRI emotional item score,VAS,and PPI score between the two groups（U=5.572、5.201、4.248、5.259、4.693,P=0.000、0.000、0.000、0.000、0.000<0.01）.The osteoporosis symptom score in the two groups was tested by two independent samples t’test.The results showed a significant difference between the two groups（t’=-11.845,P=0.000<0.01）.Two independent samples t-test was used for BMD of the lumbar spine（L2-4）and femoral neck in the two groups.The results showed that there were significant differences in BMD of the lumbar spine（L2-4）and femoral neck（t=11.544,6.006,P=0.000,0.000<0.01）.Two independent samples t-test was performed on the fALFF data of the PMHV group and PMOP patients by statistical analysis software in DPABI.The results showed a difference in the fALFF signal value of the limbic lobe,mainly including uncus,between the two groups（P<0.05）.ReHo results showed a difference in ReHo signal value in the inferior gyrus of the frontal lobe between the two groups（P<0.05）.Whole-brain functional connectivity analysis of 6 ROIs of PMHV group and PMOP patients,the results showed that only ROI5（L-ARC）functional connectivity was enhanced,and the brain region only included right cerebellum₉（AAL）,（P<0.05）;While ROI1（R-PVN）,ROI2（R-ARC）,ROI4（L-PVN）,and ROI6（L-VMH）showed decreased functional connectivity,involving brain regions including left Parietal_Inf（AAL）,bilateral precuneus,left superior frontal gyrus,left Putamen（AAL）,left Temporal_Sup（AAL）and left SupraMarginal（AAL）（P<0.05）.The correlation analysis between neuroimaging indexes and clinical symptom indexes showed a positive correlation between the VAS score of SF-MPQ and zfALFF value of the right marginal lobe in patients with PMOP（r=0.451,P=0.040<0.05）.The FC correlation analysis results showed a negative correlation between the zFC value of the right Superior Frontal gyrus and the PRI sensory item score of the SF-MPQ scale（r=-0.454,P=0.039<0.05）.There was a negative correlation between the zFC value of left Temporal_Sup（AAL）with functional connection of ROI4（L-PVN）and osteoporosis symptom score（r=-0.491,P=0.024<0.05）.The correlation analysis between neuroimaging indexes and condition monitoring indexes showed that there was a significant correlation between the zFC value of the left superior limbic lobe of the brain area with the functional connection of ROI6（L-VMH）and the BMD of the femoral neck（r=0.571,P=0.007<0.01）2.Study results for rs-fMRI effect mechanism of TEAT in postmenopausal osteoporosis:A total of 44 eligible cases were included in the trial,22 in the TEAT group and 22 in the DT group.Finally,a total of 18 patients in the TEAT group and 20 patients in the DT group completed the three-month observation and all data collection.The SF-MPQ score of the TEAT and DT groups selected the two independent samples rank-sum test in the statistical method,and there was no significant difference in PRI total score,PRI sensory item score,PRI emotional item score,VAS and PPI score before intervention between the two groups（U=-0.118,0.015,-0.164,0.630,0.148,P=0.906,0.988,0.870,0.529,0.882>0.05）;There was no significant difference in PRI total score,PRI sensory score,PPI,PRI total score difference,PRI sensory score difference,PRI emotional item score difference,VAS difference and PPI difference after intervention between TEAT and DT groups（U=1.076,0.221,0.147,-0.704,-0.264,-1.582,-1.350,-0.046,P=0.282,0.825,0.883,0.482,0.792,0.114,0.177,0.963>0.05）.After the intervention,there were significant differences in PRI emotional score and VAS between TEAT and DT groups（U=2.858,2.860,P=0.004,0.004<0.01）;The results showed that there were significant differences in PRI total score,PRI sensory item score,PRI emotional item score,VAS,and PPI score before and after the intervention within TEAT or DT groups by paired samples rank-sum test（z=-5.141,-4.887,-3.814,-5.286,-4.986,P=0.000,0.000,0.000,0.000<0.01）.Two independent samples t-test was used to test the score and difference of osteoporosis symptoms before and after intervention between the TEAT and DT groups.The results showed that there was no significant difference in osteoporosis symptom scores before intervention between the TEAT and DT groups（t=-0.157,P=0.876>0.05）;After the intervention,there was no significant difference in osteoporosis symptom scores between TEAT and DT groups（t=-1.342,P=0.188>0.05）;There was no significant difference in the difference of osteoporosis symptoms scores before and after intervention between TEAT and DT groups（t=0.558,P=0.580>0.05）;The results showed that there were significant differences in the osteoporosis symptoms scores before and after the intervention within TEAT or DT groups by paired samples t-test（t=10.663,6.101,P=0.000,0.000<0.01）.Two independent samples t-test was used for the BMD and difference data of the lumbar spine before and after the intervention between the TEAT and DT groups.The results showed that there was no significant difference in BMD before the intervention between the groups（t=-0.261,P=0.796>0.05）;There was no significant difference in lumbar BMD after intervention between TEAT and DT groups（t=0.382,P=0.704>0.05）;There was no significant difference in the difference of lumbar BMD before and after intervention between TEAT and DT groups（t=-0.139,P=0.890>0.05）;The results showed no significant difference in lumbar BMD before and after the intervention within TEAT or DT groups by paired samples t-test（t=-2.011,-1.943,P=0.060,0.067>0.05）.The BMD and difference data of femoral neck before and after intervention between the TEAT and DT groups were tested by two independent samples t-test.The results showed that there was no significant difference in BMD of femoral neck before intervention between the groups（t=1.095,P=0.281>0.05）;There was no significant difference in femoral neck BMD after intervention between TEAT and DT groups（t=0.666,P=0.510>0.05）;There was no significant difference in BMD difference of femoral neck before and after intervention between TEAT and DT groups（t=-0.220,P=0.827>0.05）;The results showed no significant difference in femoral neck BMD before and after the intervention within TEAT or DT groups by paired samples t-test（t=-1.923,-1.886,P=0.071,0.075>0.05）.The paired samples t-test of fALFF data of patients within the TEAT or DT groups before and after intervention by statistical analysis software in DPABI showed that there was a difference in fALFF signal value of left cerebellum in the TEAT group（P<0.05）;There was a difference in the value of fALFF signal in the right superior parietal lobule of DT patients（P<0.05）.After the intervention,the fALFF data of patients in the TEAT group and DT group were analyzed by two independent samples t-test of statistical analysis software in DPABI,and the results showed that there was a difference in the value of the fALFF signal in the left frontal cortex（OFC）between TEAT group and DT group（P<0.05）.The paired samples t-test of ReHo data of patients within the TEAT or DT groups before and after intervention by statistical analysis software in DPABI showed that there was a difference in ReHo signal value in the left ventral tegmental area（VTA）in the TEAT group（P<0.05）;There was a difference in ReHo signal value in the Frontal_Inf_Tri（AAL）in DT patients（P<0.05）.After the intervention,the ReHo data of patients in the TEAT group and DT group were analyzed by two independent samples t-test of statistical analysis software in DPABI,and the results showed that there were differences in ReHo signal values of left Precentral（AAL）,left Caudate（AAL）and right frontal lobe between TEAT group and DT group（P<0.05）.The whole-brain functional connectivity analysis of 6 ROIs in the TEAT group before and after the intervention showed that the functional connectivity was enhanced in ROI1（R-ARC）,ROI3（R-VMH）,ROI4（L-PVN）,and ROI5（L-ARC）,including the left Parital_Inf（AAL）,bilateral OFC areas,left Temporal_Inf（AAL）,and right limbic lobe（cingulate gyrus）（P<0.05）.Whole-brain functional connectivity analysis was performed on 6 ROIs in the DT group before and after the intervention.The results showed that both ROI1（R-PVN）and ROI6（LVMH）showed enhanced functional connectivity,involving brain regions including right Precuneus（AAL）and right cuneus（P<0.05）;ROI3（R-VMH）showed positive activation and negative activation at the same time,mainly involving the right Lingual（AAL）,the left Vermis₄₅（AAL）and the right Occipital_Mid（P<0.05）.The functional connectivity of the whole brain was analyzed in 6 ROIs of patients in the TEAT group and DT group after intervention.Both ROI2（R-ARC）and ROI3（R-VMH）showed enhanced functional connectivity,involving brain regions including the right Frontal_Mid（AAL）,right Precuneus（AAL）,and right Cerebellum₄₅（AAL）（P<0.05）;The positive and negative activation brain areas of ROI5（L-ARC）existed at the same time,mainly involving the functional connection of the right Precuneus（AAL）,the right Frontal_Sup（AAL）and the right Paracentral_lobule（AAL）,and the functional connection of the right Occipital_Mid（AAL）decreased（P<0.05）.The correlation analysis between the difference of neuroimaging indexes before and after intervention and the difference of clinical symptom indexes showed that there was a positive correlation between the difference of zfALFF value of left cerebellum before and after intervention and the difference of VAS score of SF-MPQ scale in TAET group（r=0.512,P=0.030<0.05）.There was a significant positive correlation between the difference of zfALFF value of right Parietal_Sup（AAL）before and after intervention in the DT group and the difference of PRI total score and PRI sensory item score of SF-MPQ scale（r=0.587,0.586,P=0.007,0.007<0.01）.There was a negative correlation between the difference of zReHo value in the right Frontal_Inf_Tri（AAL）before and after intervention and the difference of PPI score of SF-MPQ scale in the DT group（r=-0.530,P=0.016<0.05）.The correlation analysis between neuroimaging indexes and condition monitoring indexes showed that there was a positive correlation between the difference of zFC value of left Parietal_Inf（AAL）with the functional connection of ROI1（R-PVN）and the difference of femoral neck BMD before and after intervention（r=0.473,P=0.047<0.05）.Conclusions:1.Conclusions of specific imaging markers of the central nervous system in PMOP:（1）Based on the ALFF,ReHo,and FC data analysis method of rs-fMRI technology,it is speculated that the specific activation degree of the uncus,inferior frontal gyrus and the specific functional connectivity of hypothalamus（L-PVN）-superior temporal gyrus may play a critical role between bone metabolic diseases and emotional disorders,and it is the specific central nervous system imaging marker of PMOP related emotional disorders.（2）Based on the data processing method of FC,it is speculated that there is the functional loop between the hypothalamic nucleus and bone homeostasis balance/energy metabolism in PMOP patients,and DMN is an essential functional component of multiple loops.The specific functional connectivity between the hypothalamus（L-VMH）-DMN（superior marginal gyrus）reflects the level of peripheral bone mass,which is one of the specific imaging markers of the central nervous system for PMOP condition monitoring.2.Study conclusions for rs-fMRI effect mechanism of TEAT in postmenopausal osteoporosis:（1）Both TEAT and DT can improve BMD in patients with PMOP,but there are significant differences in the central nervous system between them.TEAT could inhibit the activation of the cerebellar region in patients with PMOP and play a role in the treatment of PMOP;The changes of brain activation in the DT group may only reflect the emotional changes of PMOP patients in the central nervous system.（2）TEAT may play a role in the treatment of PMOP through the functional connectivity between the hypothalamic nucleus and DMN,OFC,cingulate cortex,and other structures.The specific functional connectivity of hypothalamic（R-PVN）-DMN（inferior parietal marginal angular gyrus）could not only be used as a specific marker of PMOP but also maybe the central nervous system target of the TEAT intervention in PMOP.（3）For DT,based on the existing evidence,there is no special central nervous system effect,but its connection with the occipital lobe has particular specificity,which needs further research.