針灸治療中風後抑鬱臨床研究新聞發布會 Press conference on Clinical Study on Treating Post-stroke Depression by Acupuncture

第一部分： 東華東院 梁機培醫生

中風定義 Definition of stroke 由於腦部血液供應受到阻斷，腦部功能喪失。 分為缺血性病變與出血性病變兩個方面 中風後果：可致死亡／認知能力喪失／半身不遂 Stroke is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. Either caused by ischemia or hemorrhage of cerebrovascular tissue. Serious consequences: death / cognitive dysfunction / paraplegia

高風險因素 Risk factors 老年 高血壓 高膽固醇 糖尿病 吸煙 喝酒 曾短暫性腦缺血發作 患有非風濕性心房纖顫 Advanced age Hypertension High cholesterol level Diabetes Smoking Alcohol consumption History of transient ischemic attacks (TIA) Non-rheumatic atrial fibrillation * subjects with these factors have 10-fold increased risk of stroke in the subsequent 30 months. Woo, J. and E. M. Lau (1990). "Risk factors predisposing to stroke in an elderly Chinese population--a longitudinal study." Neuroepidemiology 9(3): 131-134.

腦血管疾病（中風）為港人的第四主要死因（2009年死亡人數是3,443） 中風在香港發病情況 Stoke in Hong Kong 根據衛生署資料，每年中風患者約3-4萬 腦血管疾病（中風）為港人的第四主要死因（2009年死亡人數是3,443） 超過90%中風死者的年齡在三十五歲以上 男士佔51%；女士佔49% According to the Department of Health, about 30,000-40,000 people experience stroke per year in Hong Kong Cerebrovascular disease (ICD10: I60-I69) (stroke) is the fourth leading cause of death in HK, reported number to be 3,443 in year 2009 More than 90% of the death aged over 35 Male accounts for 51% of mortality; female accounts for 49%. *1 Lee AC, Tang SW, Leung SS, Yu GK, Cheung RT. Depression literacy among Chinese stroke survivors. Aging Ment Health. 2009;13:349-56. *2 Number of Deaths by Leading Causes of Death by Sex by Age in 2009, Department of Health, HKSAR http://www.chp.gov.hk/en/data/4/10/27/340.html

中風的治療 Treatment of stroke 手術： 取出血塊／制止出血 藥物： 通過分解與減少血塊形成來預防發病 康復治療： 物理治療 職業治療 言語治療 Surgery: Remove clot / stop hemorrhage mechanically Medication: To break down, minimize clot enlargement and prevent the formation of new clots Rehabilitation: Physiotherapy Occupational therapy Speech and language therapy

Poor prognosis of stroke 入院時已有嚴重肢體活動障礙，神經缺損，失禁，老年，認知障礙的患者在出院時康復的機率較低。 中風預後不良 Poor prognosis of stroke 入院時已有嚴重肢體活動障礙，神經缺損，失禁，老年，認知障礙的患者在出院時康復的機率較低。 10.7%的患者需要家屬打理日常生活。 在首次中風後存活最少30天的患者之中，21%在五年內復發。 39.7%的患者在中風五年後過身。 Patients with severe disability, severe neurologic impairment, urinary incontinence, old age, and impaired cognition at admission are less likely to recover to mild disability at discharge. 10.7% were dependent in terms of activity of daily living 21% who survived at least 30 days after the initial stroke, had a recurrence within 5 years In 39.7% of patients had died in 5 years after their initial stroke *1 Sze, K. H., E. Wong, et al. (2000). "Factors predicting stroke disability at discharge: a study of 793 Chinese." Archives of Physical Medicine & Rehabilitation 81(7): 876-880. *2 Cheung, C. M., T. H. Tsoi, et al. (2007). "Outcomes after first-ever stroke." Hong Kong Medical Journal 13(2): 95-99.

第二部分： 東華醫院 梁國培醫生

Post-stroke depression (PSD) 中風後抑鬱 Post-stroke depression (PSD) 中風後抑鬱多於中風發病後三至十二月內出現。 中風患者有一半在發病首月內患上抑鬱。 社區內之高齡中風患者，抑鬱發病率高達百分之六十八。 相比基本功能喪失，抑鬱對中風患者的生活質量影響更甚。 抑鬱會阻慢中風患者的康復，降低生活質量及增加死亡率。 Between 3 and 12 months PSD is most likely observed PSD mostly occurred in 3-12 months after stroke. Half of PSD patients have depression within the first month after stroke. Depressive symptoms were highly prevalent (68%) among the community-dwelling post-stroke elders PSD have a significant impact on health-related quality of life (HRQOL), even greater than basic functional disabilities PSD impedes the rehabilitation and recovery process, jeopardizes quality of life and increases mortality. *1 Bour, A., S. Rasquin, et al. (2010). "A one-year follow-up study into the course of depression after stroke." Journal of Nutrition, Health & Aging 14(6): 488-493. *2 Lam, S. C., L. Y. K. Lee, et al. (2010). "Depressive symptoms among community-dwelling, post-stroke elders in Hong Kong." International Nursing Review 57(2): 269-273. *3 Kwok, T., R. S. Lo, et al. (2006). "Quality of life of stroke survivors: a 1-year follow-up study." Archives of Physical Medicine & Rehabilitation 87(9): 1177-1182; quiz 1287. *4 Pan, J. H., X. Y. Song, et al. (2008). "Longitudinal analysis of quality of life for stroke survivors using latent curve models." Stroke 39(10): 2795-2802. *5Gaete, J. M. and J. Bogousslavsky (2008). "Post-stroke depression." Expert Review of Neurotherapeutics 8(1): 75-92.

中風後抑鬱的表現 PSD symptoms 情緒失調（緊張／抑鬱） 神經生理功能受損，影響執行能力 反應遲鈍 自理困難 失眠 疲倦 胃腸症狀，如腹脹、腹瀉、嘔吐 失去性慾 mood abnormalities (anxiety, depressed) neuropsychological disturbances with impairment of executive functions psychomotor retardation impaired activities of daily living insomnia fatigue gastrointestinal(GI) symptoms loss of libido

SSRI類抗抑鬱藥／選擇性血清素再吸收抑制劑 例子：氟西汀（百憂解），帕羅西汀 First line drugs: 中風後抑鬱治療 PSD Treatment 一線藥物： SSRI類抗抑鬱藥／選擇性血清素再吸收抑制劑 例子：氟西汀（百憂解），帕羅西汀 First line drugs: selective serotonin reuptake inhibitors (SSRIs) Eg. Fluoxetine, Paroxetine *1 Bilge, C., Ko, et al. (2008). "Depression and functional outcome after stroke: the effect of antidepressant therapy on functional recovery." European journal of physical & rehabilitation medicine. 44(1): 13-18.

Limitations of PSD medications 藥物效果欠佳 Limitations of PSD medications 在高齡患者之中，抗抑鬱藥物效果欠佳。 有廣泛的副作用，特別對心血管系統 中風患者往往需要同時服用多種藥物，加入抗抑鬱藥物可能增加藥物交互作用，產生不可預估之藥物副作用風險。 For elderly patients, SSRI could not obtain satisfactory outcomes Broad side effects, especially on cardiovascular system. Stroke patients are often taking other drugs, the addition of antidepressant agents may increase risk of drug-drug interactions, resulting in unexpected and unpredictable adverse events *1 Paolucci S. Epidemiology and treatment of post-stroke depression. Neuropsychiatr Dis Treat. 2008; 4:145-54. *2 Bhogal SK, Teasell R, Foley N, Speechley M. Heterocyclics and selective serotonin reuptake inhibitors in the treatment and prevention of poststroke depression. J Am Geriatr Soc. 2005;53: 1051-7. *3 5. Hemeryck A, Belpaire FM. Selective serotonin reuptake inhibitors and cytochrome P-450 mediated drug-drug interactions: an update. Curr Drug Metab. 2002;3:13-37.

第三部分： 香港大學中醫藥學院 張樟進博士

中醫對中風後抑鬱的認識 本病屬中醫「鬱症」的範圍。 「氣血沖和 ,萬病不生 ,一有怫郁 ,諸病生焉。 」 《丹溪心法 •六鬱 》 「諸鬱，臟氣病也，其本源於思慮過深，更兼臟氣弱，故六鬱之病生焉。」《雜病源流犀燭‧諸鬱源流》 中風患者多見於中老年人 ,具有增齡性虛損的體質基礎 ,加之中風後遺症遷延難愈 ,久病成虛 ,「固久者伐形 」,年邁體衰、久病成虛 ,從而進一步加重臟腑功能的衰減及氣血的虛損。在此基礎上 ,復因惱怒、思慮、悲哀、憂愁等情志異常而使人體氣機紊亂 ,導致鬱症發生。 金智生、吳立文：鬱病辨治規律淺析，中醫藥學刊，2003；1(6)：1921-1922 李寶玲：抑鬱症的中醫藥研究進展，中醫雜志，2001；42(9)：566-567 嚴容：中風后抑郁癥發病機制淺析，河南中醫，2010；30(4): 335-336 張智學：中風病機探討，甘肅中醫，1997；10(6)：3-4 喬文麗：針藥并用治療中風后抑郁36例，實用中醫內科雜志，2008；22(10)：60-61

中醫對中風後抑鬱的認識 臟氣虧虛 精神抑鬱、 性情急躁、 納呆眠差 氣血瘀滯、肝失條達，引致神明失其清展 風 火 痰 瘀

針灸治療中風後抑鬱 針灸治療：通過針刺對穴位的刺激，疏通經絡，以達到行氣活血、調節身體機能之功效。 頭皮針常用穴位 頭臨泣：明目，祛風，清神 率谷：鎮驚除煩 太陽：減輕頭痛 頭維：祛風泄火，止痛明目 四神聰：調暢神智 百會、印堂：安眠

電針治療中風後抑鬱 電針是針刺穿過皮層後，將電針儀的電極連接在針體上，利用脈衝電針儀，導入脈衝電流。 通過電針的治療，能加強針感，提高針刺療效。 http://herbalmedicinesa.com/images/Acupuncture%20Stimulator%20SMY%2010%20A.JPG http://www.atlaspost.com/albumimages/31017/16949_normal_15c97.jpg

Acupuncture for depression 針灸治療抑鬱症 Acupuncture for depression 根據最近發表之調查分析指出： 針灸對重症抑鬱的效果與傳統SSRI類抗抑鬱藥相近 針灸對於改善臨床反應及中風後抑鬱的程度比SSRI類藥物效果更佳 針灸之副作用比藥物更少。 Results from a recent large-scale systematic review with meta-analysis: Acupuncture is equivalent to SSRIs in treating MDD Acupuncture is superior to SSRIs in improving clinical response and reducing the severity of PSD Acupuncture has fewer incidences of adverse events *1 Zhang ZJ, Chen HY, Yip KC, Ng R, Wong VT. The effectiveness and safety of acupuncture therapy in depressive disorders: Systematic review and meta-analysis. J Affect Disord. 2009 Jul 24. [Epub ahead of print].

Acupuncture for depression 針灸治療抑鬱症 Acupuncture for depression 肢體及頭皮為最常用於治療中風抑鬱的針灸部位。 研究發現在已入針的頭皮部位接上密集顱部電針刺激(DECAS)，能顯著改善重症抑鬱症 、中風後抑鬱及癡呆症的症狀，提示DECAS可肯能對抑鬱有特殊療效。 Acupuncture stimulation on body and scalp acupoints is the most commonly used modes for the treatment of PSD. The study shows that addition of dense cranial electroacupuncture stimulation (DCEAS), on the frontal, parietal, and temporal scalp areas, most innervated by the trigeminal nerve, significantly improve major depression, PSD and dementia. These studies suggest that DCEAS is a highly promising therapy for depressive disorders, including PSD. *0 Zhang ZJ, Chen HY, Yip KC, Ng R, Wong VT. The effectiveness and safety of acupuncture therapy in depressive disorders: Systematic review and meta-analysis. J Affect Disord. 2009 Jul 24. [Epub ahead of print]. *1 Zhang ZJ, Wang XY, Jin GX, Yao SM. The involvement of serotonergic mechanisms in electroacupuncture accelerating the response to paroxetine in patients with major depressive disorder (#844.18). Abstract of Soc. Neurosci. Meeting. Nov. 15-19, 2008, Washington DC, USA. *2 Huang Y, Xia DB, A clinical observation on scalp electroacupuncture treatment in 30 patients with major depression. Zhong Xi Yi Je He Xue Bao 2004;2:151-152. *3 Huang Y, Chen J, Zou J. effects of scalp electroacupuncture on post-stroke depression. Zhong Guo Kang Fu 2005,9:172-173. *4 HuangY, Lai XS, Tang AM. Comparative study of the specificities of needling acupoints DU20, DU26 and HT7 in intervening vascular dementia in different areas in the brain on the basis of scale assessment and cerebral functional Imaging. Chinese Journal of Integrative Medicine 2007;13:103- 108.

PSD RCT – Inclusion criteria 針灸治療中風後抑鬱 臨床研究－納入標準 PSD RCT – Inclusion criteria 於本港居住的華裔人士，年齡介乎三十五至八十歲； 近期發生缺血性／出血性中風，經電腦掃描或磁力共振確診； 根據DSM-IV-TR被確診患上抑鬱 出現明顯的抑鬱症狀，以HAMD-17 /HRDS 量表可測出16分或以上 Hong Kong residents who are ethnic Chinese aged 35-80; Most recently experience an ischemic or hemorrhagic stroke, documented by cerebral computed topographic scanning or magnetic resonance imaging before this study; Confirmed diagnosis of depression according to DSM-IV-TR; develop significant depression, with a HAMD-17 / HDRS score of 16 or greater

針灸治療中風後抑鬱 臨床研究－方法 PSD RCT-Methodology 參加者將經電腦隨機抽樣被編入真性頭皮電針或假性頭皮電針組別。 兩組患者同樣接受真性肢體針灸+抗抑鬱藥物 (FLX) 真性頭皮針組別：接受真性頭皮針。 假性頭皮針組別：接受假性頭皮針。 針灸治療共12次(每周3次，連續4周) 期間接定期接受臨床評估 Participants randomized to active or placebo group; Both groups receive ACTIVE body acupuncture + FLX; Active group: receive active DECAS additionally; Placebo group: receive placebo DECAS additionally; 12 sessions of treatment (3 session per week, for 4 weeks) Participants will receive clinical assessment during the study period

Questions regarding acupuncture 針刺痛嗎? 一般情況下，患者不會感覺到針刺的疼痛，但可能會有酸麻脹的感覺。 針刺會留疤痕嗎? 絕大部份情況下，針刺不會留疤痕，有極少數人可能會產生瘀腫。一般人凝血機制沒有問題，瘀腫會在短期之內自然消失。 針刺前有什麼準備? 針刺前不宜過於飢餓或疲勞，只要放鬆身體即可。 針刺有副作用嗎? 針刺是一個安全的治療手段，絕大多數不會有不適的感覺或不良反應。有些體質敏感的人可能會有短暫的噁心、眩暈、瘀傷的現象。 Is acupuncture painful? Acupuncture treatment may cause the feeling of soreness, numbness, and heaviness, but, in general, does not cause pain or discomfort. Does acupuncture leave a scar? No, but for some people it may leave a bruise. It will be recovered shortly if the blood congeal mechanisms are normal. Any preparation prior to acupuncture treatment? People should not be hungry or exhuasted before having acupuncture treatment. Relaxation would be the best preparation. Does acupuncure have adverse effect? Acupuncture is safe in general. But for some people, they may have nausea feeling, dizziness or bruise for a short period of time

Members of research team 研究人員 Members of research team 香港大學中醫藥學院副教授 張樟進博士 東華醫院內科康復部部門主管 李常威醫生 東華醫院內科康復部高級醫生 梁國培醫生 東華東院內科及康復科部門主管 梁機培醫生 香港大學家庭醫學及基層醫療學系博士後研究員　黃韻婷博士 香港大學中醫藥學院副研究員 萬帥章醫師 香港大學中醫藥學院　洪鴻彬醫師 香港大學中醫藥學院　李翠妍醫師 研究由醫院管理局贊助 Dr. ZHANG Zhang-jin, Associate Professsor, School of Chinese Medicine, HKU Dr. Leonard LI, COS, Rehabilitation Unit, Department of Medicine, TWH Dr. LEUNG Kwok-Pui, SMO, Rehabilitation Unit, Department of Medicine, TWH Dr. LEUNG Kei-Pui, COS, Medicine and Rehabilitation Department, TWEH Dr. Wendy WONG, Post-doctoral Fellow, Department of Family Medicine and Primary Care, HKU Mr. Marksman MAN, Research Associate, School of Chinese Medicine, HKU Mr. Ben HUNG, School of Chinese Medicine, HKU Ms. Jade LEE, School of Chinese Medicine, HKU The study is funded by the Hospital Authority

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