Cao Miao (曹淼), Zhang Lin (张林), Bi Ding-yan (贲定严), He Qing-hu (何清湖)

1 College of Integrated Medicine, Hunan University of Chinese Medicine, Changsha 410208, China

2 College of Acupuncture & Tuina, Hunan University of Chinese Medicine, Changsha 410208, China

Sleep apnea syndrome (SAS) is a common disease characterized by snoring and pauses in breathing during sleep. In severe cases, long time hypoxia may cause waking up from sleep. As the symptoms get worse, it can cause drowsiness during the day. There are three forms of sleep apnea: obstructive SAS (OSAS), central SAS (CSAS), and a combination of the above two called mixed SAS (MSAS). OSAS is the most common form.Relevant research shows that the prevalence of OSAS in adults is as high as 2% to 4%[1]. SAS is a risk factor for a variety of diseases, which are closely related to metabolic syndrome[2], diabetes[3], cardiovascular disease and so on. In addition, the disease seriously affects the quality and expectancy of lives, which has gradually attracted the attention of society and medical community.

AS for treatment, modern medicine tends to use weight loss, alcohol and smoking cessation, ventilator,local surgery, orthodontics and appliance. As the disease has a complex pathogenesis, there is no effective drug[4]. In recent years, there have been more studies on traditional Chinese medicine for SAS,including acupuncture therapy. The advantage of acupuncture in SAS treatment lies in its safety, no adverse reactions and good patient compliance[5]. In order to summarize the regularity of acupuncture for SAS and improve the curative effect, we searched and retrieved the corresponding databases to analyze literatures of acupuncture for SAS, excavated and summarized points selection pattern using data mining method, so as to provide references for clinical work.

1 Materials and Methods

1.1 Literature resources

All literatures on acupuncture treatment of SAS were selected between the time that databases were established and the date of retrieval (March 25th, 2017).Those databases included China National Knowledge Infrastructure (CNKI), Wanfang Academic Journal Full-text Database (Wanfang), Chongqing VIP Database(CQVIP), PubMed and Science Direct.

1.2 Research methods

1.2.1 Retrieval strategy

Key words were ‘Snoring Disease’ or ‘Sleep Apnea Syndromes’ paired with ‘Acupuncture’ or ‘Needling’.

1.2.2 Inclusion criteria

The content of the study was to observe the clinical efficacy of acupuncture treatment for SAS; diagnostic criteria were clearly defined as SAS and the diagnostic and efficacy evaluation standards were generally accepted by international or domestic counterparts;acupuncture was the main treatment and had definite effect; point prescriptions were clearly described.

1.2.3 Exclusion criteria

Acupuncture was used as an adjunctive treatment;treatment included Chinese materia medica. Didn't describe specific acupuncture prescription; duplicate publications or literature repeated in literature review would be counted once.

1.2.4 Data collection

A total of 35 papers were collected after carefully reading[6-40], which included 2 English papers[6-7]. Among them, 8 articles chose major points first[8-15], and then selected adjunct points according to syndromes.According to the form of ‘one group of main points +one group of adjunct points = 1 prescription’, 37 prescriptions were extracted from these 8 articles. The rest 27 articles[6-7,16-40]used fixed points prescriptions. A total of 64 valid prescriptions were extracted.

1.2.5 Standardization of data and establishment of database

Data standardization: Normalizing points and meridians referring toScience of Acupuncture and Moxibustion[41].

Database establishment: Excel was used to establish the acupuncture prescription for SAS database and then imported information into SPSS 20.0 version and SPSS Modeler 14.1 version.

Statistical software: Descriptive analysis was performed using SPSS 20.0 software. Association rules were analyzed by SPSS Modeler 14.1 software.

2 Results

2.1 Descriptive analysis results

2.1.1 Point frequency analysis

A total of 64 points were calculated for point frequency. A total of 83 points (including 11 extra points)with a total frequency of 583. In their ranking order, the top points were Lianquan (CV 23), Zhaohai (KI 6),Fenglong (ST 40), Sanyinjiao (SP 6), Sishencong (EX-HN 1)and Zusanli (ST 36). Sishencong (EX-HN 1) was the most frequently used extra point (Table 1).

Table 1. Selected points analysis

2.1.2 Meridian selection analysis

A total of 72 meridian points were involved with a total frequency of 519 in the 64 prescriptions. The distribution of meridians was shown in Table 2. The points used for SAS treatment distributed in 14 meridians, including the Conception and Governor Vessels. The sum frequency of the Stomach Meridian,the Conception Vessel plus Spleen Meridian was 299 times, accounting for 51.29%. Thirty-six points in these meridians were used, accounting for 43.38% of the total number of points (Table 2).

2.1.3 Point locations analysis

The result showed that the main locations of points of SAS treatment were head, face, neck and lower limbs(Table 3).

2.2 Association rules analysis

The SPSS Modeler 14.1 data mining software was used to correlate the 21 points with the frequency of 10 or more, and the top 20 rules with confidence ≥90 and support ≥20% were listed (Table 4).

Table 2. Selected meridians analysis

Table 4. Association rules analysis

The correlation analysis results were shown in Figure 1. The thicker the connection line, the stronger the association strength. Sishencong (EX-HN 1), Zhaohai(KI 6), Lianquan (CV 23), Lieque (LU 7), Sanyinjiao (SP 6)and Fenglong (ST 40) were mostly strongly associated with each other, and these 6 points also had higher association strength with other points than the connection between other points.

Figure 1. Commonly used points mesh plots for SAS

3 Discussion

There are no definite records of SAS in ancient Chinese medical literature. According to its clinical manifestations, SAS falls under the category of snoring or drowsiness. As for its pathogenesis, theZhu Bing Yuan Hou Lun(Treatise on the Origins and Manifestations of Various Disease) states that, it is located in the throat and often diagnosed as deficiency in root cause with excess in symptoms or combined deficiency and excess. Contributing factors include phlegm dampness, phlegm heat, qi stagnation and blood stasis. These factors retain in the throat and impair the breathing[41]. SAS is mainly caused by lung qi impairment and spleen deficiency. It is often associated with obesity. As a result, the treatment strategies are to strengthen the spleen, resolve dampness, clear phlegm and circulate qi.

This study showed that the most commonly used points for SAS were Lianquan (CV 23), Zhaohai (KI 6),Fenglong (ST 40), Sanyinjiao (SP 6), Sishencong (EX-HN 1)and Zusanli (ST 36). Lianquan (CV 23) is a crossing point of the Conception Vessel and Yin Link Vessel. It is located in the throat, between the thyroid cartilage and hyoid bone, and epiglottis is in its deep. Glottis is below the throat, thyrohyoid muscle and tongue muscle lie in there. Pharyngeal will be obstructed during sleep,which is mainly concentrated in the soft palate and retrolingual airway[42]. Lianquan (CV 23) is a local point for SAS and benefits throat, comforts tongue and smooth airway. Fenglong (ST 40) is the Luo-Connecting point of the Stomach Meridian and is a key point for expelling phlegm. Zusanli (ST 36) is the He-Sea point of the Stomach Meridian and can fortify the spleen and drain dampness. Sanyinjiao (SP 6) is the crossing point of the three yin meridians of the foot, and it can dispel dampness and eliminate phlegm. Zhaohai (KI 6) is the crossing point of Kidney Meridian and Yin Heel Vessel. It can tonify qi, supplement kidney as well as regulate Yin Heel Vessel. Yin and Yang Heel Vessels manage sleep, so regulating the qi of Yin and Yang Heel Vessels is beneficial to sleep. Sishencong (EX-HN 1) is located in the top of head, and can regulate sleep and improve the quality of sleep in SAS patients.

The most frequently used meridians were Stomach Meridian, Conception Vessel, Spleen Meridian and Kidney Meridian. For Stomach Meridian, Fenglong(ST 40) and Zusanli (ST 36) were frequent selections;Sanyinjiao (SP 6), Gongsun (SP 4) and Yinlingquan (SP 9)were frequent points distributed in Spleen Meridian.When used together, these points can dispel phlegm and soothe the throat. Most SAS patients show increased abdominal girth, neck girth and other obesity characteristics, which also reflect the saying that ‘the fatties get dampness’. The selected points from the Stomach and Spleen Meridians could help spleen and stomach transport, dispel dampness and phlegm, so as to smooth airway, and promote qi movement fundamentally. Lianquan (CV 23) and other points were local selections. Zhaohai (KI 6) and other points from Kidney Meridian can harmonize yin and yang and tranquilize mind to help sleep. Meanwhile, points locate in head, face, neck and lower limbs were the most commonly selected, reflecting that local selections and distant selections are of equal importance.

Points combination is essential in SAS treatment.Therefore, understanding the correlation rule is the key to choosing points. Through association rules analysis,the results showed that the confidences of the top 20 compatibility laws of the points were all 100%,indicating that in the listed compatibility laws,consequents follow the antecedents inevitably. For instance, if Shenmen (HT 7) was indwelled in a prescription, then Sishencong (EX-HN 1) must follow.Sanyinjiao (SP 6) would be combined if Gongsun (SP 4)was selected. The listed points have strong correlations,suggesting that these point combinations should be selected at the same time. The support measure is the ratio of the corresponding data in all the data. In the order of support degree, Shenmen (HT 7)-Sishencong(EX-HN 1) had the highest support in all the prescriptions, suggesting that this is the most common combination in SAS treatment. Shenmen (HT 7) and Sishencong (EX-HN 1) both can calm the mind. The second frequently used combination was Lieque (LU 7)-Lianquan (CV 23)-Zhaohai (KI 6). Lieque (LU 7) belongs to the Lung Meridian, and Zhaohai (KI 6) belongs to the Kidney Meridian. Based on mutual generation between metal and water theory, these two points can tonify yin and lower fire. Together with Lianquan (CV 23) in local area, they can smooth airway, soothe mind and help sleep. The remaining groups also have different meanings for clinical practice.

Via our primary data mining, we sorted out the main points and combination rules in acupuncture treatment of SAS. The results can provide ideas for clinical treatment and scientific research. It also shows that through the data mining method, the abundant connotation of the existing literature can be effectively explored, laying a foundation for raising the level of clinical diagnosis and treatment.

Conflict of Interest

The authors declared that there was no potential conflict of interest in this article.

This work was supported by Hunan Provincial Innovation Foundation for Postgraduate (湖南省研究生科研创新项目, No. CX2017B427).

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