Static Muscle Contraction effect on Muscle Activity, Trapezius Blood Flow, and Autonomic Indices

(Warning! Long post!)
This article (see below) is of interest to me because of the monitoring of HRV (Heart rate variability, a measure of autonomic balance, or stress response) at rest and during different challenges such as cold stress test, static hand grip test, and deep breathing test. The author was kind enough to send me an unofficial copy of his/their study.
In the introduction it is pointed out that changes in muscle activity and muscle blood flow due to stress and unfavorable muscle loads are possible factors for initiation and maintenance of muscle pain through accumulation of metabolites, which stimulate nociceptive afferents. Sometimes impaired muscle circulation can accompany chronic neck pain. In previous studies fibromyalgia patients and subjects with trapezius myalgia were found to have restricted MBF (muscle blood flow) in response to acupuncture by needle stimulation in the trapezius muscle. This may be due to aberrations in the autonomic nervous system. Indeed, various studies have found evidence for ANS (autonomic nervous system) involvement in diffuse and widespread muscle pain, and fibromyalgia patients may have elevated sympathetic tone at rest. These aberrations can be exacerbated by mental stress. Less is known about localized muscle pain, such as addressed in this article.
So in a nutshell, this study found that subjects with muscle pain showed HRV results that indicated reduced basal parasympathetic activity. Their findings (which I won't go into in detail here) indicated differences in intrinsic autonomic regulation, implying sympathetic-to-parasympathetic imbalance in chronic neck-shoulder pain. What has caused this imbalance is due to chronic pain, mental stress, or deconditioning is not known.
Their conclusion was that their findings support the hypothesis of ANS involvement at systemic and local levels in individuals with chronic neck-shoulder pain.
I bring this study to your attention for a few reasons.
1. It underscores what I tell first time patients with chronic pain from musculoskeletal problems: your pain may be worse after the first and even second acupuncture session because of an increase in blood flow that liberates many of the metabolites that can be "caught" in the vicious cycle of muscle tension and reduced blood flow.
2. It reinforces my belief in using points that have been studied and shown to decrease the stress response.
3. It reinforces my belief that autonomic balance remains a key component in pain management and in turn acupuncture treatment.
4. I was not aware of the blunted response of fibromyalgia patients to needling in the trapezius, so will have to amend and add means of increasing blood flow to the area during needling in these patients.

To read more about acupuncture, autonomic nervous system and my practice please click here.



Effects of static contraction and cold stimulation on cardiovascular autonomic indices, trapezius blood flow and muscle activity in chronic neck-shoulder pain

Department of Family Medicine and Public Health Sciences,
Division of Occupational and Environmental Health, Wayne
State University, 3800 Woodward Ave., Detroit, MI, USA
e-mail: bengt.arnetz@pubcare.uu.se
D. M. Hallman B. B. Arnetz
Department of Public Health and Caring Sciences,
Uppsala University, Uppsala, Sweden
123
Eur J Appl Physiol
DOI 10.1007/s00421-010-1813-z
Systemic cardiovascular characteristics
Subjects with muscle pain showed lower SDNN and LFHRV
during rest than the control group, indicating reduced
basal parasympathetic activity. However, there was no
increase in sympathetic activity as measured by LFnorm.
This is in line with recent studies that found diminishedHRV
in FM patients (Cohen et al. 2000) and in subjects with low
back pain (Kalezic et al. 2007). No significant difference was
found in IBI, in contrast with other studies on neck–shoulder
pain (Gockel et al. 1995; Sjo¨rs et al. 2009). In the present study, differences in autonomic reactivity
were indicated in response to HGT, but not in response to
CPT and DBT, namely the BP response to HGT was lower
in the pain group. These results are in accordance with the
blunted BP responses to exercise (Andersen et al. 2010;
Gockel et al. 1995) and normal BP responses to CPT
(Acero et al. 1999) demonstrated in previous studies
amongst subjects with neck–shoulder pain. Similar results
have been reported in patients with FM (Kadetoff and
Kosek 2010; Giske et al. 2008), indicating sympathic
hyporeactivity to various stressors (Martinez-Lavin 2007).
In the present study, however, only static contraction was
sensitive for differences in systemic BP, HRV and local
MBF, suggesting an altered exercise pressor reflex in the
pain group.
However, the increased LF reactivity observed in the
pain group during HGT should be interpreted with caution
as LF oscillations are influenced by both branches of the
ANS (Berntson et al. 1997). The current findings indicated
differences in intrinsic autonomic regulation, implying
sympathetic-to-parasympathetic imbalance in chronic
neck–shoulder pain. Whether this is a consequence of
chronic pain or due to other factors, e.g. mental stress or
deconditioning, requires further investigation. It is worth
noting, however, that although MVC was lower in the pain
Relations between symptoms and autonomic function
As expected, general health scores, as assessed with the
SF-36 questionnaire were lower in the pain group compared
to the healthy controls. More important, clinical
symptoms, e.g. dizziness and sweating, were more frequently
observed in the pain group. Using correlation
coefficients, a negative relationship was found between
disability of neck pain and resting LFnorm HRV and a
positive relation between disability and LFnorm reactivity
to static contraction. This is in line with previous findings
in low back pain (Gockel et al. 2008). Furthermore, an
inverse relationship between pain intensity and resting
SDNN was seen in the present study suggesting reduced
HRV with increased pain. Results show that it is worth to
plan treatment of neck–shoulder pain, aiming to restore
ANS balance at systemic and local levels.
myalgia had decreased vasodilatation capacity in these
muscles. Similarly, patients with generalised chronic
muscle pain, e.g. fibromyalgia (FM), had reduced MBF
following dynamic and during static exercise compared to
controls (Elvin et al. 2006). FM patients and subjects with
trapezius myalgia were found to have restricted MBF in
response to acupuncture by needle stimulation in the trapezius
muscle (Sandberg et al. 2005a).
A possible mechanism seems to be aberration in the
autonomic nervous system (ANS) (Maekawa et al. 2002;
Passatore and Roatta 2006). In chronic muscle pain, sympathetic
activity due to nociceptive stimulation may cause
disturbances of blood flow regulation in the affected
muscle and enhance muscle activation. This, in addition,
may be further exacerbated by mental stress (Larsson et al.
1995; Lundberg 2002).
Results from several studies provide evidence for ANS
involvement in diffuse and widespread muscle pain
(Martinez-Lavin 2007; Okifuji and Turk 2002). The autonomic
state in FM patients is characterised as elevated
sympathetic tone at rest, and hypo-reactivity to various
stressors, e.g. orthostatic stress, mental stress and isometric
exercise (Martinez-Lavin 2007; Giske et al. 2008). In
general, signs of ANS aberrations are reflected in heart rate
variability (HRV) and blood pressure (BP).
Although ANS may be involved in chronic muscle pain
of different origins, less is known about the degree of
autonomic involvement in localised chronic muscle pain,
especially pain in the neck–shoulder region (Leistad et al.
2008). Cardiovascular markers showed signs of sympathetic
dominance among persons with neck pain (Gockel
et al. 1995), low back pain (Gockel et al. 2008; Kalezic
et al. 2007), whiplash-associated disorders (Kalezic et al.
2010; Passatore and Roatta 2006) and distal forearm pain
among office workers (Gold et al. 2004; Sharma et al.
1997). Increased resting HR was found in subjects with
trapezius myalgia, whereas stress reactivity was unaltered
(Sjo¨rs et al. 2009).
To improve prevention and treatment, more knowledge
about ANS involvement in neck–shoulder pain is needed.
Tests are required which would differentiate between those
with and without muscle pain. Preferably, adequate assessment
should include multiple tests which target d

Monitoring the Autonomic Nervous System and HRV in rats after Acupuncture

I often don't know what to make of these studies, but find them super interesting nonetheless, and somehow can't help but incorporate their findings into my practice for better or for worse. What I love about this study is that they actually saw a difference between electroacupuncture on Stomach 36 and Pericardium 6, both in pain reduction and autonomic response as measured by heart rate, LF(low frequency portion of HRV) and LF/HR (low frequency to high frequency ratio-a common measure of stress response.) They saw no reduction when using Liver 3 nor the sham, non-acupoint. I wish we had more studies like this, comparing one set of points and another. For one, it helps get away from the ever present placebo problem in research, and for two it might help inform our practice!!
The study model is 4 groups, sham point, Stomach 36, Pericardium 6, Liver 3, 9 rats in each group. They used alternating 2Hz/15Hz electro, (got to haul out my alternating device again...)
The abstract for the study follow. The emphases are mine. Poor rats...

(To read more about acupuncture, HRV, and my practice, please click here.

Zhen Ci Yan Jiu. 2010 Oct;35(5):335-41.
[Effects of electroacupuncture of different acupoints on changes of blood pressure and autonomic nerve system after colorectal distension in rats].

Chen SP, Gao YH, Yu XC, Liu JL.
Institute of Acu-moxibustion, China Academy of Chinese Medical Sciences, Beijing 100700, China.
Abstract

OBJECTIVE: To observe the influence of electroacupuncture (EA) of different acupoints on changes of mean arterial pressure (MAP), heart rate (HR) and heart rate variability (HRV) in colorectal distension (CRD) rats, so as to analyze the specificity of actions of acupoints in relieving visceral pain and regulating activities of the autonomic nerve system.

METHODS: Forty-five Wistar rats were randomized into control, Zusanli (ST 36), non-acupoint, Neiguan (PC 6) and Taichong (LR 3) groups (n = 9/group). Under anesthesia, CRD was given to the rats by using an aerostat for 5 min. EA (2 Hz/15 Hz, 2 mA) was applied to bilateral ST 36, non-acupoint (1.0 cm lateral to ST 36), PC 6 and LR 3 for 15 min, respectively. Electrocardiogram of the cervico-chest lead was recorded by using a bioelectric amplifier, and MAP recorded by using a pressure transducer and an amplifier. Low frequency and high frequency of HRV were analyzed by Chart 5.0.

RESULTS: Following CRD, the HR, MAP, LF and LF/HF levels increased significantly in all the 5 groups (P <> 0.05). Compared with the control group, 5 min and 15 min after EA ,and 10 min after ceasing EA, MAP values of ST 36 and PC 6 groups were decreased obviously (P < style="font-weight: bold;">The LF levels of both ST 36 and PC 6 groups at 5 min after EA, and those of ST 36, PC 6 and LR 3 at 15 min after EA were significantly lower than those of control group (P <> 0.05).

CONCLUSION: EA of ST 36 and PC 6 can suppress CRD-induced increase of MAP, HR and LF/HF, suggesting beneficial effects of EA in relieving visceral pain and mediating autonomic nerve system. The aforementioned effects of EA of LR 3 and non-acupoint are not obvious.

Moxibustion Activates Host Defense Against Herpes Simplex Virus in Mice

As time consuming as it is to use moxibustion in modern practice, it does seem to be the mainstay of enhancing immune function. I use it most often in patients with allergy and HIV. During my training the treatment rooms were full of moxa smoke. Here, at least in my practice, even using smokeless moxa, many notice and comment on the smell. This study reinforces my own biases, so of course I love it! ;)
Of note is that they used the moxa preventatively, before the virus was introduced. (Anecdotally this makes sense vis a vis my attempts to get patients in for treatment before the allergy season, and ongoing treatment to prevent illness in HIV positive patients.)
Also, of interest is that not only cytokine production but also natural killer cells.
The abstract follows, emphases are mine.

(To read more about acupuncture and my practice, please click here.)

Microbiol Immunol. 2010 Sep;54(9):551-7.
Moxibustion activates host defense against herpes simplex virus type I through augmentation of cytokine production.

Takayama Y, Itoi M, Hamahashi T, Tsukamoto N, Mori K, Morishita D, Wada K, Amagai T.

Department of Immunology and Microbiology, Meiji University of Integrative Medicine, Hiyoshi-cho, Nantan, Kyoto 629-0392, Japan.
Abstract

Moxibustion is a technique used in traditional oriental medicine, the aim of which is to cure and/or prevent illness by activating a person's ability for self-healing. In this study, we assessed how moxibustion would affect the immune system and whether it would augment protective immunity. Mice were treated with moxibustion at Zusanli (ST36) acupoints; we analyzed mortality and cytokine activity in sera after infection with herpes simplex virus type 1 (HSV-1), and cytokine gene expression in the skin and the spleen without a virus challenge. Our study demonstrates that pretreatment of BALB/c mice with moxibustion resulted in a marked increase in the survival rate after infection with lethal doses of HSV-1, and elevated serum levels of IL-1β and IFN-γ on days 1 and 6 post-infection with HSV-1. Semi-quantitative RT-PCR assay showed that moxibustion treatment augmented the expression of IL-1α, IL-1β, IL-6, universal-IFN-α, MIP-1α, and TNF-α mRNA in the skin, and IL-1α, IL-1β, IL-12p40, IL-15, u-IFN-α, MIP-1α, and TNF-α mRNA in the spleen. Moreover, moxibustion induces augmentation of natural killer cell activity. Collectively, our study demonstrates that moxibustion activates protective responses against HSV-1 infection through the activation of cytokine production including IFN, and of NK cells.

Tension Myoneural Syndrome, A Theory

This is from an article in Anesthesiology News. You have to be registered to read the interview in its entirety and to register you have to be willing to have the ad replete glossy sent to your home every month, so I will assume that most will just take my word for it...
This is an interview with a physician named John Sarno, who makes a case for the underlying emotional issues, pain or rage, that can cause a patient to be under pressure to be a perfectionist, that leads to physical pain. He cites the study in the New England Journal of Medicine back in 1994 which shows that bulges and protrusions in discs in people with low back pain frequently may be coincidental. He believes that if you educate people as to the common psychogenic origins of of these pain syndromes, that he calls "tension myoneural syndrome," or TMS, they get better. He has seen more than 10,000 such patients over 30 years and that roughly 3/4 of them have gotten better.
His basic theory goes something like this. That the physical pain serves to distract the patient's attention from emotional pain or rage, which often derives from the pressure people put on themselves to be good or perfect. In this attempt to live up to these high standards, something in the unconscious, an inner child, becomes very, very angry. He tries to educate patients to the fact that the drive to be perfect angers the unconscious. Once the person recognizes that this is what is happening they no longer automatically react to pressure with anger and rage. They no longer need the distraction.
He says that in addition to musculoskeletal maladies, the most common illnesses are gastrointestinal. Migraines and other headaches are classic problems as well. Other conditions that can result are chronic or recurrent sinus infections, and "globus hystericus," the feeling of a lump in the throat. Allergic problems and frequent urination are others.
He postulates that the brain reduces the amount of oxygen to a given part of the body. He uses various physical therapeutic means to increase circulation, heat, exercise and deep massage. He sees increasing circulation as key, and that "the brain was causing all this through the autonomic nervous system, which controls blood flow."


(To read more about acupuncture and my practice, please click here.)

Migraines provide an excellent example of this process. The migraine is a condition of spasmodic narrowing of the blood vessels. The narrowing ususally takes place in one large blood vessel, such as the carotid. First you experience pain ,a nd if it persists long enough, you may have a stroke. Several studies support this oxygen-deprivation hypothesis

.
He goes on to cite a 1993 paper on neuroendocrine-immune interactions in the New England Journal of Medicine (NEJM 1993, 329:1246-1253) that concluded that "the central nervous sytem influences on the immune system are well-documented and provide a mechanism by which emotional states could influence the course of diseases involving immune functions."

I wanted to make a few points about this article since it touches on issues that are important in my practice and my view of Chinese Medicine.
1. The mind and body are not separate entities in Chinese Medicine. Indeed, each organ has its own emotional state that it is responsible for. That is one reason that I was interested in Chinese Medicine. It is a way to help heal the mind through the body without necessarily engaging the cognitive portion. This can be incredibly useful and healthy.
2. The example of migraine is classic Chinese Medicine doctrine. Migraine is often caused by a stagnation of liver qi from an underlying perfectionism and rage. We treat by dredging the liver and calming the Shen, as well as local points which increase circulation.
3. To the extent that I've done research it has been on the autonomic nervous system and it's pivotal role in the effectiveness of acupuncture. Dr. Sarno's theories do nothing to dispute that theory; though he seems to prescribe a slightly different remedy.
4. The increase in circulation has been clearly established with acupuncture treatment with infra-red documentation and the like.
5. I'd never considered that the brain would be selectively decreasing blood flow to an area of the body, but I find this hypothesis fascinating. I frequently will treat the spinal level involved in the nerves that feed an area that is in pain, and thought of the autonomic nervous system as a more general relaxation and restoration of function. More food for thought!
6. The increase in immune function with acupuncture is well documented, I've posted about it here, and here,and am heartened to see other practitioners accepting this link.
7. Globus Hystericus in Chinese Medicine is a common feature of the condition "running piglet" which is treated through the Chong Mai extra meridian and the liver meridian very effectively.

Acupuncture in the Elderly to Attenuate Stress and Improve Immunity

Acupuncture is so helpful in the elderly population, and can safely alleviate some of the aches and pains and other issues without the use of pharmaceuticals. Unfortunately, the elderly are often the "hardest sell." Since treatment can take more visits before they start to see results than in younger people, they get impatient and want to abandon the series of sessions. This article can offer some good arguments to encourage them to stick with it (pardon the much overused pun.) The points used are a very simple prescription of the most basic immune points, a very simple prescription, indeed. The abstract is copied in its entirety.
(To read more about acupuncture and my practice, please click here.)

Neurosci Lett. 2010 Oct 22;484(1):47-50. Epub 2010 Aug 13.
Acupuncture is effective to attenuate stress and stimulate lymphocyte proliferation in the elderly.

Pavão TS, Vianna P, Pillat MM, Machado AB, Bauer ME.

Laboratory of Cellular and Molecular Immunology, Institute of Biomedical Research, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre (RS), Brazil.
Abstract

Acupuncture has increasingly been used to treat many conditions, including psychiatric disorders and immunological-related disorders. However, the effects of acupuncture as stress management and immune functions in the elderly are largely unclear. Here we investigated the effects of acupuncture on stress-related psychological symptoms and cellular immunity in young adults and elderly subjects. The acupuncture treatment consisted of six sessions and the procedures included the insertion of needles at bilateral acupoints LI4, SP6 and ST36. Psychological variables (depression, anxiety and stress) were investigated by means of self-assessment inventories. Peripheral blood mononuclear cells were isolated and cultured in vitro to measure mitogen-induced T-cell proliferation as well as cellular sensitivity to dexamethasone. All data were assessed before and after the intervention. Acupuncture was able to significantly reduce depression anxiety (p<0.001) and stress (p<0.001) scores. The intervention also increased T-cell proliferation, with greater intensity in the elderly group (p=0.004). No changes in cellular sensitivity to dexamethasone were observed following acupuncture. We conclude that acupuncture was efficient to attenuate the psychological distress as well as to increase an important feature of cellular immunosenescence.

Ghost writing Medical Research and Its Repercussions, from the Atlantic

Playing Doctor

How to spin pharmaceutical research
By Carl Elliott

This is another article about the corruption of medical research, but this one focuses on a more subtle aspect of industry sponsored research: the ghost writer. It has an amusing intro where we meet a ghost writer, Dave, and how he is taught to "spin" research findings to highlight the beneficial aspects of a given drug. You should really read the whole article, it's not too long.

The mechanics of the ghostwriter’s job are fairly simple, David says. Early on, a medical-communications agency and its pharmaceutical-company sponsors will agree on a title for an article and a potential author, usually an academic physician with a reputation as a “thought leader.” The agency will ask the thought leader to “author” the article, sometimes in exchange for a fee. The ghostwriter will write the article, or perhaps an extended outline containing the message the company wants to transmit, and send it along to the physician, who may make some changes or simply sign it as written and submit it to a journal, usually scrubbed of any mention of the ghostwriter, the agency, or the pharmaceutical company. David says he rarely even sees the published articles he writes.

Every so often, the issue of ghostwriting moves out of medical schools, where it is generally tolerated or ignored, and into the wider public sphere, where it is treated as a moral scandal. The most recent burst of outrage came in July during an investigation by the U.S. Senate Finance Committee, which has been looking into whether GlaxoSmithKline tried to steer attention away from the cardiac risks of its diabetes drug Avandia (whose use was recently restricted by the Food and Drug Administration). The committee found not merely that GSK had “downplayed scientific findings” to minimize the apparent risks of Avandia, but that it had used a ghostwriting campaign for the drug. (The company had called the ghosting effort “Case Study Publication for Peer Review,” or CASPPER.)

Ghostwritten articles surface again and again in litigation (in cases concerning Vioxx, Fen-Phen, Zyprexa, Premarin, Neurontin, and Zoloft, to mention just a few). Years before the Avandia scandal, GlaxoSmithKline paid $2.5 million to the State of New York to settle a lawsuit alleging that it had concealed studies suggesting an increased risk of suicidal behavior in children and teenagers taking Paxil, most notoriously in an article “authored” by Dr. Martin Keller of Brown University. One 2003 study in The British Journal of Psychiatry found that ghostwriters working for a single medical-communications agency had produced more than half of all medical-journal articles published on Zoloft over a three-year period.

It goes on to say that the moral outrage is often about "plagiarism," when the real crime, as David puts it, is that "spinning the data perverts science." Depressingly enough, it looks as though it is not going to stop any time soon. The journals have some weak rules about acknowledging some "editorial assistance," but allow the practice to continue. As an example, the Paxil article as noted above, has not been retracted in any way, so probably goes on being cited by unwitting practitioners. The ghost writers are well paid, but just tools to the greater enterprise of the pharmaceutical sales, and are not the real problem. As it says in the article " Medical writing has little glamour, and whatever moral purpose it might once have carried has been rubbed away by the constant friction with commerce." So for scientists by training, like Dave, this work can be quite demoralizing. Unfortunately, the whole set up is also quite dangerous.

Here are some previous posts dealing with the similar issues. Here, here, here, and here.

(To read more about acupuncture and my practice, please click here.)