Discussion:Heart Rate Variability Analysis in the Acupuncture Clinic: Correlation with Clinical Outcomes

n
The goal of having a non-invasive monitoring system that can detect subtle shifts with acupuncture physiologically is the thrust of the author’s research. Exploring HRV with acupuncture over the last several years revealed, somewhat counterintuitively, that there is an intra-treatment increase in HRV. This phenomenon has been corroborated in other studies[i][ii]. The Bäcker study saw only decreases in LFR, other studies have only seen changes in HF.[iii]. With more trustworthy HRV data collection and analysis, comparing of acupoints, various types of acupuncture stimulation, duration of treatment, and spacing of visits would be of interest also.

nThis study is far from scientific, but rather a case study in monitoring HRV in the actual acupuncture clinic, and the author felt compelled to share and tabulate the results of these recent efforts. Clinical outcomes are not graded per se in this study, but are the result of careful interviews on subsequent patient visits.

nHRV measurement and analysis is an exacting undertaking, but with the addition of nonlinear measurements, which are less affected by artifact, the results are more trustworthy. In this study there are noted outliers where there were strong responders who had significant and profound relief from symptoms, but their HRV did not reflect that (PeAl,GuPa,RuSu). The correlation is not perfect.

nComparing patients and treatment sessions instead of control groups, can still give interesting and provocative findings. In controlled studies not available to the clinical practitioner, these trends could hopefully be verified.

nAnd finally, there is an ever increasing focus on the adverse physiological effects of stress. Recent Nobel Prize winning research[iv] shows the effects on a cellular level of stress on aging. Traditionally, in Chinese Medicine, prevention and anti-aging are pillars of practice. If acupuncture can be shown to be an effective treatment option for physiological stress, not only will the ancient practitioners be vindicated, but we will be offering real preventative treatment.

[i] Acupuncture in migraine: investigation of autonomic effects Bäcker M, Clin J Pain. 2008 Feb;24(2):106-15

[ii] Effect of acupuncture on heart rate variability in primary dysmenorrheic women.
Kim E, Cho JH, Jung WS, Lee S, Pak SC.Am J Chin Med. 2011;39(2):243-9.

[iii] Auton Neurosci. 2011 Apr 26;161(1-2):116-20. Epub 2011 Jan 7.

Acupuncture to Danzhong but not to Zhongting increases the cardiac vagal component of heart rate variability.

Kurono Y, Minagawa M, Ishigami T, Yamada A, Kakamu T, Hayano J

[iv] Accelerated telomere shortening in response to life stress. PNAS 2004 Dec 7;101(49):17312-5 Blackburn E
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Results: Heart Rate Variability Analysis in the Acupuncture Clinic: Correlation with Clinical Outcomes

Results

nIt is feasible to evaluate HRV in the acupuncture clinic both by nonlinear and linear measurements. The total calculation time is 7 minutes.

n

nPatients who responded to their acupuncture treatment tended to exhibit a decrease in their LFR/HFR ratio from segment “a” to segment “b”, an increase in their SD1/SD2, and an increase in their Samp En: all of these trends indicating a decrease in their stress response

n

nNon-responders, or patients who were aggravated by a particular treatment tended to show no change or an increase in their LFR/HFR from minute and a decrease in their SD1/SD2 from the first to second time window, and an increase in their Sample Entropy

n

nThere were notable exceptions, i.e. patients who were strong responders, who did not exhibit the consistent pattern above. In these patients, Sample Entropy was the strongest predictor of successful treatment.

n

nBecause of the prevalence of artifact in heart rate monitoring, the addition of nonlinear measures gives added confidence to the measurements obtained.

nChanging the needle placement prescription and type of stimulation changed outcomes corresponding to HRV results in some cases.
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Materials and Methods Heart Rate Variability Analysis in the Acupuncture Clinic: Correlation with Clinical Outcomes

Materials and Methods

Design, Setting, and Patients: Case study of 20 patients representing 80 treatment sessions. The presenting diagnoses were varied including hypertension(3), low back pain/sciatica (3), headache/migraine(5), depression/anxiety(4), peripheral neuropathy (2), allergy (1), IBS(1), PCOS (1). When patients were in a prone or lateral position, the data was collected but not used in the study.

Controls: This study did not use controls, rather compared like kind data between acupuncture sessions and between patients.

Intervention: All patients received body acupuncture according Traditional Chinese Medicine principles. Electro-acupuncture was used if following a protocol (PCOS), or if manual acupuncture was not proving effective. Heart rate data was collected after needle placement for 20 minutes, and analyzed after treatment. The heart rate tracing was analyzed by pasting into the Kubios system, read out in 5 minute windows starting at 1 minute. The use of 5 minute intervals has precedent in the literature, and is seen as an appropriate time window for analysis. The specific 5 minute intervals (minute 1 to 6, and then 6 to 11) are used because of previous studies showed them to be the most indicative. These were then saved as an Excel Spreadsheet for tabulating. The heart rate tracings had to be scanned for artifact by filtering. Tracings with too many artifacts were excluded from study.

Main Outcome Measure: Patients were assessed by symptom resolution. Some conditions were easier to quantify than others. Headaches, panic attacks, insomnia, knee pain easier to quantify than IBS and PCOS for example. Their HRV data were compared for the time frames “a” (60 to 360 sec) and “b” (360 to 660 sec) using Kubios shareware for:

1. Time series: pnn50 % (not included in current results because of poor correlation)

2. Frequency Domain: FFT (LFR/HFR) ratios and HFR ms

3. Nonlinear results: Poincaré Plots (SD1/SD2) and Sample entropy
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References for Heart Rate Variability in the Acupuncture Clinic

Here are the references for the previous post.

[i] Ernst M, Lee M. Sympathetic effects of manual and electrical acupuncture of the Tsusanli knee point: comparison with the Hoku hand point sympathetic effects. Exp Neurol. 1986;94: 1–10.

[ii] Anderson S, Lundeberg T. Med Hypothesis. 1995;45:273–28

[iii] Napadow- Monitoring acupuncture effects on human brain by FMRI.Hui KK, Napadow V, Liu J, Li M, Marina O, Nixon EE, Claunch JD, LaCount L, Sporko T, Kwong KK. J Vis Exp. 2010 Apr 8;(38). pii: 1190. doi: 10.3791/1190.

[iv] Autonomic Neuroscience 2007 May 30;133(2) 158-69Specific acupuncture sensation correlates with EEGs and autonomic changes in human subjects Shigekazu Sakai, Etsuro Hori, Katsurni Umeno, Nobuhide Kitabayashi, Taketoshi Ono, Hisao Nishijo *

[v] Acupuncture in migraine: investigation of autonomic effects Bäcker M, Grossman P, Schneider J, Michalsen A, Knoblauch N, Tan L, Niggemeyer C, Linde K, Melchart D, Dobos GJ Clin J Pain. 2008 Feb;24(2):106-15.

[vi] Medical Acupuncture Volume 19, Number 1, 2007Analysis of Heart Rate Variability in Acupuncture Practice: Can It Improve Outcomes? K. Sparrow, MD

[vii] Chambers AS, Allen JJ. Vagal tone as an indicator of treatment repsonse in major depression. Psychophysiology. 2002;39:861–864.

[viii] Poincaré Plots:A MiniReview ReyLab, Beth Israel Deaconess Medical Center Harvard Medical SchoolDept. Psychiatry, Taipei Veterans General Hospital, Taiwan Albert C.C.Yang, MD

[1] Tulppo et al. Circulation2005; 112:314-319

[1] Medicina (Kaunas) 2010;46(6):,393-400Linear and nonlinear heart rate dynamics in elderly inpatients.Relations with comorbidity and depression Cristina Blasco-Lafarga1, 2, Ignacio Martínez-Navarro1, María Elisa
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Heart Rate Variability Analysis in the Acupuncture Clinic: Correlation with Clinical Outcomes

This is the poster I presented last weekend at the ISAMS in Irvine. ISAMS stands for International Scientific Acupuncture and Meridian Symposium. How was the response to my poster? It was somewhat mixed but overall positive. Some of the researchers really "got" what I'm trying to do. Others really couldn't wrap their minds around the nonscientific nature of my study, and what the point was. What is the point? There is some profound response that happens during acupuncture in some patients. I can't give up on this project because when you see a profound response clinically to an acupuncture series or even session, my hunch is that HRV is a measure that is subtle enough to register that change physiologically. Now I only have to prove it... There are many confounding problems with HRV, time of day, body positioning, need for normal sinus rhythm, all of which mitigate the utility of HRV. However, as a modality to register change, at least in some responders, some of the time it might show what is happening that allows these dramatic effects.
What I incorporated for this study was Sample Entropy comparisons. It is a nonlinear measure of HRV which is less dependent on a pristine heart rate tracing, and hence more attractive for clinic use. To quote some other researchers on complexity measures

“The fractal organization of human HR dynamics is determined by a delicate interplay between sympathetic and vagal outflow, with the breakdown of fractal HR behavior toward more random dynamics occurring during coactivation of sympathetic and vagal outflow[i] A system’s complexity will be reflected in the dynamical fluctuations generated by the free-running conditions Complexity (healthy systems) > Complexity (pathologic systems) Healthy systems operating, far from equilibrium, have greater adaptability and functionality than pathologic systems, therefore• Disease, aging, drug toxicities should degrade complexity."

I would add STRESS decreases complexity, also.

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[i] Tulppo et al. Circulation 2005; 112:314-319

Introduction

The goal of these studies is to develop a system of

1. Reliable measurement of HRV (Heart Rate Variability) during acupuncture treatment to help guide and inform treatment.

2. To establish the utility of acupuncture as a stress reducing treatment.

3. To develop a dependable system of measurement to be used to correlate with more invasive and expensive measures of stress and health such as cortisol measurements, fMRI, EEG, or even telomere evaluations.

The Autonomic Nervous System and Acupuncture: Autonomic balance has been implicated in acupuncture’s results [i][ii]. Increased parasympathetic activity and decreased sympathetic activity can be beneficial to the patient by decreasing stress and elevated cortisol levels. Elevated cortisol and sympathetic tone and have an incalculable negative impact on pain, mood, immunity, longevity, and health in general.

HRV and Autonomic Nervous System: The basic concept of HRV is that within parameters, more complexity is a sign of greater health. HRV declines in old age, high stress, or a variety of illnesses. It is an indirect measure of sympathetic/parasympathetic tone. HRV is often measured after a physiological intervention, such as postural change, a cardiac stressor, or even mental challenges to assess autonomic tone and cardiac health.

Acupuncture and HRV: Acupuncture is a subtle intervention that achieves its results by triggering multiple neurotransmitters including local and central effects, and it may be possible to detect some of those changes by subtle changes in HRV. HRV has been studied with acupuncture in the laboratory setting, on healthy volunteers, and in the clinic on specific patients. HRV has been explored in conjunction with fMRI[iii] and EEG[iv] in the acupuncture context also. There are a few studies correlating HRV with positive clinical outcomes[v][vi][vii], but in general, HRV is for the most part relegated to studies, not as a practical tool to be used in the clinic. There is good reason for this. There are multiple confounds in combining clinical acupuncture and HRV, including the constraints of clinical practice and the propensity to artifact in cardiac monitoring. The author hypothesized that with the newer capabilities of Kubios shareware to analyze HRV with nonlinear methods, inclusion of nonlinear parameters could prove to be more reliable and sensitive to subtle shifts in HRV than linear methods.

With a decrease in the stress reponse, one would expect to see the following.

Fast Fourier Transform. A Decrease in the LFR/HFR from segment “a” (1 minute to 6 minutes) and “b” (minutes 6 to 11.)

Poincare Plots (SD1/SD2) are a valuable method which is a simple visualization tool, can identify ectopic beats so is less dependent on a pristine heart tracing.[viii] Would expect to see an increase in the SD1/SD2 between a and b segments.

Sample Entropy , SampEn is widely accepted as a more consistent and less biased complexity measure than Approximate Entropy. You would expect to see an increase in Sample Entropy from the first to the second time window.

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