Differences in cortical response to acupressure and electroacupuncture stimuli.

I don't pretend to understand all the ins and outs of brain imaging. From what I can understand, though, is that there is a system of "recruitment" in patients with chronic pain, whereby there is an ever larger area of the brain devoted to the pain stimulus so that it is outsized compared to the actual insult. Acupuncture tends to mitigate this "maladaptive neuroplasticity." I won't comment on the differences between acupressure and acupuncture since I don't feel competent to interpret. (Info on my practice here.)

BMC Neurosci. 2011 Jul 27;12:73.
Differences in cortical response to acupressure and electroacupuncture stimuli.
Witzel T, Napadow V, Kettner NW, Vangel MG, Hämäläinen MS, Dhond RP.
Harvard Medical School, Martinos Center for Biomedical Imaging, Charlestown, MA 02129, USA.
Abstract
BACKGROUND:
FMRI studies focus on sub-cortical effects of acupuncture stimuli. The purpose of this study was to assess changes in primary somatosensory (S1) activity over the course of different types of acupuncture stimulation. We used whole head magnetoencephalography (MEG) to map S1 brain response during 15 minutes of electroacupuncture (EA) and acupressure (AP). We further assessed how brain response changed during the course of stimulation.
RESULTS:
Evoked brain response to EA differed from AP in its temporal dynamics by showing clear contralateral M20/M30 peaks while the latter demonstrated temporal dispersion. Both EA and AP demonstrated significantly decreased response amplitudes following five minutes of stimulation. However, the latency of these decreases were earlier in EA (~30 ms post-stimulus)
than AP (> 100 ms). Time-frequency responses demonstrated early onset, event related synchronization (ERS), within the gamma band at ~70-130 ms and the theta band at ~50-200 ms post-stimulus. A prolonged event related desynchronization (ERD) of alpha and beta power occurred at ~100-300 ms post-stimulus. There was decreased beta ERD at ~100-300 ms over the course of EA, but not AP.
CONCLUSION:
Both EA and AP demonstrated conditioning of SI response. In conjunction with their subcortical effects on endogenous pain regulation, these therapies show potential for affecting S1 processing and possibly altering maladaptive neuroplasticity. Thus, further investigation in neuropathic populations is needed.
Whole article is available here.

Insomnia in Menopausal Women Treated with Auricular Acupuncture:HRV correlation

(Warning, this post is only for those interested in the tiny niche of acupuncture and HRV.)
Gotta love this study since it correlates HRV with treatment outcomes. Yay! Though there has been quite a bit of research on HRV and acupuncture, there has been precious little looking at whether HRV response correlates with clinical outcomes. In this study they found nLF to go down and nHF to go up in patients who had effective treatment (i.e. less insomnia) and for nLF to go up in the nonresponders. Progress! Some researchers insist that one needs to look only at non-normalized values and that HF is more predictive than LF, but we'll take what we can get.

Menopause. 2011 Jun;18(6):638-45.

The relationship of subjective sleep quality and cardiac autonomic nervous system in postmenopausal women with insomnia under auricular acupressure.

Kung YY, Yang CC, Chiu JH, Kuo TB.

Source

Institute of Traditional Medicine, National Yang-Ming University, Taipei, Taiwan.

Abstract

OBJECTIVE:

The aim of this study is to examine the relationship between the changes in self-reported sleep symptoms and cardiac sympathovagal activity among women with postmenopausal insomnia (PI) who received auricular acupressure (AA) therapy.

METHODS:

A pretest/posttest study design was conducted at Taipei Veterans General Hospital, Taiwan, from August 2008 to July 2009. Forty-five women (mean ± SD age, 56.2 ± 5.4 years) with PI (4.9 ± 3.5 years of insomnia) received an AA therapy course on five auricular points every night before going to sleep for 4 weeks. Heart rate variability (HRV), the Chinese version of the Pittsburgh Sleep Quality Index, and the Menopause Rating Scale were measured before and after AA treatment.

RESULTS:

The total sleep duration and sleep efficiency were increased, and the sleep latency was shortened significantly (P < 0.01) after AA therapy. The total Menopause Rating Scale and somatovegetative subscale scores were reduced significantly (P < 0.05) after the intervention. A greater percentage change in Pittsburgh Sleep Quality Index was moderately correlated with both a lower percentage change in high-frequency power of HRV (r = -0.660, P < 0.001) and a greater percentage change in normalized low-frequency power (nLF) of HRV (r = 0.599, P < 0.001). An elevation of high-frequency power and a reduction of nLF of HRV were observed in the responder group, whereas a raise in nLF of HRV was noted in the nonresponder group.

CONCLUSIONS:

This study suggests that AA intervention leads to more cardiac parasympathetic and less cardiac sympathetic activity, which contributes to the improvement of PI.

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Mammograms: Value Still Questioned

Another study has come out questioning the real value of mammograms. I won't copy the whole piece, but will quote the most important part, which best explains why mammograms may not be as helpful as one might logically think. More is not always better, and early detection doesn't ensure a better outcome.
October 24, 2011, 4:01 pm
Mammogram’s Role as Savior Is Tested
By TARA PARKER-POPE
Stuart Bradford

Has the power of the mammogram been oversold?

At a time when medical experts are rethinking screening guidelines for prostate and cervical cancer, many doctors say it’s also time to set the record straight about mammography screening for breast cancer. While most agree that mammograms have a place in women’s health care, many doctors say widespread “Pink Ribbon” campaigns and patient testimonials have imbued the mammogram with a kind of magic it doesn’t have. Some patients are so committed to annual screenings they even begin to believe that regular mammograms actually prevent breast cancer, said Dr. Susan Love, a prominent women’s health advocate. And women who skip a mammogram often beat themselves up for it.

A new analysis published Monday in Archives of Internal Medicine offers a stark reality check about the value of mammography screening. Despite numerous testimonials from women who believe “a mammogram saved my life,” the truth is that most women who find breast cancer as a result of regular screening have not had their lives saved by the test, conclude two Dartmouth researchers, Dr. H. Gilbert Welch and Brittney A. Frankel...

Dr. Welch says it’s important to remember that of the 138,000 women found to have breast cancer each year as a result of mammography screening, 120,000 to 134,000 are not helped by the test...

How is it possible that finding cancer early isn’t always better? One way to look at it is to think of four different categories of breast cancer found during screening tests. First, there are slow-growing cancers that would be found and successfully treated with or without screening. Then there are aggressive cancers, so-called bad cancers, that are deadly whether they are found early by screening, or late because of a lump or other symptoms. Women with cancers in either of these groups are not helped by screening.

Then there are innocuous cancers that would never have amounted to anything, but they still are treated once they show up as dots on a mammogram. Women with these cancers are subject to overdiagnosis — meaning they are treated unnecessarily and harmed by screening.

Finally, there is a fraction of cancers that are deadly but, when found at just the right moment, can have their courses changed by treatment. Women with these cancers are helped by mammograms. Clinical trial data suggests that 1 woman per 1,000 healthy women screened over 10 years falls into this category, although experts say that number is probably even smaller today because of advances in breast cancer treatments.

“Of all the women who have a screening test who have breast cancer detected, and eventually survive the cancer, the vast majority would have survived anyway,” Dr. Begg said. “It only saved the lives of a very small fraction of them.”..

Dr. Love, a clinical professor of surgery at the David Geffen School of Medicine at the University of California, Los Angeles, says the scientific understanding of cancer has changed in the years since mammography screening was adopted. As a result, she would like to see less emphasis on screening and more focus on cancer prevention and treatment for the most aggressive cancers, particularly those that affect younger women. Roughly 15 percent to 20 percent of breast cancers are deadly.

More needs to be done on the causes of all these cancers, but with funding so tight it's difficult to see how this is going to happen.
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More ISAMS:Lixing Lao presenting recent studies shoulder pain, electroacupuncture and inflammation

More from the ISAMS conference.
The indomitable Dr. Lixing Lao gave a presentation on the current state of Acupuncture research. He reported on a German Study looking at shoulder pain published in Pain by Molsberger. This was a study comparing sham, with verum and conservative management. The verum acupuncture group showed 65% of patients with at least 50% improvement in their pain and well being scores persisting to the 3 month mark. Sham had 40% improvement, but that deteriorated by the 3 month mark.
"“Research should be supported to provide a better understanding of the mechanisms involved, and such research may lead to improvements in treatment.”
(That's what I'm trying to do!!)
In persistent inflammatory pain, there is a dual mechanism of electroacupuncture (10 Hz, but not 100Hz)in rats. There is a direct effect on the CNS, an analgesic mechanism, there is also an effect on the hypothalamus/pituitary/adrenal axis leading to less edema. (I discussed that study here.) They discuss the exact mechanism involving CRF. They also show that EA significantly increased plasma ACTH levels compared to sham EA leading to a decrease in edema. They also show that EA significantly increased plasma corticosterone levels compared to sham EA. (This makes me wonder if that's why I often see no decrease in the stress response with electroacupuncture.
Conclusion
EA activates CRF-containing neurons to significantly increase plasma corticosterone and ACTH levels, suggesting that EA activates the HPA.(Hypothalamus/Pituitary/Adrenal)
•Corticosterone, ACTH and CRF receptor antagonists blocked EA anti-inflammation but not anti-hyperalgesia, suggesting that corticosterone, ACTH and CRF are involved in EA anti-inflammation but not EA anti-hyperalgesia.
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Clinical Inertia: It Can Be Good For Your Health

This article cites a fascinating study in JAMA that looks at the benefits of the "less is more" approach to certain aspects of medicine. The authors "Phillips et al¹ intended to limit the discussion of inertia to disorders in which abnormal values may be the only manifestation of the disease, such as diabetes, hypertension, and dyslipidemia." This is a key characteristic of the conditions that can be treated to the point of danger in the name of prevention.

October 20, 2011, 10:20 am
When Doing Nothing Is the Best Medicine
By DANIELLE OFRI, M.D.

“Don’t just do something; stand there!”

It’s one of those phrases that attending physicians will spout off to their medical students while on rounds, trying to sound both sagacious and clever at the same time. It sometimes grates, but it does make a valid point, because so much of medicine is about “doing something.”

Sore throat? Prescribe an antibiotic.

New headache? Get a CT scan.

P.S.A. at the upper limit of normal? Get a biopsy.

Blood pressure still high? Add on another medication...

Of course, every “thing” a doctor does also has side effects — rampant bacterial resistance from antibiotic overuse; major increases in radiation exposure from unnecessary CT scans; incontinence or impotence from prostate cancer treatments that may do nothing to prolong life; toxic drug interactions from multiple medications, particularly in the elderly.

The admonishment “Don’t just do something; stand there!” reminds us that we should stop and think before we act, that there are many instances in which doing nothing is greatly preferable to doing something...

They focused on three common medical conditions — diabetes, elevated cholesterol and hypertension — for which there are established clinical guidelines for doctors to follow and “quality measures” that evaluate medical care. For all three illnesses, “lower is better” is the dominant mantra.

But while “lower is better” is probably true for large populations, that is not always the case for individual patients. In fact, there are some clinical trials in which aggressively lowered blood sugar or blood pressure have been associated with higher rates of dying.

Of course there are myriad situations where aggressive intervention is required, but it is helpful to have the reminder that sometimes less harm is done if you leave "well enough" alone.
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Central Neural Actions of Acupuncture, Insights from Brain Imaging

This is the abstract from Richard Harris' talk at the ISAMS conference. Unfortunately, I had to leave before he gave his talk and it is a bit complicated. I have the slides from the talk and once I make my way through them, I will try to make some sort of comment. The abstract follows and after that is the final slide of the presentation.

Central Neural Actions of Acupuncture, Insights from Brain Imaging
Richard Harris PhD, Assistant Professor, Chronic Pain and Fatigue Research Center Department of Anesthesiology, University of Michigan
Functional neuroimaging has been used to study the mechanistic effects of acupuncture for the past 12 years. Over this time researchers have found specific effects of acupuncture on the central nervous system, both in healthy controls as well as in diseased populations. These effects appear to be largely divergent from the “placebo effect”. An investigation of the temporal dynamics of acupuncture yields a complex
array of actions on the central nervous system. During needle insertion and manipulation, acupuncture activates sensory cortical regions while deactivating the limbic system. The degrees of these effects are distinct from the sensation of pain and are related to the “De Qi” sensation. These effects are also more prevalent during electrical stimulation as compared to manual needle manipulation. Following needle removal, modulation of brain connectivity is observed wherein cortical and brain stem regions alter connection strengths between the pain network as well as the Default Mode Network. These effects may be related to analgesia. Over the course of long-term therapy, with multiple treatment sessions, there is a build-up of effects that involve synaptic plasticity and/or changes in synaptic strengths, involving dynamic regulation of neurotransmitter receptors. Finally, immediate actions of acupuncture on the nervous system are modulated over the course of therapy such that the effects of one acupuncture session may be different from a subsequent session. Acupuncture effects are clearly complex and multifactorial, having impact on the central nervous system as assessed by multiple neuroimaging methods.

(This is the final slide from the presentation.)
What if Mechanisms of Acupuncture and Sham are Different?
Implications for clinical trials: specific effects of needling are not additive with placebo effects. Would a pathway analysis make more sense?
Synergistic effects of acupuncture with other interventions.
Exogenous opiates administered following a course of acupuncture may be more effective. (Reduction in post surgical opiate use. Kotani et al. Anesthesiology2001.)
Acupuncture is not a sham.

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Treating Hypertension (High Blood Pressure) in the Acupuncture Clinic

This is the abstract from a study on hypertensive patients from Professor John Longhurst's lab. It is a sort of summary of his findings discussed here and here.
A few comments... He uses electroacupuncture because he says it's easier to make it standard across patients. This was something I noticed repeatedly at the conference: most researchers are using electroacupuncture. I had a few different discussions with Dr. Longhurst, and he thinks that if you don't do electroacupuncture, you're really not stimulating because the stimulus goes away during the session. I don't agree with that. I think that the needles provoke a "micro-injury" just by being there and work just fine, even if you don't repeatedly stimulate them. Manual acupuncture, without electro, is my standard operating procedure. I use electro acupuncture if I'm following a specific protocol, for example for infertility or PCOS, or in musculoskeletal cases where the patient has reached a "plateau." I hardly ever start with electrical stimulation because of the tendency for it to aggravate the condition and the patient. I would never have the heart to do electrical stimulation at P6, as they do in this study. It's such a sensitive spot, I will try their other choice of LI11 and LI10 which is equally effective according to their work.
1

Acupuncture Treatment of Hypertension
John C. Longhurst, MD, PhD and Peng Li, MD, Department of Medicine, University of California, Irvine
Heart disease in both men and women has become the major cause of death and disability in both developed and developing countries. Coronary atherosclerosis, the leading cause of heart disease, has a number of risk factors that increase its incidence. These include hypertension, hypercholesterolemia, diabetes mellitus, family history, obesity, physical inactivity and chronic stress. Hypertension, in particular, is reversible if patients are treated early and blood pressure is lowered to normal levels. Although a number of drug therapies have been shown to be valuable in lowering this risk factor, many patients do not take medications faithfully because of their common side effects and need for daily dosing. As such, there is a strong rationale developing alternative regimens to control blood pressure. One such therapy is acupuncture. Acupuncture is a form of integrative medicine that has substantial evidence demonstrating its mechanisms of action to lower sympathetic outflow, one of the major causes of elevated blood pressure. For example, studies in our laboratory show that, through an opioid mechanism in the brain stem, acupuncture can lower reflex elevations in blood pressure. Furthermore, we have shown that low frequency, low intensity electroacupuncture at some acupoints, such as P5-P6 and S36-S37, is most effective in lowering elevated blood pressure for prolonged periods of time. In the last decade several studies have been conducted showing that acupuncture is capable of lowering blood pressure to a small extent for the period of time during which it is applied. Although these studies indicate a possible role for acupuncture in treating hypertension, they have been confounded by use of a variety of different acupoints, some of which may not have strong cardiovascular actions, use of manual acupuncture, which unlike electroacupuncture cannot be standardized between patients, the use of very frequent acupuncture, which because of patient incompliance could limit success for long-term treatment, and the absence of regular follow-up, which does not provide an understanding of the duration of acupuncture’s action. To overcome these obstacles, we have embarked on a program of treatment of patients with mild to moderate hypertension using 30 min of low intensity (2 mA), low frequency (2 Hz) electroacupuncture at P5-P6 and S36-S37, a modality and site of action that we have shown has the greatest action on sympathetic outflow and elevated blood pressure in our experimental studies. Furthermore, all patients were off antihypertensive medications for the duration of the study and agreed to acupuncture treatment once weekly for an eight week period with a further follow-up for an additional eight weeks to determine acupuncture’s duration of action. Ambulatory automated blood pressure monitoring demonstrated that both average and 24 hour peak systolic and mean arterial blood pressures were lowered by electroacupuncture after 4-6 weeks of therapy by as much as 11-18 mmHg and that the duration of action of lasted for up to 4 weeks after termination of acupuncture in 73% of individuals treated. Conversely, 69% of a group of control hypertensive subjects treated at LI6-LI7 and GB37-GB39 (cardiovascular inactive acupoints demonstrated in our experimental studies), , did not demonstrate any change in blood pressure. These studies, guided by our results in experimental studies, suggest that low intensity and low frequency electroacupuncture applied once weekly at 2 acupoints demonstrated to have a strong influence on sympathetic activity after 4-6 weeks demonstrate a profound and prolonged antihypertensive response in many patients with mild or moderate hypertension. Additional work is needed to determine the optimal frequencies of repetitive stimulation during the initial period of intervention as well as during follow-up therapy for reinforcement of the blood pressure lowering action of acupuncture. Supported by grants from the NIH, HL063313 and HL072125-10, the Dana and Adolph Coors Foundations.

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Acupuncture's Effect in Induced Arthritis in Mice

This was my favorite presentation at the conference. It was convincing in that it showed decreases in different measures of inflammation and immune function after acupuncture. But what was sort of mind blowing for me was that they only used an acupoint on the back, Ming Men. None of the standard points at or around the limb in question. I never had the chance to ask the author how they picked this protocol. Might have been easier to do with unrestrained rats, but fascinating, nonetheless. Perhaps I should incorporate this is the clinic? A single point for arthritis??

Mechanisms of acupuncture's action in arthritis and immune modulation
Tadashi Hisamitsu, MD, PhD
Showa University, Tokyo, Japan
To evaluate the effects and possible mechanism of acupuncture on the arthritic disease, the influence of electro-acupuncture (EA) and Mox on collagen-induced arthritis (CIA) animal was examined. DBA/1J mice were immunized with bovine type II collagen (CII). The main incidence of arthritis started about on day 30 and lasted to day 60 after the first immunization. EA stimulation or Mox, begun on day 21 simultaneously with the second immunization, was applied three times a week for 3 weeks at the acu-point equivalent to GV4 (governor vessel 4, Ming Men, Meimon). The results showed that EA and Mox delayed the onset, attenuated the severity of arthritis, and reduced the anti-collagen antibody level. Furthermore, these stimulation significantly increased serum IL-6 concentration and regulatory T cell (CD4+ CD25+ Foxp3+ T cell) number, and decreased splenic endogenous IL-1 β and serum prostaglandin E2 (PGE2) concentration. These data suggest that EA has an inhibitory effect on murine CIA, and the partial mechanism of its therapeutic result may be attributed to inhibiting the productions of IL-1β and PGE2 and activation of regulatory T cell. In the Oriental Medicine, reduction of the blood fluidity is one of the important pathological symptom. In the pain and stress model animal, the blood fluidity is markedly lowered like “a stagnant blood”. Increase of platelet adhesion and/or reduction of erythrocyte deformability results from sympathetic activation, increase of blood ATP level and increase of oxidative stress may have important role on this changes. EA applied several acu-points significantly improved these changes.

Huang Study from ISAMS: Heart Rate Variability in the Acupuncture Clini

This was a study published by a group from China. Their results are not in agreement with most other studies on Heart Rate Variability and acupuncture as measured by FFT. They found that there was no change in the LF/HF ratio. They did find an increase in the Sample Entropy with acupuncture, which concurs with my findings posted in previous posts. She was not able to answer me how they filtered and checked for artifact in their heart rate tracings, so they might not have done that. That is a key part of the analysis for LF/HFR which may account for their different findings.
Abstract
Acupuncture has been shown to alter the functional status of the autonomic nervous system. The purpose of the present study was to study the effect of acupuncture on heart rate variability, using linear and non-linear methods of analysis. We consecutively recruited 40 patients, including cases of insomnia, stomachache,
diarrhea, dizziness, cervical syndrome, low back pain, gonarthritis, peripheral facial paralysis, post-traumatic organic brain syndrome and urinary retention. Different acupoint prescriptions were used, according to the textbook for Five-years-education of Traditional Chinese Medicine Specialty in Chinese Universities.
Heart rate variability was recorded before, during, and after acupuncture. Acupuncture substantially reduced variability, causing a 41 % reduction in the standard deviation. Using Fourier analysis, variance both in the low (LF) and the high frequency (HF) range were markedly reduced, whereas the LF/HF ratio (an indication of sympatho-vagal balance) was not altered. The heart rate was unchanged. Sample entropy, which is a measure of the complexity of time series, significantly increased (+ 35 %). Thus, acupuncture produced a pattern of changes different from that seen in pathological conditions, where increased variability and reduced complexity is expected.
Key words : acupuncture - fourier analysis - heart rate variability - sample entropy

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.

---

[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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