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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HRV Analysis in the Acupuncture Clinic: Feasibility and Effectiveness

I had to rework my abstract for the upcoming (click on the logo for a link)
So I'll go ahead and post it here.  I've been working on my poster presentation and I will probably try to illustrate how I use the HRV to help guide my treatments rather than try to convince anyone of the scientific validity of the approach.  Once I get it all together, I'll post it here.  The committee wanted my abstract not to be so, er, abstract.  So I included the conditions treated and type of acupuncture used.  But since it had to be under 2,300 characters, I ended up changing it a fair amount. (For info on my practice, please click here.)

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

Kristen Sparrow, MD

Private Practice

San Francisco, California

Background:  Heart Rate Variability (HRV) analysis is a non-invasive method of assessing autonomic tone and has been studied in conjunction with acupuncture in a number of contexts. Acupuncture can lower sympathetic tone and enhance vagal activity, i.e decrease the stress reponse.

 In contrast to the research setting, there are time and efficiency constraints in the private acupuncture practice. In addition there can be monitoring artifacts which make frequency and time domain HRV analysis unreliable.  The author hypothesizes that analysis using nonlinear HRV analysis in addition to the aforementioned analysis methods will give a more sensitive and dependable evaluation of the patients’ autonomic state and show a more consistent correlation with clinical outcomes. The ultimate goal is to use HRV as an additional feedback in the clinic to achieve better results and hence, better outcomes.

Objective:

To correlate patient’s responses to acupuncture treatment with their intra- treatment HRV measurements across time, frequency and nonlinear domains.

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).

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.  HRV data was collected after needle placement for 20 minutes, and analyzed after treatment. 

Main Outcome Measure: Patients were assessed by symptom resolution. 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 %

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

3. Nonlinear results:  Poincaré Plots (SD1/SD2) and Sample entropy

Results:

Patients who responded to their acupuncture treatment tended to exhibit a decrease in LFR/HFR in the segment “a,” compared to “b” by at least 30% and/or an increase from “a” to “b” in the nonlinear measurement SD1/SD2 by at least 20%.

 Non-responders, or patients who were aggravated by a particular treatment tended to show no change or an increase in their LFR/HFR from “a” to “b”   and a decrease in their SD1/SD2 from “a” to “b.”

Conclusions: In this study the correlation between increased HRV during acupuncture treatment and positive response to acupuncture was supported. Use of nonlinear analysis in addition to frequency domain measures added to the sensitivity of HRV outcome measures.

Follow up on patient with Severe Thoracic Spine Pain

This is the follow up on a patient I posted on earlier here.
When the patient came in for a follow up visit, his pain was at a 5 level (5 out of 10.) He had had another episode of severe spasm the day before requiring Dilaudid. But it had resolved on its own. He thinks that the acupuncture is helping to quell the severe spasms.
I tried doing cupping on his back since it can be helpful when muscle tightness is involved, but it ended up aggravating after about 10 minutes. So the cups came off.
His readings, again, showed a decrease in the stress response( values follow.) The whole idea is to be able to "balance" his system, reduce his stress there by increase his pain threshold. From there we can reduce his medications and get him moving again with a gentle stretching and exercise plan.
His reading for 60 to 360 seconds, and 360 to 660 seconds.
LFR/HFR- .76 and .24
SD1/SD2- .52 and .56 (not much change, granted)
Sample entropy 1.67 and 1.88

(Brief primer: LFR/HFR stands for Low Frequency/High Frequency HRV. If this decreases, it is interpreted to mean that the stress response in decreased. So decrease in LFR/HFR=decreased stress. The other measure SD1/Sd2, is a nonlinear method, if this ratio increases =decreased stress.)
(For more info on my practice, please click here, for information about stress and acupuncture please click here.)

Severe Thoracic Spine Pain in a New Patient

I was off last week, trying to squeeze in a few vacation days, but ended up seeing an emergency patient who was desperate for some alternatives. He is a young man, 25, with chronic back pain on Methadone, Vicodin and Valium. He is able to work at his desk job in spite of the pain and medications, but landed in the Emergency Room on 8.8.11 at 2:00 a.m. due to out of control, severe, 10 out of 10 thoracic back pain. They gave him some Dilaudid and he made it home, but called me "in extremis" and so I agreed to see him.
(Brief primer: LFR/HFR stands for Low Frequency/High Frequency HRV. If this decreases, it is interpreted to mean that the stress response in decreased. So decrease in LFR/HFR=decreased stress. The other measure SD1/Sd2, is a nonlinear method, if this ratio increases =decreased stress.)
He was tearful and shakey , and was extremely tender to the touch in a swath 8" wide from T9 to L1. He appeared to have some muscle spasm from inspection and light palpation. I did an acupuncture treatment that was aimed at general pain reduction and to decrease his stress response. I also treated the spine above the level of the pain, since that can sometimes affect the lower area without aggravation. I did some moxa on the affected area. I also monitored his HSoRV after needle placement. The initial trend is pictured above. The LFR/HFR from the 60-360 second versus the 360 to 660 segment were .96 to 1.18, which does not show a stress response reduction. But his nonlinear analysis shows an increase in his SD1/SD2 from .23 to .41, which is significant and his Sample Entropy increased from 1.23 to 1.63 which is definitely positive and suggestive of a decrease in his stress response.
When he returned to clinic on 8.11.11 his pain level was a 5 out of 10 and had been able to sleep, finally, after his treatment on the 8th.
This is how his LFR/HFR looked on 8.11.11. A more dramatic decline than on the previous run, but similar. His numbers were
LFR/HFR .23 for the 60 to 360 segment, and .16 for the 360 to 660 segment. SD1/SD2 were .5 to .65 respectively. Sample entropy unchanged 1.59 to 1.62. So we'll how he did clinically when I see him today.

Heart Rate Variability in the Acupuncture Clinic

Hi all.
Here is my abstract I'm submitting for an Acupuncture Research Conference in the fall. I hope they accept it. If so, I'll have a poster presentation, the lowest rung of a research presentation, but they're fun to do. Wish me luck! (Other research, on same topic of course, here.)

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

Kristen Sparrow, MD

Private Practice

San Francisco, California

Background: Heart Rate Variability (HRV) analysis is a non-invasive method of assessing autonomic tone and has been studied in conjunction with acupuncture in a number of contexts. Poor health outcomes such as impaired immunity, lowered pain thresholds, mood disorders, and even accelerated aging accompany chronic stress. Acupuncture has been shown to lower sympathetic tone and enhance vagal activity, i.e decrease the stress reponse.

In contrast to the research setting, there are time and efficiency constraints in the private acupuncture practice. In addition there can be monitoring artifacts which make frequency and time domain HRV analysis impractical and unreliable. The author hypothesizes that analysis using nonlinear analysis in addition to the aforementioned analysis methods will give a more sensitive and dependable evaluation of the patients’ autonomic state and show a more consistent correlation with clinical outcomes.

Objectives:

1. Assess the feasibility of evaluating HRV across time, frequency and nonlinear domains in the acupuncture clinic setting.

2. To compare intra-treatment HRV response in patients who have positive treatment outcomes to those who do not.

Design, Setting, and Patients: Case study of 20 patients presenting to a private acupuncture clinic, representing 80 treatment sessions.

Intervention: All patients received body acupuncture prescribed by the tenets of Traditional Chinese Medicine. HRV data was collected after needle placement for 20 minutes using J and J Engineering I 330 2 Biofeedback Device. . HRV data were analyzed after each treatment.

Main Outcome Measure: Patients were assessed by symptom resolution. Their HRV data were compared for the time frames “a” (60 sec to 360 sec) and “b” (360 sec to 660 sec) using Kubios shareware for the following:

1. Time series: pnn50 %

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

3. Nonlinear results: Poincaré Plots (SD1/SD2) and Sample entropy

Results:

Patients who responded to their acupuncture treatment tended to exhibit a decrease in LFR/HFR in the segment “a,” compared to “b” by at least 30% and/or an increase from “a” to “b” in the nonlinear measurement SD1/SD2 by at least 20%.

Non-responders, or patients who were aggravated by a particular treatment tended to show no change or an increase in their LFR/HFR from “a” to “b” and a decrease in their SD1/SD2 from “a” to “b.”

Conclusions: In this study the correlation between increased HRV suggesting vagal enhancement during acupuncture treatment and positive response to acupuncture was supported. Use of nonlinear analysis in addition to frequency domain measures added to the sensitivity of HRV outcome measures.

HRV in Post Stroke Patients Teleacupuncture Analysis

This study is from the same group I've linked to and discussed here, here and here. This is Part 1, so I'll be looking forward to their further studies coming up. There is the added advantage that you can view the entire journal article online.
What they found is that using acupuncture on one single point, pericardium 5, on one side lowered increased HRV. (For further information about my practice and research .)

Results. Acupuncture does not change heart rate in the post-stroke patients; however, total HRV increased significantly (P < .05) during and 5–10 minutes after acupuncture. In addition, balance between sympathetic and parasympathetic activity (low frequency/high frequency HRV ratio) changes markedly during treatment. Conclusions. Based on innovative HRV analysis, it could be demonstrated that teleacupuncture between China/Harbin and Austria/Graz over a distance of about 8,500 km is no longer a future vision; it has become reality."

Effect of acupuncture on heart rate variability in primary dysmenorrheic women

I feel obliged to link to this study since it combines my interest in HRV, and acupuncture. But it is not as awesome as I would like since it uses a point combination that I don't understand, and it doesn't give any data on the clinical outcome of the patients. At least in the abstract. I will try to get a copy of the entire paper and report back to you. (Info on my practice here.)

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.

Department of Gynecology, College of Oriental Medicine, Kyung Hee University, Seoul, South Korea.

Primary dysmenorrhea is a common gynecological complaint among young women that is related to an autonomic nervous system (ANS) disturbance. Acupuncture is one of several therapeutic approaches for primary dysmenorrhea, since it can modulate ANS function. The heart rate variability (HRV) parameters such as high frequency (HF), low frequency (LF) and LF/HF ratio are generally accepted tools to assess ANS activity. The purpose of this study was to investigate the effects of acupuncture applied at Hegu (LI4) and Sanyinjiao (SP6) points on HRV of women with primary dysmenorrhea during the late luteal phase. The experimental design was a crossover and patient-blinded procedure. All subjects participated in Sham (SA) and Real Acupuncture (RA) procedure, separated by one month, in a crossover sequence. The participants included 38 women (mean age 22.3 years; weight 53.8 kg; height 162.6 cm). HRV measurement was 15 min before and 15 min after an acupuncture procedure. The RA procedure was performed at two bilateral acupoints, but needles were inserted subcutaneously to the acupuncture points for the SA procedure. The RA induced a significant decrease in LF/HF ratio and a significant increase in the HF power, while SA treatment caused a significant increase only in the HF power. Manual acupuncture at bilateral acupoints of LI4 and SP6 may play a role in dysmenorrhea treatment with autonomic nervous system involvement.

Acupuncture HRV results vary with point choice

I do have some problems with this study, even though it does address my two favorite topics, HRV(heart rate variability-a way to monitor stress response) and acupuncture. I strongly disagree with their opening statement that there is no evidence that acupuncture has effects on HRV. There have been studies too numerous to mention on this topic, and it begs the question of why they would study the issue if there was no evidence. I also wonder why they picked an acupuncture method that is not in current practice, i.e. a single "instantaneous" puncture. I would love to hear that single point, "instantaneous" puncture is just as effective as traditional "point combination," 20 minute sessions. That would be a boon to my practice and will await more studies with an open mind. All that said, I am buoyed by the thought that some points affect HRV more than others since that may give some keys to more effective acupuncture treatment.

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

Acupuncture to Danzhong but not to Zhongting increases the cardiac vagal component of heart rate variability.
Auton Neurosci. 2011 Jan 6.
Kurono Y, Minagawa M, Ishigami T, Yamada A, Kakamu T, Hayano J.

The Oriental Medical Center, Nagoya, Aichi, Japan.
Abstract

There is currently no convincing evidence that acupuncture has any specific effects on autonomic nervous function as assessed by heart rate variability (HRV). We examined whether the stimulation of neighboring acupunctural points, Danzhong (CV17) and Zhongting (CV16) on the anterior median line of the thorax, induced different effects on HRV. In 14 healthy males, epifascial acupunctural stimulation (single instantaneous needle stimulation on the fascial surface without producing De-Qi sensation) was performed at CV17 and CV16 on different days in a clinical study utilizing a cross-over design. We found that the stimulation of CV17, but not of CV16, decreased the heart rate (P=0.01, repeated measures ANOVA) and increased the power of the high-frequency component of the HRV, an index of cardiac vagal activity (P=0.01). The low-frequency to high-frequency ratio, an index of sympathetic activity showed no significant changes for either point. Our observations could not be explained as either nonspecific or psychological/placebo effects of needle stimulation. This study provides strong evidence for the presence of a specific acupunctural point that causes the modulation of cardiac autonomic function.

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.

Metabolic Syndrome and Heart Rate Variability (HRV)

This study is related to my last post concerning acupuncture and metabolic syndrome and insulin resistance in that acupuncture can enhance HRV so may help with Insulin resistance and its relationship to metabolic syndrome. Because the ANS (autonomic nervous system) decrease has been associated with a higher risk of sudden cardiovascular and cerebrovascular disease. So they explored the relationship between ANS control of the cardiovascular system and metabolic syndrome. In this study they looked at short term HRV (5 minutes) and long term (overnight and 24 hour sessions) in relation to metabolic syndrome status, high-density lipoprotein cholesterol (HDL-C), and waist circumference. Both nighttime and 24-h HRV showed closer associations with metabolic syndrome than did short-term HRV.

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Metabolic Syndrome and Short-Term and Long-Term Heart Rate Variability in Elderly Free of Clinical Cardiovascular Disease: The PROOF Study.
Assoumou HG, Pichot V, Barthelemy JC, Dauphinot V, Celle S, Gosse P, Kossovsky M, Gaspoz JM, Roche F.
Rejuvenation Res. 2010 Sep 6
University Hospital and Jean Monnet University , Pres Lyon, Saint-Etienne, France .
Abstract Objective: Autonomic nervous system (ANS) activity decrease has been associated with a higher risk of sudden cardiovascular and cerebrovascular disease. Thus, we explored the relationship between ANS control of the cardiovascular system and metabolic syndrome. Methods: We analyzed the relationship with both short-term and long-term heart rate variability (HRV) and metabolic syndrome in the cross-sectional PROgnostic indicator OF cardiovascular and cerebrovascular events (PROOF) cohort study of 1,011 elderly subjects recruited amongst the inhabitants of the city of Saint Etienne, France, aged 65.6 +/- 0.8 years at the inclusion date. Physical examination included measurements of height, weight, systolic and diastolic blood pressure, waist circumference, and biological parameters. HRV variables were measured over 5-min, nighttime, and 24-h periods using Holter monitoring. Results: After adjustment for current type 2 diabetes, depression, and smoking, we found that metabolic syndrome status, high-density lipoprotein cholesterol (HDL-C), and waist circumference were significantly (p < 0.05) associated with total power, very-low frequency, low-frequency/high-frequency (LF/HF) ratio, and normalized LF. HDL-C and metabolic syndrome status were significantly associated with decreased long-term HRV variables. Both nighttime and 24-h HRV showed closer associations with metabolic syndrome than did short-term HRV (5-min). Metabolic syndrome severity was associated with a decrease in both the long-term and short-term HRV variables. Conclusions: ANS control alteration of the cardiovascular system was more pronounced when evaluated by long-term than short-term HRV recordings, particularly in women.

Austrian Acupuncture Study and HRV study Part 4: Chronic Fatigue

In the final section of the Austrian study, 24 hour Heart Rate Variability (HRV) monitoring was performed on 9 patients with chronic fatigue. The really fascinating result in this study, both from a clinical and scientific standpoint is that not only did the patients HRV improve, but their sleep wake cycle was restored to normal. In one illustrative patient, there was no discernible autonomic difference in the patients readings during a 24 hour cycle when the patient started. By the fourth session there was a discernible difference between day and night, and by the end of the 10 sessions there was significant clinical improvement. This could be of some importance since there often is marked sleep disturbance in patients with chronic fatigue and fibromyalgia. Some of the clinical benefit seen with acupuncture for chronic fatigue and fibromyalgia could be from improving patients’ sleep quality, in addition to decreasing the stress response. (See pictures at end of post.)

The study was performed as follows.
There were a total of ten acupuncture sessions for each patient. The patients had 2 or 3 24 hour HRV measurements done. One was before treatment began, then after the 4th treatment and then after the 10th treatment.
The point selection was Xinshu BL15,Geshu BL17, ShenshuBL23, Dachangshu BL25. In the one illustrative patient mentioned above, a diagnosis of Kidney Qi deficiency was ascribed. In addition to the points described above ear acupuncture was applied at Shenmen , liver (97)and an antidepression point (psychotropic point 3), and laser acupuncture (dichromatic red 685 nm and infrared 785 nm; 30-40 mW, diameter 500 mm, duration 10 minutes) were performed at the acupoints Hegu (LI4) and Zusanli (ST36).
Before treatment

After 10 treatments.


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Austrian Acupuncture and HRV study Part 1

I will be discussing this study from a center at the University of Graz that looks at HRV and acupuncture, laser acupuncture, and moxibustion. The author kindly sent me a full copy of his study.
Transcontinental and Translational High-tech Acupuncture Research Using Computer-based Heart Rate and “Fire of Life” Heart Rate Variability Analysis by Gerard Litscher published in Journal of Acupuncture Meridian Studies
The first of four parts shows that acupuncture and acupressure on Yin Tang (the point between the eyebrows) calms the nervous system, showing a decrease in heart rate and a decrease in the LFR/HFR ratio of HRV.
The study explores acupuncture, acupressure and placebo acupuncture on Yin Tang (the point between the eyebrows prescribed to calm the spirit) and the Heart Rate Variability (HRV) response. HRV has been shown to be a fair correlate with the physiological stress response. Within certain parameters, the more variability in the heart rate the healthier the subject. Low Frequency/High Frequency ratio is shown to decrease with a decrease in the stress response or increase in restorative function.
What they found was that heart rate decreased significantly during acupuncture and acupressure on Yintang. The sham acupuncture point also decreased heart rate but less so. The Low Frequency/High Frequency ratio (LFR/HFR) ratio decreased with acupressure but decreased more in females.
The results reinforce the use of this particular point to "calm the spirit."

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Increased Yin-Deficient Symptoms and Aggravated Autonomic Nervous System Function in Patients with Metastatic Cancer.

This is a truly fascinating study. It is a veritable "East Meets West" extravaganza. They are looking at both symptoms of Yin Deficiency and Autonomic dysfunction as measured by Heart Rate Variability, and metastastic disease. Yin deficiency is a part of some very prominent conditions in Traditional Chinese Medicine for example, Tuberculosis, High Blood Pressure, Menopausal Hot Flashes. As an anecdotal example, one of my current patients being treated for hypertension had remarkable and sustained lowering of both systolic and diastolic blood pressure with the addition of a powerful Yin tonic. To try to correlate the symptoms of Yin Deficiency with metastasis, not only broadens the reach of TCM diagnosis, but adds to our understanding of the yin yang imbalance. What drew my attention to it was the attention paid to Autonomic Dysfunction and it is food for thought that there was a definite correlation with Yin Deficiency and autonomic imbalance. It gives us one more lens to try to make sense of vexing conditions that be difficult to treat.

(To read more about acupuncture and my practice, please click here.)
Here are some excerpts of the abstract.
1. J Altern Complement Med. 2010 Sep 28.
Increased Yin-Deficient Symptoms and Aggravated Autonomic Nervous System Function in Patients with Metastatic Cancer.Lin SC, Chen MX.
1 Department of Nursing, Show Chwan Memorial Hospital , Changhua, Taiwan .
Abstract Objectives: The objectives of this study were to investigate the
differences in severity of yin-deficiency syndrome (YDS) and function of the
autonomic nervous system (ANS) between patients with cancer with metastasis and
those without metastasis. ...
Interventions: The severity of YDS in each subject was evaluated using a questionnaire containing 12 items about symptoms and signs related to YDS. The severity of each symptom or sign was rated on a 4-point scale. Outcome measures: The total score on the questionnaire represented the severity of YDS. ANS function in each subject was evaluated by measuring heart rate variability (HRV), including time and frequency domains. ...
Results: The patients with metastasis had significantly higher average total YDS score and heart rate compared with the patients without metastasis. In contrast, they had significantly lower HRV, including standard deviation of the 5-minute average R-R
interval, total power, very-low-frequency power, and low frequency (LF) power,but not high-frequency (HF) power and LF/HF ratio. Conclusions: The results of this study indicate that patients with metastatic cancer have more severe YDS and
impaired ANS function than those without metastasis.