Effect of Acupuncture-Point Stimulation on Diastolic Blood Pressure in - PDF by zqq12999

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									Research Report

Effect of Acupuncture-Point Stimulation on Diastolic
Blood Pressure in Hypertensive Subjects:
A Preliminary Study




Electrical stimulation of four specijic acupuncture points (Liver 3, Stomach 36,                              Tim Wllllams
Large lntestine 11, and the Groovefor Lowering Blood Pressure) was examined                                   Karen Mueller
 in order to determine the effect of thb stimulation o n diastolic blood pressure in                          Mark W Cornwall
 10 subjects with diastolic hypertension. Subjects were randomly divided into two
groups: (1) a n Acu-ES group, which received electrical stimulation applied to the
four antihypertensive acupuncture points, and (2) a Sham-ES group, which re-
 ceived electrical stimulation applied to non-acupuncture-point areas. A repeated-
 measures analysis of variance revealed a sign$cant, immediate poststimulation
 reduction of diastolic blood pressure for the Acu-Es group versus the Sham-ES
group. Further studies are needed to determine whether there are other acupunc-
 ture points, stimulation characteristics, or modalities that can enhance this treat-
 ment effect and whether the treatment effect can last for a clinically signijicant
period of time. W i l l i a m T, Mueller 4 Cornwall MW: Effect of acupuncture-point
 stimulation o n diastolic blood pressure in hypertensive subjects: a preliminary
 study. Phys T h e 1991;71:523-529.1

Key Words: Acupuncture/acupressure;Blood pressure; Electrotherapy, electrical
stimulation; Hypertension.




Research exploring the physiologic                   has facilitated an increasing accept-            disorders such as angina pectoris and
mechanisms underlying acupuncture                    ance of acupuncture in western medi-             hypertension.'-5
suggests that somatic processes may                  cine, in which it has been used suc-
be altered through the production of                 cessfully for the production of                  Traditional acupuncture involves the
systemic vasodilation, increased en-                 analgesia during surgery, pain control           use of small-diameter needles, which
dorphin release, and alterations in                  in conditions such as migraine head-             are inserted into the skin. The litera-
hormonal secretion.' Such research                   ache, and treatment of cardiovascular            ture suggests that effective stimulation
                                                                                                      of acupuncture points may also be
                                                                                                      produced through direct pressure:
T Williams, BS, FT,is Staff Physical Therapist, Havasu Samaritan Regional Hospital, Lake Havasu       the use of ultrasound7~fj helium-
                                                                                                                                and
City, AZ 86403. He was a senior physical therapy student at Northern Arizona University, Flagstaff,   neon lasers,"" and the application of
AZ,when this article was written.                                                                     electric currents via the use of surface
K Mueller, MS, PT, is Assistant Professor, Department of Physical Therapy, Northern Arizona Univer-   o r implanted electr0des.'2-'~
sity, PO Box 15105, Flagstaff, AZ 86011-5105 (USA). Address all correspondence to Ms Mueller.

MW Cornwall, PhD, FT,is Assistant Professor, Department of Physical Therapy, Northern Arizona
                                                                                                      The effective use of acupuncture,
University                                                                                            regardless of the method used, in-
                                                                                                      volves the accurate detection of acu-
The results of this study were presented in poster format at the Annual Conference of the Ameri-
can Physical Therapy Association, June 11-15, 1989, Nashville, TN.                                    puncture points on the body surface.
                                                                                                      Previous studies17-19 have shown acu-
This study was approved by the Northern Arizona University Human Subjects Institutional Review        puncture points to have a markedly
Board.
                                                                                                      lower electrical resistance than the
This article was submitted July 31, 1989, and was accepted March 6 1991

34 / 523                                                                                 Physical Therapy /Volume 71, Number 7 /July 1991
skin around them. This finding has           significant reduction of systolic and       criteria, 12 of whom agreed to partici-
allowed clinicians to use devices such       diastolic BP in hypertensive rats fol-      pate (2 subjects showed normotensive
as an ohmmeter to accurately locate          lowing the application of low-              diastolic BPS when they arrived for
acupuncture points.                          frequency electrical stimulation to         the first data-collection session and
                                             the sciatic nerve.                          were excluded from the study). Of
Hypertension is a major risk factor                                                      the 10 subjects who completed the
for coronary artery disease and              The purpose of this study was to de-        study, 2 were female and 8 were
stroke, which are, respectively, the         termine the effect of electrical stimula-   male. Their mean age was 46 years
first and third highest causes of            tion of selected acupuncture points         (range= 27-72 years). All subjects
mortality in the United States.20Cur-        on diastolic BP in hypertensive sub-        gave written informed consent.
rent treatment for hypertension in-          jects immediately following and 5
cludes sodium restriction, pharma-           minutes after stimulation. We hypoth-       Test Environment
cologic management, and lifestyle            esized that hypertensive subjects who
modifications such as stress manage-         received electrical stimulation of four     The testing environment was carefully
ment ancl e ~ e r c i s e . 2 ~
                            Although these   selected acupuncture points would           controlled in order to minimize fac-
methods of treatment are generally           show a significant decrease in dia-         tors that could influence diastolic
considered to be effective, they fre-        stolic BP immediately following treat-              All
                                                                                         BP.26127 testing was performed in
quently require permanent lifestyle          ment, whereas there would be no             an acoustically insulated audiology
changes. Thus, poor patient compli-          immediate posttreatment change in a         booth in which the temperature was
ance is common. The drawbacks of             group of hypertensive subjects who          maintained between 23" and 25°C.
antihypertensive medication include          received electrical stimulation applied
side effects, such as fatigue, electro-      to non-acupuncture-point areas.             In order to minimize psychological
lyte imbalance, and impotence,                                                           factors affecting diastolic BP, the fol-
which ofi.en result in patient intoler-      Method                                      lowing steps were taken to ensure a
ance.21 The substantial cost of long-                                                    relaxed atmosphere during testing.
term medication can also be prob-            Subjects                                    Subjects were instructed to wear
lematic. These disadvantages suggest                                                     loose and comfortable clothing. The
a need for alternative strategies in         Subjects were selected on the basis of      investigators refrained from wearing
the management of hypertension.              two inclusion criteria: (1) a resting       laboratory coats during all sessions,
                                             diastolic BP between 90 and 120 mm          because the use of such apparel has
The use of needle acupuncture as a           Hg and (2) no past o r present use of       been associated with increased BP
method of treatment for hypertension         antihypertensive medication.                ("white-coat hypertension") in some
has been explored in both western                                                        patients.28Except for a standing mer-
and Chinese literature. Tam and YiuZ2        All subjects were patients under the        cury column sphygmomanometer and
found that acupuncture produced a            care of two physicians with a specialty     a stethoscope, the testing equipment
significant reduction in systolic and        in family practice. In addition, all sub-   was placed away from the subject's
diastolic blood pressure (BP) immedi-        jects had been diagnosed with border-       view. Finally, a large poster of a pleas-
ately upon stimulation. In a study ex-       line hypertension within the previous       ant outdoor scene was placed on the
ploring the physiologic mechanisms           6 months. The diagnosis of borderline       wall facing the subject.
of this effect, Omural measured circu-       hypertension was assigned by these
latory changes during acupuncture in         physicians to any patient with a dia-       Procedure
400 patients and reported a general-         stolic BP greater than 90 mm Hg dur-
ized vasodilation response, which co-        ing two consecutive office visits. Pa-      Subjects were randomly divided
incided with a decrease in systolic          tients diagnosed with borderline            into two groups by the use of a coin
and diastolic BP. He also found that         hypertension were counseled by the          toss. Four subjects comprised the
slight decreases in BP often occurred        physicians about dietary modifications      Acu-Es group (test group), which
in patient,^ receiving acupuncture,          and exercise and were instructed to         received electrical stimulation ap-
regardless of the condition treated.         monitor their BP at home. Subse-            plied to the four acupuncture
Furthermore, the most dramatic de-           quently, if these patients reported         points, and six subjects formed the
creases were found in patients with          three consecutive at-home diastolic BP      Sham-ES group (control group),
essential hyperten~ion.~  Peng23 sug-        readings above 90 mm Hg, their diag-        which received electrical stimulation
gested that acupuncture stimulation          nosis was changed from borderline to        applied to non-acupuncture-point
may cause vasodilation.                      essential hypertension. AU subjects         areas. The two subjects who were
                                             who participated in this study were         excluded from the study had previ-
There is little research on the effect of    still considered by these physicians to     ously been assigned to the Acu-ES
electrical stimulation of acupuncture        be borderline hypertensive.                 group. Because they were the last two
points on systolic and diastolic BP.                                                     subjects scheduled for data collection,
Studies by Yao et a12*and Hoffman            The two physicians contacted 22 sub-        an uneven distribution of subjects
and Thon:n25 have demonstrated a             jects who met the study's inclusion         resulted.

Physical Therapy /Volume 71, Number
All diastolic BP measurements were                  tem l setup began with the applica-
                                                          V                                     Lowering Blood Pressure. This is the
performed by one investigator (KM),                 tion of a NeuroAid 3.5 model 7 7 9 P        groove that is found behind the ear
who was blinded as to the subject's                 disposable gel electrodet on the volar      when the auricle is folded down. This
group assignment. Prior to the study,               surface of the subject's right forearm.     order was followed for all subjects.
this investigator established a test-               The subject was fitted with a BP cuff       The exact location of the acupuncture
retest reliability of .99 for diastolic BP          on the right arm and allowed to sit         points in Acu-ES group subjects was
using an intraclass correlation coeffi-             quietly for 5 minutes. Following this       determined by using the hand-held
cient (ICC[l,k])*9 the index of reli-
                    as                              5-minute period, a pretreatment dia-        treatment probe to find the area in
ability. The diastolic BP of 10 subjects            stolic BP measurement was taken.            the region of the acupuncture point
was measured twice, with a 1-minute                 Immediately after the pretreatment          with the lowest electrical resistance.
interval between the first and second               diastolic BP measurement, the groups
measurements, and the measurements                  received their respective treatments. A     Subjects in the Sham-ES group re-
were compared for consistency. Dia-                 second diastolic BP measurement was         ceived a control treatment using elec-
stolic BP was measured according to                 taken immediately after treatment.          trical stimulation characteristics identi-
American Heart Association guide-                   The subjects remained seated for an         cal to those used for the Acu-ES
lines.3O All electrical stimulation was             additional 5 minutes, whereupon the         group; however! this stimulation was
performed by one investigator (TW)                  final diastolic BP measurement was          applied to non-acupuncture-point
as well.                                            taken.                                      areas. 'These non-acupuncture-point
                                                                                                areas were located by placing the
A Neuroprobea System l stimulator*
                         V                          Treatment for subjects in the Acu-ES        probe over the general anatomical
was used to detect acupuncture points               group consisted of electrical stimula-      area of the acupuncture point as de-
and to provide electrical stimulation.              tion of four selected acupuncture           scribed previously, then moving the
We used a remote hand-held treat-                   points. Selection of these points was       probe approximately 15 cm (6 in)
ment probe with a metal tip measur-                 based on acupuncture texts1-5 and           away to an area at which a high elec-
ing 22 mm long and 3 mm wide. No                    discussions with three certified acu-       trical resistance was encountered.
conductive medium was used.                         puncture practitioners. The four acu-       These areas were also stimulated on
                                                    puncture points selected received the       the subjects' left side in the same or-
The NeuroprobeB System IV provides                  highest number of recommendations           der as for the Acu-ES group.
both audtory and visual signals when                from these sources.
the active hand-held treatment probe                                                            Data Analysis
is in contact with skin areas of low                Electrical stimulation was applied to
resistance. As previously mentioned,                acupuncture points on the left side of      The test for differences in diastolic BP
these areas correspond to acupunc-                  all subjects in the Acu-ES group.           between immedate posttreatment and
ture points.                                        Figure 1 illustrates the anatomical lo-     5-minute posttreatment measurements
                                                    cations of the four acupuncture             as well as for differences in diastolic
The Neuroprobea System l provides
                             V                      points. These anatomical locations          BP between the two experimental
a medium-frequency sinusoidal signal                were used to detect the general area        groups was performed using a mixed
of 10,000 Hz. All subjects in the study             of the acupuncture points, and the          two-way analysis of variance (ANOVA).
received continuous electrical stimula-             hand-held treatment probe was used          The factor of time (pretreatment-
tion at 10,000 Hz (the "MF continu-                 to determine the exact area for elec-       immediately after treatment versus
ous" pulse-rate setting on the Neuro-               trical stimulation. The first point stim-   pretreatment-5 minutes after treat-
probe@' System N). This stimulation                 ulated was Liver 3, located on the          ment) was designated as the repeated-
was divided into two 30-second doses                dorsal surface of the foot, between         measures variable. An alpha level of
applied to each selected acupuncture                the first and second metatarsals, at the    .05 was used for the determination of
point, with a 5- to 7-second interval               metatarsophalangeal joints. The sec-        significant differences.
between each dose. The output inten-                ond point stimulated was Stomach 36.
sity of each dose was set at the lowest             This point is located 3.8 cm (1.5 in)
point at which the subject could de-                distal to the lower border of the pa-
tect the stimulation.                               tella and 1.3 cm (0.5 in) lateral to the    Table 1 shows the diastolic BP read-
                                                    anterior tibia1 ridge. The third point      ings of each subject before, immedi-
The test procedure for each subject                 stimulated was Large Intestine 11.          ately after, and 5 minutes following
was as follows. The subject was seated              This point is located at the lateral end    electrical stimulation. The results of
in a comfortable chair inside the treat-            of the elbow flexion fold. The fourth       an independent Student's t test re-
ment booth. The Neuroprobea Sys-                    point is known as the Groove for            vealed no statistically significant differ-
                                                                                                ence (t=-.93, df=8, P>.05) for the
                                                                                                pretreatment measurements of the
                                                                                                Acu-ES and Sham-ES groups. Table 2
'Physio Technology Inc, 1505 SW 42nd St, Topeka, KS 66609.
                                                                                                shows the between-group means and
+ ~ e u r Division, Medrronic Inc, 7000 Central Ave IYE, Minneapolis, MN 55440
          o                                                                                     standard deviations of the diastolic

36 / 525                                                                           Physical Therapy /Volume 71, Number 7 /July 1991
                                                                                       this reason, we were only able to re-
                                                                                       cruit a small group of subjects who
                                                                                       met the inclusion criteria for our
                                                                                       study. In spite of the difficulty of re-
                                                                                       cruiting appropriate subjects, we
                                                                                       based our selection criteria on the
                                                                                       work of Tam and Y ~ uwho sug-
                                                                                                                   , ~ ~
                                                                                       gested that acupuncture is more effec-
                                                                                       tive in lowering BP in subjects who
                                                                                       have no history of antihypertensive
                                                                                       medication use than in subjects with a
                                                                                       history of antihypertensive medication
                                                                                       use. These investigators also found
                                                                                       that results are even greater when the
                                                                                       diagnosis of hypertension has been


                                                                                       Results of studies investigating the use
                                                                                       of acupuncture on pharmacologically
                                                                                       managed hypertensive subjects sug-
                                                                                       gest that antihypertensive medication
                                                                                       may interfere with the effects of acu-
                                                                                       puncture treatment. Sugioka et a131
                                                                                       found that the use of acupuncture had
                                                                                       no effect on patients who had just
                                                                                       completed a course of antihyperten-
                                                                                       sive medication. Clearly, there is a
                                                                                       need for further studies to explore
                                                                                       how antihypertensive medications and
                                                                                       length of time since the diagnosis of
                                                                                       hypertension interact with the electri-
                                                                                       cal stimulation of acupuncture points.
Flgure l. Anatomical locations of the four acupuncture points used in this study.
                                                                                       Another limitation of this study was
changes between immediate posttreat-      The magnitude and duration of this           the transient duration of the reduc-
ment and. pretreatment measurements       reduction, however, are insufficient for     tion in diastolic BP. In designing a
and between 5-minute posttreatment        such stimulation to be of current clini-     preliminary study, our objective was
and pretreatment measurements.            cal value as a means of treatment for        to determine the efficacy of electrical
Table 3 shows the ANOVA results,          hypertension. Nonetheless, the results       stimulation as a means of lowering
which demonstrate a significant differ-   of this study suggest the possibility that   diastolic BP. Because environmental
ence (df== Pe.05) between treat-
            1,                            further research may lead to the dis-        factors can have a profound effect on
ment groups and between the two           covery of stimulation characteristics,       BP, major emphasis was given to the
posttreatment measurement sessions.       modalities, and acupuncture points           reduction of patient anxiety. Accord-
No signiEicant interaction (P>.05) was    that will promote a sustained reduc-         ingly, we selected electrical stimula-
found between the treatment groups        tion of diastolic BP into the therapeutic    tion characteristics that would pro-
and the rwo posttreatment measure-        range. The discovery of such factors         duce the most immediate treatment
ment sessions. Figure 2 graphically       could, in turn, result in the use of elec-   effect. These stimulation characteris-
illustrates the mean changes in dia-      trical stimulation of acupuncture points     tics resulted in an average treatment
stolic BP over time for the two           as a viable method of treatment for          time of about 5 minutes. As previ-
groups.                                   hypertension.                                ously mentioned, the literature sug-
                                                                                       gests that a frequency of 10,000 Hz
Discussion                                A major limitation of this study was         produces an immediate, but short-
                                          the small number of subjects. Because        lasting, treatment effect.32.33 The re-
The results of this preliminary study     of the risk for stroke and heart dis-        sults of our study support this litera-
support the hypothesis that medium-       ease associated with untreated hyper-        ture, because the differences in
frequency electrical stimulation of se-   tension, however, many physicians            diastolic BP between the Acu-ES and
lected acupuncture points results in a    choose not to delay the prescription         Sham-ES groups were no longer
significant reduction in diastolic BP.    of antihypertensive medication. For          significant 5 minutes posttreatment.
                                                                                       Further studies are needed to deter-

Physical Therapy /Volume 71, Number 7/July 1991
Table 1.            Diastolic Blood Pressure Measurements (in Millimeters of Mercury)


                                                                Measurement
                                                Age                                   lmmedlate                               5-Minute
Groupa                      Sex                 (Y)             Pretreatment          Posttreatment                           Posttreatment




ACU-ES
ACU-ES
ACU-ES
-
X
SD
Range
Sham-ES
Sham-ES
Sham-ES
Sham-ES
Sham-ES
Sham-ES
-
X
SD
Range


"Acu-ES group received electrical stimulation of four antihypertensive acupuncture points; Sham-ES group rece~vedelectrical stimulation of four nun-
acupuncture-point areas.


mine whether longer treatment du-                        frequency, long-duration current              different from those used to reduce
rations at a frequency of 10,000 Hz                      (such as that used in transcutaneous          BP. Whether an indirect antihyperten-
will result in longer periods of                         electrical nerve stimulation) may pro-        sive effect results from such treatment,
treatment effectiveness.                                 duce longer-lasting treatment effects.        however, remains to be determined.
                                                                                                       Further research on the indirect effects
Although our study involved the use                      Electrotherapeutic modalities are             of electrical stimulation of acupuncture
of 10,000-Hz electrical current, hrther                  widely used by physical therapists for        points for the treatment of muscu-
research involving lower frequencies                     the treatment of musculoskeletal prob-        loskeletal problems in normotensive
may prove beneficial. Research by Fox                    lems. The acupuncture points used to          and hypertensive subjects may prove
and Melzack13suggests that a lower-                      treat musculoskeletal problems are            to be enlightening. Perhaps it is possi-
                                                                                                       ble that desirable reductions in BP


Table 2.            Means and Standard Deviations of Changes Between Diastolic Blood Pressure Measurements


                                               Measurement
                                               Pretreatment Versus lmmedlate                                Pretreatment Versus 5-Minute
                                               Posttreatment                                                Posttreatment
                                               -                                                            -
                                               X                             SD                             X                                    SD




"Acu-ES group received electrical stimulation of four antihypenensive acupuncture points; Sham-ES group received electrical stimulation of four non-
acupuncture-point areab.
             different (+I,
h~ignificantly                       P<.05).
"Not significantly different ( P > . 0 5 ) .
                                                                                                                                                       1


38 / 527                                                                               Physical Therapy/Volume 71, Number 7IJuly 1991
-
Table 3.

Source of
Varlatlon
                  Results of Analysis of Variance




Group
Error 1
Time
Groupxtime
Error 2



occur in hypertensive patients receiv-              In summary, the results of this study       duces a quick, but short-lasting, thera-
ing electrotherapy for musculoskeletal              suggest numerous possibilities for          peutic effect. The results of our study
problems.                                           future research. We suggest several         indicate that stimulation of four se-
                                                    replications of this study, manipulat-      lected acupuncture points with a cur-
The four acupuncture points used in                 ing the variables of treatment dura-        rent of 10,000 Hz produces a signifi-
this study are among several that are               tion, electrical modality used, stimula-    cant reduction in diastolic BP in
stated in the acupuncture literature to             tion characteristics, and acupuncture       hypertensive subjects. Although the
have an antihypertensive effect. Peri-              points selected.                            duration and magnitude of this effect
cardium ti; Gall Bladder 20, 21, and                                                            were insufficient to be of clinical
41; Stomach 9 and 37; Kidney 1;                     Conclusion                                  value, the results of this study support
Spleen 1 and 2; and Heart 7 are other                                                           the efficacy of electrical stimulation as
acupuncture points that can be used                 This study was designed to validate         a means of lowering diastolic BP.
to lower 13P.l-5 We suggest that future             the current literature concerning the
studies be conducted using one or                   electrical stimulation of acupuncture       Acknowledgments
more of tlhese alternative acupuncture              points affecting diastolic BP and to
points. Bilateral stimulation to se-                provide a basis for future research.        We would like to express our thanks
lected acupuncture points may also                  Thus, we designed a preliminary             to the following individuals: Michael
prove to be effective.                              study, with an emphasis on accuracy         Ryan, MD, and Corwin Demarse, MD,
                                                    of acupuncture-point detection, using       for their assistance in locating sub-
                                                    a clinically available modality that pro-   jects; Kay Evje and Susan Nassan, li-
                                                                                                censed acupuncturists, for their ad-
                                                                                                vice; Graydon Bell, PhD, for his
                                                                                                contribution to our statistical analysis;
                                                                                                and Paul Hansen, PhD, PT, for his edi-
                                                                                                torial comments. Finally, we extend
                                                                                                special thanks to all of our subjects.


                                                                                                References

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Jackson JR. Effects of auricular transcutaneous




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40 / 529                                                                               Physical Therapy /Volume 71, Number 7 /July 1991

								
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