HEART RATE
VARIABILITY
and Acupuncture
Results from
TRANSCONTINENTAL
STUDIES
TCM Research CenterMedical University of Graz
Editor: Gerhard Litscher
III
Editor: Gerhard Litscher
Heart Rate Variability and Acupuncture –
Results from Transcontinental Studies
PABST SCIENCE PUBLISHERS Lengerich, Berlin, Bremen, Miami, Riga, Viernheim, Wien, Zagreb
IV
Bibliographic information published by Die Deutsche Bibliothek
Die Deutsche Bibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data is available in the Internet at http://dnb.ddb.de.
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The authors and the publisher of this volume have taken care that the information and recommendations contained herein are accurate and compatible with the standards generally accepted at the time of publication. Nevertheless, it is difficult to ensure that all the information is given entirely accurate for all circumstances. The publisher disclaims any liability, loss, or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this volume.
Gerhard LITSCHER, Prof. MSc PhD MDsc
MEDICAL UNIVERSITY OF GRAZ Head of the Research Unit for
Complementary and Integrative Laser Medicine, of the Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and of the TCM Research Center Graz Auenbruggerplatz 29
8036 Graz / Austria
Tel: +43 316 385-13907, -83907 Fax: +43 316 385-13908
Email: gerhard.litscher@medunigraz.at
© 2016 Pabst Science Publishers, 49525 Lengerich, Germany
Evidence-based Complementary and Alternative Medicine, Hindawi, New York, USA Gerhard Litscher, Graz, Austria
Printing: DMS, Graz, Austria ISBN 978-3-95853-169-7
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Preface
Heart rate variability (HRV) is a parameter of the neurocontrol of the heart and is used more and more in recent scientific research and practice, not only in Western, but also in evidence-based traditional medicine. Today innovative research including the latest recording technology and also artificial intelligence techniques are used for data acquisition and data analysis of HRV in acupuncture and herbal medicine research.
The scope of HRV is not yet completely clear, but it is known that there are intraindividual and interindividual variances and that heart rate variation depends on age. Apart from that, circadian variations (sleep-wake-cycle), physical condition as well as mental and physical exertion are important influencing factors. HRV can also be affected by diverse conditions such as age-related and so-called lifestyle diseases like diabetic neuropathy, renal failure, essential hypertension, cardiac disorders, coronary artery disease or intracranial lesions.
This book focuses on the latest innovative aspects concerning HRV and complementary medicine. Altogether, 19 manuscripts underwent a peer-review process. Some of the chapters report results of HRV in combination with different kinds of acupuncture (manual needle acupuncture, laser acupuncture, electroacupuncture). Data from 233 patients, 42 healthy volunteers and 49 animals were evaluated and are presented in this book. In China, electrocardiograms (ECGs) are registered and the data are transferred via internet to the Medical University of Graz immediately following the acupuncture treatment. In Graz, the analysis of the ECGs is performed. The acupuncturists in China are informed about the results of the analysis immediately and the success of the therapy can be demonstrated objectively. Teleacupuncture bridges on the one hand Eastern and Western medicine and on the other hand science and practice; it may contribute to the omission of redundant research studies and a simplification of the diagnostic and therapeutic procedure, thereby not only cutting costs but also saving time.
HRV can be used as reliable indicator of the state of health. It becomes less random with the aging process and the appearance of age-related diseases. However, it could be demonstrated that in special syndromes like fatigue and stress one can counteract this process using different preventive methods like acupuncture. This has been demonstrated in recent investigations concerning patients with burn-out syndrome as performed in transcontinental teleacupuncture studies between China and Graz.
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Teleacupuncture demonstrates that automated teletherapeutic procedures can be performed even over a long distance under complex and critical circumstances. This could probably be useful under special circumstances (cooperation between experts from different continents) as demonstrated in our Sino-Austrian collaboration.
July 2016
Gerhard Litscher
Medical University of GrazVII
Acknowledgments
The editor would like to thank all the other 47 authors from China and Austria.
Above all, I want to thank Ms. Ingrid Gaischek, MSc (Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and TCM Research Center Graz, Medical University of Graz, Graz, Austria) for her valuable support in every respect. Without her continuous support, this book would have never seen the printer’s ink.
The scientific work in this book is generously supported by the Austrian Federal Ministry of Science, Research and Economy and Eurasia-Pacific Uninet (project EPU 04/2015), and I would like to thank everyone involved. The investigations were and are still supported by the German Academy of Acupuncture (DAA; President Bernd Ramme, MD), Munich, Germany; the Department of Science of the City of Graz, Austria; the Austrian Federal Ministries of Science, Research and Economy and of Health, Vienna, Austria; and Eurasia-Pacific Uninet, Vienna, Austria. The scientific activities are performed within the areas ‘Sustainable Health Research’ and ‘Neuroscience’ at Medical University of Graz.
There are indeed many people to thank in realizing this type of book. The editor wishes to thank everyone sincerely. Further acknowledgments can be found in each chapter.
Special thanks also to both publishers, Pabst Science Publishers, especially to Dr. Wolfgang Pabst, and to Hindawi Publishing Corporation, who permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Within this book, 19 peer-reviewed articles are summarized. The editor of this book is the corresponding author of all articles, sometimes in partner-ship with Chinese and Austrian colleagues.
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CONTENTS
1 Biomedical teleacupuncture between China and Austria using heart rate variability, part 1: Poststroke patients 1
1.1 Introduction 1
1.2 Subjects and methods 1
1.2.1 Patients 1
1.2.2 Biosignal recording and evaluation parameters 2 1.2.3 Acupuncture and procedure 4
1.2.4 Statistical analysis 4
1.3 Results 4
1.4 Discussion 7
1.5 Acknowledgments 10
1.6 References 10
2 Brain-modulated effects of auricular acupressure on the
regulation of autonomic function in healthy volunteers 13
2.1 Introduction 13
2.2 Methods and subjects 14
2.2.1 A new system for ear acupressure (vibration
stimulation) 14 2.2.2 Recording systems and evaluation parameters 15
2.2.3 Volunteers, acupuncture and procedure 16
2.2.4 Statistical analysis 17 2.3 Results 17 2.4 Discussion 23 2.5 Conclusion 26 2.6 Acknowledgments 26 2.7 References 26
3 Sino-European transcontinental basic and clinical high-tech acupuncture studies, part 1: Auricular acupuncture increases heart rate variability in anesthetized rats 30
3.1 Introduction 30
3.2 Materials and methods 30
3.2.1 Animals 30
3.2.2 Electrocardiographic monitoring 31 3.2.3 Acupuncture stimulation and procedure 32
3.2.4 Statistical analysis 33 3.3 Results 33 3.4 Discussion 36 3.5 Conclusions 39 3.6 Acknowledgments 40 3.7 References 40
IX
4 Sino-European transcontinental basic and clinical high-tech acupuncture studies, part 2: Acute stimulation effects on heart rate and its variability in patients with insomnia 43
4.1 Introduction 43
4.2 Materials and methods 43
4.2.1 Patients 43
4.2.2 Electrocardiographic monitoring 44 4.2.3 Acupuncture stimulation and procedure 44
4.2.4 Statistical analysis 46 4.3 Results 46 4.4 Discussion 49 4.5 Conclusions 51 4.6 Acknowledgments 51 4.7 References 52
5 Biomedical teleacupuncture between China and Austria using heart rate variability, part 2: Patients with depression 54
5.1 Introduction 54
5.2 Subjects and methods 54
5.2.1 Patients 54
5.2.2 Biosignal recording in Asia and data analysis
in Europe 55
5.2.3 Clinical acupuncture and procedure 55
5.2.4 Statistical analysis 57
5.3 Results 57
5.4 Discussion 59
5.5 Acknowledgments 61
5.6 References 61
6 Sino-European transcontinental basic and clinical high-tech acupuncture studies, part 3: Violet laser stimulation in
anesthetized rats 64
6.1 Introduction 64
6.2 Animals and methods 64
6.2.1 Sprague-Dawley rats and blood pressure monitoring 64 6.2.2 Electrocardiographic monitoring in rats 65 6.2.3 Violet laser stimulation and procedure 65
6.2.4 Statistical analysis 67 6.3 Results 67 6.4 Discussion 74 6.5 Conclusions 75 6.6 Acknowledgments 76 6.7 References 76
X
7 Sino-European transcontinental basic and clinical high-tech acupuncture studies, part 4: ‘Fire of Life’ analysis of heart rate variability during acupuncture in clinical studies 79
7.1 Introduction 79
7.2 Materials and methods 80
7.2.1 HRV monitoring 80 7.2.2 HRV data analysis 80 7.2.3 Patients 81 7.2.4 Procedure 81 7.2.5 Acupuncture points 82 7.3 Results 82 7.3.1 Standard analysis 82 7.3.2 HRV-scatterplots 84
7.3.3 HRV – frequency domain (‘Fire of Life’ analysis) 86
7.4 Discussion 87
7.5 Conclusions 88
7.6 Acknowledgments 88
7.7 References 89
8 A transcontinental pilot study for acupuncture lifting-thrusting and twisting-rotating manipulations 92
8.1 Introduction and background 92
8.1.1 Research objective 93 8.2 Methods 93 8.2.1 Healthy volunteers 93 8.2.2 Acupuncture operations 93 Lifting-thrusting 93 Twisting-rotating 94
8.2.3 Instruments and measurement methods 94
8.2.4 Statistical analysis 96
8.3 Results 96
8.3.1 Influence of BP and HR caused by different needling
manipulations 96 8.3.2 Influence of different needling manipulations on skin
microvascular perfusion on the acupoint and its
corresponding area 97
8.3.3 Influence of different needling manipulations on HRV 98 8.3.4 Needling sensation caused by different needling
manipulations 98
8.4 Discussion 100
8.5 Conclusion 100
8.6 Acknowledgments 101
XI
9 Ear acupressure, heart rate, and heart rate variability in patients with insomnia 103
9.1 Introduction 103
9.2 Materials and methods 103
9.2.1 Patients 103
9.2.2 Electrocardiographic monitoring 104 9.2.3 Ear acupressure stimulation and procedure 104
9.2.4 Statistical analysis 106 9.3 Results 106 9.4 Discussion 108 9.5 Conclusions 110 9.6 Acknowledgments 110 9.7 References 110
10 Intravenous laser blood irradiation, interstitial laser acupuncture, and electroacupuncture in an animal experimental setting:
Preliminary results from heart rate variability and
electrocorticographic recordings 112
10.1 Introduction 112
10.2 Animals and methods 113
10.2.1 Sprague-Dawley rats 113
10.2.2 Intravenous laser irradiation 113 10.2.3 Interstitial laser acupuncture 114
10.2.4 Electroacupuncture 114 10.2.5 Procedure 114 10.2.6 Measurement parameters 115 10.2.7 Statistical analysis 115 10.3 Results 115 10.4 Discussion 119 10.5 Conclusions 121 10.6 Acknowledgments 121 10.7 References 122
11 Effects of acupuncture on heart rate variability in beagles;
Preliminary results 125
11.1 Introduction 125
11.2 Materials and methods 125
11.2.1 Animals 125
11.2.2 Electrocardiographic monitoring 125 11.2.3 Acupuncture stimulation, drugs, and procedure 126
11.2.4 Statistical analysis 127
11.3 Results 127
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11.5 Conclusions 130
11.6 Acknowledgments 130
11.7 References 130
12 Laser acupuncture: Two acupoints (Baihui, Neiguan) and two modalities of laser (658ௗnm, 405ௗnm) induce different effects
in neurovegetative parameters 133
12.1 Introduction 133
12.2 Materials and methods 133
12.2.1 Stimulation methods 133
Manual needle acupuncture 133
Red laser 134 Violet laser 135 12.2.2 Neurovegetative monitoring 135 12.2.3 Volunteers 135 12.2.4 Acupuncture points 136 12.2.5 Measurement procedure 136 12.2.6 Statistical analysis 137 12.3 Results 137 12.4 Discussion 139 12.5 Conclusions 141 12.6 Acknowledgments 141 12.7 References 141
13 Improvement of the dynamic responses of heart rate variability patterns after needle and laser acupuncture treatment in patients with burnout syndrome: A transcontinental
comparative study 146
13.1 Introduction 146
13.2 Patients and methods 147
13.2.1 Patients 147
13.2.2 Teleacupuncture between China and Europe 148 13.2.3 Needle and laser acupuncture and procedure 148
13.2.4 Statistical analysis 151
13.3 Results 151
13.4 Discussion 155
13.5 Acknowledgments 156
13.6 References 156
14 Continuous auricular electroacupuncture can significantly improve heart rate variability and clinical scores in patients
with depression: First results from a transcontinental study 158
14.1 Introduction 158
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14.2.1 Patients 159
14.2.2 Biosignal recording in China and data analysis
in Europe 159
14.2.3 Auricular electroacupuncture (punctual stimulation)
and procedure 160 14.2.4 Statistical analysis 162 14.3 Results 162 14.4 Discussion 166 14.5 Acknowledgments 167 14.6 References 167
15 Effectiveness of interstitial laser acupuncture depends upon dosage: Experimental results from electrocardiographic and electrocorticographic recordings 171
15.1 Introduction 171
15.2 Animals and methods 172
15.2.1 Sprague-Dawley rats 172
15.2.2 Interstitial laser acupuncture 172
15.2.3 Procedure 173 15.2.4 Measurement parameters 173 15.2.5 Statistical analysis 173 15.3 Results 174 15.4 Discussion 176 15.5 Acknowledgments 178 15.6 References 178
16 Manual acupuncture and laser acupuncture for autonomic regulations in rats: Observation on heart rate variability
and gastric motility 180
16.1 Introduction 180
16.2 Animals and methods 181
16.2.1 Animal preparation 181
16.2.2 Gastric motility recording 181 16.2.3 Electrocardiographic monitoring 182 16.2.4 Stimulation 182 Laser acupuncture 182 Manual acupuncture 182 16.2.5 Statistical analysis 182 16.3 Results 183
16.3.1 Gastric motility under resting condition 183 16.3.2 Effects of MA and LA on gastric motility induced
by different acupoints 183
16.3.3 Effects of MA and LA at different acupoints on HRV 185
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16.5 Conclusion 188
16.6 Acknowledgments 188
16.7 References 189
17 The influence of new colored light stimulation methods on heart rate variability, temperature, and well-being: Results of a pilot study in humans 191
17.1 Introduction 191
17.2 Materials and methods 191
17.2.1 Subjects 191
17.2.2 New colored light stimulation methods 192 17.2.3 Temperature measurements 193 17.2.4 Electrocardiographic measurements 194 17.2.5 Procedure 194 17.2.6 Statistical analysis 195 17.3 Results 195 17.4 Discussion 199 17.5 Acknowledgments 201 17.6 References 201
18 Can tongue acupuncture enhance body acupuncture? First results from heart rate variability and clinical scores in
patients with depression 204
18.1 Introduction 204
18.2 Materials and methods 205
18.2.1 Patients 205
18.2.2 Teleacupuncture 205
18.2.3 Body acupuncture, tongue acupuncture, and
procedure 206 18.2.4 Statistical analysis 207 18.3 Results 208 18.4 Discussion 212 18.5 Acknowledgments 214 18.6 References 214
19 Acupuncture point laterality: Investigation of acute effects of Quchi (LI11) in patients with hypertension using heart
rate variability 216
19.1 Introduction 216
19.2 Subjects and methods 217
19.2.1 Patients 217
19.2.2 Heart rate variability (HRV) and teleacupuncture 218 19.2.3 Clinical acupuncture and procedure 218
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19.3 Results 220 19.4 Discussion 223 19.5 Acknowledgments 224 19.6 References 225 20 List of references 227XVI
Editor (and author)
Gerhard LITSCHER, Prof. MSc PhD MDsc
Head of the Research Unit for Complementary and Integrative Laser Medicine, of the Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and of the TCM Research Center Graz at the Medical University of Graz,
Doctor of technical and Doctor of medical sciences, several research stays and international lectures, about 600 scientific publications (184 SCI/PubMed-listed), partly on basic acupuncture research, author and/or editor of 13 books, currently editor-in-chief and/or member of the editorial board of more than 35 international scientific journals (e.g. Editor-in-chief of the Internet Journal of Alternative Medicine (IJAM), Associate Editor for Medical
Acupuncture, Associate Editor of the Journal of Acupuncture and Meridian Studies (JAMS),
one of the editors and lead guest editor of Evidence-based Complementary and Alternative
Medicine (eCAM), Associate Editor of BMC Complementary and Alternative Medicine,
Editor-in-chief of medicines – evidence-based classical, complementary and integrative
medicine and of OBM Integrative and Complementary Medicine, and one of the
Editors-in-chief of Integrative Medicine International). Prof. Litscher’s special interests are computer-based High-Tech Acupuncture Research and Neuromonitoring.
- University Professor at Medical University of Graz, Austria - Guest Professor at Medical University of Vienna, Austria
- Visiting Professor at the Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
- Visiting Professor at Capital Medical University, Beijing, China
- Visiting Professor at Heilongjiang University of Chinese Medicine, Harbin, China - Professor honoris causa (Prof.h.c.) at Beijing Hospital of Traditional Chinese
Medicine, Capital Medical University School of Clinical Traditional Chinese Medicine, Beijing, China
- Visiting Professor at Chinese People’s Liberation Army General Hospital, Beijing, China
- Visiting Professor at China Medical University, Taichung, Taiwan - Visiting Professor at University of Science of Technology, Beijing, China - Visiting Professor at Hubei University of Chinese Medicine, Wuhan, China
- Visiting Professor at Beijing University of Chinese Medicine, School of Acupuncture-Moxibustion and Tuina, Beijing, China
- Honorary Professor at Hubei Provincial Collaborative Innovation Center of Preventive Treatment by Acupuncture & Moxibustion, Wuhan, China
- Visiting Professor at Shanghai University of Traditional Chinese Medicine, Shu Guang Hospital, Shanghai, China
- President of EMLA-Austria (European Medical Laser Association, 2012 – 2013) - President for Science and Research of ISLA-transcontinental (International Society
for Medical Laser Applications) since August 2012
- Vice-President of IMedLA (International Medical Laser Association), responsible for Europe, since August 2012
- German Vice-President of the German-Chinese Research Foundation for Traditional Chinese Medicine (DCFG-TCM), since October 2014
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Authors (in alphabetical order)
Guang-Yu Cheng, MScSchool of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China; Heilongjiang University of Chinese Medicine, Harbin, China
Wei-Ping Cheng, Prof. MD
Director of the Second Neurology Department, the Second Acupuncture Department and Epileptic Therapeutic Centre, First Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, China
Xiao Feng, MSc
Heilongjiang University of Chinese Medicine, Harbin, China
Ingrid Gaischek, MSc
Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and TCM Research Center Graz, Medical University of Graz, Graz, Austria
Xin-Yan Gao, Prof. MD PhD
Head of the Department of Physiology, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Hao-Ming Geng, MD
Heilongjiang University of Chinese Medicine, Harbin, China
Wei He, Assoc.Prof. MD PhD
Head of the Department of Meridian, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Ling Hu, Assoc.Prof. MD PhD
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Tao Huang, Prof. MD PhD
Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Science, Beijing, China
Shu-Yong Jia, technologist
Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
XVIII
Yue-Bo Jiang, MD
Department of Acupuncture, People’s Liberation Army General Hospital, Beijing, China
Xiang-Hong Jing, Prof. MD PhD
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Hai-Xue Kuang, Prof. PhD
Former President of Heilongjiang University of Chinese Medicine, Harbin, China
Qian-Qian Li, MSc
Acupuncture and Moxibustion Center, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
Daniela Litscher, MSc PhD
Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and TCM Research Center Graz, Medical University of Graz, Graz, Austria
Cun-Zhi Liu, Assoc.Res. MD PhD
Acupuncture and Moxibustion Center, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
Kun Liu, Ass.Prof. MD PhD
Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Yvonne Michenthaler, MD
Former member of the TCM Research Center Graz, Medical University of Graz, Graz, Austria
Qian-Qian Niu, MSc
Heilongjiang University of Chinese Medicine, Harbin, China
Hong-Yan Shang, technologist
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Ze-Min Sheng, MD
Privatclinic Lassnitzhoehe, Lassnitzhoehe, Austria, and TCM Research Center Graz, Graz, Austria
XIX
Guang-Xia Shi, MSc
Acupuncture and Moxibustion Center, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
Hong Shi, Associate senior technologist
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Xian Shi, Prof. MD PhD
Department of Acupuncture, People’s Liberation Army General Hospital, Beijing, China
Hang Su, MD
Department of Geriatrics, Kunming Medical University, Kunming, China
Yang-Shuai Su, MD PhD
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Kazuo Sugimoto, MD
Heilongjiang University of Chinese Medicine, Harbin, China
Zhong-Ren Sun, Prof. MD PhD
President of Heilongjiang University of Chinese Medicine, Harbin, China
Jing-Qiao Tao, MSc
Department of Acupuncture, People's Liberation Army General Hospital, Beijing, China
Yu-Ying Tian, Associate senior technologist
Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Jan Valentini, MD
Former member of the TCM Research Center Graz, Medical University of Graz, Graz, Austria
Guang-Jun Wang, Ass.Prof. MD PhD
Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Huan Wang, MD PhD
Department of Acupuncture, People’s Liberation Army General Hospital, Beijing, China
XX
Lin-Peng Wang, Prof. MD PhD
Director of the Acupuncture and Moxibustion Center, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
Lu Wang, Prof. MD LAc
Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and TCM Research Center Graz at the Medical University of Graz, Graz, Austria; Visiting Professor of the Heilongjiang University of Chinese Medicine, Harbin, China
Xiao-Min Wang, Prof. MD PhD
Vice President of the Capital Medical University, Director of the Department of Neurobiology, Capital Medical University, Beijing, China
Xiao-Yu Wang, Ass.Prof. MD PhD
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Yong-Yue Wang, MSc
Heilongjiang University of Chinese Medicine, Harbin, China
Mei-Ling Wu, Master student
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Juan-Juan Xin, PhD
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Yang-Yang Xu, MD
Heilongjiang University of Chinese Medicine, Harbin, China
Li-Jian Yang, MSc
Beijing Key Laboratory of Traditional Chinese Veterinary Medicine, Beijing University of Agriculture, Beijing, China
Zhao-Kun Yang, Master student
Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
XXI
Wei-Bo Zhang, Prof. PhD
Head of the Department of Biomedical Engineering, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Jian Zhao, MSc
Clinical Medicine of Heilongjiang University of Chinese Medicine, Harbin, China
Zeng-Kai Zhao, MSc
Department of Acupuncture, People's Liberation Army General Hospital, Beijing, China
Bing Zhu, Prof. MD PhD
Former Director of the Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
Tian-Yu Zou, MSc
1
1. Biomedical Teleacupuncture between China
and Austria Using Heart Rate Variability,
Part 1: Poststroke Patients
L. Wang, J. Valentini, K. Sugimoto, W.P. Cheng,
G.Y. Cheng, H.M. Geng, I. Gaischek, H.X. Kuang,
G. Litscher
1.1 Introduction
In recent times, sophisticated medical equipment has become the main reason and factor in the advancement of acupuncture. However, many hospitals for Traditional Chinese Medicine (TCM) in China do not have clinical engineering departments. The establishment of teleacupuncture is an excellent new possibility for eơectively combining transcontinental clinical and basic acupuncture research [1-4].
The novel concept of the current teleacupuncture technology has been implemented at the TCM Research Center Graz in Austria (http://litscher.info and http://tcm-graz.at) in 2010 in cooperation with the Heilongjiang University of Chinese Medicine in Harbin, China, over a distance of about 8,500 km.
This paper describes the first results from teleacupuncture measurements in poststroke patients using computer-based heart rate variability (HRV) recordings before, during, and after acupuncture under standardized clinical conditions in China. Analyses were performed in Graz, Austria, immediately after acupuncture sessions, and the protocol was then sent back to Harbin, China, via internet.
1.2 Subjects and methods
1.2.1
Patients
Electrocardiographic signals were recorded in 29 adult patients (15 female, 14 male; mean age ± SD 64.7 ± 11.3 years; range 40 – 80 years). All patients with the Chinese diagnosis “Zhong Feng” received acupuncture treatment for poststroke rehabilitation and were not under the influence of centrally
2
active medication. None of the patients had a body temperature out of the normal range (mean ± SD 36.2 ± 0.2 °C; range 36.0 – 36.7 °C). Body height was 165.2 ± 8.1 cm, and body weight was 64.3 ± 9.5 kg. The study design was approved by the local ethics committee, and the noninvasive recording procedure (electrocardiogram (ECG)) was performed in compliance with the Declaration of Helsinki. All persons were informed about the nature of the investigation and the results of the own measurement, at the latest one day after ECG-monitored acupuncture session.
1.2.2
Biosignal recording and evaluation parameters
Basis for determining HRV is the duration of RR intervals measured during a special time period (5 minutes). ECG registration was performed with three adhesive electrodes (Skintact Premier F-55; Leonhard Lang GmbH, Innsbruck, Austria) applied to the chest.
For our investigations at the Heilongjiang University of Chinese Medicine, a medilog AR12 HRV (Huntleigh Healthcare, Cardiơ, United Kingdom) system which was partly developed in Austria was used (see Fig. 1.1, left side). By recording with 4096 samples per second, the new system can detect R waves extremely accurately. R-peak time resolution is 244 microseconds and the P and T time resolution 1,953 microseconds. The dimensions of the HRV recorder are 70×100×22 millimeters, the weight is about 95 grams with batteries [5].
3
Fig. 1.1: Teleacupuncture between China and Austria. Left: acupuncture research in a poststroke patient at the Heilongjiang University of Chinese Medicine using equipment from the Medical University of Graz (with permission of the patient and the two doctors from Graz and Harbin). Right: data analysis in the high-tech acupuncture lab at the Medical University in Graz, Austria.
All raw data were stored digitally on a special memory card. After removing the card from the portable system, the data were read by a card reader connected with a standard computer in China and then transferred to the TCM Research Center Graz via internet. With a new software [1,2,5], the biosignals were analyzed, and HRV was displayed in a way to help to judge the function of the autonomic nervous system. Viewing this innovative kind of analysis helps to show how well the human body reacts to sport, stress, recovery, and also acupuncture [1-5]. For oƫine visual inspection, all ECG raw data can be displayed on a screen.
Mean heart rate (HR), total HRV, and the LF (low frequency)/HF (high frequency) ratio of HRV served as evaluation parameters. These parameters are recommended by the task force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology [6] and provide an understanding of the eơects of sympathetic and parasympathetic systems on HRV. In addition, the blood pressure was recorded discontinuously.
4
1.2.3
Acupuncture and procedure
Acupuncture was performed at the acupoint Tongli (HT.5) on the left heart meridian in all patients. Tongli is located 1 cun (relative body measure; the breadth of the distal phalanx of the thumb) proximal to HT.7 (Shenmen), radial to the tendon of m. flexor carpi ulnaris. Its use is also indicated in cases of speech disturbances, aphasia, and mental disorders [7]. Sterile single-use needles (0.30×30 mm; Huan Qiu, Suzhou, China) were used. Needling was performed perpendicularly (depth about 1 cm), and the needles were stimulated clockwise and counterclockwise for 15 seconds each, with two rotations per second, resulting in 30 rotations per stimulation. Stimulation was done immediately after inserting the needle, 10 minutes later, and before removing the needle (comp. Fig. 1.2). For the present study, an acupuncture session between the third and seventh treatment was chosen for ECG monitoring.
Fig. 1.2: Measurement procedure. The data before (measurement phases a,b), during (c–f), and after (g,h) manual needle acupuncture stimulation were measured and statistically analyzed.
1.2.4
Statistical analysis
Data were analyzed using SigmaPlot 11.0 software (Systat Software Inc., Chicago, USA). Graphical presentation of results uses box plot illustrations. Testing was performed with Friedman repeated measures ANOVA on ranks and Tukey test. The criterion for significance was P<0.05.
1.3 Results
Results of mean HR from the ECG recordings before, during, and after acupuncture of the 29 patients are shown in Figure 1.3. There were no significant alterations within the diơerent conditions (a–h). Blood pressure,
5
measured discontinuously, did not change significantly during the measurement procedure.
Fig. 1.3: Mean heart rate. Box plot illustration in 29 poststroke patients before (a,b), during (c–f), and after (g,h) needle acupuncture. No significant (n.s.) changes were found. The horizontal line in the box gives the position of the median. The end of the box defines the 25th and 75th percentile, and the error bars mark the 10th and 90th
percentile.
Analysis of total HRV showed the following interesting results (Fig. 1.4). There was a positive eơect in the sense of a significant increase in total HRV during and after acupuncture. This eơect appeared already after inserting the needles (phase c) and reached a significant level after the second stimulation period (phase e). Then, while removing the needles, a slight decrease of HRV could be observed. After the third stimulation and removing the needles, there was again a significant increase in HRV (phases g and h).
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Fig. 1.4: Total heart rate variability. Graphical box plot presentation of significant (כ) P<0.05) changes during (e) and after (g,h) acupuncture. Note the significant increase in total HRV. For further explanations compare with Fig. 1.3.
Furthermore, the biosignal monitoring during acupuncture showed substantial reductions in the LF/HF ratio (Fig. 1.5). During acupuncture, the values decreased markedly and reached a maximal reduction 5 minutes after removing the needles (phase h), even though the magnitude of the changes varied from patient to patient.
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Fig. 1.5: LF (low frequency)/HF (high frequency) ratio. Note that the ratio decreases during acupuncture treatment in 29 poststroke patients. For further explanations, see Figure 1.3.
1.4 Discussion
Since the pioneering work of the TCM Research Center at the Medical University of Graz in Austria, high-tech acupuncture including teleacupuncture has been recognized as a unique and powerful tool for investigating eơects of acupuncture, especially within transcontinental studies [1-4,8].
There have been several other experiments with telemedicine in China, and other telemedical services are in operation [9]. Other authors stated in a publication that “China is a large country and is rapidly modernizing. In reporting about telemedicine in China as well as reporting about all technology associated with computer and communication applications in China, one can never be sure whether one’s information is up to date, complete and accurate” [9]. To the best of our knowledge, teleacupuncture has not previously been reported and was first described by our research group last year [1-4,8,10]. It is defined as the exchange of medical acupuncture information across distance [10]. The realization of this innovative concept of teleacupuncture could probably be useful under special circumstances (cooperation between experts from diơerent continents) as demonstrated in our Sino-Austrian collaboration [8].
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Within the present preliminary clinical pilot study, teleacupuncture using data analysis of diơerent parameters like HR and HRV in the time and frequency domain was performed for control of possible therapeutic eơects of acupuncture in a collective of poststroke patients in Harbin. The acupuncturists in China were informed about the findings immediately after the analysis in Graz, and the eơects of the therapy could be demonstrated objectively.
HRV is a widely accepted measurement method for the assessment of the patient’s neurophysiological state. The better HRV, the healthier the patient. Patients at risk for special diseases like hypertension, arteriosclerosis, diabetes, cancer, or other health problems have low HRV. However, even today the quantification of HRV and the knowledge of the mechanism as well as the measurement in special diseases still pose unresolved questions. In general, the RR intervals in the ECG are controlled by the blood pressure control system, influenced by the hypothalamus and in particular controlled by the vagal cardiovascular center in the lower brainstem. HRV can be quantified over time using registration of percentage changes in RR-intervals in the time domain as well as the changes in the frequency range by analysis of electrocardiographic power spectra [6]. HRV is interpreted as a brainstem reflex with an aơerent arc via the vagus and glossopharyngeal nerves and an eơerent arc mainly via vagal fibres [11,12]. HRV has stochastic and rhythmic components. With spectral analysis, variability can be classified into individual ranges which represent biological rhythms. The following influences can be distinguished for diơerent ranges of HRV: (a) respiratory sinus arrhythmia (approximately 0.15–0.5 Hz); centrally nervous respiratory impulses and interaction with pulmonary aơerents; (b) the so-called “10-s-rhythm” (approximately 0.05–0.15 Hz); natural rhythm of cardiovascularly active neurons in the lower brainstem (circulatory center and its modulation by feedback with natural vasomotoric rhythms via baroreceptor feedback); (c) longer wave HRV rhythms (approximately <0.05 Hz); eơects from the renin angiotensin system or temperature regulation as well as metabolic processes [6].
The scope of HRV is not yet completely clear, but it is known that there are intraindividual and interindividual variances and that HRV depends on age, circadian variations (sleep-wake-cycle), physical condition, and mental and physical exertion. HRV can also be aơected by diverse conditions such as age-related diseases (diabetic neuropathy, renal failure, essential hypertension, cardiac disorders, coronary artery disease, and intracranial lesions) and diơerent medications. The narrowness of HRV after heart transplantation [13] is similar to that seen in deep comatose patients and in brain-dead subjects [12], in whom complex reflex mechanisms are no longer
