Chinese Medicine, 2011, 2, 71-76
doi:10.4236/cm.2011.22013 Published Online June 2011 (http://www.SciRP.org/journal/cm)
Clinical Teleacupuncture between China and Austria
Using Heart Rate Variability in Patients with Depression
Lu Wang1, Guangyu Cheng2, Zemin Sheng1,3, Qianqian Niu2, Weiping Cheng2, Xiao F e n g2,
Jan Valentini1,2, Ingrid Gaischek1, Xinyan Gao1,4, Haixue Kuang2, Gerhard Litscher1*
1TCM Research Center Graz and Research Unit of Biomedical Engineering in Anesthesia and
Intensive Care Medicine, Medical University of Graz, Graz, Austria
2Heilongjiang University of Chinese Medicine, Harbin, Ch ina
3Privatclinic Lassnitzhoehe, Lassnitzhoehe, Austria
4Department of Physi ol o gy , Institute of Acupuncture and Mo xibustion, China Academy of
Chinese Medical Sciences, Beijing, China
Received April 12, 2011; revised April 18, 2011; accepted April 19, 2011
Abstract
In previous studies by the same research group it has been shown in post-stroke patients that the autonomic
system can be affected by acupuncture. Within this study, teleacupuncture between China and Austria is used
for quantifying the effects of heart rate variability (HRV) in Chinese patients suffering from depression. In
22 Chinese depression patients (17 f, 5 m; mean age ± SD 52.3 ± 10.6 years; range 31 - 70 years) electrocar-
diographic signals before, during and after acupuncture at the acupoint Jianshi (PC 5) were recorded in
Harbin and analyzed in Graz using teleacupuncture via internet. HRV data were analyzed in the time and
frequency domain and a protocol from Austria was sent to the team in China immediately after the treatment
and recording session. Mean heart rate decreased significantly (p < 0.001) during and after acupuncture,
whereas total HRV increased significantly during (p ≤ 0.034) and after (p < 0.001) acupuncture, always im-
mediately following manual needle stimulation. Furthermore, there is a marked decrease in balance between
sympathetic and parasympathetic activity (low frequency/high frequency HRV ratio) during treatment. This
study shows that HRV could be a useful parameter for quantifying clinical effects of acupuncture on the
autonomic nervous system. Teleacupuncture between China and Austria over a distance of more than 8,500
km has been successfully used.
Keywords: Traditional Chinese Medicine (TCM), Teleacupuncture, Heart Rate Variability (HRV),
Sino-Austrian Cooperation, Depression
1. Introduction
An innovative 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 China Academy of Chi-
nese Medical Sciences in Beijing [1-5] and the Heilong-
jiang University of Chinese Medicine in Harbin, China,
over a distance of more than 8,500 km [6].
This paper describes the first results from teleacu-
puncture measurements in depression 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 [6].
2. Subjects and Methods
2.1. Patients in Harbin
We investigated 22 adult patients (17 female, 5 male;
mean age ± SD 52.3 ± 10.6 years; range 31 - 70 years)
suffering from depression (Chinese diagnosis ‘Yu Zheng’)
and therefore receiving acupuncture treatment. The
clinical evaluation of the patients was performed imme-
diately before HRV data recording using three main
scales: the Hamilton rating scale for depression (HRSD)
[7], the Hamilton anxiety rating scale (HAM-A) [8], and

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72
the Athens insomnia scale (AIS) [9]. The patients were
not under the influence of centrally active medication.
The study was carried out in compliance with the Decla-
ration of Helsinki, and all patients gave oral informed
consent.
2.2. Biosignal Recording in China and Data
Analysis in Austria
The duration of RR-intervals is measured during a spe-
cial time period (5 min), and on this basis HRV is deter-
mined. Electrocardiographic (ECG) registration is per-
formed using three adhesive electrodes (Skintact Premier
F-55; Leonhard Lang GmbH, Innsbruck, Austria) which
are applied to the chest.
The Chinese researchers used a medilog® AR12 HRV
(Huntleigh Healthcare, Cardiff, United Kingdom) system
(see Figure 1, middle) from the TCM Research Center in
Graz for the common investigations. This system has a
sampling rate of 4096 Hz, and can therefore detect R-
waves extremely accurately [10].
The raw data are stored digitally on a CompactFlash
(CF) 32 MB 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 inter-
net. With a new software [1,2,10] 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 [1-6,10].
Similar to a previous study [6], mean heart rate (HR),
total HRV, and the LF (low frequency)/HF (high fre-
quency) ratio of HRV were chosen as evaluation pa-
rameters, as such being recommended by the Task Force
of the European Society of Cardiology and the North
American Society of Pacing and Electrophysiology [11].
2.3. Acupuncture and Procedure
All patients received manual needle acupuncture at the
acupoint Jianshi (PC5) on the left pericard meridian
(Figure 2). Jianshi is located on the palmar side of the
forearm, and on the line connecting Quze (PC3) and
Daling (PC7), 3 cun (relative body measure; the breadth
of the distal phalanx of the thumb) proximal to the
transverse crease of the wrist, between the tendons of m.
palmaris longus and m. flexor carpi radialis. Its use is
indicated for example in cases of cardiac pain, vomiting,
epilepsy, malaria and mania [12]. Sterile single-use nee-
dles (0.30 × 30 mm; Huan Qiu, Suzhou, China) were
used. Needling was performed perpendicularly (depth
about 15 mm), and the needle was stimulated clockwise
and counterclockwise for 15 seconds each, with six rota-
tions per second, resulting in 90 rotations per stimulation.
Stimulation was done immediately after inserting the
needle, 10 minutes later and before removing the needle
(comp. Figure 3).
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.
3. Results
Figure 4 shows the results of mean HR from the ECG
recordings before, during and after acupuncture of the 22
patients. There was a significant decrease in HR during
the second half of the acupuncture phase and after acu-
puncture (p < 0.001).
Figure 1. Research cooperation between China and Austria.
Electrocardiographic teleacupuncture measurements were
performed in Harbin (left) with equipment from the Medi-
cal University of Graz (middle), and the data were trans-
ferred to Graz (right). With permission of the patient.
Figure 2. Manual needle acupuncture at the acupoint Jian-
shi (PC5).

L. WANG ET AL.
73
Figure 3. Measurement procedure. The data before (meas-
urement phases (a,b), during (c-f) and after (g,h) manual
needle acupuncture stimulation at the acupoint Jianshi
(comp. Figure 2) were measured and statistically analyzed.
In contrast to this decrease in HR, total HRV increased
significantly (p = 0.034) already after inserting the nee-
dle and stimulating it for the first time (Figure 5, phase
c). This increase became more pronounced after the sec-
ond stimulation (Figure 5, phase e; p < 0.001) and espe-
cially following the third stimulation (Figure 5, phase g;
p < 0.001). It is interesting that between the stimulation
phases total HRV was lowered again, with the median
continually increasing with respect to the previous non-
stimulation phase, resulting in a final median value
markedly above baseline values (Figure 5, right).
Substantial reductions in the LF/HF ratio during acupunc-
ture can be seen in Figure 6, with a minimum in phase f.
Figure 4. Mean heart rate. Box plot illustration in 22 patients with depression before (a,b), during (c-f) and after (g,h) needle
acupuncture. Signific ant changes (**) p < 0.001) were found in the phases e-h, each compared to baseline values a and b, re-
spectively. The horizontal line in the box gives the position of the median. The end of the box defines the 25th and 75th per-
centile, the error bars mark the 10th and 90th percentile.
Figure 5. Total heart rate variability. Graphical box plot presentation of significant (*) p = 0.034; **) p < 0.001) changes during
(c,e) and immediately after (g) acupuncture. Note the marked increase in total HRV. Further exp lanations comp . Figure 4.

L. WANG ET AL.
74
A separate graphical presentation of the calculation
of the LF-band and the HF-band can be found in Fig-
ure 7. Both parameters increased, however, not to the
same extent. Therefore, LF/HF ratio decreased in gen-
eral (comp. Figure 6). The increase of LF was signifi-
cant in phase g, as was that of HF, also in phase g
(Figure 7).
The results of the different scales as described in the
Method section showed the following mean ± SD values:
HRSD 21.2 ± 11.5; HAM-A 21.5 ± 10.7; and AIS 15.0 ±
5.0.
4. Discussion
Depression, a special form of mental illness, is growing in
both Western and Eastern world. From the point of view
of TCM the main syndromes of depression are qi stagna-
tion and blood stasis, liver qi depression and transforma-
tion of fire due to qi stagnation [13]. In China, there are
several pre-clinical and clinical studies using Chinese
herbal medicine which are the basis for design of new
therapeutic programmes for treatment of depression [13].
In addition, acupuncture is also used in several evidence-
Figure 6. LF (low frequency)/HF (high frequency) ratio. Note that the ratio decreases during acupuncture treatment in the 22
patients. Further explanations see Figure 4.
Figure 7. LF- and HF band of HRV. **) p = 0.004; *) p < 0.05. Further explanations concerning the box plot presentation see
Figure 4.

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75
based studies concerning this topic of research. Altogether,
the number of publications in the pubmed-database
(www.pubmed.gov) can be seen in Table 1.
Although there are a great number of referenced pub-
lications, there are only six articles concerning depres-
sion, acupuncture and HRV at the moment (April 2011).
These publications should be discussed in context with
our results in the following. In 2001, Callahan [14] stated
that HRV has been shown to be a strong predictor of
mortality and is adversely affected by problems such as
anxiety and depression. Pignotti and Steinberg [15]
demonstrated that a lowering of subjective units of dis-
tress was in most cases also related to an improvement in
HRV. In the third paper from 2001, Sakai et al. [16] in-
cluded HRV in a general concept of behavioural health
services, and the authors reported HRV as a useful pa-
rameter. In 2003, Agelink et al. [17] also undertook a
study to evaluate the effects of needle acupuncture on
cardiac autonomic nervous system function in patients
with minor depression or anxiety disorders. In contrast to
our 22 patients, the 36 patients from that group were
randomly distributed into a verum acupuncture group
and a placebo group. Similar to our investigations, 5
minute-intervals of ECG were analyzed and the acu-
puncture group also showed a significant decrease of the
mean resting heart rate, 5 and 15 minutes after needle
application (comp. Figure 4), combined with a trend
towards an increase of the HF-band of HRV and a de-
crease of the LF spectral power (comp. Figure 7). The
latter effects resulted in both studies ([17] and present
study) in an overall decrease of mean and median LF/HF
ratio in HRV. In the study by Agelink et al. [17], this
effect was only significant in verum acupuncture in pa-
tients with minor depression or anxiety. Therefore a rela-
tive increase of cardiovagal modulation of heart rate, and
physiological regulatory effects due to acupuncture stimu-
lation could be detected in the present study which con-
firms the results of other authors [17], although the acu-
puncture schemes were different (He.7 Shenmen and
PC7 Neiguan [17] vs. PC5 Jianshi (this study)). In a fur-
ther publication, Yun et al. [18] described in 2005 the
dynamic range of biologic functions. They stated that
Table 1. Number of publications listed in the scientific da-
tabase pubmed (April 2011).
Heart rate variability Acupuncture Depression
13,415 16,199 254,249
Heart rate variability
+ Acupuncture
Heart rate variability
+ Depression
Acupuncture +
Depression
65 536 424
Heart rate variability +
Acupuncture + Depression
6
reduced variation of physical exertion, environmental
stressors, and thermal gradients that characterize modern
life styles, may reduce the autonomic dynamic range
resulting in lowered HRV and a myriad of systemic dys-
functions. Acupuncture may operate through increasing
autonomic variability. As already mentioned in a previ-
ous study [6], a systematic clinical review on acupunc-
ture and HRV was published by Lee et al. in 2010 [19]
which searched the literature using 14 data bases. Twelve
randomized clinical trials (RCTs) met all inclusion crite-
ria. Five RCTs found significant differences in HRV
between patients treated with acupuncture vs. those
treated with sham acupuncture (controls). The majority
of the other RCTs showed inconsistent results [19]. The
authors stated that more rigorous research appears to be
warranted. The number, size, and quality of the RCTs
that are available are too low to draw firm conclusions
[19]. Another review article concerning the topic of HRV
and acupuncture was published by our research group
already in 2007 [20]. In this paper, it could be demon-
strated that in special syndromes like fatigue and stress
one can counteract the aging process using different pre-
ventive methods like acupuncture [20]. This was demon-
strated in recent investigations concerning patients with
burn-out syndrome as performed in a further teleacu-
puncture study between Beijing and Graz [1,21].
5. Conclusions
Within the present study, teleacupuncture using data
analysis of different parameters like HR and HRV in the
time and frequency domain was performed for control of
possible stimulation effects of acupuncture in patients
with depression in Harbin. The acupuncturists in China
were informed about the findings immediately after the
data analysis which was performed in Graz.
The following conclusions can be drawn from this
teleacupuncture study:
Firstly, stimulation at the acupoint Jianshi (PC5) sig-
nificantly decreased HR in depression patients.
Secondly, total HRV increased significantly during
and after acupuncture, always immediately following
needle stimulation.
Thirdly, the balance between sympathetic and para-
sympathetic activity (LF/HF ratio reduction) changed
markedly during and after manual needle acupuncture.
Fourthly, we have shown that teleacupuncture over a dis-
tance of about 8,500 km can lead to new insights into basic
and clinical questions concerning acupuncture research.
6. Acknowledgements
This work was supported by the Austrian Federal Minis-

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76
tries of Science and Research and of Health and the
Eurasia Pacific Uninet (project “Bioengineering and
clinical assessment of high-tech acupuncture - a Sino-
Austrian research pilot study”); and the OeNB Ju-
biläumsfonds (project 13463) and performed within the
areas “Sustainable Health Research” and “Neuroscience”
at the Medical University of Graz.
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