Effect of enpishin (press tack acupuncture needles) on autonomic function, WBC count and oxidative stress

doi:10.4236/health.2011.37072

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Vol.3, No.7, 437-443 (2011)

doi:10.4236/health.2011.37072

Health

Effect of enpishin (press tack acupunctur e needles) on

autonomic function, WBC count and oxidative stress

Mitsunori Tsumaki1, Yoshitomo Saita1, Hiroshi Ikeda1, Kazuo Kaneko1, Takehiko Yukishita2,

Keiko Lee2, Sungdo Kim2, Shinichi Yokota2, Nobuhiro Suetake2, Hiroyuki Kobayashi2*

1Department of Orthopaedics, Graduate School of Medicine, Juntendo University School of Medicine, Tokyo, Japan;

2Department of Hospital Administration, Graduate School of Medicine, Juntendo University School of Medicine, Tokyo, Japan.

*Corresponding Author: koba@juntendo.ac.jp

Received 27 April 2011; revised 27 June 2011; accepted 13 July 2011.

ABSTRACT

Acupuncture as a vital component of traditional

medical systems of the Far East has been used

to restore and maintain health for over three

millennia. However, the neurobiological corre-

lates of this therapy remain largely unknown.

The purpose of this study was therefore to de-

termine the effect of enpishin acupuncture (pre-

ss tack needles (PTN)) on autonomic function,

WBC count, and oxidative stress between sub-

jects that received either verum or placebo PTN

treatment. Twenty men (mean(SD) age: 36.7(5.1)

years) who provided oral consent were ran-

domized to receive either verum PTN (n = 9) or

placebo PTN (n = 11). Bi-Digital O-Ring Test

(BDORT) was used to select the acupoints for

each participant. Autonomic function and oxi-

dative stress level were analyzed before and

after the treatment via heart rate v ariability (HRV)

and free radical analysis system (FRAS4), re-

spectively. Pre- and post-treatment WBC count

was also evaluated. Verum PTN group had a

statistically significant increa se ( p = 0. 008) in Ln

TP, an index of overall autonomic activity. Sub-

jects in this group also had a significantly

greater (p = 0.006) variation in Ln TP than the

placebo PTN group in response to the treatment.

Similarly, Ln HF of subjects receiving verum

PTN showed a marked increase (p = 0.0026) af-

ter the treatment. Moreover, a significantly

greater (p < 0.001) variation in mean Ln HF be-

fore and after the treatment was noted in the

verum group than the placebo group, reflecting

a greater parasympathetic activation in the

former. In contrast, sympathetic activity was not

significantly influenced by verum PTN based on

the lack of observed changes in LF/HF ratio. In

addition, both groups failed to demonstrate

significant variations in pre- and post-treatment

mean Ln LF/HF ratio. Further, no significant in-

tergroup difference was found with regard to

mean variation in Ln LF/HF ratio. Ver um PTN did

not induce significant changes in WBC count

and markers of oxidative stress, namely reac-

tive oxygen species (ROM) and biological anti-

oxidant potential (BAP). How ever, a comparison

of variations in pre- and post-treatment mean

WBC count showed a significant difference (p =

0.020) between the two treatment modes: verum

group showed a slight increase (225 ± 384.5),

while placebo group showed a minimal de-

crease (–190 ± 272.6). Our findings suggest tha t

PTN increases overall autonomic activity, par-

ticularly the parasympathetic function.

Keywords: Heart Rate Variability; Press Tack

Needles; Acupoints; Bi-Digital O-Ring Test;

Oxidative Stress

1. INTRODUCTION

Acupuncture as a vital component of traditional med-

ical systems of the Far East has been used to restore and

maintain health for over three millennia. It has become

one of the most popular complementary and alternative

medicine (CAM) modalities in the West, most notably in

England and the United States [1-3].

Acupuncture is an invasive procedure in which a

stainless steel needle of 0.2 - 0.4 mm width is inserted

about 1-3 cm into the tissue at a specific acupuncture or

trigger point in the body [4]. It has been used to treat a

vast array of medical conditions as well as sports-related

injuries and muscle fatigue [5-7]. Some of its putative

effects include analgesia and improvement in cardio-

vascular function and peripheral circulation [8,9]. Ac-

M. Tsumaki et al. / Health 3 (2011) 437-4 43

438

cording to the 1997 statement issued by the National

Institute of Health (NIH) Consensus Panel on Acupunc-

ture, there is “clear evidence” of acupuncture’s efficacy

for postoperative or post-chemotherapy nausea and vom-

iting, and “reasonable evidence” in relieving menstrual

cramps, tennis elbow, fibromyalgia, postoperative dental

pain, lower back pain, myofascial pain, and epicondylitis

[10]. More recently, teleacupuncture using computer-

controlled heart rate variability (HRV) analysis per-

formed trans-continentally has shown that acupuncture

influences the autonomic nervous system (ANS) as re-

flected in changes in the sleep-wake cycle [11]. However,

the efficacy and mechanism of acupuncture have not

been clarified from a Western medical perspective and

there is still a paucity of data from prospective random-

ized controlled trials, resulting in differing opinions

among physicians regarding the efficacy of acupuncture.

Japanese style acupuncture is known to be one of the

gentler forms of needling, nonetheless, it may cause pain

or minor bruising during insertion into the skin and

muscles and thus discourage sensitive patients and ath-

letes from seeking such skin-penetrating treatments, es-

pecially before exercising or a competition. For these

reasons, enpishin (a.k.a. press tack needles (PTN)) was

developed in Japan to provide a less invasive alternative.

These minimally invasive needles are 0.2 mm wide and

0.6 mm long and are virtually risk-free from causing

tissue damage or infection. Previous studies have found

PTN to be efficacious for the treatment of muscle fatigue

and pain [10,12,13] as well as for pain and mood distur-

bances related to low back pain [14]. Despite its wide-

spread use, scientific evidence demonstrating its efficacy

is scarce. The aim of this study was therefore to evaluate

the effects of PTN on autonomic function, WBC count,

and oxidative stress in verum and placebo PTN groups,

and in so doing determine the therapeutic value of PTN.

2. STUDY PARTICIPANTS AND

METHODS

2.1. Stud y Participants

The protocol of this study was approved by the Insti-

tutional Review Board (IRB) at Juntendo University, and

oral consent was obtained from all participants. Twenty

men (mean(SD) age: 36.7(5.1) years) were randomized

to receive either verum PTN (n = 9) or placebo PTN (n =

11). Participants were blinded to treatment allocation

and were briefed on the purpose and nature of the study,

as well as the physical and mental burden of participat-

ing in the study. All eligible participants were non-

smokers, free from underlying diseases such as hyper-

tension, hyperlipidemia, cardiovascular disease, and dia-

betes, and denied ongoing use of cardiovascular medica-

tions, sedative hypnotics, anxiolytics, or other psycho-

tropic medications. On the test day, participants with a

body temperature below 37˚C, without pronounced fa-

tigue, with more than 6 hours of sleep before the test,

and who had refrained from alcohol consumption were

included in the study. Measurements were performed

between 10:00 and 18:00 hours to account for circadian

variations in ANS. Participants were asked to abstain

from all foods and drinks 3 hours prior to the test, and to

empty their bladder shortly before the test. After a

20-minute rest, measurements were taken in a sitting

position while a respiratory rate of 13 breaths per minute

was maintained. All measurements and tests were car-

ried out under quiet conditions in a temperature and hu-

midity controlled (24˚C, 60%) laboratory.

2.2. Methods

2.2.1. Enpishin (Press Tack Acupuncture

Needles (PTN))

Single-use Pyonex PTN (0.2 mm diameter × 0.6 mm

length, Seirin Co. Ltd, Shizuoka, Japan) and placebo

PTN were used in the study. PTN had an adhesive plas-

ter that affixed them on the skin. Acupoints on the body

were first marked and PTN were embedded in the skin

overlying these points. Verum PTN was indistinguish-

able in physical appearance from placebo PTN unless

the end of the tack was felt with a fingertip. Placebo

PTN had a blunt tip that did not pierce the skin, however,

it created a sensation similar to that of skin puncture and

tissue penetration, making it difficult for the subjects to

discriminate between the two PTNs (Figures 1(a) and

1(b)) [15].

2.2.2. Selection of Acupoints

For this study, acupoints located on the wrist and the

upper abdomen conducive for regulating the autonomic

and immune systems were selected from the list (Table

1). The Bi-Digital O-Ring Test (BDORT) was performed

in all participants to select the acupoints that maximized

the treatment effect of PTN in each participant. BDORT

is a non-invasive, diagnostic test that utilizes changes in

finger strength as an index of electromagnetic resonance.

Participants were asked to place one finger on each acu-

point lightly and sequentially, while simultaneously

touching the tips of the thumb and one finger (e.g. index

finger) of the opposite hand to form an “O” (O-ring or a

fairly perfect circle). The examiner (acupuncturist) then

exerted a pull on the O-ring with both of his index finger

and thumb while the participant resisted. The partici-

pant’s finger strength was compromised and O-ring

pulled apart easily if the opposite hand was touching an

afflicted acupoint [16,17]. Acupoints that corresponded

M. Tsumaki et al. / Health 3 (2011) ***-* **

439

(a)

(b)

Figure 1. (a) Physical appearance of verum PTN vs placebo

PTN. (b). Needle tip of verum PTN.

Table 1. List of acupoints used in treatment (WHO 2000)

[18].

Wr ist HT7, PC7, LU9, LI5, TE4, SI5

Upper abdomen LR14, ST19, CV12, CV15

with the most significant drop in finger strength were

selected for the treatment. A total of three points (one

from each body area) were selected and marked with a

red pen. Electrical devices such as cell phones, home

electrical appliances, and medical devices that emit elec-

tromagnetic frequencies and interfere with BDORT were

removed from a 3-meter radius of the testing area.

2.2.3. Autonomic Indexes Based on HRV

Analysis

ANS consists of sympathetic and parasympathetic

nerves that work antagonistically to modulate the rhythm

of the heartbeat. Sympathetic dominance occurs during

stress response such as nervous tension and agitation,

while parasympathetic predominance slows heart rate.

Thus the extent of autonomic influence and factors that

affect it such anxiety and stress can be estimated by

measuring heart rate and R-R interval variability.

HRV analysis consists of time and frequency domain

analysis. The standard deviation of beat-to-beat intervals

(SDNN) obtained from time domain measures reflects

fluctuations in heart rate due to respiratory sinus ar-

rhythmia and serves as the marker of parasympathetic

activity [19]. Frequency domain analysis is accom-

plished by a power spectral analysis of time domain

measures of HRV. The Total Power (TP) is the total NN

interval spectral power and the measure of overall ANS

activity [20]. The R-R interval is the distance between

the two largest spikes (R wave) in the EKG. The spectral

analysis of R-R interval variations yields High Fre-

quency (HF) (>0.15 Hz) and Low Frequency (LF) (0.04

- 0.15 Hz) components. The major contributor to the HF

component is the parasympathetic portion of cardiac

autonomic modulation. HF typically corresponds to res-

piratory sinus arrhythmia and therefore primarily reflects

respiration-mediated HRV. Conversely, the LF compo-

nent reflects the interplay of both sympathetic and para-

sympathetic modulation of heart rate. A similar consid-

eration applies to the ratio of HF and LF as an index of

sympathovagal balance. The current consensus is that

the LF/HF ratio and HF reflect sympathetic and para-

sympathetic activity, respectively [21]. The frequency

domain parameters are obtained from fast Fourier

Transform (FFT) spectral analysis. In this study, fre-

quency domain measures, including very low frequency

(VLF), HF, LF, LF/HF ratio, and total power (TP) were

used as outcome measures.

2.2.4. White Blood Cell (WBC) Count

Blood (10 cc) from the cubital vein using a blood col-

lection vacuum tube was used to determine the WBC

count. Differential WBC count was not evaluated in this

study.

2.2.5. Oxidative Stress Test

Free radical analytical system (FRAS4) was used to

evaluate the status of the endogenous antioxidant de-

fense system. FRAS4 (Diacron International, Italy) con-

sists of d-ROM test (reactive oxygen metabolites) and

BAP test (biological antioxidant potential) to provide a

global assessment of oxidative stress and antioxidant

capacity. For our experiment, one drop of blood from the

vein of the fingertip (20 μL) was used for both tests. The

rationale behind the d-ROM and BAP tests to determine

the level of oxidative stress and antioxidant capacity is

as follows. When free radicals attack and react with var-

M. Tsumaki et al. / Health 3 (2011) 437-4 43

440

ious substances in the body such as lipids, amino acids,

proteins, and nucleotides, these substances in turn be-

come peroxidized and prompt intracellular formation of

hydroperoxides (ROOH). The d-ROM test measures the

blood concentration of ROMs, primarily ROOH (optical

measurement, 505/546 nm), as the level of free radicals

in the body. These are measured in CARR.U. units, with

one CARR.U. equaling 0.08 mg/dL of hydroperoxide.

Meanwhile, BAP test evaluates the redox effect by mea-

suring the substances in the serum with reduction poten-

tial. Venous blood samples are mixed with Fe(III)-con-

taining reagents, then the amount of discoloration in the

Fe(III)-reduced sample is determined by a photometer.

The amount of redox-active iron ions that reacts with the

blood sample is an estimate of the antioxidant potential,

which is expressed as μM or μEq/L.

2.3. Acupuncture Intervention

Before conducting the PTN treatment, HRV analysis

and blood tests were carried out in all participants. Addi-

tionally, HRV analysis was performed before the blood

draw to prevent the pain of venipuncture from affect-

ing autonomic functions. While participants remained

quietly seated, a probe was attached to the left index

finger to measure their HRV for 3 minutes using the

APG Heart Rater SA-3000P (Tokyo Iken, Japan). Blood

tests included WBC count, ROM test as an index of

oxidative stress, and BAP test as an index of antioxidant

power.

After a 5-minute rest following the blood tests and

upon cessation of bleeding, verum or placebo PTN was

embedded in the acupoints selected individually for each

participant via BDORT by the same licensed acupunc-

turist with over 30 years of clinical experience. Blinding

of the acupuncturist was achieved by having the practi-

tioner place PTN on the skin without viewing the needle

tip. Participants remained quietly seated during the 10-

-minute treatment.

HRV analysis and blood tests were repeated after the

PTN treatment. All assessments were performed by an

observer blinded to treatment allocation.

2.4. Statistical Analysis

Autonomic parameters (TP, LF, HF, and LF/HF ratio)

generated from HRV analysis were logarithmically

transformed to obtain a normal distribution. Pre- and

post-treatment means of Ln TP, Ln LF, Ln HF, Ln

LF/HF ratio of the verum and placebo PTN groups were

calculated, and the changes in mean values in each group

were determined using the Wilcoxon signed-rank test.

Treatment effect was estimated from changes in mean

values, and the difference in these changes between the

two groups was also determined by the Wilcoxon sig-

ned-rank test. Similarly, the difference between pre- and

post-treatment means of WBC count, ROM, and BAP, as

well as the difference in mean values between the two

groups were analyzed. The significance level for all cas-

es was set at 5%. The SPSS Ver.11.5 software was used

for all analyses.

3. RESULTS

3.1. Autonomic Function

Table 2 lists pre- and post-treatment autonomic pa-

rameters (mean ± SD), and Ta b l e 3 lists the changes in

these means.

Verum treatment resulted in a significant increase in

mean Ln TP (p = 0.008), Ln LF (p = 0.028), and Ln HF

(p = 0.008), whereas placebo treatment resulted in a sta-

tistically significant decrease in mean Ln HF (p = 0.026).

When compared with placebo PTN, verum PTN in-

duced significantly greater changes in mean Ln TP (p =

0.006: Table 2), Ln LF (p = 0.020), and Ln HF (p <

0.001).

3.2. WBC Count, BAP and ROM

Pre- and post-treatment WBC count, BAP, and ROM

(mean ± SD) are shown in Table 4. The changes in these

means are summarized in Tab le 5. Our data showed that

there were no significant differences in pre- and post-

treatment means of WBC count, ROM and BAP between

the treatment modes (verum vs placebo). However, there

Table 2. Pre- and post-treatment HRV parameters (mean ± SD).

Verum PTN group Placebo PTN group

Before After Before After

Mean SD Mean SD

Ln TP 6.52 1.15 7.43 0.82 0.008 7.56 1.30 7.45 0.92 0.424

Ln LF 5.48 1.24 6.48 1.15 0.028 6.78 1.46 6.40 1.26 0.091

Ln HF 5.17 1.64 5.90 1.11 0.008 5.39 0.86 5.02 0.84 0.026

Ln LF/HF 0.30 1.30 0.57 1.33 0.441 1.39 0.95 1.38 1.05 0.722

M. Tsumaki et al. / Health 3 (2011) ***-* **

441

Table 3. Changes in HRV parameters (mean ± SD).

Verum PTN group Placebo PTN group

Mean SD Mean SD

Ln TP 0.91 0.62 –0.10 0.81 0.006

Ln LF 1.00 1.11 –0.38 0.64 0.020

Ln HF 0.73 0.68 –0.37 0.46 0.000

Ln LF/HF 0.27 0.90 –0.02 0.65 0.503

Table 4. Pre- and post-treatment WBC count, ROM and BAP (mean ± SD).

Verum PTN group Placebo PTN group

Before After Before After

Mean SD Mean SD

WBC 6812.5 2882.2 7037.5 944.9 0.127 5480 3182.1 5290.0 986.0 0.057

ROM 1978.3 179.5 1977.8 124.2 0.889 2133.7 158.4 2169.5 83.3 0.541

BAP 319.5 41.2 326.5 45.6 0.401 343.2 31.7 329.2 53.3 0.110

Table 5. Changes in WBC count, ROM and BAP (mean ± SD).

Verum PTN group Placebo PTN group

Mean SD Mean SD

WBC 225 384.5 –190 272.6 0.020

ROM –0.5 154.2 35.8 93.9 0.722

BAP 7.0 28.8 –14.0 27.3 0.183

was a significant difference (p = 0.002) in changes in

mean WBC count between the two treatments: verum

PTN (225 ± 384.5) and placebo PTN (–190 ± 272.6).

4. DISCUSSION

The main finding from our study was that verum PTN

increased overall autonomic function, in particular, the

parasympathetic activity. Verum PTN resulted in a sig-

nificant increase in Ln TP as well as in changes in mean

Ln TP than those produced by placebo PTN, suggesting

an enhanced overall ANS activity. Similarly, verum

treatment significantly increased Ln HF and changes in

mean Ln HF than placebo treatment, underscoring its

ability to augment parasympathetic function. By contrast,

a significant change in sympathetic function was not

observed after the verum treatment, as observed from the

lack of statistically significant changes in mean Ln

LF/HF. In addition, there was no statistical intergroup

difference in changes in mean Ln LF/HF ratio to indicate

any PTN effect on sympathetic tone.

Verum PTN did not induce significant changes in

WBC count, ROM, and BAP. However, there was a sig-

nificant difference in changes in mean WBC count be-

tween verum and placebo PTN groups: WBC count of

the former increased slightly while it decreased margin-

ally in the latter. Interestingly, a small increase in WBC

count in the verum PTN group was observed within 10

minutes of the treatment. Rapid changes in blood chem-

istry following a mild, superficial stimulation of 0.6 mm

depth with PTN are intriguing findings that warrant fur-

ther investigation.

Based on our findings, PTN acupuncture augmented

parasympathetic input without affecting the sympathetic

tone. According to Nishijo, the efficacy of acupuncture

can be explained in part by neural reflexes: stimulation

of skin and subcutaneous tissue induces a reflex via a

parasympathetic efferent pathway, while deep needling

into the muscles induces a reflex via a sympathetic

β-receptor efferent pathway [22]. In fact mild, superfi-

cial stimulation with PTN is purported to selectively

activate parasympathetic nerves. From these findings,

we hypothesize that PTN would more efficacious than

deep needling with thicker Chinese needles for the treat-

M. Tsumaki et al. / Health 3 (2011) 437-4 43

442

ment of certain conditions such as tension headaches

produced by sympathetically mediated vasoconstriction.

The pain-relieving effect of acupuncture has garnered

much attention since the release of Chinese reports on

acupuncture anesthesia, however pain relief is not the

only indication for acupuncture as it is a therapeutic in-

tervention designed to improve health in general. In fact,

studies have shown that excitation of the polymodal re-

ceptor by acupuncture may activate or modulate the en-

docrine, immune, and autonomic systems to produce

multifarious therapeutic effects [23]. Unfortunately, there

is still little research on the efficacy of acupuncture tech-

niques that employ shallow insertions such as PTN. Most

studies on PTN have investigated its musculoskeletal

effects such as alleviation of muscle soreness after en-

durance activities like marathon or triathlon. Several

studies on intradermal or shallow acupuncture have fou-

nd that such acupuncture can relieve periarthritic pain in

the shoulder [24], ameliorate post-thoracotomy pain [25],

reduce postoperative pain after abdominal surgery [26],

and beneficially influence lipid metabolism in simple

obesity [27]. To our knowledge our study is the first to

examine the neurobiological correlates of PTN that are

not related to pain modulation.

A few studies have demonstrated that acupuncture

stimulation enhances NK cell activities [28] and modu-

lates the number and ratio of immune cell types [29].

Although differential leukocyte count was not evaluated

in this study, we anticipate that further investigation will

reveal a selective increase in lymphocytes than granulo-

cytes, based on previous reports and our own findings

that showed improved vagal tone after PTN treatment.

Regarding the lack of antioxidative response, we sur-

mised that a minimally invasive procedure like PTN did

not stress the body significantly to warrant a defense

response by the host. It might also be possible that a

short treatment with few PTN compared to protocols

employed in clinical practice (i.e., longer treatment time

and more PTN) failed to achieve a meaningful influence

on oxidative stress.

In summary, our findings suggest that PTN enhances

overall autonomic activity, especially the vagal tone, and

may activate WBCs. However, inter-individual varia-

tions in pre- and post-treatment HRV parameters among

our participants indicate that studies with a larger sample

size are needed to confirm our results. Furthermore, an

exploration of the effects of different acupoint combina-

tion and needle retention time in different population

groups will help clarify the efficacy of PTN acupunc-

ture.

5. CONCLUSIONS

Our findings suggest that PTN increases overall auto-

nomic activity, particularly the parasympathetic func-

tion.

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