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Gerhard Gerhard Litscher Litscher and and Detlef Detlef Schikora Schikora (Eds.) (Eds.)

Laserneedle- Laserneedle-

Acupuncture Acupuncture

Science

and

Practice

Detlef Schikora Schikora (Eds.) (Eds.) Laserneedle- Laserneedle- Acupuncture Acupuncture Science and Practice P ABST
Detlef Schikora Schikora (Eds.) (Eds.) Laserneedle- Laserneedle- Acupuncture Acupuncture Science and Practice P ABST

PABST

III

Gerhard Litscher and Detlef Schikora

(Eds.)

Laserneedle - Acupuncture

Science and Practice

(Eds.) Laserneedle - Acupuncture Science and Practice PABST SCIENCE PUBLISHERS Lengerich, Berlin, Bremen, Miami,

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>.

This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. 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 given is 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 Department of Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine Auenbruggerplatz 29 8036 Graz / Austria Tel. ++43 316 385-3907, -83907 Fax ++43 316 385-3908 E-mail: gerhard.litscher@meduni-graz.at

Detlef Schikora, PhD University of Paderborn Faculty of Science Warburger Straße 100 33095 Paderborn / Germany Tel. ++49 5251 60-3566 Fax ++49 5251 60-3490 E-mail: schikora@upb.de

© 2005 Pabst Science Publishers, 49525 Lengerich, Germany

Printing: D+L Printpartner GmbH, 46395 Bocholt, Germany

ISBN 3-89967-199-6 (Europe), ISBN 1-59326-074-1 (USA)

V

Preface

This compendium of „Laserneedle-Acupuncture“ conveys scientific and first practical results from the field of laserneedle acupuncture in an abridged and concise form.

Just the thought of being pricked with needles is very uncomfortable for many people. Using the new, advanced laserneedle acupuncture method up to eight laserneedles are applied to the skin simultaneously, however, without puncturing the skin. Thus, painless, non-invasive acupuncture is possible for the first time.

First public presentation of the laserneedle-system was in the year 2000 at the Medica fair in Düsseldorf. Three years of intensive scientific research and developmental work preceded.

The basic idea of laserneedles originated from analysis of laser acupuncture, which was developed and spread throughout Europe in the 1990´s. It was obvious, that the technique of classic acupuncture as it had been practised for centuries, namely the simultaneous stimulation of therapy-specific acupoint combinations, became to leave its natural course. Today and in the past, acupoints are stimulated one after another using laser light, even though no evidence regarding identical effects achieved with Traditional Chinese Medicine has been documented in classic or modern literature. Suddenly, the simultaneous puncturing of acupoints according to the basic scheme of Chinese acupuncture was no longer important when practicing the Western method of laserpuncture.

With the development of laserneedles, the goal to maintain the fascination of acupuncture itself was pursued: the complex diagnostic systemic approach on the one hand, and the simple manner of therapeutic application and its effects on the other. Simultaneous procedures, simple, manual handling during needle acupuncture with needle-equivalent stimulation effects and stimulation characteristics were the developmental goals of our laserneedle project.

The main part of this volume includes „Peer-Review“ studies and thus, represents a scientifically substantiated work dealing with laserneedle acupuncture in particular and acupuncture in general. Noted scientists and well-known users have taken part in this book and reported about the scientific investigations and use of this new, advanced method in the field of acupuncture.

VI

Non-invasive laserneedle stimulation can induce specific, reproducible effects in the brain. This is expressed by changes in different parameters such as cerebral blood flow velocity, which can be objectified using modern neuromonitoring methods for the first time. The results in this book show that cerebral effects induced by the new, painless laserneedle technique lie within similar dimensions as those evoked by manual needle acupuncture. For the first time, laserneedle acupuncture allows simultaneous optical stimulation of individual acupoint combinations. At the same time, variations in acupuncture on the body, ear or hand, as performed in our first study were made possible. Based on these investigations, the cerebral effects of laserneedle stimulation could be systematically objectified, specified and optimized for the first time. These scientific findings do not only have extensive consequences in laser medicine, but also build an important bridge between traditional Eastern and innovative Western medicine.

Contact between the editors of this compendium developed in a typical modern way: per e-mail. Professor Litscher from the Medical University of Graz reported his interest in performing studies with laserneedle acupuncture to the University of Paderborn. Dr. Schikora from Paderborn answered back that he was very interested. What developed from this contact is documented in this book. Currently studies with laserneedle acupuncture are being performed in several University Clinics in Germany, Austria, Switzerland and France. All of these studies will contribute to a better understanding and objectification of effects not only for acupuncture with laserneedles but also for classic acupuncture and promote the use of this comprehensive, natural medical treatment method. Scientists agree that the 21 st Century will be the Century of Photons, like the 20 th Century was the Century of Electrons. It is certain, that exact understanding of the elementary interaction of photons with biological molecules, will lead to new, natural medical treatment methods which will reach far beyond acupuncture.

Detlef Schikora

University of Paderborn

January 2005

Gerhard Litscher

Medical University of Graz

VII

Contents

1. Laserneedles in acupuncture

1

1.1 Introduction and motivation

1

1.2 Dose-effect relationships in acupuncture

4

1.3 Laserneedle acupuncture as a placebo method

7

1.4 Physical characteristics of laserneedles

11

1.5 Acknowledgements

16

1.6 References

 

16

2. Cerebral vascular effects of noninvasive laserneedles measured by transorbital and transtemporal Doppler sonography

18

2.1 Introduction

 

18

2.2 Methods

20

 

2.2.1

Non-invasive laserneedles

20

2.2.2

Multidirectional transorbital and transtemporal Doppler sonography

22

2.2.3

Participants

23

2.2.4

Acupuncture and procedure

23

2.2.5

Statistical analysis

25

2.3 Results

25

2.4 Discussion

27

2.5 Conclusion

28

2.6 Acknowledgements

29

2.7 References

 

29

3. Near-infrared spectroscopy for objectifying cerebral effects of needle and laserneedle acupuncture

32

3.1 Introduction

 

32

3.2 Methods

32

 

3.2.1

Near-infrared spectroscopy

32

3.2.2

Laserneedle stimulation

33

3.2.3

Healthy volunteers, acupuncture, measurement procedure

34

3.2.4

Statistical analysis

36

3.3 Results

36

3.4 Discussion

38

3.5 Acknowledgements

41

3.6 References

 

41

4. Communication between acupoint and brain proved by ultrasound

43

4.1

Introduction

43

VIII

4.2.1

TCD monitoring of the anterior and posterior cerebral arteries with a new probe holder

43

4.2.2

Participants

44

4.2.3

Laserneedle acupuncture

45

4.2.4

Statistical analysis

48

4.3 Results

48

4.4 Discussion

53

4.5 Acknowledgements

55

4.6 References

55

5. Histological investigations regarding micromorphological effects of laserneedle illumination. Results of an animal experiment

57

5.1 Introduction

57

5.2 Methods

57

5.2.1

Procedure

57

5.2.2

Laserneedle stimulation

59

5.2.3

Laser Doppler flowmetry and temperature measurement

59

5.3 Results

60

5.4 Discussion

61

5.5 Acknowledgements

62

5.6 References

62

6. Effects of laserneedle stimulation on microcirculation and skin temperature

64

6.1 Introduction

64

6.2 Method and volunteers

64

6.2.1

Laser Doppler flowmetry

64

6.2.2

Volunteers and procedure

65

6.2.3

Statistical analysis

67

6.3 Results

67

6.4 Discussion

70

6.5 References

72

7. Effects of acupressure, manual acupuncture and laserneedle acupuncture on EEG bispectral index (BIS) and spectral edge frequency (SEF) in healthy volunteers

73

7.1 Introduction

73

7.2 Material and methods

73

7.2.1 Subjects

73

7.2.2 Procedure and study design

74

7.2.3 Evaluation parameters

76

IX

7.3 Results

77

7.4 Discussion

81

7.5 Acknowledgements

85

7.6 References

85

8. Acupuncture using laserneedles modulates brain function:

first evidence from functional transcranial Doppler sonography (fTCD) and functional magnetic resonance imaging (fMRI)

87

8.1 Introduction

87

8.2 Methods

88

8.2.1

Painless laserneedles

88

8.2.2

Functional multidirectional transcranial Doppler sonography (fTCD)

88

8.2.3

Functional magnetic resonance imaging (fMRI)

89

8.2.4

Participants

89

8.2.5

Experimental design and procedure

89

8.2.6

Evaluated parameters

91

8.2.7

Statistical analysis

92

8.3 Results

92

8.4 Discussion

96

8.5 Conclusions

98

8.6 Acknowledgements

98

8.7 References

98

9. Quantification of gender specific thermal sensory and

pain thresholds before and after laserneedle stimulation

101

9.1 Introduction

101

9.2 Method

101

9.2.1

Volunteers

101

9.2.2

Measurement of thermal sensitivity and thermal pain thresholds

102

9.2.3

Laserneedle acupuncture and procedure

103

9.2.4

Statistical analysis

105

9.3 Results

105

9.4 Discussion

109

9.5 Acknowledgements

110

9.6 References

110

10. Biological effects of painless laserneedle acupuncture - a short summary of important scientific results

112

10.1 Introduction

112

10.2 Methods

112

X

10.2.2

Functional multidirectional transcranial Doppler- sonography (fTCD)

113

10.2.3

Functional magnetic resonance imaging (fMRI)

113

10.2.4

Near infrared spectroscopy (NIRS)

113

10.2.5

Laserneedle stimulation

113

10.2.6

Healthy volunteers, animal experiment and procedures

114

10.2.7

Statistical analysis

114

10.2.8

Evaluation parameters

115

10.3 Results

115

10.4 Discussion

121

10.5 Conclusion

122

10.6 Acknowledgements

122

10.7 References

122

11. Increases in intracranial pressure and changes in blood flow velocity due to acupressure, needle and laserneedle acupuncture?

124

11.1 Introduction

124

11.2 Material and methods

124

11.2.1

Volunteers, patient, acupressure and procedure

124

11.2.2

Measurement techniques, evaluation parameters

and statistical analysis

126

11.3 Results

127

11.4 Discussion

131

11.5 Acknowledgements

133

11.6 References

133

12. Laserneedle acupuncture - clinical studies

135

12.1 Introduction

135

12.2 Material, patients and methods

136

12.3 Results

139

12.3.1

Lumbar, thoracic and cervical spine syndromes as well as post cervical and lumbar intervertebral disk prolapse

139

12.3.2

Gonarthrosis, coxarthrosis, rhizarthrosis, periarthritis in the shoulder, epicondylitis, tendinitis, Morbus Bechterew and fibromyalgia-syndrome

140

12.3.3

Remaining paresis after stroke

141

12.3.4

Cephalgia, migraine and trigeminal neuralgia

142

12.3.5

Arterial obstruction disease

143

12.3.6

Gastropathy and bronchial asthma

143

12.3.7

Depression, anxiety, panic attacks, psychovegetative exhaustion

143

XI

12.4 Discussion

144

12.5 References

145

13. Pain therapy with laserneedle acupuncture

147

13.1 Introduction

147

13.2 Case reports

147

13.3 Argumentation

148

13.4 Discussion

150

13.5 References

151

14. Pain therapy of osteoarthrosis / osteoarthritis-patients using the laserneedle system in a medical practice with emphasis on rheumatology and pain therapy

152

14.1 Introduction

152

14.2 Patients and method

152

14.3 Results

154

14.4 Discussion

154

14.5 References

155

15. Laserneedles in gynecology

156

15.1 Introduction

156

15.2 Material, test persons, technique

157

15.3 Case studies

158

15.3.1 Induction of labor with laserneedles

158

15.3.2 Carpal tunnel syndrome

160

15.3.3 Urogenital symptoms, back pain, hot flushes

161

15.3.4 Breast cancer with mastectomy, transmission in scars 162

15.3.5 Dysmenorrhoea, lack of energy

164

15.3.6 Childlessness, temperature curve, cycle regulation

165

15.4 Results and discussion

166

15.5 References

168

16. Laserneedles in gynecology - a study with questionnaires

169

16.1 Introduction

169

16.2 Test persons

169

16.3 Method

170

16.4 Results

171

16.5 Discussion

177

16.6 References

178

17. Laserneedle therapy in dentistry

179

17.1 Introduction

179

17.2 Methods and materials

179

XII

17.3.1 Oral surgery

179

17.3.2 Endodontology

180

17.3.3 Crown - bridges

181

17.3.4 Pain therapy

181

17.3.5 Myoarthropathy

181

17.3.6 Neuralgia

182

17.3.7 Sedation in case of dental phobias

182

17.3.8 Nausea during molding

182

17.4 Discussion

183

17.5 References

183

18. Laserneedle stimulation as a potential additive method for post operative pain treatment

185

18.1 Introduction

185

18.2 Method

185

18.2.1

Patients and procedure

185

18.2.2

Laserneedle acupuncture

186

18.2.3

Statistical analysis

187

18.3 Results

187

18.4 Discussion

188

18.5 Acknowledgements

189

18.6 References

189

19. Effects of laserneedle stimulation in the external auditory meatus on very early auditory evoked potentials

190

19.1 Introduction

190

19.2 Methods

190

19.2.1

Laserneedle stimulation in the external auditory meatus

190

19.2.2

Auditory evoked potentials of early latency

191

19.2.3

Volunteers and procedure

192

19.2.4

Statistical analysis

193

19.3 Results

193

19.4 Discussion

195

19.5 Acknowledgements

198

19.6 References

199

20. List of references

200

21. Websites

202

XIII

Editors (and authors):

Gerhard Litscher, Prof MSc PhD MDsc Department of Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine, Medical University of Graz Auenbruggerplatz 29

8036 Graz / Austria

Detlef Schikora, PhD

Faculty of Science University of Paderborn Warburger Strasse 100

33098 Paderborn / Germany

Authors:

Konrad B. Borer, MD Therwilerstrasse 11

4153 Reinach BL / Switzerland

Franz Ebner, Prof MD

MR Research Unit and Clinical Department of Neuroradiology Medical University of Graz Auenbruggerplatz 9

8036 Graz / Austria

Franz Fazekas, Prof MD

Department of Neurology, Medical University of Graz Auenbruggerplatz 22

8036 Graz / Austria

Rudolf Helling, MD

1 st Chairman of the ‘Ärzte-Forum für Akupunktur e.V.’ Ostenallee 107

59071 Hamm / Germany

Evamaria Huber Department of Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine, Medical University of Graz Auenbruggerplatz 29

8036 Graz / Austria

XIV

Knut Kolitsch, MD General practitioner and expert for special pain therapy Oelzer Straße 12 98746 Katzhütte/Thüringen / Germany

Wolfgang Nemetz, MD Department of Anesthesiology for Neurosurgical and Craniofacial Surgery and Intensive Care, Medical University of Graz Auenbruggerplatz 29

8036 Graz / Austria

Dagmar Rachbauer, MSc MDsc Department of Neurology, Medical University of Graz Auenbruggerplatz 22

8036 Graz / Austria

Stefan Ropele, Prof PhD

Department of Neurology and MR Research Unit Medical University of Graz Auenbruggerplatz 22

8036 Graz / Austria

Matthias Saraya, MD

Department of Anesthesiology for Neurosurgical and Craniofacial Surgery and Intensive Care, Medical University of Graz Auenbruggerplatz 29

8036 Graz / Austria

Andreas Schöpfer, MD

Department of Anesthesiology for Neurosurgical and Craniofacial Surgery and Intensive Care, Medical University of Graz Auenbruggerplatz 29

8036 Graz / Austria

Gerhard Schwarz, Prof MD

Department of Anesthesiology for Neurosurgical and Craniofacial Surgery and Intensive Care, Medical University of Graz Auenbruggerplatz 29

8036 Graz / Austria

XV

Josef Smolle, Prof MD University Clinic for Dermatology, Medical University of Graz Auenbruggerplatz 8

8036 Graz / Austria

Kirsten Stähler van Amerongen, MD Gynecological Clinic Inselspital Berne University of Berne Effingerstrasse 102

3010 Bern / Switzerland

Selman Uranüs, Prof MD

Department of Surgical Research, University Surgical Clinic, Medical University of Graz Auenbruggerplatz 29

8036 Graz / Austria

Lu Wang, MD Dipl. Acup. Department of Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine, Medical University of Graz Auenbruggerplatz 29

8036 Graz / Austria

Michael Weber, MD Dipl. Chem. General practitioner, emergency medical aid, naturopathic treatment, acupuncture Lönsstraße 10 37697 Lauenförde / Germany

Nai-Hua Yang, Prof MD

University Clinic for Ophthalmology, Medical University of Graz Auenbruggerplatz 4

8036 Graz / Austria

Acknowledgements

The editors thank Mrs. Ingrid Gaischek MSc (Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine, Medical University of Graz) for skillful preparation of the text and illustrations and Mrs. Sonya Mendlik-Bauer for translating a major part of the manuscripts.

1

1. Laserneedles in acupuncture

D. Schikora

1.1 Introduction and motivation

In the past 30 years, acupuncture established itself in Europe and America. Patients perceive acupuncture as an effective, non-medicinal form of treatment which conforms to the increasing desire of living a natural and balanced life. Particularly in case of chronic pain, patients attested the predominantly satisfactory results of acupuncture, especially since side effects of long term drug treatment can be ruled out with this method. In 1998, a great advancement was made leading to the acceptance of acupuncture in Western medicine. After a Consensus Conference, the United States National Institute of Health concluded that acupuncture was proven effective in cases of post operative nausea and vomiting, nausea and vomiting accompanying chemotherapy, as well as post operative tooth pain [1]. Acupuncture was also rated for the following indications: addictive illnesses, menstrual pain, headaches, tennis elbow, fibromyalgia, back pain, carpal tunnel syndrome, bronchial asthma as well as for alternative or complementary treatment after stroke. At this conference, it was emphasized that side effects of competently performed acupuncture are rare and compared with conventional therapies seem to be much more favourable [2].

Even today, the acceptance of acupuncture in some fields of western medicine is problematic particularly because no objectified proof regarding the effects of acupuncture is available. Critics fail to see, that many excellent scientific studies exist, particularly regarding acupoint-analgesia, which provide a detailed picture of physiological pain reduction achieved by acupuncture treatments. Currently, over 200 scientific publications dealing with the elementary mechanisms of acupoint-analgesia exist. Especially the leading studies by Pomeranz and Chiu [3], as well as those by Mayer et al. [4] which deal with the analgesic effect of acupuncture resulting from an increased release of ß-endorphin, establish the complex picture of neuro- biological basics of acupoint-analgesia [5]. A systematic overview and critical rating of the current level of knowledge regarding neurobiological mechanisms in acupoint-analgesia were recently documented by Irnich and Beyer [6]. In the meantime, the acupuncture-endorphin-hypothesis could be proven in a number of different independent animal experiments. The ability to block the analgesic effect of acupuncture by injecting an opiate antagonist in the

2

acupoint is a strong indication that the afferent nervous system plays a role in transmitting the effects of acupuncture. All of these scientific results conform to the knowledge of modern pain research regarding the role of endorphins and are described to such an extent, desirable for other well- established western medical methods. The fact that these scientific results are mainly obtained from animal studies, underlines their objectivity. On the clinical level, the situation is fundamentally different. Numerous single-case and controlled studies have been documented, however definite evidence for the effects could not be proven up to this day. Of course we must note that classic needle acupuncture cannot be investigated using randomised, double- blind study designs. Neither the patient, nor therapist can be blinded, since the patient always feels the insertion or stimulation of the applied needle and the therapist always must control the position, puncture depth and angle of insertion. There is no doubt that acupuncture has to be proved in the future by objectivized, double-blind clinical trials. However, this is only possible, when an adequate placebo method for classic needle acupuncture is available. Such a method does not exist up to this date; the placebo needle used by Streitberger et al. [7] does not fulfil the requirements of a double-blind study design. The development of a real placebo method for classic needle acupuncture is definitely of initial importance for further acupuncture research and establishing acupuncture as a medical treatment method. The goal of recent extensive field studies (GERAC-Study, Model study by German private insurance companies) was to prove or refute the efficacy of acupuncture treatment in selected indications using clinically controlled methods on a statistically significant level. Objectified, clinical evidence of effects could not be obtained in these studies for the named reasons. The initial idea of laserneedles resulted from analysis of laser acupuncture, developed and spread throughout Europe in the 1990´s. It was obvious, that the century-old technique of classic acupuncture or simultaneous stimulation of therapy specific acupoint combinations began to leave its natural course. Acupoints are stimulated one after the other, even though no evidence in classic or modern literature is given, that identical effects occur. Suddenly, the puncturing of acupoints according to the basic schemes of Chinese acupuncture was no longer important in Western “Laserpuncture”. With the development of laserneedles, we tried to maintain the fascinating aspects of acupuncture: the complex diagnostic system on the one hand, the simple therapeutic procedure and the effects on the other. The simultaneous procedure, simple handling adapted to needle acupuncture, needle equivalent stimulation effects and stimulating characteristics, were the most important goals of laserneedle acupuncture. Thus, laserneedles should be applied non- invasively by direct contact between the light emitting source and the skin. It was always clear, that quantitative documented proof of the postulated equivalence between laserneedle and classical metal needles is necessary.

3

An important, but not yet investigated question concerns the connection between stimulation strength and the effects of acupuncture. We know that an inserted acupuncture needle must be moved and repositioned by the therapist to increase stimulation intensity resulting in the De-Qi sensation. This effect is not easy to quantify since the intensity of stimulation triggered by needle puncture is also not quantifiable. How the stimulation intensity at the acupoint influences the effect of acupuncture still remains an unanswered question in this context. If we assume that acupuncture is not more than a specific kind of nerve stimulation, the question arises, whether this form of acupoint stimulation correlates with the dose-effects known from the field of bio-physiology, and underlies the Weber-Fechner-Law. With laserneedles, the light dose applied at any desired acupoint combination can be measured exactly. Compared to other classic metal needles, the stimulus strength can be quantified so that determination of dosis-effect relationships is possible. A basic assumption regarding stimulation characteristics i.e. the timing factor of stimulus intensity has to be made for experimental investigation of dose-effect relationships in acupuncture. In our first approach we assumed that the nocizeptive stimulus triggered by the classic metal needle is a continuous constant stimulation which lasts as long as the needle is inserted. In order to be equivalent to this stimulation mode, the laserneedles should act in the so-called continuous wave modus. Equivalence between both needle types can only be assumed under these circumstances. Frequency-modulated laser light is generally not equivalent to the application procedure of the classic needle acupuncture. The physical characteristics of laserneedles determine their physiological influence in tissue. We have been performing theoretical studies for some time dealing with the elementary interaction between photons and complex, biological molecules. Using molecular-dynamical methods of theoretical physics, we are able to calculate and predict the interaction of electrons or photons with complex molecules, as well as the effects of molecular excitation and basic relaxation on molecular surroundings. However, this is only possible when quasi elastic scattering processes between the photons and biological molecules are the predominant interactive processes. If we assume that elementary stimulation in acupuncture is generated on a molecular level, molecular-dynamic calculation shows [8], that electrical and optical stimulation show physiologically identical results and also generate and maintain a rhythmic cascade of action potentials at the nozizeptive structures as those produced when chemical transmitters such as substance P and bradykinine are released after needle puncture. These results can define the most important physical marginal requirements for the emission characteristics of the laserneedles: the emission wave lengths should be selected in a such a way, that quasi elastic scattering processes are dominant and emission intensity at the distal output of the laserneedle should be so

4

Reizwirkung [a.u.]

stimulus effects [a.u.]

high, that responses relevant for acupuncture can be triggered by optical stimulation.

1.2 Dose-effect relationships in acupuncture

One of the fundamental biophysiological laws, the Weber-Fechner´s Law, describes the relationship between strength of perception E of a sensory stimulus and intensity of the stimulus S. As a result, the stimulus effect and stimulus response correlate and can be described with the following logarithm:

E ~ ln S

This proportionality does not imply more than that the doubling of stimulus strength not automatically leads to doubling of perception or effects of the stimulus. If we illustrate this simple relationship graphically, two important characteristics become visible and are shown in Figure 1.1.

5 4 3 2 1 0 0 2 4 6 8 10
5
4
3
2
1
0
0
2
4
6
8
10

stimulus strength [a.u.]

Reizstärke [a.u.]

Fig. 1.1: Relationship between stimulus strength and stimulus effects according to Weber-Fechner ´s Law.

The curve illustrates threshold characteristics of physiological stimulation. Sensory stimuli do not lead to any effects when stimulus intensity lies under

5

a critical threshold value. Weak external influences are filtered out by the organism. Moreover, the curve shows the saturation characteristics of physiological stimuli. Thus, a doubling of stimulus strength does not lead to the doubling of effects within the organism. Finally, this is an expression for the adaptability of the organism to external stimulation, whose intensities can vary over many orders of magnitude. Validity of Weber-Fechner´s Law has been proven for acoustic, thermal, chemical and mechanical stimuli. In our experiments, we investigated if this physiological law is also applicable to acupuncture, e.g. if stimulus strength at the acupoint and the resulting induced specific effects are correlated. For this purpose, laserneedles with different optical power density were used. Power densities which are effective on the skin were varied from 1.5 – 5 W/cm². In order to compare the effect of laserneedles under identical circumstances, parallel experiments using classic metal needles were also performed. The blood flow velocity in the ophthalmic artery (OA) and its changes during stimulation of an eye specific acupuncture scheme were studied in this Preliminary studies showed that the simultaneous stimulation of acupoints Zanzhu and Yuyao, the acupoints eye and liver on the ear, as well acupoints E2 from Korean hand acupuncture and Yan Dian from Chinese Hand acupuncture led to significant and specific increases in blood flow velocity (OA) when using metal needles or laserneedles [9] (compare chapter 2). The specific effect on the visual system could be proven by the parallel measurement of blood flow velocity in the middle cerebral artery, which remained constant i.e. did not show any changes in measurement results when using this acupuncture scheme. Measurement of blood flow velocity was performed with transorbital and transtemporal Doppler sonography. Blood pressure was registered before, during and after measurement. Treatment time was 10 minutes and blood flow velocity data was monitored continuously. A randomised, cross-over study design was used and each volunteer underwent acupuncture with laserneedles, as well as with metal needles. The study protocol was approved by the ethics commission of the Medical University of Graz, reasons for exclusion of volunteers (n = 27) were treatment with medication, visual disorders, as well as neurological and psychological deficits. Figure 1.2 shows the detected dependency of blood flow velocity in the OA as a function of power density from the laserneedles.

6

metal needle laserneedle - power density [W/cm 2 ] change in blood flow velocity [cm/s]
metal needle
laserneedle - power density [W/cm 2 ]
change in blood flow velocity [cm/s]

Fig.1.2: Change in blood flow velocity in the OA in dependence on the power density of the laserneedles during stimulation of an eye-specific acupuncture scheme. The mean changes measured in metal needle acupuncture are marked with a line.

Figure 1.2 clearly shows that acupuncture of the seven eye-specific acupoints leads to a significant increase in blood flow velocity in the OA. Metal needles yield an increase from 10 cm/s to 18 cm/s. It is obvious that changes in blood flow velocity are dependent upon the optical power densities applied when using laserneedle acupuncture. The curve conveys the best analytical adaptation of measurement values. This curve satisfies the mathematical function f (x) = c x ln (x + 0.5). This indicates that blood flow velocity in the OA is an effective parameter for acupuncture treatment and is logarithmically dependent on the stimulus intensity of the laserneedles. Thus, we can conclude, that Weber-Fechner´s Law is valid for the dose-effect relationship examined here. The threshold value I* for optical power density can be calculated from the registered and analytically determined effect curve; I* = 1.3 W/cm². This indicates that the optical power density of the laserneedles must be greater than 1.3 W/cm² in order to activate the physiological effects of acupuncture. In addition, we can see that the needle equivalence in optical power densities of the laserneedles reach I 5 W/cm². We can assume that an increase in blood flow velocity in the OA is based on a complex cerebral reaction resulting from acupoint

7

stimulation, preceded by multi-synaptic switching of optically induced acupuncture stimulation potentials. It is noteworthy, that despite the physiological complexity, the logarithmic relationship between stimulus strength I and stimulus effect is maintained. We interpret this as obvious proof, that specific effects of acupuncture underlie these logarithmic dose-effect relationships. The existence and validity of dose-effect relationships in acupuncture could be proven for the first time using the methods described here. This statement is strictly valid only when using laserneedles which trigger continuous permanent stimulation, thus allowing exact quantification of stimulus strength. To what extent low or high frequency modulation of laserneedle light can modify proven dose-effect relationships is unclear and must be investigated in further studies. Since the postulated equivalence between metal needles and laserneedles could be clearly shown in the examined context, we can conclude that classical acupuncture and its effects also should be functionally dependent on stimulus strength according to a potency rule.

1.3 Laserneedle acupuncture as a placebo method

The requirements of an adequate placebo needle and an adequate placebo method for classical needle acupuncture are clearly to define:

The requirements of a placebo needle are:

1. The placebo needle should not generate any acupuncture effect

2. The placebo needle should be of identical shape and size compared to the verum needle and therefore should not be distinguishable from a verum acupuncture needle

3. The application procedure of the verum needle and the placebo needle should be identical

4. The application procedure of the verum needle and the placebo needle should not depend on the individual experiences of the treating physician

5. The perception of the placebo needle and the verum needle at the acupoint by the patient should be identical

The requirements of an acupucnture placebo method are:

1. The fundamental rules of the classic acupuncture have to be preserved, in particular the simultaneous needling of any acupoint combination should be possible with the placebo method

8

2. The direct contact between the treating physician and the patient has to be minimized by the placebo method, to exclude any healing effect by the aura of the physician

If the placebo needle and the placebo method meets all this requirements, a double blind clinical study can be performed. We know that needle puncture at desired skin points also leads to effects that are similar to those resulting from stimulation of acupoints. For that reason, this type of acupuncture is called sham-acupuncture. A further demand on the placebo method would be to establish a clear definition between the categories of verum-acupuncture, placebo-acupuncture and sham- acupuncture. Based on these criteria the applicability of laserneedle acupuncture as a placebo method for classic needle acupuncture can be analyzed precisely. We already mentioned that laserneedles are not inserted into the skin, but applied to the skin at the acupoint. This non-invasive method of application is an important characteristic of laserneedle acupuncture. Our studies with more than 250,000 practical applications of laserneedles show that laserneedle stimulation with distal optical power densities of about 5 W/cm² are not perceived as a stimulus sensation by the majority of patients and volunteers. Of course the threshold of laser light stimulation is different and variable from person to person, however, laserneedle stimulation with a primary emission wavelength of 685 nm at acupoints on the body is not perceivable for most patients. The cerebral effects generated by laserneedle acupuncture were investigated systematically using multi-directional functional Doppler sonography, near-infrared spectroscopy (NIRS) and functional magnetic resonance imaging [10]. In other chapters of this book we show that laserneedles with power 5 W/cm² lead to specific changes in cerebral blood flow velocity during stimulation of visual acupoints nearly identical to those in needle acupuncture. In addition to these experimental studies, the effects of acupuncture regarding changes in cerebral oxyhaemoglobin concentrations were investigated. Here, a visual acupuncture scheme was used and in this case, non-specific cerebral parameters could be analysed. This was done using a randomized, cross-over design with direct comparison between metal needle and laserneedle stimulation. Details from these experiments are described in

[11].

Measurement of cerebral concentrations of oxyhaemoglobin and desoxyhaemoglobin were done using NIRS: Figure 1.3 shows the results of these measurements dependent on the optical power of the laserneedles.

9

metal needle laserneedle - power [mW]
metal needle
laserneedle - power [mW]

Fig. 1.3: Changes in cerebral oxyhaemoglobin concentration when using a visual acupuncture scheme with metal needles and laserneedles of different optical power. The curve shows the best analytical adaptation to the measurement values of laserneedle stimulation.

The experimental data in Figure 1.3 show that laserneedle stimulation with an optical power of about 40 mW leads to changes in oxyhaemoglobin concentration, similar to the effects when using metal needles. The equivalency between metal needle stimulation and laserneedle stimulation can also be proven with these cerebral effects. These experiments also yield the best analytical adaptation of the measurement results in a logarithmic function, i.e. cerebral oxyhaemoglobin concentration parameters also underlie a physiological dose-effect relationship. The definition of verum-acupuncture, placebo-acupuncture and sham- acupuncture presents a fundamentally unsolved and principally unsolvable problem for classic acupuncture with metal needles. We examined the possibilities to differentiate and define these three modalities experimentally for laserneedle acupuncture. Hereby, acupoint combinations were stimulated with laserneedles, which according to traditional Chinese medicine are coherent with the visual or olfactory system. Figure 1.4 shows the scheme of visual distant points used.

10

10 Fig. 1.4: Distant acupuncture points Hegu, Zusanli, Kunlun and Zhiyin of the visual system (left)
10 Fig. 1.4: Distant acupuncture points Hegu, Zusanli, Kunlun and Zhiyin of the visual system (left)

Fig. 1.4: Distant acupuncture points Hegu, Zusanli, Kunlun and Zhiyin of the visual system (left) and the selected sham-points (right).

Stimulation of the olfactory system was done with acupoints Yinxiang, Pianli and Hegu. Changes in blood flow velocity in the posterior cerebral artery (PCA) and anterior cerebral artery (ACA) were used for determining the effects of acupuncture stimulation and registered with functional Doppler sonography. In addition, changes in activity in the frontal area and olfactory cortex were detected using functional MR-imaging. Detailed information regarding these measurements [10] are described in chapter 8.

A randomised, controlled cross-over study design was used and can be

divided in the following test situations:

The verum situation, characterized by activated laserneedles at the selected acupoint, the placebo-situation characterized by non-activated laserneedles at the acupoints and the sham-situation, characterized by activated laserneedles at the selected sham-points. The verum-situation showed a specific, significant increase in blood flow velocity in the PCA and ACA in our volunteers (n = 41), resulting in

specific, significant activity in the occipital and olfactory cortex visible in MR-imaging. No significant changes in functional Doppler sonography and

in functional MR-imaging were registered in the placebo-situation or sham-

situation. From these experimental studies, we conclude that a clear differentiation between verum-acupuncture and placebo- or sham-acupuncture is possible in regard to laserneedle acupuncture. In this context, the basic difference between acupuncture with laserneedles and with metal needles becomes obvious and fulfils and important criterion for an adequate placebo- acupuncture method. Since the reproducible De-Qi sensations can be

11

triggered with laserneedle acupuncture and the proven cerebral effects do not pose special demands regarding the positioning of the laserneedles, we conclude that acupuncture with laserneedles fulfils all requirements of a complete placebo experiment. We want to emphasize that the proven physiological equivalence between metal needles and laserneedles applies to all of the reports and scientific results achieved with laserneedles and in turn is also valid for classic needle acupuncture. Therefore, the use of laserneedle acupuncture, performed in randomised, double-blind studies, can be of great advantage for clinically objectifying the effects of acupuncture.

1.4 Physical characteristics of laserneedles

The laserneedles were developed at the University of Paderborn to provide a therapeutically and methodically equivalent, non-invasive instrument to the classic metal needle.

non-invasive instrument to the classic metal needle. Fig. 1.5: Laserneedle for acupuncture. Figure 1.5 shows a

Fig. 1.5: Laserneedle for acupuncture.

Figure 1.5 shows a laserneedle. You can see that laserneedles are acupuncture needles with optical fibres that can be applied to the skin in such a way that the distal light emitting region of optical fibre is in contact with the surface of the skin. A major goal of these scientific studies was to develop photonic acupuncture needles for simultaneous stimulation of selected acupoint combinations on the body and ear which can be used in the exact same way as metal needles, The optical power densities at the distal laserneedle exit were set in such a way, that metal needle equivalent stimulation effects are guaranteed.

12

Physical foundation of stimulation effects in the numerous experimental studies is the emission of laser light with a wavelength of 685 nm (red light) as well as the complementary emission of infrared laser light with wavelengths of 880 – 950 nm. Hence, laserneedles emit “bi-chromatic“ light with a power density of 5 - 10 W/cm² at the exit of the laserneedle. Complementary, bi-chromatic emission is based on light conversion, i.e. red laser light also activates the infra-red photons in the light wave conductor. Laser light leaving the laserneedle is coherent and is routinely examined with Michelson-Interferrometry regarding its characteristics of coherence. Chronological and spatial coherence of emitted photons is immediately lost when entering the skin and diffuse scattering becomes a determining factor. The physiologically determinant power density range of 5 - 10 W/cm² is achieved by a specially developed method of optical tailoring of the fibre core. In Table 1.1 we can see that this method is very effective, when we want to reach a maximum of power density with a minimum of laser strength.

Laser power

Laser-spot diameter

Optical power density

at the skin

50

mW

5 mm

0.25

W/cm²

50

mW

0.5 mm

25.5

W/cm²

50

mW

0.05 mm

2550 W/cm²

Tab. 1.1: Connection between laser power, laser-spot diameter and optical power densities.

Exemplary calculations show that a power density of 0.25 W/cm 2 results when laser power of 50 mW and spot-diameter of 5 mm at the skin, commonly used in one-hand, laser-pens is applied. In order to reach the required physiological range of power density for the laserneedles, a 20 W laser must be used! As illustrated in Table 1.1, reduction of the spot- diameter by the factor 10 leads to an increase in optical power densities by a factor of 100. The emission characteristics of laserneedles described here, in particular regarding the optical power densities affecting the skin from 5 - 10 W/cm², as well as the bichromatic emissions of red and infrared laser light are based on patented technologies only realised in laser-acupuncture needles and are available under the trade name LASERneedle ® [12].

13

Contact application guarantees that the applied light dose can be exactly determined and reproduced. The next figure (Fig. 1.6) graphically illustrates how much light energy is transferred from a laserneedle during acupuncture treatment into the skin.

60 50 40 30 20 10 0 0 5 10 15 20 25 applied light
60
50
40
30
20
10
0
0
5
10
15
20
25
applied light energy dose per laserneedle [J]

duration of treatment [min]

Fig. 1.6: Light dose of a laserneedle dependent on the duration of treatment.

In order to determine the entire optical power transferred into tissue during stimulation of acupoints, the value in the graph needs only to be multiplied with the number of laserneedles applied. Transmitted light energy of about 320 J, equivalent to about 80 cal or that contained in less than a half teaspoon of yogurt, resulted after a treatment time of 20 minutes, using 8 laserneedles. In this chapter, we have already noted, that the emission wave length of laserneedle light should be selected in such a way, that quasi elastic scattering processes in tissues are dominant and the adsorption of photons can be neglected.

Figure 1.7 shows the absorption behaviour of the most important tissue structures, dependent on the emission wave length of laser light.

14

14 Fig. 1.7: Absorption behaviour of important tissue structures dependent on the emission wave length of

Fig. 1.7: Absorption behaviour of important tissue structures dependent on the emission wave length of laser light.

Figure 1.7 shows that all important tissue structures from the skin yield a minimum in absorption coefficients ranging from 550 -1100 nm within the electromagnetic spectrum. This is particularly true for water, oxyhaemoglobin and melanin. In this “window”, the absorption of photons and production of heat can be neglected since the scattering of photons on tissue molecules is the dominant interactive process. Therefore, this range is very suitable for optical stimulation at the surface of the skin. The depth which photons can reach with diffuse, elastic scattering processes is once again dependent on the wave length. Simple estimates show that even at a depth of 2 - 3 cm, photon densities exist, which can trigger molecular activity at nocizeptive structures. Light wave conductors available today are made of plastic (PMMA), quartz or sapphire and have comparably little absorption in the „window“ area, so that conduction losses in the optical fiber are practically neglectable.

Laserneedles use semi-conductor laser diodes as a light source. Figure 1.8 shows a semi-conductor laser diode schematically.

15

15 Fig. 1.8: Schematic illustration of a semi-conductor laser diode. We can see that lasers consisting

Fig. 1.8: Schematic illustration of a semi-conductor laser diode.

We can see that lasers consisting of mono-crystalline (Ga, Al, In) As are about 1 x 0.5 x 0.1 mm in size, and are about as big as a salt grain. The optically active area of a semi-conductor laser diode is once again smaller by a factor of 1000 and is comprised of layers that are only a few nanometres thick. The fact that the light field emitted by a laser diode doesn’t have a circular, but rather an elliptical diameter, is of decisive importance for optical fibre laserneedles. Since the standard light wave conductors available today have a circular diameter they lead to optical losses when an elliptical light field is fenced in a round fibre core. These loses are relatively low and according to technical standings, losses in a fiber are less than 10 %.

The optical power densities alone and not the primary laser strength are responsible for the physiological stimulation effects of laserneedles at the acupoint. The results from our studies show that metal needle equivalent acupuncture can only be performed within a range of 5 - 10 W/cm². Today, we attribute power densities of 10 W/cm² to the field of photodynamic therapies. The question, whether power densities in this range lead to histologic damage is of great importance and was investigated experimentally by our study group [13] (see chapter 5). In an animal study, we could prove that no micromorphologic changes occurred during 20 minute application of laserneedles with about 5 W/cm². Neither micro- thrombosis or extravasation could be proven, nor changes in endothelial cells of dermal blood vessels could be observed.

Thermic interaction at the acupoint was determined with infrared thermography. As a result, a heating effect of laserneedle light can be neglected. We measure an increase in temperature of about 1 °C at the

16

immediate contact area during a 20 minute treatment period. If we discuss the conditions during head- and ear acupuncture with laserneedles, we must consider that light intensity in the skin decreases exponentially and is weakened to about 50 % of the initial value when it reaches the skull. Since the stratum corneum, epidermis and dermis have different refractive indexes for optical light, wave transmitting effects occur in the layers of the skin which distribute the laser light laterally over an area of about one to 2 cm². As a result, a proportional reduction in optical power densities up to two magnitudes of order and the power density of laserneedle light is reduced to physiologically unimportant values after transmission through the skin. Transmitted part of the radiation of the laserneedles is completely absorbed by the skull. Using animal experiments, we could also show that no laserneedle-radiation (continuous wave modus) at the surface of the cortex can be observed [14].

Today, the new laserneedles for acupuncture provide instruments which are extensively characterized in medical-scientific studies. About 750,000 acupuncture treatments with laserneedles are performed worldwide in the last two years. In particular, patients appreciate this painless but still effective method of acupuncture. The medical potential of this new acupuncture method is huge. At the moment, ten University Clinics in Germany, Austria, Switzerland and France are perfoming scientific studies. The goal of these studies is to study and understand the basics of acupuncture and to get a step closer to the clinical objectification of the effects of acupuncture.

1.5 Acknowledgements

The author would like to thank all of his colleagues who took part in the development of laserneedles.

1.6 References

[1]

NIH Consensus Conference (1998) Acupuncture. JAMA 280: 1518-

1524

[2]

Yamashita H, Tsukayama H, Hori N, Kimura T, Tanno Y (2000)

[3]

Incidence of adverse reactions associated with acupuncture. J Altern Complement Med 6: 345-350 Pomeranz B, Chiu D (1976) Naloxone blockade of acupuncture

[4]

analgesia: endorphin implicated. Life Sci 19: 1757-1762 Mayer DJ, Price DD, Rafil A (1977) Antagonism of acupuncture analgesia in many by the narcotic antagonist naloxone. Brain Res 2:

368-372

17

[5]

Pomeranz B (1998) Wissenschaftliche Grundlagen der Akupunktur.

[6]

Springer, Berlin-Heidelberg-New York-London-Paris-Tokio-Hongkong Irnich D, Beyer A (2002) Neurobiologische Grundlagen der

[7]

Akupunkturanalgesie. Schmerz 16: 93-102 Streitberger K, Kleinhenz J (1998) Introducing a placebo needle into

[8]

acupuncture research. Lancet 352: 364-365 Frauenheim T, Schikora D (2003) J Med Phys, subm.

[9]

Litscher G, Schikora D (2002) Cerebral vascular effects of non-

[10]

invasive laserneedles measured by transorbital and transtemporal Doppler sonography. Lasers Med Sci 17: 289-295 Litscher G, Rachbauer D, Ropele S, Wang L, Schikora D (2004) Die schmerzfreie Lasernadelakupunktur moduliert die Gehirnaktivität:

Erste Nachweise mit funktioneller transkranieller Dopplersonographie (fTCD) und funktionellem Magnetresonanzimaging (fMRI). Schmerz & Akupunktur 1: 4-11

[11] Litscher G, Schikora D (2002) Near-infrared spectroscopy for objectifying cerebral effects of needle and laserneedle acupuncture. Spectroscopy 16: 335-342

[12]

Schikora D. Europäisches Patent EP01/08504

[13]

Litscher G, Nemetz W, Smolle J, Schwarz G, Schikora D, Uranüs S (2004) Histologische Untersuchungen zu mikromorphologischen Einflüssen von Lasernadelstrahlung - Ergebnisse einer tierexperimentellen Untersuchung. Biomed Tech 49: 2-5

18

2. Cerebral vascular effects of non invasive laserneedles measured by transorbital and transtemporal Doppler sonography

G. Litscher, D. Schikora

2.1

Introduction

The term "acupuncture" is used to refer to the insertion of needles into the body, at special chosen sites, for the treatment or prevention of symptoms and conditions. “Laserpuncture” is known as a method to stimulate sequentially acupoints by low level laser radiation. In contrast to that "laserneedles" allow to stimulate appropriate acupoint combinations simultaneously and with higher radiation doses and therefore represent a new non invasive optical stimulation which is described in this book. The laserneedles used in this study emit red light in cw-mode with an output power of 30 - 40 mW per laserneedle, which results in a radiant exposure energy of about 2.3 kJ/cm² at each acupuncture point during a treatment time of about 10 min. Due to the well defined contact application and the possibility to stimulate simultaneously up to eight acupoints, the laserneedles allow to attribute the resulting cerebral vascular effects unambiguous and exactly to the total laser radiation dose exposed at the acupuncture point combination selected. This opens the new scientific possibility to describe the input stimulus strength of complex acupuncture treatments with well established physical parameters. The aim of this study was to provide a possible first selective evidence of specific effects of laserneedle acupuncture and needle acupuncture on brain and eye using a combination of vision related acupoints of traditional Chinese medicine, Korean hand acupuncture and ear acupuncture. Quantification of differences in cerebral effects [1] between laserneedle acupuncture and needle acupuncture was performed using a randomized cross-over study design.

19

CC omputeromputer-- CC ontrolledontrolled LL aserpunctureaserpuncture CC omputeromputer-- CC ontrolledontrolled
CC
omputeromputer--
CC
ontrolledontrolled
LL
aserpunctureaserpuncture
CC
omputeromputer--
CC
ontrolledontrolled
AA
cupuncturecupuncture ®®
CC ontrolledontrolled AA cupuncturecupuncture ®® Fig. 2.1: Computer-Controlled Acupuncture ® (CCA ®

Fig. 2.1: Computer-Controlled Acupuncture ® (CCA ® ) [1] and Computer-Controlled Laserpuncture (CCL) with multidirectional ultrasound probe holder devices in the biomedical engineering lab of the Medical University of Graz. Details concerning the method can be found on the website http://litscher.info.

20

CC omputeromputer-- CC ontrolledontrolled LL aserpunctureaserpuncture LaserneedlesLaserneedles MED-UNI GRAZ
CC
omputeromputer--
CC
ontrolledontrolled
LL
aserpunctureaserpuncture
LaserneedlesLaserneedles
MED-UNI GRAZ

Fig. 2.2: The laserneedle system is a class 3B laser system, therefore it is compulsory to wear specific laser protection glasses.

2.2

Methods

2.2.1 Non invasive laserneedles

The non invasive laserneedles were constructed to fulfil two essential requirements of acupuncture [2]:

(i)

They allow the simultaneous stimulation of up to eight acupuncture points in any different combinations on the body, the head, the hands and the ears.

(ii)

The emitted laser intensity is so adjusted that a stimulus can be induced without destroying the surrounding tissue.

The laser radiation of eight 55 mW - laserdiodes was coupled into eight optical fibres and the laserneedles are arranged at the distal ends of the optical fibres. Due to coupling losses the output power of each laserneedle was reduced to 30 - 40 mW. The fibre core diameter used in the study was of about 500 µm. For our experiments seven vision related acupuncture points were chosen and irradiated simultaneously. The average time of irradiation was of about 10 min resulting in an energy density of about 2.3 kJ/cm² at

21

each acupoint and a total sum of 16.1 kJ/cm² for seven acupoints. To maintain the fundamental advantage of non invasiveness, the laserneedles were fixed onto the skin but not pricked into the skin. Fig. 2.3 depicts the measured intensity profile across the optical fibre output. The insert shows a photograph of the distal laserneedle end. Due to the direct contact of the laserneedles and the skin, no loss of intensity occurs and the laser power, which affects the acupuncture points, can by exactly determined by integration of the intensity curve shown in Fig. 2.3. Actually, the output intensity of each laserneedle was determined in such a way, resulting in an average irradiance intensity at one acupoint of about 3.8 W/cm².

1 laser-needle emission- characteristics emission wavelength: 685 nm total output power at distal end: 30
1
laser-needle emission-
characteristics
emission wavelength:
685 nm
total output power
at distal end:
30 mW
optical cladding
fibre core
a[tisnetni ].u.y

-2

-1

30 mW optical cladding fibre core a[tisnetni ].u.y -2 -1 11 2 optical fibre diameter [

11

2

optical fibre diameter [ a.u.]

Fig. 2.3: Emission characteristics of a tailored laserneedle used in the present study (a.u. = arbitrary units). The coherence of the laser radiation at the distal output of the optical fibre was examined by Michelson-Interferometry. The inset shows a photograph of the distal end of a laserneedle.

Due to the fact that the contact area exposed to laser rays is constant and the beam divergence can be neglected, the effective laser radiation dose at the acupoints was determined directly from the output intensity of the laserneedles and the treatment duration.

22

3500 3000 2500 2000 1500 1000 500 0 0 200 400 600 800 1000 1200
3500
3000
2500
2000
1500
1000
500
0
0
200
400
600
800
1000 1200 1400
eesal m ²/J[ytisnedygrenr ]c

time [s]

Fig 2.4: Energy density at the laser-needle contact area in dependence on the treatment time. Due to the contact type application, as well the exposed area as the laser intensity are constant and the laser radiation dose at the acupuncture point can be determined with high accuracy from treatment time.

2.2.2

Multidirectional

transorbital

and

transtemporal

Doppler

sonography

Transorbital and transtemporal Doppler sonographic examinations were performed with a Multi-Dop T unit (DWL Electronic Systems GmbH, Sipplingen, Germany). A 4 MHz and a 2 MHz probe were used in a multidirectional ultrasound probe holder construction. The monitoring arrangement for simultaneous recording of Doppler sonographic signals in the ophthalmic artery (OA) and the middle cerebral artery (MCA) was stationary at the circumference of the head. Blood flow profiles in the OA were measured transorbitally with the smallest power value able to detect signals (max. 20 mW/cm²). Under acoustic control, the angle and position of the probes were adjusted until the greatest possible signal amplitude was reached. Alterations in the blood flow velocities of both arteries were registered continuously and simultaneously. In addition blood pressure was measured non invasively before, during and after stimulation (Cardiocap® CC-104, Datex Medical Electronics, Hoevelaken, The Netherlands).

23

2.2.3 Participants

The study protocol was approved by the institutional ethics committee of the Medical University of Graz (11-017 ex 00/01) and all 27 participants gave written informed consent. Fourteen female and 13 male aged 21 - 38 years (mean age 25.15 + 4.12 ( x + SD) years) were examined. None of the subjects was under the influence of centrally active medication and had visual deficits. All persons were free of neurological or psychological disorders. They were paid for their participation.

2.2.4 Acupuncture and procedure

Seven vision related acupoints were tested in two sessions (laserneedle acupuncture and needle acupuncture) in the same persons. The acupuncture scheme consisted of two traditional Chinese acupoints: UB.2 Zanzhu (location: in the depression of the medial end of the eyebrow. Needling method: puncture transversely 0.5 - 0.8 cun) and Ex.3 Yuyao (location: at the midpoint of the eyebrow. Needling method: puncture transversely 0.3 - 0.5 cun). In addition two ear acupoints (eye and liver: locations see Fig. 2.5. Needling method: puncture perpendicular 0.3 cun) and two vision-related acupoints from Korean hand acupuncture (E2: location see Fig. 2.5. Needling method: puncture transversely 0.1 – 0.2 cun) and one from Chinese hand acupuncture (Yan Dian: location: on the ulnar side of the thumb distal to the first metacarpal bone. Needling method: puncture perpendicular 0.2 cun) were used [3-5]. Three different acupuncture systems were used together because the combination shows an enhanced effect of the parameters measured in the study [5].

24

Yuyao Zanzhu Liver Eye E2 Yan Dian

Yuyao Zanzhu

Liver

Yuyao Zanzhu Liver Eye E2 Yan Dian

Eye

E2

Yuyao Zanzhu Liver Eye E2 Yan Dian

Yan Dian

Fig. 2.5: Vision related acupuncture points used in this study. Traditional Chinese Medicine: Zanzhu and Yuyao. Ear acupuncture: eye and liver. Korean hand acupuncture: E2. Chinese hand acupuncture: Yan Dian.

The acupoints were punctured with sterile, single-use needles after local disinfection of the skin. We used three different types of needles (body: 0.25 x 25 mm, Huan Qiu, Suzhou, China; ear: 0.2 x 13 mm, European Marco Polo Comp., Albi, France; hand: 0.1 x 8 mm, Sooji-Chim, Korea). Needle stimulation was achieved by rotating with lifting and thrusting of the needles.

25

In case of laserneedle acupuncture the acupoints were cleaned with alcohol, the laserneedles were put in contact to the skin and stable fixed by plaster stripes. The acupoint scheme was the same as described above.

During the experiments the subjects were in a relaxed and comfortable position on a bed in our laboratory. Then the monitoring equipment was positioned. After a 10-minute resting period the laserneedles or acupuncture needles were applied. The choice for the initial stimulation was randomized.

The mean blood flow velocity (v m ) in the OA and the MCA were evaluated simultaneously and continuously [1]. Each person was studied with laserneedle acupuncture and needle acupuncture. The choice of the measuring procedure was randomized and the interval between the experiments was 20 to 30 minutes.

2.2.5 Statistical Analysis

The data were tested with Kruskal-Wallis ANOVA on ranks using the computer program SigmaStat (Jandel Scientific Corp., Erkrath, Germany). The results of the conditions before (a), during (b) and after (c) acupuncture were given as means ( x) + standard deviation (SD) or standard error (SE). The criterion for significance was defined as p < 0.05.

2.3

Results

The demographic data, the laser- and acupuncture schemes and the measurements of mean blood flow velocity in the OA and MCA are summarized in Fig. 2.6.

26

Participants n=27 14 female, 13 male, mean age 25.15 + 4.12 (SD), range 21 – 38 years Randomized, cross-over design

R Non invasive Laserneedles Manual Needle Acupuncture Ophthalmic artery (OA) 20 v m (cm/s) Ophthalmic
R
Non invasive Laserneedles
Manual Needle Acupuncture
Ophthalmic artery (OA)
20 v m (cm/s)
Ophthalmic artery (OA)
b
20
b
15
15
SE
p<0.001*
p=0.01*
10
10
c
a c
a
Middle cerebral artery (MCA)
Middle cerebral artery (MCA)
b
b
60
60
50
a
c
a c
40
before (a)
during (b)
after (c)
before (a)
during (b)
after (c)
Mean blood
Laserpuncture
x+ SE
Mean blood
Acupuncture
flow velocity
flow velocity
x+SE
Ophthalmic
10.33+0.88
14.67+1.15
11.33+0.96
Ophthalmic
10.22+0.83
19.15+1.20
12.22+0.94
artery (cm/s)
artery (cm/s)
Middle cerebral
54.93+3.28
54.56+3.26
55.07+3.50
Middle cerebral
53.93+3.33
56.04+3.44
55.04+3.47
artery (cm/s)
artery (cm/s)

*Kruskal-Wallis ANOVA on Ranks

Fig. 2.6: Subjects, acupoints, and graphical (means + standard error (SE)) as well as numeric data of the mean blood flow velocity of the ophthalmic artery (OA) and the middle cerebral artery (MCA) before (a), during (b), and after (c) stimulating with laserneedles or needling vision related acupoints in 27 healthy volunteers in a crossover design.

The results showed significant increases of v m in the OA during (b) laserneedle acupuncture (p = 0.01) and needle acupuncture (p < 0.001). At

27

the same time only minor, insignificant changes in v m were seen in the MCA. The mean arterial blood pressure (before laserneedle acupuncture:

79.2 + 6.6 (SD) mmHg; before needle acupuncture: 77.5 + 6.6 mmHg) was not significantly changed during laserneedle acupuncture (78.4 + 6.4 mmHg) or needle acupuncture (79.1 + 6.5 mmHg). The maximum amplitude of v m in the OA was detected with a delay of 10 - 30 sec after the initial stimulus by the needles and with a delay of 20 - 60 sec after the initial stimulus by the laserneedles.

2.4

Discussion

Important factors have led to the expanding use of laser technology in medicine. These factors are the increasing understanding of the wave-length selective interaction and associated effects of ultraviolet-infrared radiation with biologic tissues, including those of acute damage and long-term healing, the rapidly increasing availability of lasers emitting at those wavelengths that are strongly absorbed by molecular species within tissues, and the availability of both optical fiber and lens technologies [6]. Fusion of these factors has led to the development of the new laserneedle system which is described for the first time in scientific literature by our research group.

Acupuncture using laserneedles has the advantage that the stimulation can hardly be felt by the patient. The operator may also be unaware of whether the laserneedle system is active, and therefore true double-blind studies can be performed, which was almost impossible up to now in acupuncture research. The new system has the added advantage that it can be used at all standard acupuncture points [32].

The effectiveness of unconventional complementary medical methods, such as laserpuncture, have previously been documented mainly as single cases. There are only few theoretical and clinical studies concerning laserpuncture in scientific literature [7-16].

Recent scientific and technological progress has truly revolutionized acupuncture. The usage of advanced exploratory tools, such as laser Doppler flowmetry [17], laser Doppler imaging [18], ultrasound [1,5,19,20] or magnetic resonance imaging [1,21], provides revealing insights and attempt to shine scientific light upon the most spectacular of the eastern medical procedures.

Similar like in animal studies [22,23] we have found recently that the brain is the key to acupuncture’s and laserpuncture’s effects. New experimental

28

constructions to measure ultrasound, light and bioelectrical processes can reproducibly demonstrate effects of stimulation of acupoints in the brain

[1,5,19,20,24-28].

Studies with biosensors and probes in a specially designed helmet showed that acupuncture can increase significantly and specifically the blood flow velocity in different cerebral arteries and increase the oxygen supply to the brain [1,5,19,20,24,25,27,28]. Laserpuncture and manual needle acupuncture can also lead to an increase in oxygenated hemoglobin in the tissue oxygen index [20,29]. However, laserpuncture and needling at placebo points did not produce the same effects on cerebral oxygenation.

Laserpuncture has been established for many years and was reviewed by Pöntinen et al. [30]. Nonetheless, the changes of cerebral function elicited with commercially available low level lasers were in average one magnitude of order less pronounced than those elicited with conventional needle acupuncture [1,19,20,29].

Streitberger et al. [31] have reported that the stimulus strength at the acupuncture points are of decisive importance for the therapeutic efficiency of acupuncture treatments. Using placebo-needles in comparison with metal needles, it was found that the efficiency of acupuncture treatments decreases significantly, if placebo needles were used.

Our present study shows that the new high optical stimulation with laserneedles can elicit reproducible cerebral effects which are in the same order (half dimension) with respect to the maximum amplitude of the mean blood flow velocity (v m ) as compared to needle acupuncture. As it is shown in Fig. 2.3 the maximum blood flow velocity rate ratio v m (needle) / v m (laserneedle) for the acupuncture scheme selected is of about 2. Regarding the stimulus dynamics we found that the delay time between the initial stimulus and the occurrence of the maximum amplitude of v m is in the order of 10 - 60 sec for both methods. This allows to conclude that obviously the basic mechanism of signal activation and transmission are comparable for both acupuncture methods. Interestingly, the maximum flow rate for laserneedles was obtained after exposing a total (sum of seven acupoints) laser ray dose of about 1.6 kJ/cm².

2.5

Conclusion

In conclusion, the results of the laserneedle applications for acupuncture demonstrate specific, significant alterations in blood flow velocity of the ophthalmic artery after stimulating vision-related acupoints on the body, ear

29

and hand. At the same time blood flow velocity in the middle cerebral artery did not change significantly. For needle acupuncture qualitatively the same behavior was observed. The cerebral effects of the laserneedles were comparable to the alterations of the needle acupuncture, they differ absolutely by a factor of ~ 2. This is a significant improvement compared to the common low-level-handylaser (LLLT) acupuncture (cerebral effects factor ~ 10 lower as for needle acupuncture). Further studies using different laser stimulus intensities and wavelengths are in progress, to optimize the adjustment of the new noninvasive laserneedles and to clarify the elementary excitations at the acupoints.

2.6 Acknowledgements

The present report is the product of many co-workers. We are especially indebted to Ms. Lu Wang MD, Evamaria Huber, Ms. Petra Petz MSc and Ms. Ingrid Gaischek MSc (all Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine, Medical University of Graz / Austria) for their support to this study. We would also express our thanks to Dr. Leopold Dorfer, President of the Austrian Society for Controlled Acupuncture and to Dr. Michael Weber, Member of the EGFAA for their help. We thank Petra Thöne, Tanja Prohaska, Marianne Hubbert and Jörg Reitemeyer for technical support.

2.7 References

[1]

[2]

[3]

[4]

Litscher G, Cho ZH (Eds) (2000) Computer-Controlled Acupuncture ® . Pabst Science Publishers, Lengerich-Berlin-Rom-Riga-Wien-Zagreb Schikora D. European Patent Nr. PCT/EP 01/08504 König G, Wancura I (1989) Neue Chinesische Akupunktur. Lehrbuch und Atlas der Akupunkturpunkte. Wilhelm Maudrich, Wien-München- Bern Yoo TW (2001) Koryo hand therapy - Korean hand acupuncture. Eum Yang Mek Jin Publishing Co, Seoul

Wien-München- Bern Yoo TW (2001) Koryo hand therapy - Korean hand acupuncture. Eum Yang Mek Jin
Wien-München- Bern Yoo TW (2001) Koryo hand therapy - Korean hand acupuncture. Eum Yang Mek Jin
Wien-München- Bern Yoo TW (2001) Koryo hand therapy - Korean hand acupuncture. Eum Yang Mek Jin

[5] Litscher G (2002) Computer-based quantification of traditional Chinese-, ear- and Korean hand acupuncture: Needle-induced

changes of regional cerebral blood flow velocity. Neurol Res 24: 377-

380

[6]

Judy MM (1995) Biomedical lasers. In: Bronzino JD. (Ed) The

[7]

Biomedical Engineering Handbook. CRC Press, IEEE Press, Boca Raton (USA), pp. 1333-1345 Fargas-Babjak A (2001) Acupuncture, transcutaneous electrical nerve stimulation, an laser therapy in chronic pain. Clin J Pain 17 (4. Suppl):

30

[8]

Radmayr C, Schlager A, Studen M, Bartsch G (2001) Prospective

[9]

randomized trial using laser acupuncture versus desmopressin in the treatment of nocturnal enuresis. Euro Urol 40(2): 201-205 Naeser MA (1997) Neurological rehabilitation: acupuncture and laser

acupuncture to treat paralysis in stroke, other paralytic conditions, and pain in carpal tunnel syndrome. J Altern Complement Med 3(4): 425 -

428

[10] Read A, Beaty P, Corner J, Sommerville Ville C (1996) Reducing naltrexone-resistant hyperphagia using laser acupuncture to increase endogenous opiates. Brain Inj 10(12): 911-919

[11]

Troshin OV (1994) A clinico-neurophysiological analysis of the single

[12]

action of laser puncture. Lik Sprava 5-6: 148-153 Qin JN (1987) Laser acupuncture anaesthesia and therapy in People's

[13]

Republic of China. Ann Acad Med Singapore 16(2): 261-263 Nikolaev NA (1986) Therapeutic efficacy of laser and electropuncture reflexotherapy in correcting the initial manifestations of cerebral circulatory insufficiency. Zh Nevropathol Psikhiatr Im S S Korsakova 86(1): 60-64

[14] Omura Y (1983) Non-invasive circulatory evaluation and electro- acupuncture & TES treatment of diseases difficult to treat in Western medicine. Acupunct Electrother Res 8(3-4): 177-256 [15] Schlager A, Oehler K, Huebner KU, Schmuth M, Spoetl L (2000)

[16]

Healing of burns after treatment with 670-nanometer low-power laser light. Plast Reconstr Surg 105(5): 1635-1639 Schlager A, Offer T, Baldissera I (1998) Laser stimulation of

184-191

[17]

acupuncture point P6 reduces postoperative vomiting in children undergoing strabismus surgery. Br J Anaesth 81(4): 529-532 Sandner-Kiesling A, Litscher G, Voit-Augustin H, James RL, Schwarz

G (2001) Laser Doppler flowmetry in combined needle acupuncture and moxibustion: a pilot study in healthy adults. Lasers Med Sci 16(3):

[18]

Litscher G, Wang L, Huber E, Nilsson G (2002) Changed skin blood

perfusion in the fingertip following acupuncture needle introduction as evaluated by laser Doppler perfusion imaging. Lasers Med Sci 17: 19-

25

[19]

Litscher G, Wang L, Wiesner-Zechmeister M (2000) Specific effects of

[20]

laserpuncture on the cerebral circulation. Lasers Med Sci 15: 57-62 Litscher G (2001) High-Tech Akupunktur ® . Pabst Science Publishers,

Lengerich-Berlin-Rom-Riga-Wien-Zagreb [21] Cho ZH, Wong EK, Fallon J (Eds) (2001) Neuro-Acupuncture I.

[22]

[23]

Neuroscience Basics. Q-Puncture Inc, Los Angeles Ji G, Zhao L, Shi R, Liu Y, Wang S, Wu F (1996) Effects of electrical acupuncture on the cerebral blood flow and the pial microcirculatory blood flow in dogs. Zhen Ci Yan Jiu 21(2): 43-46 Uchida S, Kagitani F, Suzuki A, Aikawa Y (2000) Effect of acupuncture-like stimulation on cortical cerebral blood flow in anesthetized rats. Jpn J Physiol 50(5): 495-507

Effect of acupuncture-like stimulation on cortical cerebral blood flow in anesthetized rats. Jpn J Physiol 50(5):

31

[24]

Litscher G, Wang L, Yang NH, Schwarz G (1999) Computer-controlled

373-377

[25]

acupuncture. Quantification and separation of specific effects. Neurol Res 21(6): 530-534 Litscher G, Wang L, Yang NH, Schwarz G (1999) Ultrasound-

monitored effects of acupuncture on brain and eye. Neurol Res 21(4):

[26]

Litscher G, Yang NH, Schwarz G, Wang L (1999) Computer-controlled

[27]

acupuncture. A new construction for simultaneous measurement of blood flow velocity of the supratrochlear and middle cerebral arteries. Biomed Techn 44(3): 58-63. Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I (1998) Robotic

218

[28]

transcranial Doppler sonography probes and acupuncture. Int J Neurosci 95(1-2): 1-15 Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I, Eger E (1998)

[29]

Effects of acupuncture on the oxygenation of cerebral tissue. Neurol Res 20 Suppl 1: 28-32 Litscher G, Wang L (2000) Cerebral near infrared spectroscopy and

acupuncture - results of a pilot study. Biomed Technik 45(7-8): 215-

[30]

Pöntinen PJ, Pothmann R (1998) Laser in der Akupunktur.

Hippokrates, Stuttgart

[31]

Streitberger K, Kleinhenz J (1998) Introducing a placebo needle into acupuncture research. Lancet 352: 364-365

[32] Litscher G, Schikora D (2002) Effects of new noninvasive laserneedles on brain function. IFMBE Proceedings, 2 nd European Medical and Biological Conference (EMBEC) 4. - 8.12.2002 Vienna, pp. 996-997

32

3. Near-infrared spectroscopy for objectifying cerebral effects of needle and laserneedle acupuncture

G. Litscher, D. Schikora

3.1 Introduction

The connection between puncturing the body with a needle and the reaction at another area of the body is still unclear. However, it has been proven that when particular acupuncture points are stimulated with needles or laser light, specific effects in the brain can be objectivized and quantified with modern cerebral monitoring methods [1-3].

In this present study, we objectivized the systematic changes of oxygenation in the brain [4] using cerebral near-infrared spectroscopy (NIRS), after stimulating acupuncture points according to traditional Chinese medicine (TCM), Korean and Chinese hand acupuncture, ear acupuncture and combinations of these different methods.

We analyzed a total of 328 recordings after manual needle and laserneedle stimulation from 88 healthy volunteers [5,6].

3.2 Methods

3.2.1 Near-infrared spectroscopy

The NIRS method allows the evaluation of changes in cerebral oxygenation through the intact skull and is also gaining importance in acupuncture research because of its non-invasive approach [6-10]. The NIRO 300 Monitor (Hamamatsu Photonics, Japan) is a new instrument in this field of research. Parameters such as changes in oxyhemoglobin ( O 2 Hb) and desoxyhemoglobin ( HHb) are determined by Lambert-Beer´s principle [4]. The system can measure the absolute value (µmol) of changes in parameters, but not the level (absolute concentration) at which these changes occur (in positive or negative direction). The measurement value is zero, as long as no change in concentration occurs. Placement of the sensor (emitter and near-infrared detectors) on the head with a silicone holder is easy and reproducible. Data output of O 2 Hb and HHb were presented on a color LCD-display and color printer.

33

In addition to the spectroscopic method, non-invasive, standard monitoring parameters such as blood pressure (Cardiocap ® CC-104, Datex Medical Electronics, Hoevelaken, Netherlands) were determined before, during and after different manners of stimulation.

3.2.2 Laserneedle stimulation

The laserneedle-technique represents a new, non-invasive method for optic stimulation of acupuncture points and was first described in literature in 2002 [5,6,11,12]. Laserneedle ® (Schikora D.: European Patent Nr. PCT/EP 01/08504) acupuncture allows the simultaneous stimulation of individual acupuncture point combinations. Variations and combinations of acupuncture at different areas of the body, ear or hand, as performed particularly in this study are possible (compare Fig. 3.1). Details regarding this method can also be found in preceding studies [5,6,11,12].

method can also be found in preceding studies [5,6,11,12]. Fig. 3.1: Test person during laserneedle st

Fig. 3.1: Test person during laserneedle stimulation and simultaneous registration of NIRS parameters. Right bottom: single active laserneedle and application device.

Changes in near-infrared spectroscopic parameters in the frontal region of the brain were continuously registered and analyzed.

34

3.2.3 Healthy volunteers, acupuncture, measurement procedure

In this study, a total of 328 measurements on 88 healthy volunteers (50 female, 38 male) mean age 25.7 + 4.0 ( x + SD) years (19 - 38 years) were performed. The study protocol was approved by the ethics committee of the Medical University of Graz (11-017) and all test persons gave their written consent. None of the volunteers had visual, neurological or psychological deficits or were under the influence of central nervous system effective drugs.

A maximum of 7 acupuncture points in different measurement series (needle

acupuncture and laserneedle acupuncture) were investigated. The acupuncture scheme included two acupuncture points from TCM: Zanzhu (localization: at the medial end of the eyebrow, perpendicular to and above the inner corner of the eye, at the foramina of the supraorbital nerve;

needling: perpendicular 0.5 - 0.8 cun) and Yuyao (localization: at the middle

of the eyebrow, perpendicular and above the pupil; needling: inclined 0.3 -

0.5 cun). In addition, 2 ear acupuncture points (eye and liver: localization see Fig. 3.2; needling: inclined 0.3 cun) and 2 eye acupuncture points from Korean hand acupuncture (E2: localization see Fig. 3.2; needling:

perpendicular 0.1 – 0.2 cun) and one acupuncture point from Chinese hand acupuncture (Yan Dian: localization: on the ulnar side of the middle phalanx

of the thumb; needling: inclined 0.2 cun) were included in the study [11-13].

In addition, possible responses in NIRS parameters after needling and stimulating of a placebo point (localization: lateral from the radius 6 cun above the horizontal fold of the wrist exactly on the radial ledge, lateral from the pulmonary meridian) were tested.

The different acupuncture schemes were applied alone and in combination, since preliminary studies indicated that the selection of different combinations also result in different effects in the cerebral parameters to be measured (e.g. bloodflow velocity in the ophthalmic artery) [11-13] (Fig.

3.2).

35

liverliver YuyaoYuyao ZanzhuZanzhu eyeeye E2E2 YanYan DianDian
liverliver
YuyaoYuyao
ZanzhuZanzhu
eyeeye
E2E2
YanYan DianDian

Fig. 3.2: Acupuncture schemes used in this study.

Acupuncture points were needled with single-use needles after local disinfection of the skin. We used three different types of needles (body: 0.25 x 25 mm, Huan Qiu, Suzhou, China; ear: 0.2 x 13 mm, European Marco Polo Comp., Albi, France; hand: 0.1 x 8 mm, Sooji-Chim, Korea). Stimulation was performed with simultaneous rotating, pulling and thrusting movements of medium intensity.

In the case of laserneedle acupuncture, the skin at the acupuncture point was cleaned with alcohol, the laserneedle was positioned at the surface of the skin and then fixated with special adhesive tape. We used the same acupuncture schemes as in the combined measurements using needle acupuncture.

During the experimental phase, the test persons were positioned in a relaxed manner on a lounge. After applying the near-infrared spectroscopic sensors in the frontal area of the skull, a 10 minute resting period was observed. Then, either laserneedle stimulation was activated or the acupuncture needles were inserted and stimulated for 10 seconds. Thereafter, the laser was activated for 10 minutes or the needles were left alone. The maximum amplitude of O 2 Hb and HHb (phase during acupuncture) was analyzed during this period of time. Randomized selection of which technique should be started with, as well as selection of sequence of the particular type of

36

stimulation (body, ear, hand, combination) was done. The resting period between each investigation was at least 30 minutes.

3.2.4 Statistical analysis

Data was analyzed with the computer program SigmaStat (Jandel Scientific Corp., Erkrath, Germany). Results from the phases before (=zeropoint calibration), during and 5 minutes after needle acupuncture or of laserneedle acupuncture are shown in the diagrams as mean values, respectively.

3.3

Results

At the left side of Figure 3.3, the hypothetical functional curve of stimulus intensity dependent upon the treatment time is shown. This diagram gains in importance due to the actually measured, specific cerebral data in regard to changes in O 2 Hb and HHb shown at the right. During manual, metal needle stimulation a nearly exponential maximum increase in O 2 Hb and an exponential decrease to a higher level than initially, occurred, whereas the trend of O 2 Hb during laserneedle NIRS response remains plateau-like.

StimulusStimulus intensityintensity -- cerebralcerebral NIRSNIRS responseresponse OO 22 HbHb metalmetal needleneedle aa
StimulusStimulus intensityintensity -- cerebralcerebral NIRSNIRS responseresponse
OO 22 HbHb
metalmetal needleneedle
aa
HHbHHb
OO 22 HbHb
laserneedlelaserneedle
HHbHHb
bb
timetime [s][s]
1010 minmin
B.J., 22y, f
nte sittS
Stimulus
ymui
lus int
in
ISnse
.a[ity
]u.SI
a[ .u.]

Fig. 3.3: Left: Stimulus intensity (SI f(t)) as a function of time (hypothesis). Right: Real measured cerebral responses of NIRS-parameters O 2 Hb (oxyhemoglobin) and HHb (desoxyhemoglobin) on manual, brief (20 seconds) acupuncture needle stimulation (a) and laserneedle stimulation (b) in 22-year-old female test person. The arrows indicate the beginning of stimulation.

37

Figures 3.4 and 3.5 show the mean values of maximum change in O 2 Hb (Fig. 3.4) and HHb (Fig. 3.5) parameters during and 5 minutes after manual needle acupuncture or laserneedle acupuncture.

after manual needle acupuncture or laserneedle acupuncture. Fig. 3.4: Changes in µmol of oxyhemoglobin (O 2

Fig. 3.4: Changes in µmol of oxyhemoglobin (O 2 Hb) during needling of a placebo point, 3 hand acupuncture points, 2 ear acupuncture points, 2 acupuncture points from TCM, a combination of hand, ear and body acupuncture as well as laserneedle stimulation and an intensity-increased (+ 30 %) laserneedle acupuncture (from left to right) during and 5 minutes after acupuncture.

38

38 Fig. 3.5: Cerebral changes (generally decr eases) in desoxyhemoglobin (HHb). For further descriptions see Fig.

Fig. 3.5: Cerebral changes (generally decreases) in desoxyhemoglobin (HHb). For further descriptions see Fig. 3.4.

It is obvious that needling and stimulation of the placebo point does not lead to marked changes in cerebral NIRS parameters during and 5 minutes after acupuncture. Manual needling and laserneedle stimulation leads to a marked increase in O 2 Hb (compare Fig. 3.4) and simultaneous decrease in HHb (compare Fig. 3.5) when using the combined Korean hand acupuncture (E2) and Chinese hand acupuncture (Yan Dian), as well as TCM-body (Zhanzu and Yuyao) acupuncture, as well as combined body, ear, and hand acupuncture. This effect is still present 5 minutes after removing the needles or deactivating laserneedle stimulation. An almost negligible, but contrary behavior of O 2 Hb and HHb occurs when both ear points (eye and liver) are needled or stimulated with laser. None of the acupuncture stimulation methods or combinations resulted in significant changes in standard monitoring parameters (blood pressure).

3.4

Discussion

One of the main advantages of the laserneedle technique is its non- invasiveness. It is possible to apply the laser in such a manner, that the test

39

person cannot feel optical stimulation of the acupuncture point. In addition, the acupuncturer does not need to know if the system is activated or deactivated. Thus, double-blind studies using this new method are possible

in acupuncture research for the first time. This method of study was already

performed by our research group [14] and included simultaneous and continuous monitoring of blood flow velocity in the posterior cerebral artery and the middle cerebral artery in 17 healthy volunteers. This study showed that laserneedle stimulation of distant acupuncture points at hands and feet (Hegu, Zusanli, Kunlun, Zhiyin) is able to achieve marked and specific changes in cerebral blood flow velocity [12,14].

Even though laser puncture using Low-Level-Laser stimulation devices is an established method, measurable cerebral effects lie far below conventional needle acupuncture [15]. The results from the first studies [11,12,14] using the laserneedle system revealed significant changes in cerebral parameters (blood flow velocities), which were otherwise only achieved by manual needle acupuncture. The proportion of maximum change in blood flow velocity (needle/laserneedle) is approximately factor 2.

Since Chinese medicine and acupuncture are considered an integrative part

of TCM based on energetic processes, the registration of changes in the

cerebral metabolism could express energetic processes in the brain and obviously plays a key role in investigating the effects of acupuncture. To date, it has not been possible to obtain non-invasive and continuous results regarding regional cerebral oxygenation. Near-infrared spectroscopy can register changes in oxygenation in the cerebral vascular region very sensitively. The advantages of transcranial oximetry are its non- invasiveness, low risks and continuity, as well as its easy and time-saving application. A wide range of indications are the result for the potential use of this spectroscopic method [4].

A number of factors which can influence adequate interpretation of data

must be considered. Contamination with surrounding light, mechanical irritations, intracerebral hematoma, misplacement of optodes or other user errors are just some possibilities which should be noted [4].

A number of studies which deal with NIRS conclude that NIRS can exactly

determine extremely small changes in cerebral hemodynamics, as a response

to

different functional stimulations.

In

this study [5,6], 328 systematic NIRS registrations on healthy volunteers

during manual and laserneedle acupuncture stimulation were performed for the first time. The results from two preceding publications [8,9] were the reference points for this study.

40

The first study regarding acupuncture and NIRS [8] indicated that the changes in the occipital region after acupuncture stimulation in 3 healthy volunteers, was measurable and reproducible in each of the test persons. In the second study [9], NIRS-changes were measurable and reproducible at the central region after acupuncture stimulation at the Hegu point. This study showed, that reproducible changes in frontally monitored NIRS parameters could be determined, after stimulation of specific eye acupuncture points.

In general, changes in NIRS parameters are unspecific and we do not know if an isolated decrease in saturation is caused by an increase in cerebral oxygenation consumption or results from a decrease in cerebral blood flow. Therefore, not only the extent of oxygenation is shown, but the interaction between oxygenation and desoxygenation is reflected. This is possible since the measurement zone is mainly dominated by the venous part of the cerebral vascular bed (~ 75 %). The arterial part (~ 20 %) or the capillary (~ 5 %) flow region is respectively smaller [4].

For these reasons, we were able to determine changes, which for example occur due to an increase in oxygenation. Which ruling mechanisms are present is still unclear. Increased desoxygenation by stimulus-induced neuronal activation, i.e. caused by changes in membrane potentials or release of neurotransmitters could be possibilities [16]. For whatever reason, acupuncture obviously influences the oxygen metabolism of the brain in healthy test persons.

Similar to this study using ear acupuncture, a paradox contra-directional change in blood flow velocity (increase) and regional cerebral O 2 -saturation (decrease) occurred in a vascular based case of dementia, when an individually adapted acupuncture scheme was used [16]. The described case report showed that acupuncture could improve the clinical status of vascular dementia. Using NIRS and transcranial Doppler sonography, we were able to register the effects on cerebral blood flow velocity and the O 2 -metabolism. In combination with clinical findings, an inverse decrease in regional cerebral O 2 -saturation during simultaneous increase in cerebral blood flow velocity during acupuncture could be interpreted, as a sign of increased cerebral oxygenation. A decrease in regional cerebral O 2 -saturation does not necessarily indicate a poor condition of the O 2 -metabolism in the sense of reduced oxygen supply, however could also document the beneficial effects of regionally increased oxygenation, activated by acupuncture [16]. In a similar manner, the minor contradirectional regional changes in NIRS parameters using ear acupuncture could be interpreted, since the monitoring method conveys the balance between oxygenation and desoxygenation.

41

Further studies are necessary to investigate the importance of these phenomena on acupuncture, since not only the influence in general and in detail of laser acupuncture, but also the influence of combined ear and body acupuncture, are still discussed controversially. Spectroscopic methods probably are useful tools for this investigations.

3.5 Acknowledgements

The authors thank Ms. Lu Wang MD for performing the acupuncture, Ms. Evamaria Huber for help in data recording and Ms. Petra Petz MSc for her valuable support in data analysis (all Department of Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine, Medical University of Graz).

3.6 References

[1]

Litscher G (2001) High-Tech Akupunktur ® . Pabst Science Publishers,

Cho ZH, Wong EK, Fallon J (2001) Neuro-Acupuncture. Q-puncture,

[2]

Lengerich Berlin Düsseldorf Litscher G, Cho ZH (Eds.) (2000) Computer-Controlled Acupuncture ® .

[3]

Pabst Science Publishers, Lengerich Berlin Düsseldorf Riga Scottsdale Wien Zagreb

[4]

Los Angeles Litscher G, Schwarz G (Eds.) (1997) Transcranial cerebral oximetry. Pabst Science Publishers, Lengerich Berlin Düsseldorf Riga Scottsdale Wien Zagreb

[5] Litscher G, Schikora D (2002) Nahinfrarot-spektroskopische

[6]

Untersuchungen zur Nadel- und Lasernadelakupunktur. AKU Akupunktur Theorie und Praxis 3: 140-146 Litscher G, Schikora D (2002) Near-infrared spectroscopy for

[7]

objectifying cerebral effects of needle and laserneedle acupuncture. Spectroscopy 16: 335-342 Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I, Eger E (1998)

[8]

Effects of acupuncture on the oxygenation of cerebral tissue. Neurol Res 20/S1: 28-32 Litscher G, Wang L (2000) Zerebrale Nahinfrarot-Spektroskopie und Akupunktur – Ergebnisse einer Pilotstudie. Biomed Technik 45: 215-

218

[9]

Litscher G, Wang L, Huber E (2002) Veränderungen zerebraler nahinfrarot-spektroskopischer Parameter während manueller Akupunkturnadelstimulation. Biomed Technik 47: 76-79

[10] Litscher G, Wang L (2002) Computergestützte Objektivierung der Grenzen der Akupunktur. AKU Akupunktur Theorie und Praxis 30/1: 13-

42

[11] Litscher G, Schikora D (2002) Cerebral effects of noninvasive laserneedles measured by transorbital and transtemporal Doppler sonography. Lasers Med Sci 17: 289-295

[12] Litscher G, Schikora D (2002) Neue Konzepte in der experimentellen Akupunkturforschung - Computerkontrollierte Laserpunktur (CCL) mit

der Laserneedle

®

Technik. Der Akupunkturarzt / Aurikulotherapeut

28(3): 18-28 [13] Litscher G (2002) Computer-based objectivation of traditional Chinese-, ear- and Korean hand acupuncture, Needle-induced changes of regional cerebral blood flow velocity. Neurol Res 24: 377-380 [14] Litscher G, Schikora D (2002) Effects of new noninvasive laserneedles on brain function. IFMBE Proceedings, 2 nd European Medical & Biological Engineering Conference (EMBEC), Vienna, December 2002:

996-997

[15] Litscher G, Wang L, Wiesner-Zechmeister M (2000) Specific effects of laserpuncture on the cerebral circulation. Lasers Med Sci 15: 57-62 [16] Litscher G, Schwarz G, Wang L, Sandner-Kiesling A (2002) Akupunktur bei vaskulär bedingtem dementiellem Abbau. Jahrestagung der Österreichischen Alzheimer-Gesellschaft. 14. Klagenfurter Arbeitstagung für Neurologie. 24. - 25. Mai 2002, Klagenfurt / Austria

43

4. Communication between acupoint and brain proved by ultrasound

G. Litscher, L. Wang, N.H. Yang

4.1 Introduction

Transcranial Doppler ultrasonography (TCD) provides a noninvasive, rapid and continuous assessment of blood flow velocity in cerebral arteries. Using new probe holder constructions, it is possible to record blood flow patterns in various cerebral arteries simultaneously and continuously [1-4].

Acupuncture has been used as a therapeutic medical technique in China for thousands of years and is indicated for a wide variety of conditions [5,6]. However, evidence of quantitative measurable effects of acupuncture is still rare in the scientific literature. We have reported a number of quantifiable effects of acupuncture on cerebral perfusion and cerebral oxygenation [1-

4,7-16].

In the present study we investigated the specific effects of laserneedle acupuncture of two acupuncture schemes on the mean blood flow velocity in the anterior (ACA) and posterior (PCA) cerebral arteries in a cross-over study design.

4.2 Methods and materials

4.2.1 TCD monitoring of the anterior and posterior cerebral arteries with a new probe holder

Doppler sonographic signals were recorded simultaneously in the left ACA and the right PCA with a Multi-Dop T system (DWL Electronic Systems GmbH, Sipplingen, Germany). Two 2-MHz probes were used in a multidirectional ultrasound probe holder.

44

ACAACA -- AcupunctureAcupuncture YingYing XiangXiang (LI.20)(LI.20)
ACAACA -- AcupunctureAcupuncture
YingYing XiangXiang (LI.20)(LI.20)

Fig. 4.1: Monitoring of the blood flow profiles in the anterior cerebral artery (ACA) and the posterior cerebral artery (PCA) and localization of the acupuncture point Ying Xiang.

The A1 segment of the ACA was assessed in its entirety at depths between

58 and 88 mm. The direction of flow in the ACA was away from the

ipsilaterally placed probe. The PCA was found by aligning the transducer slightly posteriorly and inferiorly from the bifurcation of the internal carotid artery. Between a depth of 60 to 78 mm, its P1 segment was found and showed a direction of flow toward the transducer.

The mean blood flow velocity (v m ) is an important parameter [1,8], because it describes the most intense mean values of Doppler frequency at every interval of the spectrum [17]. Forty v m values were averaged in each patient in five phases (a: 5 minutes before acupuncture; b - d: during laserneedle acupuncture and e: 2 minutes after stimulation). The averaged values of the five measured phases were compared for each subject.

4.2.2

Participants

Blood flow profiles in the ACA and PCA were measured before, during and after the acupuncture sessions in 22 adults (mean age 24.4 + 2.6 years; range

21 – 29 years). None of the subjects was under the influence of centrally

active medication. They were fully informed about the nature of the

45

investigation and gave informed consent. During the experiments the subjects were in a relaxed and comfortable positon on a bed in our laboratory. Then the TCD monitoring equipment was positioned. After a 10- minute resting period the laserneedle stimulation was activated for a duration of 20 minutes.

4.2.3 Laserneedle acupuncture

Two acupuncture schemes were tested in two sessions in the same persons. One scheme (including Yingxiang) was chosen to influence the olfactory system (Figs. 4.2 - 4.4) and one (including Zhiyin) to stimulate the optical system.

PCAPCA ACAACA NIRSNIRS -- sensorsensor
PCAPCA
ACAACA
NIRSNIRS -- sensorsensor

Fig. 4.2: Healthy volunteer during laserneedle stimulation and TCD-registration. Additionally a sensor was placed frontally for the registration of near infrared- spectroscopic signals (NIRS).

Yingxiang (LI.20) Location: Between ala nasi and nasolabial groove. Indication: Rhinitis, blocked nose, common cold, nose bleeding, facial paralysis, trigeminal neuralgia, toothache.

Hegu (LI.4) Location: At the highest point of the m. adductor pollicis with the thumb and index finger adducted. Indication: The most important analgesic point; stimulation of this point relieves pain in all parts of the body. The specific effect on the

46

head, especially in headache has been verified by clinical research.

Pianli (LI.6) Location: 3 cun proximal to Yangxi (LI.5) on the line connecting Yangxi with Quchi (LI.11). Indication: Dry throat, rhinitis, throat pain, redness of the eye, tinnitus, deafness, sore throat, edema.

Guangming (GB.37) Location: On the anterior side of the fibula, 5 cun proximal to the malleolus lateralis. Indication: Eye disorders, headache, mental disorders.

Taichong (Liv.3)

Location:

Between the first and second metatarsal bones, 2 cun proximal

Indication:

to the margin of the web. Distal point for eye disorders, pain and tension of the head and

chest, urogenital, endocrine and metabolic disorders.

47

olfactory epithelium
olfactory epithelium

Fig. 4.3: Schematic presentation of the olfactory epithelium (modified according to JW Karapelou, Spektrum der Wissenschaft Spezial, 4/1999).

48

48 Fig. 4.4: Functional magnetic resonance imaging: activation during chemical stimulation (modified according to DH Zald

Fig. 4.4: Functional magnetic resonance imaging: activation during chemical stimulation (modified according to DH Zald et al. 1997; http://james.psych.umn.edu/olfactory.html). Note the dominance on the left.

4.2.4 Statistical Analysis

The data were tested with analysis of variance (one-way repeated-measure ANOVA) with SigmaStat software (Jandel Scientific Corp., Erkrath, Germany). The results were expressed as means + standard error ( x + SE). The criterion for significance was p < 0.05.

4.3

Results

Figure 4.5 shows an example of increased v m in the ACA during laserneedle acupuncture. Stimulation of acupoint Yingxiang was repeated and the changes in v m were reproducible.

49

Laserneedle - specific effects ACA - PCA v m (cm/s) before during laserneedle-acupuncture time 1
Laserneedle - specific effects
ACA - PCA
v m (cm/s)
before
during
laserneedle-acupuncture
time
1 min

Fig. 4.5: Trend of the mean blood flow velocity v m in cm/s in the left anterior cerebral artery (ACA) and the right posterior cerebral artery (PCA) before and during laserneedle acupuncture in a 24-year-old volunteer. The arrow marks the beginning of stimulation.

Figure 4.6 (middle and lower panel) summarizes the results in all 22 subjects for both acupoint schemes. The values of v m in the ACA increased significantly (p<0.001) using acupuncture scheme A (b - d) and were higher at the end of the investigation (e) than before acupuncture (a). Insignificant changes (n.s.) in v m were seen in the PCA. However, with the vision-related acupoint scheme B the same subjects showed a significant increase of v m in the PCA without significant changes in the ACA.

50

Healthy volunteers n=22

12 female, 10 male, 21 - 29 years ( 24.4 + 2.6 years; x

+

SD )

10 male, 21 - 29 years ( 24.4 + 2.6 years; x + SD ) R

R

10 male, 21 - 29 years ( 24.4 + 2.6 years; x + SD ) R
laserpuncture scheme A Anterior cerebral artery (ACA) 50 49 48 *) 47 46 45 abcde
laserpuncture scheme A
Anterior cerebral artery (ACA)
50
49
48
*)
47
46
45
abcde
*) p < 0.001
laserpuncture scheme B Anterior cerebral artery (ACA) 52 51 50 49 48 n.s. 47 abcde
laserpuncture scheme B
Anterior cerebral artery (ACA)
52
51
50
49
48
n.s.
47
abcde
Posterior cerebral artery (PCA) 45 44 43 42 n.s. 41 40
Posterior cerebral artery (PCA)
45
44
43
42
n.s.
41
40

abcde

Posterior cerebral artery (PCA) 47 46 45 44 43 42
Posterior cerebral artery (PCA)
47
46
45
44
43
42

*)

abcde

*) p < 0.002

Fig. 4.6: Healthy volunteers, acupuncture points and graphic presentation (means) of the results of the mean blood flow velocity of the anterior cerebral artery (ACA) and the posterior cerebral artery (PCA) before (a), during (b - d) and after (e) laserneedle stimulation. The arrows mark the relative maximum changes during laserneedle stimulation referring to the basic value.

51

SpecificSpecific cerebralcerebral effectseffects ofof laserneedlelaserneedle--acupunctureacupuncture v m (cm/s) p =
SpecificSpecific cerebralcerebral effectseffects ofof
laserneedlelaserneedle--acupunctureacupuncture
v m
(cm/s)
p = 0.001 *
50
48
46
44
ACA
PCA
42
n = 22
40
38
abcde
* One Way Repeated Measures Analysis of Variance (Tukey Test)

Fig. 4.7: Absolute changes in v m during laserneedle acupuncture.

v m (cm/s) p = 0.001 * 3 2,5 2 1,5 1 ACA PCA 0,5
v m
(cm/s)
p = 0.001 *
3
2,5
2
1,5
1
ACA
PCA
0,5
n = 22
0
-0,5
-1
abcde
* One Way Repeated Measures Analysis of Variance (Tukey Test)

Fig. 4.8: Relative changes in v m during laserneedle acupuncture.

52

SpecificSpecific cerebralcerebral effectseffects ofof laserneedlelaserneedle--acupunctureacupuncture v 50 m n.s.
SpecificSpecific cerebralcerebral effectseffects ofof
laserneedlelaserneedle--acupunctureacupuncture
v
50
m
n.s.
(cm/s)
48
46
44
ACA
PCA
42
n = 22
40
38
abcde

Fig. 4.9: Absolute changes in v m during laserneedle acupuncture.

v m (cm/s) 3 n.s. 2,5 2 1,5 1 ACA PCA 0,5 0 n =
v m
(cm/s)
3
n.s.
2,5
2
1,5
1
ACA
PCA
0,5
0
n = 22
-0,5
-1
abcde

Fig. 4.10: Relative changes in v m during laserneedle acupuncture.

53

4.4

Discussion

Transcranial Doppler ultrasonography measures blood flow profiles in cerebral arteries. The technique is used to detect stenoses, emboli and malformations of intracranial arteries, assess cerebral collateral circulation before surgery, monitor cerebral vasospasm, and document cerebral circulatory arrest, as well as for intraoperative monitoring.

Acupuncture is a form of traditional Chinese medicine (TCM) that has developed over thousands of years. Until now, modern Western medicine has used acupuncture mostly for complementary or supportive purposes. There are hundreds of acupoints on the human body. These are points at which according to TCM the flow of the vital force Qi can be stimulated [5,6]. In this study we used laserneedles, a new way to stimulate these points.

In previous studies we have found that the brain is the key to understanding acupuncture’s effects [1-4,7-14]. New experimental constructions to measure ultrasound, light and bioelectrical processes can reproducibly demonstrate effects of acupuncture in the brain. We have shown that acupuncture with needles can increase overall cerebral blood flow. Studies with biosensors and probes in a specially designed helmet showed that acupuncture can increase the blood flow velocity in the middle cerebral artery and increase the oxygen supply to the brain.

The present study is a further step to objectify the effects of acupuncture. In 22 participants we found that laserneedle acupuncture of specific acupoints increases blood flow in specific regions of the brain.

An acupuncture scheme including two points in the face (Yingxiang) which TCM places in connection with the olfactory system increased mean blood flow velocity in the ACA significantly (p < 0.001). The ACA supplies most of the frontal and medial mass of the cerebrum including part of the olfactory cortex. At the same time, blood flow in the PCA stayed nearly unchanged.

In contrast, an acupuncture scheme including a point on the foot (Zhiyin) which is in connection with the optic system increased blood flow in the PCA significantly (p = 0.002). Simultaneously blood flow in the ACA stayed nearly unchanged.

Cho et al. [16] have described similar effects in the brain by stimulating vision-related acupoint Zhiyin with functional magnetic resonance imaging

54

and after light stimulation. Control studies with stimulation of other points on the foot did not produce specific activation in the visual cortex.

Acupuncture - fMRI Vis.Vis. Ref.Ref. AcupAcup ((lightlight)) (Zhiyin)(Zhiyin)
Acupuncture - fMRI
Vis.Vis. Ref.Ref.
AcupAcup
((lightlight))
(Zhiyin)(Zhiyin)

Fig. 4.11: Functional magnetic resonance imaging (fMRI) at the Medical University of Graz (fMRI-results: Cho et al. [2]).

In our study we measured the blood flow profiles in the left ACA and the right PCA. This procedure was chosen for technical reasons and due to previous reports in the literature. Zald et al. [17] found that olfactory stimuli increased regional cerebral blood flow exactly in the left lateral orbitofrontal cortex. Cerebral blood flow in this study was measured with a slow bolus O- 15 water technique and positron emission tomography.

We are convinced that sophisticated biomedical technology, particularly noninvasive ultrasound techniques, can objectify some effects of traditional Chinese medicine. In acupuncture the brain likely plays a key intermediate role. However, brain activity in and of itself does not explain anything about the healing power of acupuncture.

55

4.5 Acknowledgements

The authors thank Ms. Ingrid Gaischek MSc (Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine, Medical University of Graz) for her valuable help.

4.6 References

[1]

Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I (1998) Robotic transcranial Doppler sonography probes and acupuncture. Intern J Neurosci 95: 1-15

[2] Litscher G, Yang NH, Schwarz G (1999) Computerkontrollierte

[3]

Akupunktur ® : Eine neue Konstruktion zur simultanen und kontinuierlichen Erfassung der Blutflußgeschwindigkeit in der A. supratrochlearis und A. cerebri media. Biomed Technik 44: 58-63 Litscher G, Wang L, Yang NH (1999) Ultrasound-monitored effects of

Quantifizierung des Einflusses der Akupunktur. Biomed Technik 42:

[4]

acupuncture on brain and eye. Neurol Res 21: 373-377 Litscher G, Yang NH, Wang L (1998) Quantitative Separation

[5]

spezifischer Akupunktureffekte von Gehirn und Auge mittels bidirektionaler Ultraschallmeßkonstruktion. AKU 26(4): 212-217 Engin I: Chinese acupuncture and moxibustion. Shanghai China,

[6]

Publishing House of Shanghai College of Traditional Chinese Medicine, 1990 Mao-Liang Q (1996) Chinese acupuncture and moxibustion. Churchill

[7]

Livingstone, London Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I (1997)

Transkranielle Doppler-Sonographie - Robotergesteuerte Sonden zur

116-122

[8]

Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I, Eger E (1998)

[9]

Effects of acupuncuture on the oxygenation of cerebral tissue. Neurol Res 20(1): 28-32 Litscher G, Schwarz G, Sandner-Kiesling A (1997) Transcranial near

[10]

infrared spectroscopy and transcranial Doppler sonography during acupuncture. In Litscher G, Schwarz G (Eds) (1997) Transcranial Cerebral Oximetry. Pabst Science Publishers, Lengerich, pp. 184-198 Litscher G, Wang L, Wiesner-Zechmeister M (2000) Specific effects of laserpuncture on the cerebral circulation. Lasers Med Sci 15: 57-62

[11] Litscher G, Schwarz G, Sandner-Kiesling A (1998)

Computerkontrollierte Akupunktur ® . Akupunktur Theorie und Praxis 26(3): 133-142 Litscher G, Wang L, Yang NH, Schwarz G (1999) Computer-controlled acupuncture – Quantification and separation of specific effects. Neurol Res 21:530-534

[12]

56

[13]

Litscher G, Yang NH, Wang L (1998) Ultrasound-controlled

acupuncture. Internet J Anesthesiology 2/4:

http://www.ispub.com/journals/IJA/Vol2N4/acu.htm

[14] Litscher G, Yang NH, Wang L (1999) Acupuntura controlada por

[15]

[16]

[17]

[18]

ultrasonidos. http://www.tmed.uam.es/dpto/anesne tas/ijae/vol2n4e/articulos/acu.h tm Litscher G, Wang L (1999) Visualisierung von peripheren Durchblutungsänderungen während der Akupunktur mittels Thermographie. Biomed Technik 44: 129, 1999 Cho ZH, Chung SC, Park JP, Park HJ, Lee HJ, Wong EK, Min BI (1998) New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Natl Acad Sci 95: 2670-2673 McCartney JP, Thomas-Lukes KM, Gomez CR (1997) Handbook of Transcranial Doppler. Springer, New York Zald DH, Pardo PJ, Pardo JV et al (1997) Left orbitofrontal activation during aversive chemical stimulation. http://james.psych.umn.edu/olfactory.html

al (1997) Left orbitofrontal activation during aversive chemical stimulation. http://james.psych.umn.edu/olfactory.html
al (1997) Left orbitofrontal activation during aversive chemical stimulation. http://james.psych.umn.edu/olfactory.html
al (1997) Left orbitofrontal activation during aversive chemical stimulation. http://james.psych.umn.edu/olfactory.html

57

5. Histological investigations regarding micromorphological effects of laserneedle illumination. Results of an animal experiment

G.

Litscher, W. Nemetz, J. Smolle, G. Schwarz,

D.

Schikora, S. Uranüs

5.1 Introduction

For the first time, laserneedle stimulation allows simultaneous and continuous laser illumination of individual acupuncture points [3,4]. Due to the contact of the laserneedle with the skin, the illuminated area at the acupuncture point remains constant and the relevant doses can be varied exactly by altering the duration of illumination.

Goal of this animal experiment was to investigate the influence of laserneedle illumination on micro morphological structures of the skin and obtain objectified information regarding the effects of characteristic densities and illumination doses for laserneedles.

5.2 Methods

5.2.1

Procedure

In this animal study, we performed experiments regarding the microcirculation in the skin and surface skin temperature, before, during and after laserneedle stimulation. We used a sus scrofa domesticus, which was put under general anaesthesia in the animal surgical unit, at the Department of Surgical Research, University Clinic of Surgery (Figure 5.1). The study was performed according to the rules of the ethical commission (animal study approval number GZ 66.010/10-BRGT/2003).

58

58 Fig. 5.1: Animal experimental investigation with laserneedle stimulation. Illumination of the skin using 8

Fig. 5.1: Animal experimental investigation with laserneedle stimulation. Illumination of the skin using 8 laserneedles (circular positioning scheme). The microcirculation and temperature sensor is located in the middle of the positioning scheme.

Pre-medication was done in two steps on the day of intervention:

a) Orally: Diazepam (Gewacalm ® ) 10 mg, Ketamin (Ketanest S ® ) 250 mg, Azaperom (Stresnil ® ) 80 mg. b) 20 min after oral pre-medication, intramuscular: Atropin 0.5 mg, Diazepam (Gewacalm ® ) 20 mg, Ketamin (Ketanest S ® ) 50 mg, Azaperom (Stresnil ® ) 80 mg. Anaesthesia was started 20 minutes after pre-medication: Etomidate- ® Lipuro 40 mg, Fentanyl 0.5 mg i.v. Intubation was done during spontaneous respiration and muscle relaxation with Pancuroniumbromid (Pavulon ® ) 4 mg. Maintenance of anaesthesia was performed with: Thiopental 4 g, Fentanyl 1.5 g, Pancuroniumbromid (Pavulon ® ) 20 mg/500 NaCl 0.9 % as continuous instillation. Ventilation was performed instrumentally according to characteristic biometric data. At the time of excision, hemodynamic parameters (blood pressure 130/70 mmHg; heart rate 80/min; central venous pressure 5 mmHg), as well as oxygenation (SaO 2 99 %) and ventilation (etCO 2 38 mm) were all in the normal range.

Data registration of the measurement parameter Flux (= product of mean flow velocity and concentration of red blood cells), surface skin temperature and room temperature were measured during anaesthesia. A total of five measurement values were analyzed (a = 2 min before; b = 2 min, c = 10 min, d = 18 min after beginning stimulation and e = 2 min after deactivating laserneedle stimulation; compare Figure 5.3).

59

After completing the experiment, four histological samples from the shaved cutis at the thoracic-abdominal transition were investigated, two had been illuminated with laser the other two were used as negative controls.

5.2.2 Laserneedle stimulation

Laserneedle stimulation is new optic method, which is used for stimulating acupuncture points. Illumination of different variations and combinations on the body, ear, or hand are possible. Figure 5.2 shows the characteristic emission of a fitted laserneedle, which was used in this study. The coherence of laser illumination at the distal exit point was measured with Michelson- interferrometry. The laserneedles used (wavelength: 685 nm) emitted red light in a „continuous wave“ mode with an output of 30 - 40 mW per laserneedle, resulting in a power density of 4.6 W/cm² or an energy density of ~ 4.6 kJ/cm². The transmitted energy into the skin is 55 J per laserneedle during a treatment period of 20 minutes.

1 laser-needle emission- characteristics emission wavelength: 685 nm total output power at distal end: 30
1
laser-needle emission-
characteristics
emission wavelength:
685 nm
total output power
at distal end:
30 mW
optical cladding
fibre core
[isnetni ].u.aty

-2

-1

30 mW optical cladding fibre core [isnetni ].u.aty -2 -1 11 2 optical fibre diameter [

11

2

optical fibre diameter [ a.u.]

Fig. 5.2: Emission characteristics of a laserneedle (a.u. = arbitrary units).

5.2.3 Laser Doppler flowmetry and temperature measurement

Laser Doppler signals were registered with a Laser Doppler device (DRT4), by Moor Instruments Ltd. (Devon, England). Probe output is defined as 1 mW. Laser wavelength was 780 nm, the raw signal was filtered with a digital filter from 20 Hz to 22.5 kHz. A DPIT–probe (diameter 8 mm, length

60

7 mm) was used for registration. An additional unit for measuring temperature (accuracy 0.1 °C) was integrated.

5.3

Results

Figure 5.3 shows the results from the three measurement parameters at different measurement times before (a), during (b - d) and after (e) laserneedle activation. Skin surface temperature and room temperature parameters did not show marked changes, whereas the Flux value increased significantly 2 minutes after activation (b) and reached a maximum at the end of laserneedle stimulation at measurement point (d). Thereafter, this value was reduced to its initial level.

Temp.

(°C)

Flux

(a.u.)

45

40

35

30