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Research Report
Effect of Acupuncture-Point Stimulation on Diastolic
Blood Pressure in Hypertensive Subjects:
A Preliminary Study
Electrical stimulation of four specijic acupuncture points (Liver 3, Stomach 36,
Large lntestine 11, and the Groovefor Lowering Blood Pressure) was examined
in order to determine the effect of thb stimulation o n diastolic blood pressure in
10 subjects with diastolic hypertension. Subjects were randomly divided into two
groups: (1) a n Acu-ES group, which received electrical stimulation applied to the
four antihypertensive acupuncture points, and (2) a Sham-ES group, which received electrical stimulation applied to non-acupuncture-point areas. A repeatedmeasures analysis of variance revealed a sign$cant, immediate poststimulation
reduction of diastolic blood pressure for the Acu-Es group versus the Sham-ES
group. Further studies are needed to determine whether there are other acupuncture points, stimulation characteristics, or modalities that can enhance this treatment effect and whether the treatment effect can last for a clinically signijicant
period of time. W i l l i a m T, Mueller 4 Cornwall MW: Effect of acupuncture-point
stimulation o n diastolic blood pressure in hypertensive subjects: a preliminary
study. Phys T h e 1991;71:523-529.1
Tim Wllllams
Karen Mueller
Mark W Cornwall
Key Words: Acupuncture/acupressure;Blood pressure; Electrotherapy, electrical
stimulation; Hypertension.
Research exploring the physiologic
mechanisms underlying acupuncture
suggests that somatic processes may
be altered through the production of
systemic vasodilation, increased endorphin release, and alterations in
hormonal secretion.' Such research
has facilitated an increasing acceptance of acupuncture in western medicine, in which it has been used successfully for the production of
analgesia during surgery, pain control
in conditions such as migraine headache, and treatment of cardiovascular
T Williams, BS, FT,is Staff Physical Therapist, Havasu Samaritan Regional Hospital, Lake Havasu
City, AZ 86403. He was a senior physical therapy student at Northern Arizona University, Flagstaff,
AZ,when this article was written.
K Mueller, MS, PT, is Assistant Professor, Department of Physical Therapy, Northern Arizona University, PO Box 15105, Flagstaff, AZ 86011-5105 (USA). Address all correspondence to Ms Mueller.
MW Cornwall, PhD, FT,is Assistant Professor, Department of Physical Therapy, Northern Arizona
University
The results of this study were presented in poster format at the Annual Conference of the American Physical Therapy Association, June 11-15, 1989, Nashville, TN.
This study was approved by the Northern Arizona University Human Subjects Institutional Review
Board.
disorders such as angina pectoris and
hypertension.'-5
Traditional acupuncture involves the
use of small-diameter needles, which
are inserted into the skin. The literature suggests that effective stimulation
of acupuncture points may also be
produced through direct pressure:
the use of ultrasound7~fjand heliumneon lasers,"" and the application of
electric currents via the use of surface
o r implanted electr0des.'2-'~
The effective use of acupuncture,
regardless of the method used, involves the accurate detection of acupuncture points on the body surface.
Previous studies17-19 have shown acupuncture points to have a markedly
lower electrical resistance than the
This article was submitted July 31, 1989, and was accepted March 6 1991
34 / 523
Physical Therapy /Volume 71, Number 7 /July 1991
skin around them. This finding has
allowed clinicians to use devices such
as an ohmmeter to accurately locate
acupuncture points.
Hypertension is a major risk factor
for coronary artery disease and
stroke, which are, respectively, the
first and third highest causes of
mortality in the United States.20Current treatment for hypertension includes sodium restriction, pharmacologic management, and lifestyle
modifications such as stress management ancl e ~ e r c i s e . 2Although
~
these
methods of treatment are generally
considered to be effective, they frequently require permanent lifestyle
changes. Thus, poor patient compliance is common. The drawbacks of
antihypertensive medication include
side effects, such as fatigue, electrolyte imbalance, and impotence,
which ofi.en result in patient intolerance.21 The substantial cost of longterm medication can also be problematic. These disadvantages suggest
a need for alternative strategies in
the management of hypertension.
The use of needle acupuncture as a
method of treatment for hypertension
has been explored in both western
and Chinese literature. Tam and YiuZ2
found that acupuncture produced a
significant reduction in systolic and
diastolic blood pressure (BP) immediately upon stimulation. In a study exploring the physiologic mechanisms
of this effect, Omural measured circulatory changes during acupuncture in
400 patients and reported a generalized vasodilation response, which coincided with a decrease in systolic
and diastolic BP. He also found that
slight decreases in BP often occurred
in patient,^ receiving acupuncture,
regardless of the condition treated.
Furthermore, the most dramatic decreases were found in patients with
essential hyperten~ion.~
Peng23 suggested that acupuncture stimulation
may cause vasodilation.
There is little research on the effect of
electrical stimulation of acupuncture
points on systolic and diastolic BP.
Studies by Yao et a12*and Hoffman
and Thon:n25 have demonstrated a
Physical Therapy /Volume 71, Number
significant reduction of systolic and
diastolic BP in hypertensive rats following the application of lowfrequency electrical stimulation to
the sciatic nerve.
The purpose of this study was to determine the effect of electrical stimulation of selected acupuncture points
on diastolic BP in hypertensive subjects immediately following and 5
minutes after stimulation. We hypothesized that hypertensive subjects who
received electrical stimulation of four
selected acupuncture points would
show a significant decrease in diastolic BP immediately following treatment, whereas there would be no
immediate posttreatment change in a
group of hypertensive subjects who
received electrical stimulation applied
to non-acupuncture-point areas.
Method
Subjects
Subjects were selected on the basis of
two inclusion criteria: (1) a resting
diastolic BP between 90 and 120 mm
Hg and (2) no past o r present use of
antihypertensive medication.
All subjects were patients under the
care of two physicians with a specialty
in family practice. In addition, all subjects had been diagnosed with borderline hypertension within the previous
6 months. The diagnosis of borderline
hypertension was assigned by these
physicians to any patient with a diastolic BP greater than 90 mm Hg during two consecutive office visits. Patients diagnosed with borderline
hypertension were counseled by the
physicians about dietary modifications
and exercise and were instructed to
monitor their BP at home. Subsequently, if these patients reported
three consecutive at-home diastolic BP
readings above 90 mm Hg, their diagnosis was changed from borderline to
essential hypertension. AU subjects
who participated in this study were
still considered by these physicians to
be borderline hypertensive.
The two physicians contacted 22 subjects who met the study's inclusion
criteria, 12 of whom agreed to participate (2 subjects showed normotensive
diastolic BPS when they arrived for
the first data-collection session and
were excluded from the study). Of
the 10 subjects who completed the
study, 2 were female and 8 were
male. Their mean age was 46 years
(range= 27-72 years). All subjects
gave written informed consent.
Test Environment
The testing environment was carefully
controlled in order to minimize factors that could influence diastolic
BP.26127
All testing was performed in
an acoustically insulated audiology
booth in which the temperature was
maintained between 23" and 25°C.
In order to minimize psychological
factors affecting diastolic BP, the following steps were taken to ensure a
relaxed atmosphere during testing.
Subjects were instructed to wear
loose and comfortable clothing. The
investigators refrained from wearing
laboratory coats during all sessions,
because the use of such apparel has
been associated with increased BP
("white-coat hypertension") in some
patients.28Except for a standing mercury column sphygmomanometer and
a stethoscope, the testing equipment
was placed away from the subject's
view. Finally, a large poster of a pleasant outdoor scene was placed on the
wall facing the subject.
Procedure
Subjects were randomly divided
into two groups by the use of a coin
toss. Four subjects comprised the
Acu-Es group (test group), which
received electrical stimulation applied to the four acupuncture
points, and six subjects formed the
Sham-ES group (control group),
which received electrical stimulation
applied to non-acupuncture-point
areas. The two subjects who were
excluded from the study had previously been assigned to the Acu-ES
group. Because they were the last two
subjects scheduled for data collection,
an uneven distribution of subjects
resulted.
All diastolic BP measurements were
performed by one investigator (KM),
who was blinded as to the subject's
group assignment. Prior to the study,
this investigator established a testretest reliability of .99 for diastolic BP
using an intraclass correlation coefficient (ICC[l,k])*9as the index of reliability. The diastolic BP of 10 subjects
was measured twice, with a 1-minute
interval between the first and second
measurements, and the measurements
were compared for consistency. Diastolic BP was measured according to
American Heart Association guidelines.3O All electrical stimulation was
performed by one investigator (TW)
as well.
tem lV setup began with the application of a NeuroAid 3.5 model 7 7 9 P
disposable gel electrodet on the volar
surface of the subject's right forearm.
The subject was fitted with a BP cuff
on the right arm and allowed to sit
quietly for 5 minutes. Following this
5-minute period, a pretreatment diastolic BP measurement was taken.
Immediately after the pretreatment
diastolic BP measurement, the groups
received their respective treatments. A
second diastolic BP measurement was
taken immediately after treatment.
The subjects remained seated for an
additional 5 minutes, whereupon the
final diastolic BP measurement was
taken.
A Neuroprobea System lV stimulator*
was used to detect acupuncture points
and to provide electrical stimulation.
We used a remote hand-held treatment probe with a metal tip measuring 22 mm long and 3 mm wide. No
conductive medium was used.
Treatment for subjects in the Acu-ES
group consisted of electrical stimulation of four selected acupuncture
points. Selection of these points was
based on acupuncture texts1-5 and
discussions with three certified acupuncture practitioners. The four acupuncture points selected received the
highest number of recommendations
from these sources.
The NeuroprobeB System IV provides
both audtory and visual signals when
the active hand-held treatment probe
is in contact with skin areas of low
resistance. As previously mentioned,
these areas correspond to acupuncture points.
The Neuroprobea System lV provides
a medium-frequency sinusoidal signal
of 10,000 Hz. All subjects in the study
received continuous electrical stimulation at 10,000 Hz (the "MF continuous" pulse-rate setting on the Neuroprobe@' System N). This stimulation
was divided into two 30-second doses
applied to each selected acupuncture
point, with a 5- to 7-second interval
between each dose. The output intensity of each dose was set at the lowest
point at which the subject could detect the stimulation.
The test procedure for each subject
was as follows. The subject was seated
in a comfortable chair inside the treatment booth. The Neuroprobea Sys-
Subjects in the Sham-ES group received a control treatment using electrical stimulation characteristics identical to those used for the Acu-ES
group; however! this stimulation was
applied to non-acupuncture-point
areas. 'These non-acupuncture-point
areas were located by placing the
probe over the general anatomical
area of the acupuncture point as described previously, then moving the
probe approximately 15 cm (6 in)
away to an area at which a high electrical resistance was encountered.
These areas were also stimulated on
the subjects' left side in the same order as for the Acu-ES group.
Data Analysis
Electrical stimulation was applied to
acupuncture points on the left side of
all subjects in the Acu-ES group.
Figure 1 illustrates the anatomical locations of the four acupuncture
points. These anatomical locations
were used to detect the general area
of the acupuncture points, and the
hand-held treatment probe was used
to determine the exact area for electrical stimulation. The first point stimulated was Liver 3, located on the
dorsal surface of the foot, between
the first and second metatarsals, at the
metatarsophalangeal joints. The second point stimulated was Stomach 36.
This point is located 3.8 cm (1.5 in)
distal to the lower border of the patella and 1.3 cm (0.5 in) lateral to the
anterior tibia1 ridge. The third point
stimulated was Large Intestine 11.
This point is located at the lateral end
of the elbow flexion fold. The fourth
point is known as the Groove for
'Physio Technology Inc, 1505 SW 42nd St, Topeka, KS 66609.
+ ~ e u r Division,
o
Medrronic Inc, 7000 Central Ave IYE, Minneapolis, MN 55440
36 / 525
Lowering Blood Pressure. This is the
groove that is found behind the ear
when the auricle is folded down. This
order was followed for all subjects.
The exact location of the acupuncture
points in Acu-ES group subjects was
determined by using the hand-held
treatment probe to find the area in
the region of the acupuncture point
with the lowest electrical resistance.
The test for differences in diastolic BP
between immedate posttreatment and
5-minute posttreatment measurements
as well as for differences in diastolic
BP between the two experimental
groups was performed using a mixed
two-way analysis of variance (ANOVA).
The factor of time (pretreatmentimmediately after treatment versus
pretreatment-5 minutes after treatment) was designated as the repeatedmeasures variable. An alpha level of
.05 was used for the determination of
significant differences.
Table 1 shows the diastolic BP readings of each subject before, immediately after, and 5 minutes following
electrical stimulation. The results of
an independent Student's t test revealed no statistically significant difference (t=-.93, df=8, P>.05) for the
pretreatment measurements of the
Acu-ES and Sham-ES groups. Table 2
shows the between-group means and
standard deviations of the diastolic
Physical Therapy /Volume 71, Number 7 /July 1991
this reason, we were only able to recruit a small group of subjects who
met the inclusion criteria for our
study. In spite of the difficulty of recruiting appropriate subjects, we
based our selection criteria on the
work of Tam and Y ~ uwho
, ~ sug~
gested that acupuncture is more effective in lowering BP in subjects who
have no history of antihypertensive
medication use than in subjects with a
history of antihypertensive medication
use. These investigators also found
that results are even greater when the
diagnosis of hypertension has been
Results of studies investigating the use
of acupuncture on pharmacologically
managed hypertensive subjects suggest that antihypertensive medication
may interfere with the effects of acupuncture treatment. Sugioka et a131
found that the use of acupuncture had
no effect on patients who had just
completed a course of antihypertensive medication. Clearly, there is a
need for further studies to explore
how antihypertensive medications and
length of time since the diagnosis of
hypertension interact with the electrical stimulation of acupuncture points.
Flgure l. Anatomical locations of the four acupuncture points used in this study.
changes between immediate posttreatment and. pretreatment measurements
and between 5-minute posttreatment
and pretreatment measurements.
Table 3 shows the ANOVA results,
which demonstrate a significant difference (df==
1,Pe.05) between treatment groups and between the two
posttreatment measurement sessions.
No signiEicant interaction (P>.05) was
found between the treatment groups
and the rwo posttreatment measurement sessions. Figure 2 graphically
illustrates the mean changes in diastolic BP over time for the two
groups.
The magnitude and duration of this
reduction, however, are insufficient for
such stimulation to be of current clinical value as a means of treatment for
hypertension. Nonetheless, the results
of this study suggest the possibility that
further research may lead to the discovery of stimulation characteristics,
modalities, and acupuncture points
that will promote a sustained reduction of diastolic BP into the therapeutic
range. The discovery of such factors
could, in turn, result in the use of electrical stimulation of acupuncture points
as a viable method of treatment for
hypertension.
Discussion
A major limitation of this study was
the small number of subjects. Because
of the risk for stroke and heart disease associated with untreated hypertension, however, many physicians
choose not to delay the prescription
of antihypertensive medication. For
The results of this preliminary study
support the hypothesis that mediumfrequency electrical stimulation of selected acupuncture points results in a
significant reduction in diastolic BP.
Physical Therapy /Volume 71, Number 7/July 1991
Another limitation of this study was
the transient duration of the reduction in diastolic BP. In designing a
preliminary study, our objective was
to determine the efficacy of electrical
stimulation as a means of lowering
diastolic BP. Because environmental
factors can have a profound effect on
BP, major emphasis was given to the
reduction of patient anxiety. Accordingly, we selected electrical stimulation characteristics that would produce the most immediate treatment
effect. These stimulation characteristics resulted in an average treatment
time of about 5 minutes. As previously mentioned, the literature suggests that a frequency of 10,000 Hz
produces an immediate, but shortlasting, treatment effect.32.33 The results of our study support this literature, because the differences in
diastolic BP between the Acu-ES and
Sham-ES groups were no longer
significant 5 minutes posttreatment.
Further studies are needed to deter-
Table 1.
Diastolic Blood Pressure Measurements (in Millimeters of Mercury)
Measurement
Groupa
Age
(Y)
Sex
Pretreatment
lmmedlate
Posttreatment
5-Minute
Posttreatment
ACU-ES
ACU-ES
ACU-ES
X
SD
Range
Sham-ES
Sham-ES
Sham-ES
Sham-ES
Sham-ES
Sham-ES
X
SD
Range
"Acu-ES group received electrical stimulation of four antihypertensive acupuncture points; Sham-ES group rece~vedelectrical stimulation of four nunacupuncture-point areas.
mine whether longer treatment durations at a frequency of 10,000 Hz
will result in longer periods of
treatment effectiveness.
frequency, long-duration current
(such as that used in transcutaneous
electrical nerve stimulation) may produce longer-lasting treatment effects.
Although our study involved the use
of 10,000-Hz electrical current, hrther
research involving lower frequencies
may prove beneficial. Research by Fox
and Melzack13suggests that a lower-
Electrotherapeutic modalities are
widely used by physical therapists for
the treatment of musculoskeletal problems. The acupuncture points used to
treat musculoskeletal problems are
Table 2.
different from those used to reduce
BP. Whether an indirect antihypertensive effect results from such treatment,
however, remains to be determined.
Further research on the indirect effects
of electrical stimulation of acupuncture
points for the treatment of musculoskeletal problems in normotensive
and hypertensive subjects may prove
to be enlightening. Perhaps it is possible that desirable reductions in BP
Means and Standard Deviations of Changes Between Diastolic Blood Pressure Measurements
Measurement
Pretreatment Versus lmmedlate
Posttreatment
X
SD
Pretreatment Versus 5-Minute
Posttreatment
-
X
SD
"Acu-ES group received electrical stimulation of four antihypenensive acupuncture points; Sham-ES group received electrical stimulation of four nonacupuncture-point areab.
h~ignificantlydifferent (+I,
P<.05).
"Not significantly different ( P > . 0 5 ) .
1
38 / 527
Physical Therapy/Volume 71, Number 7IJuly 1991
Table 3.
Results of Analysis of Variance
Source of
Varlatlon
Group
Error 1
Time
Groupxtime
Error 2
occur in hypertensive patients receiving electrotherapy for musculoskeletal
problems.
The four acupuncture points used in
this study are among several that are
stated in the acupuncture literature to
have an antihypertensive effect. Pericardium ti; Gall Bladder 20, 21, and
41; Stomach 9 and 37; Kidney 1;
Spleen 1 and 2; and Heart 7 are other
acupuncture points that can be used
to lower 13P.l-5 We suggest that future
studies be conducted using one or
more of tlhese alternative acupuncture
points. Bilateral stimulation to selected acupuncture points may also
prove to be effective.
In summary, the results of this study
suggest numerous possibilities for
future research. We suggest several
replications of this study, manipulating the variables of treatment duration, electrical modality used, stimulation characteristics, and acupuncture
points selected.
Conclusion
This study was designed to validate
the current literature concerning the
electrical stimulation of acupuncture
points affecting diastolic BP and to
provide a basis for future research.
Thus, we designed a preliminary
study, with an emphasis on accuracy
of acupuncture-point detection, using
a clinically available modality that pro-
duces a quick, but short-lasting, therapeutic effect. The results of our study
indicate that stimulation of four selected acupuncture points with a current of 10,000 Hz produces a significant reduction in diastolic BP in
hypertensive subjects. Although the
duration and magnitude of this effect
were insufficient to be of clinical
value, the results of this study support
the efficacy of electrical stimulation as
a means of lowering diastolic BP.
Acknowledgments
We would like to express our thanks
to the following individuals: Michael
Ryan, MD, and Corwin Demarse, MD,
for their assistance in locating subjects; Kay Evje and Susan Nassan, licensed acupuncturists, for their advice; Graydon Bell, PhD, for his
contribution to our statistical analysis;
and Paul Hansen, PhD, PT, for his editorial comments. Finally, we extend
special thanks to all of our subjects.
References
80 t'
Pretreatment
Immediate Posttreatment
Measurement
5-Minute
Posttreatment
Flgure 2. Mean changes in diastolic blood pressure (in millimeters of mercuty)
over time &or Acu-ES and Sham-ES groups. (O=Sham-ESgroup, X=Acu-ES group,)
Physical Therapy /Volume 71, Number 7IJuly 1991
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treatment: effects of acupuncture o n cardiovascular and nervous systems. Acupunct Electrother Res 1975.1:51-140.
2 O'Connor J, Bensky B. Acupuncture: A Comprehensive Text. Seattle, Wash: Eastland Press;
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7 Khoe WH. Ultrasound acupuncture used in
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