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Laserneedle-Acupuncture (Gerhard Litscher, Detlef Schikora) PDF
Laserneedle-Acupuncture (Gerhard Litscher, Detlef Schikora) PDF
Laserneedle-
Acupuncture
Science
and
Practice
PABST
III
(Eds.)
Laserneedle - Acupuncture
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Preface
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.
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
January 2005
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
Addendum................................................................................................. 203
XIII
Authors:
Konrad B. Borer, MD
Therwilerstrasse 11
4153 Reinach BL / Switzerland
Rudolf Helling, MD
1st 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
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
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
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
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.
4
[a.u.]
effects [a.u.]
3
Reizwirkung
2
stimulus
0
0 2 4 6 8 10
stimulus strength
Reizstärke [a.u.][a.u.]
Fig. 1.1: Relationship between stimulus strength and stimulus effects according to
Weber-Fechner ´s Law.
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
experiments. . 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
2
laserneedle - power density [W/cm ]
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
t 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
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
Fig. 1.4: Distant acupuncture points Hegu, Zusanli, Kunlun and Zhiyin of the visual
system (left) and the selected sham-points (right).
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.
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
Tab. 1.1: Connection between laser power, laser-spot diameter and optical power
densities.
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
applied light energy dose per laserneedle [J]
50
40
30
20
10
0
0 5 10 15 20 25
duration of treatment [min]
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
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.
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.
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)
Incidence of adverse reactions associated with acupuncture. J Altern
Complement Med 6: 345-350
[3] Pomeranz B, Chiu D (1976) Naloxone blockade of acupuncture
analgesia: endorphin implicated. Life Sci 19: 1757-1762
[4] Mayer DJ, Price DD, Rafil A (1977) Antagonism of acupuncture
analgesia in many by the narcotic antagonist naloxone. Brain Res 2:
368-372
17
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
C omputer-
C ontrolled
L aserpuncture
C omputer-
C ontrolled
A cupuncture®
C omputer-
C ontrolled
L aserpuncture
Laserneedles
MED-UNI GR
AZ
2.2 Methods
2.2.1 Non invasive laserneedles
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
30 mW
optical cladding
fibre core
-2 -1 1 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
2500
2000
1500
1000
500
0
0 200 400 600 800 1000 1200 1400
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.
2.2.3 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 (Cx + 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.
Yuyao Zanzhu
Liver
Eye
E2
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
The mean blood flow velocity (vm) 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.
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 (Cx) + 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
15 15
SE p<0.001*
p=0.01*
10 10
c
a c
a
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 Mean blood Acupuncture
flow velocity Cx+ SE flow velocity Cx+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 same time only minor, insignificant changes in vm 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 vm 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].
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
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 (vm) as compared to needle acupuncture. As it is shown
in Fig. 2.3 the maximum blood flow velocity rate ratio
'vm (needle) / 'vm (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 vm 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] Litscher G, Cho ZH (Eds) (2000) Computer-Controlled Acupuncture®.
Pabst Science Publishers, Lengerich-Berlin-Rom-Riga-Wien-Zagreb
[2] Schikora D. European Patent Nr. PCT/EP 01/08504
[3] König G, Wancura I (1989) Neue Chinesische Akupunktur. Lehrbuch
und Atlas der Akupunkturpunkte. Wilhelm Maudrich, Wien-München-
Bern
[4] Yoo TW (2001) Koryo hand therapy - Korean hand acupuncture. Eum
Yang Mek Jin Publishing Co, Seoul
[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
Biomedical Engineering Handbook. CRC Press, IEEE Press, Boca
Raton (USA), pp. 1333-1345
[7] Fargas-Babjak A (2001) Acupuncture, transcutaneous electrical nerve
stimulation, an laser therapy in chronic pain. Clin J Pain 17 (4. Suppl):
105-113
30
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].
3.2 Methods
3.2.1 Near-infrared spectroscopy
Fig. 3.1: Test person during laserneedle stimulation and simultaneous registration of
NIRS parameters. Right bottom: single active laserneedle and application device.
liver
Yuyao Zanzhu
eye
E2
Yan Dian
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 'O2Hb 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.
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 O2Hb and HHb shown at the right. During manual, metal needle
stimulation a nearly exponential maximum increase in O2Hb and an
exponential decrease to a higher level than initially, occurred, whereas the
trend of O2Hb during laserneedle NIRS response remains plateau-like.
O2Hb
metal needle
a HHb
O2Hb
laserneedle
HHb
b
time [s] 10 min
B.J., 22y, f
Fig. 3.3: Left: Stimulus intensity (SI f(t)) as a function of time (hypothesis).
Right: Real measured cerebral responses of NIRS-parameters O2Hb
(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 O2Hb
(Fig. 3.4) and HHb (Fig. 3.5) parameters during and 5 minutes after manual
needle acupuncture or laserneedle acupuncture.
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 O2Hb (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 O2Hb 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
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.
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.
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.
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,
Lengerich Berlin Düsseldorf
[2] Litscher G, Cho ZH (Eds.) (2000) Computer-Controlled Acupuncture®.
Pabst Science Publishers, Lengerich Berlin Düsseldorf Riga Scottsdale
Wien Zagreb
[3] Cho ZH, Wong EK, Fallon J (2001) Neuro-Acupuncture. Q-puncture,
Los Angeles
[4] 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
Untersuchungen zur Nadel- und Lasernadelakupunktur. AKU
Akupunktur Theorie und Praxis 3: 140-146
[6] Litscher G, Schikora D (2002) Near-infrared spectroscopy for
objectifying cerebral effects of needle and laserneedle acupuncture.
Spectroscopy 16: 335-342
[7] Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I, Eger E (1998)
Effects of acupuncture on the oxygenation of cerebral tissue. Neurol
Res 20/S1: 28-32
[8] 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-
19
42
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].
ACA - Acupuncture
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 (vm) 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 vm 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
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.
PCA
ACA
NIRS - sensor
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
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
to the margin of the web.
Indication: Distal point for eye disorders, pain and tension of the head and
chest, urogenital, endocrine and metabolic disorders.
47
olfactory epithelium
4.3 Results
Figure 4.5 shows an example of increased vm in the ACA during laserneedle
acupuncture. Stimulation of acupoint Yingxiang was repeated and the
changes in vm were reproducible.
49
before during
laserneedle-acupuncture
time
1 min
Fig. 4.5: Trend of the mean blood flow velocity vm 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 vm 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 vm were seen in the PCA. However, with the vision-related
acupoint scheme B the same subjects showed a significant increase of vm in
the PCA without significant changes in the ACA.
50
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
48
46
44 ACA
PCA
42
n = 22
40
38
a b c d e
*
One Way Repeated Measures Analysis of Variance (Tukey Test)
'vm p = 0.001*
(cm/s) 3
2,5
2
1,5
1 ACA
0,5 PCA
n = 22
0
-0,5
-1
a b c d e
46
44 ACA
PCA
42
n = 22
40
38
a b c d e
'vm
(cm/s) 3
n.s.
2,5
2
1,5
1 ACA
0,5 PCA
0 n = 22
-0,5
-1
a b c d e
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.
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.
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
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.
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
Akupunktur®: Eine neue Konstruktion zur simultanen und
kontinuierlichen Erfassung der Blutflußgeschwindigkeit in der A.
supratrochlearis und A. cerebri media. Biomed Technik 44: 58-63
[3] Litscher G, Wang L, Yang NH (1999) Ultrasound-monitored effects of
acupuncture on brain and eye. Neurol Res 21: 373-377
[4] Litscher G, Yang NH, Wang L (1998) Quantitative Separation
spezifischer Akupunktureffekte von Gehirn und Auge mittels
bidirektionaler Ultraschallmeßkonstruktion. AKU 26(4): 212-217
[5] Engin I: Chinese acupuncture and moxibustion. Shanghai China,
Publishing House of Shanghai College of Traditional Chinese
Medicine, 1990
[6] Mao-Liang Q (1996) Chinese acupuncture and moxibustion. Churchill
Livingstone, London
[7] Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I (1997)
Transkranielle Doppler-Sonographie - Robotergesteuerte Sonden zur
Quantifizierung des Einflusses der Akupunktur. Biomed Technik 42:
116-122
[8] Litscher G, Schwarz G, Sandner-Kiesling A, Hadolt I, Eger E (1998)
Effects of acupuncuture on the oxygenation of cerebral tissue. Neurol
Res 20(1): 28-32
[9] Litscher G, Schwarz G, Sandner-Kiesling A (1997) Transcranial near
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
[10] 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
[12] Litscher G, Wang L, Yang NH, Schwarz G (1999) Computer-controlled
acupuncture – Quantification and separation of specific effects. Neurol
Res 21:530-534
56
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.
5.2 Methods
5.2.1 Procedure
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.
1
laser-needle emission-
characteristics
emission wavelength:
685 nm
30 mW
optical cladding
fibre core
-2 -1 1 2
optical fibre diameter [ a.u.]
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
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) 45 Temp.
R.-Temp.
Flux 40
Flux
(a.u.)
35
30
25
20
a b c d e
20 min
Fig. 5.3: Surface body temperature (Temp.), room temperature (R.-Temp.) and Flux
(= product of mean flow velocity and concentration of erythrocytes) in a.u. (arbitrary
units) before (a), during (b - d) and after (e) 20-minute laserneedle stimulation. Note
the increase in the Flux parameter during illumination.
a b
Fig. 5.4: Histological results of the illuminated (a) and not illuminated (b) cutis. No
micro morphological differences are evident.
5.4 Discussion
Laser has become a term for future technology, precision, rapidity, and
achievement. Although the discovery of laser dates back to Einstein, who
founded the theory of stimulated emission in 1917, the history of laser in
acupuncture is still young [8].
examinations did not show any signs of alterations in the examined layers of
skin tissue.
We assume that this results from the minimal absorption of the most
important tissue parts such as water, haemoglobin, and melatonin, which is
comparatively small at the emission wavelength of 685 nm of the
laserneedles. This indicates that photons entering the tissue are scattered at
the tissue molecules, however do not thermically counteract, as in processes
of adsorption. The skin is more or less, transparent for laser at a wavelength
of 685 nm, thus thermically induced tissue changes such as coagulation,
ablation and carbonisation can not take place and were not provable in our
experiments.
Laser illumination of 685 nm used in the laserneedles and applied in a
contact mode, with power densities between 1- 5 W/cm², did not induce
measurable micro morphological changes in the illuminated skin [10]. The
definition of relevant critical values, in particular, determination of
wavelength dependent power densities which lead to micro-morphological
tissue changes, will be clarified in further studies.
5.5 Acknowledgements
The authors thank cand. med. Evamaria Huber from the Department of
Biomedical Engineering and Research in Anaesthesia and Intensive Care
Medicine, Medical University of Graz, for her assistance in data registration.
5.6 References
[1] Fagrell B (1994) Problems using laser Doppler on the skin in clinical
practice. In: Belcaro GV, Hoffmann U, Bollinger A, Nicolaides N
(1994) Laser Doppler. Med-Orion Publishing Company, London Los
Angeles Nicosia, 49-54
[2] Kert J, Rose L (1989) Clinical Laser Therapy. Scandinavian Medical
Laser Technology, p. 13
[3] Litscher G, Schikora D (2002) Near-infrared spectroscopy for
objectifying cerebral effects of needle and laserneedle acupuncture.
Spectroscopy 16: 335-342
[4] Litscher G, Schikora D (2002) Cerebral vascular effects of non-
invasive laserneedles measured by transorbital and transtemporal
Doppler sonography. Lasers Med Sci 17: 289-295
[5] Litscher G, Schwarz G, Dalageorgos K, Neger J, Kehl G (1996) Laser-
Doppler-Flowmetrie - Erfahrungen aus der Intensivmedizin. Biomed
Technik 41: 166-169
[6] Litscher G, Möller KO, Stollberger R, Schwarz G, Fuchs G,
Baumgartner A, Leber K, Koop T, Ascher PW (1997) Laser-Doppler-
63
6.1 Introduction
Laser Doppler flowmetry (LDF) is a technique particularly used in the field
of pharmacology for comparing measures which influence circulation, for
controlling transplants and flaps in plastic surgery and for objectifying and
classifying disease stages in angiological and dermatological research and in
anesthesiology and intensive care medicine [1-6]. Flux (product of mean
flow velocity and the concentration of red blood cells), for example, and the
concentration of moving particles (erythrocytes) in the measurement volume
are calculated.
Recently, some reports in literature documented, that this method can also be
applied in the field of acupuncture for scientific investigations [7, 8]. In this
chapter, the use of laserneedle stimulation under real circumstances is
examined, based on LDF- monitoring results.
Probe output was defined with 1 mW. Edge frequencies were 20 Hz and
22.5 kHz. The temperature unit (5 °C to 50 °C) had a resolution of 0.2 °C
and accuracy of 0.5 °C. In addition to an RS-232 interface, this instrument
disposes of analogous signals (0 – 10 V) as an output voltage. The
instrument has the following dimensions: 280 x 160 x 360 mm and weighs
8 kg.
Several measurement probes are available for the DRT4 monitor. The results
documented in this study were obtained with the DPIT probe (diameter
8 mm, length 7 mm) (Fig. 6.1).
65
Hegu (LI.4)
Localization: At the highest point of the M. adductor pollicis, when the
thumb lies against the index finger.
Indication: Hegu is the most important analgesic point. Pain conditions;
particularly massive manual stimulation relieves pain in the
entire body. Specific cerebral effects of this distant point
could be proven in clinical studies.
66
Fig. 6.2: Laser Doppler perfusion and temperature monitor DRT4 (Moor
Instruments, Millwey, Axminster, England) and laserneedle stimulation.
The laserneedle was fixed to the skin at the acupuncture point with adhesive
tape, after previous cleaning of the skin with alcohol. A semi-conductor laser
with an emission wavelength of 685 nm was used as the light source. Laser
intensity was 60 mW. Details regarding the stimulation method can be found
in the previous chapters.
The Laser Doppler probe (compare Fig. 6.1) was applied at a distance of
1 cm from the laserneedle. This distance was selected based on the given
geometric dimensions of the probe holder (compare Fig. 6.1) and a supposed
optic depth in the infrared range of 1 cm. Temperature at the measurement
point and room temperature were determined for comparison.
b c d
1 min 1 min
10 min
a e
20 min
2 min 2 min
laserstimulation active
6.3 Results
Figure 6.4 summarizes the results of the three parameters; Flux, hand and
room temperature at the different measurement times (compare Fig. 6.3).
68
Temp. 34
(°C) 32
30
Flux
28 Temp.
(a.u.)
26 R.-Temp.
Flux
24
22 n = 22
20
a b c d e
20 min
*Friedman Repeated Measures
Analysis of Variance on Ranks
(Tukey Test)
Laserneedle - microcirculation
left hand
right hand
left hand
right hand
B.A., 25y, f
Fig. 6.7: Changes in parameters regarding concentration of erythrocytes (c1, c2) and
temperature (t1, t2) at the left, or right hand in the phases before (10 min), during
(30 min) and after (10 min) laserneedle stimulation.
6.4 Discussion
The Laser Doppler technique is a suitable method for measuring the
concentration and velocity of moving blood cells in surface vessels.
Penetration depth is confined to about 1 mm. Laser light is usually guided to
the output point via light conductors. Due to the Doppler effect, frequency
shifts of scattered light take place and can be determined by measuring flow
velocity. Possible advantages of this technique particularly in acupuncture
research are currently being evaluated [7-13].
Negative factors regarding this method per se are the failing standardization
combined with difficult interpretation of clinical data and high purchasing
costs of the LDF equipment. Advantages of this method are its time-saving
aspect, non-invasiveness, continuous monitoring ability and user
friendliness.
71
The results from this study indicate that the energy dose emitted by a
laserneedle in 20 minutes, is high enough to increase local skin temperature
and subcutaneous tissue temperature (mean of 0.7 °C ; p = 0.02). Thus, the
modality of periphery stimulation with laserneedles is not only optical but
also thermal.
Light dispersion on the skin was measured using a new device (O2C Oxygen
to see, LEA Medizintechnik, Giessen, Germany). Figure 6.8 shows that even
at a distance of 4 cm the laser light from the laserneedle (685 nm) can be
detected.
Laserneedle stimulation
4 cm 3 cm 2 cm 1 cm
1 cm
2 cm
3 cm
4 cm
Fig. 6.8: Light dispersion on the skin. Note the peak in the spectrum at 685 nm.
The results from this study should induce further investigations regarding the
evaluation of temporal and spatial (laser Doppler imaging) changes in
microcirculation parameters, during and after laserneedle stimulation.
Possible artifacts, as described in literature should be reduced further [4].
72
6.5 References
[1] Fagrell B (1994) Problems using laser Doppler on the skin in clinical
practice. In: Belcaro GV, Hoffmann U, Bollinger A, Nicolaides AN
(1994) Laser Doppler. Med-Orion Publishing Company, London-Los
Angeles-Nicosia, 49-54
[2] Öberg P (1990) Laser-Doppler flowmetry. Crit Rev Biomed Eng 18:
125-163
[3] Litscher G, Schwarz G, Boggett D (1995) Laser Doppler flowmetry –
Peripheral microcirculation during cessation of cerebral and
cardiocirculatory function. Biomed Technik 40: 195-199
[4] Litscher G, Schwarz G, Dalageorgos K, Neger J, Kehl G. (1996)
Laser-Doppler-Flowmetrie – Erfahrungen aus der Intensivmedizin.
Biomed Technik 41: 166-169
[5] Litscher G, Möller KO, Ratzenhofer-Komenda B, Schwarz G, Koop T,
Kovac H (1997) Laser Doppler flowmetry in the hyperbaric
environment. Lasers Med Sci 12: 342-346
[6] Litscher G, Möller KO, Stollberger R, Schwarz G, Fuchs G,
Baumgartner A, Leber K, Koop T, Ascher PW (1997) Laser-Doppler-
Datenanalyse während interstitieller Laserthermotherapie unter
Magnetresonanz-Kontrolle im Rahmen einer tierexperimentellen
Studie. Biomed Technik 42: 93-96
[7] 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:
184-191
[8] Litscher G, Wang L, Huber E, Nilsson G (2002) Changed skin blood
flow perfusion in the fingertip following acupuncture needle
introduction as evaluated by laser Doppler perfusion imaging. Lasers
Med Sci 17: 19-25
[9] Litscher G, Wang L, Nilsson G (2001) Laser Doppler Imaging und
Kryoglobulinämie. Biomed Technik 46: 154-157
[10] Sprott H, Jeschonnneck M, Grohmann G, Hein G (2000)
Microcirculatory changes over the tender points in fibromyalgia
patients after acupuncture therapy (measured with laser-Doppler
flowmetry). Wien Klin Wochenschr 112(13): 580-586
[11] Suter B, Kistler A (1994) Does acupuncture modify skin circulation via
the autonomic nervous system? Schweiz Med Wochenschr 62: 36-38
[12] Blom M, Lundeberg T, Dawidson I, Angmar-Mansson B (1993) Effects
on local blood flux of acupuncture stimulation used to treat xerostomia
in patients suffering from Sjogren’s syndrome. J Oral Rehabil 20(5):
541-548
[13] Cramp AF, Noble JG, Lowe AS, Walsh DM (2001) Transcutaneous
electrical nerve stimulation (TENS): the effect of electrode placement
upon cutaneous blood flow and skin temperature. Acupunct
Electrother Res 26(1-2): 25-37
73
G. Litscher
7.1 Introduction
Noninvasive bioelectrical neuromonitoring is gaining more and more
attention in anesthesia and critical care [1,2]. The bispectral index (BIS) and
the spectral edge frequency (SEF) are important numerical descriptors of the
EEG and both are mainly used for assessing depth of anesthesia [3]. If
anesthetists rely on BIS and SEF to detect awareness, then it is very
important to exclude other influences that could give false readings. It is
known that a number of environmental and physiologic factors may affect
BIS performance. Recently it has been reported that also
nonpharmacological interventions such as acupressure can reduce BIS
values significantly [4].
We studied 25 healthy volunteers (mean age r SD: 25.5 + 4.0 years, range
21 - 39 years; 15 women, 10 men; body weight 69.1 r 16.1 kg; height 173.5
r 9.3 cm). None of the subjects had neurological or psychological disorders
and they were not taking any medication. They were partly informed about
the nature of the investigation and were paid for their participation. The
investigators recording EEG and sedation data were blinded to the
intervention applied to the volunteers. The subjects were not informed which
of the four interventions was effectively a control (acupressure on a control
74
point). The study was approved by the Ethics Committee of the Medical
University of Graz (13-048 ex 02/03). Written informed consent was
obtained from each subject.
A period of 5 min was allowed for each subject to obtain steady state BIS
and SEF values. Thereafter with one of the four conditions - acupressure at
the acupoint Yintang, manual needle acupuncture at Yintang, laserneedle
acupuncture at Yintang or acupressure at a control point was started (Fig.
7.1). There were three treatments and additionally to investigate a possible
placebo effect, we also used acupressure at a control point.
The acupoint Yintang (Ex.1) is located midway between the medical ends of
the two eyebrows at the root of the nose (see Fig. 7.1, a - c). To assess the
reliability and validity of acupressure and manual needle acupuncture,
pressure on the acupoint and the control point was applied by the same
chinese medical doctor experienced in Traditional Chinese Medicine. The
thumb pressure was estimated to be about 3 x 105 Pa (mean force measured
~ 30 N / 1 cm²; Pascal (Pa) = N/m²; 30/0.0001=3x105).
75
a b
c d
Fig. 7.1: Different conditions of the cross-over study design: (a) acupressure at the
acupoint Yintang, (b) manual needle acupuncture at Yintang, (c) laserneedle
acupuncture at Yintang, and (d) acupressure at a control point in a 25-year-old
healthy female (with permission by the volunteer E.H.).
Manual needle acupuncture was performed using sterile single use needles
0.30 x 30 mm (Huan Qiu; Suzhou, China). After local disinfections of the
skin the needling method was oblique, in caudal direction (0.5 cm) [5].
Stimulation for a duration of 20 sec in intervals of 2 minutes consisted of a
combination of rotating and thrusting movements using a special manual
acupuncture stimulation technique (sedation method). The needle was
removed after 10 minutes.
Acupressure on the control point (location: 2 cm from lateral end of the left
eyebrow; Fig. 1, d) was performed in similar manner as on the acupoint
Yintang (duration 10 min).
All subjects had four conditions applied (Fig. 1, a - d). The persons were in a
semi-lying position with closed eyes. The choice of the stimulation
procedure was randomized within a subject and the interval between the
different sessions was at least 20 min.
The main evaluation parameters were BIS and SEF90 during different
conditions (Fig. 7.1) and time intervals (Fig. 7.2). Measurements were made
at time points a - g (see Fig. 7.2). In any one condition we recorded BIS and
SEF values continuously but sampled the data for subsequent analysis at 7
points. A single reading was taken at each point. The stimulation was not
stopped at the time of reading. The whole study session lasted 2 – 3 hours.
BIS and SEF90 represent single numbers, which should decrease
continuously with decreasing level of consciousness (hypnosis). There are
several review articles for methodological details of signal processing of BIS
and SEF [3].
b c d e f
1 min 1 min
5 min 2.5 min 2.5 min
a g
5 min 5 min
2 min 2 min
10 min
After five minutes of stimulation (Fig. 7.2, d) the subjects were asked to
move their right hand to clarify that they were awake and not asleep. In
addition before and after each stimulation mode the persons were asked to
score the stress and tension that they had based on a verbal stress scale
(VSS) from 0 (no stress) to 10 (maximum stress) [4]. Heart rate (HR) and
noninvasive blood pressure (BP) were also recorded before and after
77
The BIS and SEF data were tested with analysis of variance (one-way
repeated measures ANOVA; similar data were found to be normally
distributed in previous investigations) using SigmaStat (Jandel Scientific
Corp., Erkrath, Germany). Dunnett’s method was used for post hoc analysis.
VSS data were compared using paired t-test. The results were graphically
presented as box plots (BIS and SEF) and as scatter plot (VSS). Changes
were considered significant at a p-value < 0.05.
7.3 Results
All subjects completed the study. Figure 7.3 shows the decreases of BIS
values during acupressure applied to the acupoint Yintang in all 25 healthy
volunteers.
78
1 2 3 4
5 6 7 8
9 10 11 12
13 14 15 16
17 18 19 20
21 22 23 24
25
Yintang n=25
10 min
Fig. 7.3: The trend of BIS values of 25 healthy volunteers (1 – 25) before, during
and after acupressure performed on the acupoint Yintang. All subjects were awake.
Note the significant decrease (min. BIS = 35; no. 14) due to acupressure.
Before the subjects were stimulated, their mean BIS values (r SD) were 97.4
(98 - 95) r 1.0 and their mean SEF values (r SD) were 23.9 r 4.1 Hz (right)
and 23.5 r 4.9 Hz (left). The BIS and SEF values both decreased
significantly (p < 0.001) after starting acupressure. After 5 minutes
acupressure at the acupoint Yintang the mean BIS values were 62.9
(minimum 35; see no. 14 in Fig. 7.3) r 13.9, and the mean SEF values were
13.3 (minimum 2.9) r 8.1 Hz (right) and 13.8 (minimum 2.7) r 7.3 Hz (left).
The release of acupressure caused an increase in BIS and SEF back to the
baseline values before stimulation (compare Fig. 7.4).
79
120
100
BIS 80
60
40
30
25
20
Hz
15
10
30
25
20
Hz
15
10
Fig. 7.4: Box plots of alterations of BIS and SEF values (r right, l left) in 25 healthy
volunteers before (a), during (b - f), and after (g) acupressure (compare Fig. 7.2) on
the acupoint Yintang. The ends of the boxes define the twenty-fifth and seventy-fifth
percentiles, with a line at the median and error bars defining the tenth and ninetieth
percentiles.
80
Figure 7.5 summarizes the BIS and SEF results obtained during manual
needle acupuncture, laserneedle acupuncture and acupressure on the control
point. Significant (p < 0.05) changes were found in BIS values during
laserneedle acupuncture (measuring points d and e; compare Figs. 7.2 and
7.5) and during acupuncture on the control point (measuring points d - f).
After 7.5 minutes laserneedle acupuncture at acupoint Yintang the mean BIS
values (r SD) were 95.4 (minimum 81; see Fig. 7.5, middle, upper panel) r
4.1. After 5 minutes acupressure at the control point the mean BIS values (r
SD) were 94.2 (minimum 77; see Fig. 7.5, right, upper panel) r 4.8. SEF did
not show any significant alteration.
80 80 80
BIS
BIS
BIS
60 60 60
(d,e vs. a) (d-f vs. a)
40 40 40
20 20 20
One Way Repeated Measures ANOVA
n.s. BIS One Way Repeated Measures ANOVA BIS
(Dunnett‘s Method) BIS (Dunnett‘s Method)
0 0 0
35 35 35
30 30 30
25 25 25
20 20 20
Hz
Hz
Hz
15 15 15
10 10 10
5
n.s. 5
n.s. 5
n.s.
SEF r SEF r SEF r
0 0 0
35 35 35
30 30 30
25 25 25
20 20 20
Hz
Hz
Hz
15 15 15
10 10 10
5 5 5
n.s. n.s. n.s. SEF l
SEF l SEF l
0 0 0
a b c d e f g a b c d e f g a b c d e f g
Fig. 7.5: Box plots of changes of BIS and SEF values (r right, l left) during manual
needle acupuncture, laserneedle acupuncture and acupressure at the control point.
Further explanations see Fig. 7.4.
The results of the analysis of the VSS are demonstrated in Fig. 7.6.
81
10
4
a
a
2 a a
b
b
b b
0
(n.s. p < 0.012)
p < 0.001 paired t-test
Fig. 7.6: Mean (+ SD) values of the verbal stress score (VSS) of 25 healthy
volunteers before (a) and after (b) different modalities of nonpharmacological
stimulation (0 = no stress; 10 = maximum stress).
The VSS values were significantly (p < 0.001) reduced after pressure
application on Yintang, needle acupuncture and laserneedle acupuncture but
also after pressure application on the control point (p = 0.012). Mean
baseline VSS values were insignificant lower in laserneedle and control
conditions.
7.4 Discussion
The bispectral index and the spectral edge frequency are mainly used
intraoperatively to monitor the hypnotic effect of anesthetic drugs. There are
several studies reported in the literature proposing target values for EEG
parameters to guide the depth of anesthesia. A number of authors have
reported a low probability of recall and a high probability of
unresponsiveness during surgery at a level of 60 for BIS [8,9]. BIS values
< 50 are described as suppressing hemodynamic responses during intubation
82
shown in several test measurements using placebo points that BIS is not
affected by laserneedle stimulation per se. In the present study there were
small statistically significant but not clinically important changes with
needle acupuncture, laserneedle acupuncture and acupressure at control
point. These findings also help confirm that the BIS and SEF reductions
induced by acupressure at Yintang are not a placebo effect. Reduced
electromyographic levels could be partially responsible [21] (Fig. 7.8).
Fig. 7.7: Laserneedle stimulation at Yintang (CSA = coulor spectral array; CFM =
mean EEG-parameter; BIS = bispectral index; HR = heart rate; HRV = heart rate
variability). Note the decrease of the BIS values during laserneedle activation.
84
EEG - DELTA
Laserneedle-
Laserneedle-Stimulation – Yintang (10 min)
7.5 Acknowledgements
The author would like to express his thanks to Ms. Lu Wang MD, Ms. Petra
Petz MSc and Evamaria Huber (all Biomedical Engineering and Research in
Anesthesia and Intensive Care Medicine, Medical University of Graz) for
their valuable help.
7.6 References
[1] Litscher G, Schwarz G (2001) Editorial. Noninvasive bioelectrical
neuromonitoring in anaesthesia and critical care. Eur J Anaesthesiol
18: 785-788
[2] Litscher G (2000) Editorial. The future of neuromonitoring. Internet J
Neuromonitoring 1(1):
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijnm/vol1n
1/editorial2.xml
[3] Rampil IJ (1998) A primer for EEG signal processing in anesthesia.
Anesthesiology 89: 980-1002
[4] Fassoulaki A, Paraskeva A, Patris K, Pourgiezi T, Kostopanagiotou G
(2003) Pressure applied on the extra 1 acupuncture point reduces
bispectral index values and stress in volunteers. Anesth Analg 96:
885-889
[5] Stux G, Pomeranz B (1998) Basics of acupuncture. Springer; Berlin
Heidelberg New York
[6] Litscher G, Schikora D (2002) Cerebral vascular effects of non-
invasive laserneedles measured by transorbital and transtemporal
Doppler sonography. Lasers Med Sci 17: 289-295
[7] Litscher G, Schikora D (2002) Near-infrared spectroscopy for
objectifying cerebral effects of needle and laserneedle acupuncture.
Spectroscopy 16: 335-342
[8] Sebel PS, Lang E, Rampil IJ, White PF, Cork R, Jopling M, Smith NT,
Glas PS, Manberg P (1997) A multicenter study of bispectral
electroencephalogram analysis for monitoring anesthetic effect.
Anesth Analg 84: 891-899
[9] Liu J, Singh H, White PF (1997) Electroencephalographic bispectral
index correlates with intraoperative recall and depth of propofol-
induced sedation. Anesth Analg 84: 185-189
[10] Heck M, Kumle B, Boldt J, Lang J, Lehmann A, Saggau W (2000)
Electroencephalogram bispectral index predicts hemodynamic and
arousal reactions during induction of anesthesia in patients
undergoing cardiac surgery. J Cardiothorac Vasc Anesth 14: 693-697
[11] Chan MTV, Gin T (2000) Editorial. What does the bispectral EEG
index monitor? Eur J Anaesthesiol 17: 146-148
[12] Greif R, Laciny S, Mokhtarani M, Doufas AG, Bakhshandeh M, Dorfer
L, Sessler DI (2002) Transcutaneous electrical stimulation of an
86
8.1 Introduction
A new noninvasive laserneedle system has been developed and used for the
first time in acupuncture research recently [1,2]. This new optical
stimulation technique has the advantage that the stimulation is absolutely
painless. Moreover laserneedle acupuncture allows to stimulate appropriate
acupoint combinations simultaneously and with higher radiation doses than
commercially available low level hand held laser equipment.
The laser radiation of eight laser diodes is coupled into eight optical fibers
and the laserneedles are arranged at the distal ends of the optical fibers. Due
to the direct contact of the laserneedles and the skin, no loss of intensity
occurs and the laser power, which affects the acupoints, can be exactly
determined [1,2].
The dynamics of the metabolic mechanism that regulates cerebral blood flow
has already been studied in normal human subjects using fTCD [3,4]. Blood
flow velocity in the posterior cerebral artery (PCA), supplying the visual
cortex, increased by 16.4 % in response to light stimulation of the retina.
88
The method of fTCD has also been used in previous studies in acupuncture
and laserneedle research to investigate specific changes in blood flow
velocities of different cerebral arteries [1]. Functional magnetic resonance is
sensitive to subtle regional changes in the blood oxygenation level from
increased neuronal activity during a specific task or stimulation. It has been
successfully used to map the sites of brain activations during needle and low
level laser acupuncture [5-9]. These studies report increase (positive
activation) and decrease (negative activation) of the BOLD (blood
oxygenation level dependent) signal. However, fMRI has not been used up
to now during laserneedle stimulation.
8.2 Methods
8.2.1 Painless laserneedles
For our experiments eight acupuncture points were chosen and irradiated
simultaneously. The laserneedles used in this study emit red light in cw-
mode with an output power of 30 - 40 mW per laserneedle (wavelength:
685 nm). The fiber core diameter used in this study was about 500 µm. The
time of irradiation was 20 min (fTCD measurements) resulting in an energy
density of about 4.6 kJ/cm² at each acupoint and a total sum of 36.8 kJ/cm²
for all acupoints. The laserneedles were fixed onto the skin using plaster
stripes but not pricked into the skin.
8.2.4 Participants
The study protocol was approved by the institutional ethics committee of the
Medical University of Graz (11-017 ex 00/01) and all 18 participants gave
written informed consent. None of the subjects was under the influence of
centrally active medication. All persons were free of neurological or
psychological disorders including the absence of visual deficits. A
honorarium was given for participation.
Fig. 8.1: Vision related acupuncture points and placebo points used in this study. All
acupoints (left panel, from bottom to top and from right to left: Hegu, Zusanli,
Kunlun, Zhiyin) and all placebo points (right panel) were stimulated bilaterally.
The acupoints were cleaned with alcohol. Then the laserneedles were put in
contact with the skin and fixed by plaster stripes. During the experiments the
subjects were in a relaxed and comfortable position on a bed in our
laboratory (fTCD measurements) or lying in the scanner (fMRI
investigation). For the fTCD investigations we started randomly with either
acupoint or placebo stimulation.
Acupoints
Hegu (LI.4):
Location: On the dorsum of the hand, between the 1st and 2nd metacarpal
bones, in the middle of the 2nd metacarpal bone on the radial
side.
Indications: Headache, redness, swelling and pain of the eye.
Zusanli (Sp.36):
Location: 3 cun below Dubi (S 35), one finger-breadth from the anterior
crest of the tibia.
Indications: Gastric pain, abdominal distension, vomiting, diarrhea,
dysentery, has tonification effect.
Kunlun (UB.60):
Location: In the depression between the tip of the external malleolus and
tendo calcaneus.
Indications: Headache, neck rigidity, dizziness.
91
Zhiyin (UB.67):
Location: On the lateral side of the small toe, about 0.1 cun lateral to the
corner of the nail.
Indications: Headache, pain in the eye, nasal obstruction, epistaxis,
malposition of fetus.
The mean blood flow velocity (vm) in the PCA and the MCA were evaluated
simultaneously and continuously at different measurement points (a - e in
Fig. 8.2A) [10]. Each person was studied performing stimulation on vision
related acupoints and placebo points. The interval between the fTCD-
experiments was 20 to 30 minutes and the subjects were instructed to keep
their eyes closed during the whole fTCD experiments.
Similarly, during fMRI investigations the subject could not see whether the
laser was off or on. The fMRI study used a block design with alternating one
minute resting condition (‘R’) and one minute activation condition (‘A’)
(Fig. 8.2B). The experiment started with ‘R’ followed by the laserneedle
acupuncture condition (‘A’). A total of 6 ‘R’ and 6 ‘A’ intervals was
registered. Altogether the fMRI data acquisition took 12 minutes.
b c d
1 min 1 min
10 min
A a
20 min Laserneedle Stimulation
e
2 min 2 min
A A A A A A
B R R R R R R
1 min
12 min
Fig. 8.2: Measurement profiles for fTCD (A) and fMRI (B) measurements.
92
The fTCD data before (a), during (b - d), and after (e) laserneedle
acupuncture (comp. Fig. 8.2A) were tested with Kruskal-Wallis one way
ANOVA on ranks (SigmaStat, Jandel Scientific Corp., Erkrath, Germany).
The criterion for significance was p < 0.05.
The fMRI data were analysed using SPM 99 (SPM 99, Department of
Imaging Neuroscience, London, UK). All volumes from the subject were
realigned using the first volume as a reference and resliced using sinc-
interpolation. The functional images were spatially normalized to a standard
echo planar template in Tailarach space.
8.3 Results
The results of the alterations of mean blood flow velocities in the PCA and
MCA before, during, and after laserneedle and placebo acupuncture are
summarized in Figure 8.3.
93
+ 2.5 cm/s
40 SE
MCA
50
40
a b c d e
40 SE
MCA
50
40
a b c d e
Fig. 8.3: Mean blood flow velocity (vm) of the posterior cerebral artery (PCA) and
the middle cerebral artery (MCA) before (a), during (b - d), and after (e) stimulating
vision related acupoints (A) and placebo points (B) with laserneedles in 17 healthy
volunteers. Note the trend towards an increase (+ 2.5 cm/s) in vm in the PCA during
acupoint stimulation.
the laserneedles (vm; Cx r SE, acupoint stimulation, PCA: 42.2 r 2.5 before
(a), 44.2 r 2.6 during (b - d), 42.3 r 2.4 cm/s after (e)). Stimulation at
placebo points did not increase vm of the PCA and of the MCA (Fig. 8.3B),
rather there was a trend towards a small decrease of mean values of the mean
vm in both arteries (vm, Cx r SE, placebo point stimulation, PCA: 42.9 r 2.6
before (a), 41.7 r 2.6 during (b - d), 42.1 r 2.8 cm/s after (e)).
The mean arterial blood pressure before and after laserneedle acupuncture
was almost identical (76.7 r 7.6 (SD) vs. 75.8 r 6.8 mmHg).
The results of the fMRI investigation are shown in Figures 8.4 and 8.5 and
Table 8.1. Significant changes in brain activation were found in the occipital
lobe and in the frontal lobe.
right left
Fig. 8.4: First evidence of significant effects of changes in brain activation during
laserneedle stimulation of vision related acupoints in the occipital and frontal areas
in a 27-year-old healthy female using fMRI investigation.
95
-1
-2
-3
R 12 min
Time [min]
Fig. 8.5: The time course of signal change correlated with the experimental fMRI
paradigm. Note the signal increases during active laserneedle acupoint stimulation
(A) and the signal decreases during resting condition (R).
Tab. 8.1: Regions of significant activation (occipital and frontal areas) due to
laserneedle stimulation of vision related acupoints. The p-values are corrected (p <
0.05) at the cluster level for multiple comparisons. Compare Fig. 8.4.
96
8.4 Discussion
Recent scientific and technological progress especially regarding the
application of modern brain function monitoring systems has truly
revolutionized acupuncture research. The usage of advanced exploratory
tools, such as functional multidirectional transcranial ultrasound Doppler
sonography or functional magnetic resonance imaging, provides insights and
attempt to shine scientific light upon the most spectacular of the eastern
medical procedures [3,4]. Recently it has been attracted interest that the
brain is the key to acupuncture’s and laser puncture’s effects. New
experimental constructions to measure ultrasound, light and bioelectrical
processes can reproducibly demonstrate effects of stimulation of acupoints in
the brain [1,2,5-21].
The new laserneedle system has been described for the first time in scientific
literature recently [1]. In addition previous studies from our group show that
the new optical stimulation with laserneedles can elicit reproducible cerebral
effects which are in the same order with respect to the maximum amplitude
of the mean blood flow velocity as compared to needle acupuncture [1]. The
stimulation performed within this study could not be felt by the patient. The
operator was also unaware of whether the stimulation was active, and
therefore a true double-blind study was performed. Moreover laserneedle is
the first laser system commercially available that could be used at eight or
more standard acupuncture points simultaneously.
In addition to fTCD we used for the first time fMRI in a healthy volunteer
during laserneedle stimulation of the same vision related acupoints as used
for the fTCD measurements. Bilateral stimulation of the acupoints produced
bilateral positive activation over the frontal cortex. A time-logged increase
of the BOLD signal was also seen at the left superior occipital gyrus
(Brodmann Area 19). Apparently the stimulation of vision-implicated
acupoints (Kunlun, UB.60 and Zhiyin, UB.67) activated the visual cortex.
These findings are in accordance with other fMRI acupuncture studies. Cho
et al. [7] reported that needling of acupoints (UB.60, 65, 66 and 67) on the
foot created activation in the visual cortex similar to actual visual stimuli.
Needling of non-acupoints on the foot 2 to 5 cm away from the vision
related acupoints as control caused no activation in the occipital lobes [7].
It has been demonstrated using fMRI that needle acupuncture [7] and laser
puncture [9] of the vision-related acupoint Zhiyin (UB.67) activates the
visual cortex of the human brain. As a further study on the effect of this
acupoint stimulation on the visual cortex, Lee et al. [22] examined c-Fos
expression in binocularly deprived rat pups. Interestingly, acupuncture
stimulation of UB.67 resulted in a significant increase in the number of c-
Fos-positive cells in the primary visual cortex, while acupuncture
stimulation of other points less important for visual function had no
significant effect on c-Fos expression in the primary cortex.
8.5 Conclusions
(a) Using the new laserneedle acupuncture method we were able to
stimulate multiple vision-associated acupuncture points at the same
time. The results showed insignificant increases in cerebral blood flow
velocity of the PCA after stimulation of vision-related acupoints on the
foot. At the same time blood flow velocity in the MCA showed minor
changes. Stimulation at placebo points did not show increases in blood
flow velocity in both arteries.
(b) The fMRI results of a healthy volunteer after laserneedle stimulation
of the same acupoints showed significant changes in occipital and
frontal brain areas.
(c) Both techniques, fTCD and fMRI, can be used to study cerebral effects
of laserneedle acupuncture in a complementary way [24].
8.6 Acknowledgements
The authors thank Evamaria Huber (Biomedical Engineering and Research
in Anesthesia and Intensive Care Medicine, Medical University of Graz,
Austria) and Martin Kronbichler (Department of Psychology, University of
Salzburg, Austria) for their support to this study.
8.7 References
9.1 Introduction
The quantitative determination of border values for thermal sensory and pain
threshold testing has been clinically used for several years and is of great
importance in the fields of neurology, psychiatry, and neurophysiology [6].
Several guidelines regarding the correct application of „Quantitative sensory
testing“ (QST) were published in scientific literature [4].
Goal of this study was to determine normal values and objectify possible
gender specific differences. For the first time, QST was used, in combination
with scientific tests using the new laserneedle stimulation technique, to
quantify possible alterations before and after painless acupuncture with
laserneedles.
9.2 Method
9.2.1 Volunteers
Twenty-nine healthy adult volunteers, mean age (Cx r SD) was 24.2 r 2.7
(range from 18 to 29 years) were included in the study. Twenty volunteers
were female (mean age: 23.9 r 2.7 years) and 9 were male (mean age: 24.9 r
2.8 years). The ethical committee of the Medical University of Graz
(laserneedle stimulation; 13-048 ex 02/03) approved the tests and all
102
1
3
Fig. 9.1: Set-up in the lab of the Dept. of Biomedical Research in Anaesthesia and
Intensive Medicine, Medical University Graz. Thermal Sensory Analyser TSA-II (1)
with Notebook-Data analysis (2) and laserneedle stimulation device (3). With
generous consent from the volunteer.
Laserneedles are special light conductors which are placed vertically at the
skin, and trigger painless stimulation at the acupoint. They offer high optical
output densities regarding measurable cerebral effects compared with
acupuncture needles [9 ,10], and for the first time, allow simultaneous
optical activation of up to eight acupoints according to Traditional Chinese
Medicine (TCM).
Acupuncture was performed at the acupoints shown in Figure 9.2. First, the
skin was disinfected with alcohol at the acupoint, and then the laserneedles
are applied and fixed to the skin with special adhesive tape. During testing,
the volunteers were positioned relaxed on a bed (compare Fig. 9.1). In two
104
different tests, the laserneedles were once applied and activated for 10
minutes, or remained deactivated in an identical procedure (placebo). Which
test procedure was performed first was selected at random. Each volunteer
was tested with activated as well as deactivated laserneedles, whereby the
volunteers were not informed about and could not perceive the respective
mode being used. The resting period between both tests was at least 20
minutes.
Hegu (LI.4):
Localisation: At the highest point of M. adductor pollicis, when the thumb
lies against the index finger.
Indication: Hegu is the most important analgesic point. Pain conditions;
particularly strong manual stimulation relieves pain in the
entire body.
Needling: Vertical, 1 - 2 cm deep in direction Pe.8 Laogong.
Taiyuan (Lu.9):
Localisation: On the radial side of the bending fold at the wrist joint,
lateral from A. radialis.
Indication: Pain in the wrist region, polyneuropathy at the upper
extremity.
Needling: Vertical or inclined, 0.3 - 1 cm deep.
Quchi (LI.11):
Localisation: At the lateral end of the bending fold of the elbow during
right-angled bending of the lower arm.
Indication: Homeostatic and immuno-stimulating point.
Needling: Vertical, 2 - 3 cm deep.
3 4
5
2
1
Fig. 9.2: Laserneedle stimulation at the acupoints Hegu (1), Taiyuan (2), Quchi (3),
Shenmen – Ear point 55 (4) and Ear point 67 (5).
A „t-test“for the conditions before (I) and after (II) laserneedle stimulation
and a „paired t-test“ for the placebo test, were used to determine gender
specific differences. Significance was defined with p < 0.05. The results are
shown graphically with box-plot illustrations (Statistical program SigmaStat;
Jandel Scientific Corp., Erkrath, Germany).
9.3 Results
Figure 9.3 shows a sample „test report“. In addition to a marker at the
derivation, or stimulation region („C6 right hand palmar thumb“), the
measurement results (mean value of 3 tests) and differences (ǻ) before and
after intervention (laserneedle stimulation or placebo test) of the respective
testing mode are shown graphically in this protocol.
106
Temp.
[°C]
60
laserneedle stimulation placebo
I II I II
50
I II
I II
40
I II I II
I II I II
30
20
10
n=29
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
a b c d a b c d
Fig. 9.4: Box-plot illustration of n = 29 healthy volunteers. Cold sensation- (a) and
warm sensation thresholds (b) and cold pain- (c) and heat pain thresholds (d) before
(I) and after (II) laserneedle stimulation (left) and placebo (right). The horizontal
line in the box indicates the position of the median. The ends of the box define the
25th and 75th percentile; the error bars mark the 10th and 90th percentiles.
Temp.
[°C]60
laserneedle stimulation placebo
I II I II
50
40 I II I II
I II I II A
I II I II
30
women
*)
20
10
n=20
p = 0,009
p = 0,026
p < 0,001
p = 0,034
p < 0,001
t-test
Temp.
[°C]
I II I II
I II
I II
I II I II
I II B
I II
men
n=9
a b c d a b c d
Fig. 9.5: Gender specific analysis (female (A), male (B)). In addition to the
significant gender specific differences in pain sensation, note the difference (*) in
median values during cold pain threshold determination before (I) and after (II)
laserneedle stimulation. Further information see Fig. 9.4.
109
9.4 Discussion
There are numerous publications concerning QST reproducibility [20], the
different biological effects on thermal sensor, vibration specific and pain
thresholds and the gender specific differences and influence of age and body
size [19]. Clinical indications for QST described in this study are the
determination of sensory and pain thresholds in chronic pain disorders [17],
diabetic neuropathy [3] and use in patients with multiple sclerosis [7,18].
chronic pain with laserneedle acupuncture can lead to provable effects in the
described measurement parameters should be investigated in further studies.
9.5 Acknowledgements
The authors thank Mr. Michael Magometschnigg and Mr. Ing. Stefan Wüger
(both from INTEC Medizintechnik GmbH, Vienna, Austria) for their
organisational and technical support with Thermal Sensory Analyser TSA-II.
We also thank Ms. Ingrid Gaischek MSc. (Biomedical Engineering and
Research in Anaesthesia and Intensive Care Medicine, Medical University
Graz) for her valuable support in data analysis and writing the manuscript.
9.6 References
[1] Bajaj P, Arendt-Nielsen L, Bajaj P, Madsen H (2001) Sensory
changes during the ovulatory phase of the menstrual cycle in healthy
women. Eur J Pain 5: 135-144
[2] Becerra LR, Breiter HC, Stojanovic M, Fishman S, Edwards A, Comite
AR, Gonzalez RG, Borsook D (1999) Human brain activation under
controlled thermal stimulation and habituation to noxious heat: an
fMRI study. Magn Reson Med 41: 1044-1057
[3] Bravenboer B, van Dam PS, Hop J, Steenhoven Jvd, Erkelens DW
(1992) Thermal threshold testing for the assessment of small fibre
dysfunction: normal values and reproducibility. Diabet Med 9: 546-549
[4] Consensus report (1993) Quantitative sensory testing: a consensus
report from the Peripheral Neuropathy Association. Neurology 43:
1050-1052
[5] Davis KD, Kwan CL, Crawley AP, Mikulis DJ (1998) Functional MRI
study of thalamic and cortical activations evoked by cutaneous heat,
cold, and tactile stimuli. J Neurophysiol 80: 1533-1546
[6] Fruhstorfer H, Lindblom U, Schmidt WC (1976) Method for
quantitative estimation of thermal thresholds in patients. J Neurol
Neurosurg Psychiatry 39: 1071-1075
[7] Heijenbrok MW, Anema JR, Faes TJ, Bertelsmann FW, Heimans JJ,
Polman CH (1992) Quantitative measurement of vibratory sense and
temperature sense in patients with multiple sclerosis. Electromyogr
Clin Neurophysiol 32: 385-388
[8] Litscher G (2003) Cerebral and peripheral effects of laser needle-
stimulation. Neurol Res 25: 722-728
[9] Litscher G, Schikora D (2002) Cerebral vascular effects of non-
invasive laserneedles measured by transorbital and transtemporal
Doppler sonography. Lasers Med Sci 17: 289-295
[10] Litscher G, Schikora D (2002) Near-infrared spectroscopy for
objectifying cerebral effects of needle and laserneedle acupuncture.
Spectroscopy 16: 335-342
111
10.1 Introduction
The stimulation of acupuncture points with laser light can evoke specific
effects in the periphery and in the brain. For the first time, these effects, can
be objectified and quantified using modern biomedical engineering
techniques. Laserneedle acupuncture represents a new, painless method for
primary optical stimulation of acupuncture points [1-15]. Laserneedles, are
not inserted in the skin, however, simply applied to the acupuncture point.
This method allows the simultaneous stimulation of individually combined
points for the first time.
This study gives a current summary regarding scientific proof and innovative
aspects of painless laserneedle acupuncture. We introduce studies which
prove the peripheral effects using registration of temperature and laser
Doppler flowmetry [8,9,13], as well as publications regarding the
objectification of cerebral effects of laserneedle acupuncture aided by
functional multi-directional transcranial Doppler sonography (fTCD) [1-
3,8,9,11,12], functional magnetic resonance imaging (fMRI) [11,12] and
near infrared spectroscopy (NIRS) [2,4-6,8,9].
10.2 Methods
10.2.1 Temperature and microcirculatory monitoring
The surface temperature of the skin and the measurement parameter Flux (=
product of concentration and velocity of erythrocytes) were performed with
the Laser-Doppler-Flowmetry Monitor DRT 4 (Moor Instruments, Millway,
Axminster, England). A DPIT-probe (diameter 8 mm, length 7 mm) with a
power of 1 mW was used (compare Fig. 10.1, above). The edge frequencies
were 20 Hz and 22.5 kHz [8,9,13].
113
The fMRI-investigations were performed using a 1.5 Tesla total body system
(Intera, Philips Medical Systems, Best, Netherlands) (compare Fig. 10.4,
above). The BOLD (blood oxygen level dependent) contrast sensitive
images were acquired with a T2* weighted gradient echo sequence (single
shot planar readout, flip angle 90°, TE 50 ms, FOV 250 mm, matrix 96 x 96
interpolated at 128 x 128, layer number 30, layer thickness 4 mm). A total of
144 volume images, were registered continuously in succession, with a
repetition time of 5 seconds.
In addition, an animal study was included in this report. The animal used
was a sus scrofa domesticus, which was put under general anaesthesia in the
animal surgical suite of the Department of Surgical Research at the Medical
University of Graz (compare Fig. 10.1, left). This study was performed in
accordance with the rules defined by the ethic committee (animal study
approval number GZ 66.010/10-BRGT/2003).
Data was analysed with „One-way repeated measure ANOVA“ , using the
computer program SigmaStat (Jandel Scientific Corp., Erkrath, Germany).
The tests described in single publications were used for post hoc-analyses.
The level of significance was defined as p < 0.05 when no other value was
explicitly given.
organized and the first picture was used as reference, whereby „sinc-
interpolation“ was used.
Functional data were spatially smoothed with a 6 mm full width at half
maximum isotropic kernel. A boxcar waveform convolved with a synthetic
haemodynamic response function was used as the reference waveform. A t-
test was performed to identify regions showing significantly higher
activation during the activation condition versus the resting condition. For
significantly activated regions, a statistical threshold p < 0,05, corrected at
the cluster level for multiple comparisons, was used. The activated regions
were located with help of the Tailairach-space.
10.3 Results
Figure 10.1 shows in summary the results of an animal study [13] and a non-
therapeutic biomedical engineering study with test persons [8,9] regarding
the periphery effects of laserneedle acupuncture. The Flux, hand and room
temperature parameters were summarized at different measurement points.
The significant (p = 0.005) increase of Flux in the test persons during 20
minutes of laserneedle stimulation (b - d) must be considered. The results of
the animal study show that laserneedle stimulation (wavelength: 685 nm;
power density: 4.6 kJ/cm² per point; duration 20 min) can cause alterations
in microcirculatory parameters of the skin, in the sense of increased
circulation, however, the laser quality and intensity did not induce any
micro-morphological changes in the skin [13].
116
p = 0.005
p = 0.02
45 34
Temp.
32
Temp.
40 (°C)
30
(°C) 35
Temp. Flux 28 Temp.
Flux
R.-Temp. (a.u.) R.-Temp.
30
Flux
26
(a.u.) Flux
24
25
22
20
a b c d e n=1 20
a b c d e n = 22
20 min 20 min
modified from: Biomed. Technik, 2004, 49: 2-5 [13] modified from: Neurol. Res., 2003, 25: 722-728 [9]
Fig. 10.1: Animal (left side) and human experimental (right side) studies using
laserneedle stimulation. Flux (product of concentration and velocity of
erythrocytes), surface skin temperature (Temp.) and room temperature (R.-Temp)
before (a), during (b – d) and after (e) laserneedle activation.
Figures 10.2 and 10.3 document specific changes in cerebral blood flow
velocities in different arteries. Using the laser acupuncture scheme (TCM:
Zanzhu and Yuyao; ear: eye and liver; KHA: E2; CHA: Yan Dian) the blood
flow velocity in the OA using a wavelength of 685 nm increases
significantly (p = 0.01). However, a 30 % increase in stimulation intensity
only increases vm in the OA to a mean value of 11 %. Simultaneously, no
significant changes in vm occurred in the MCA. Using laserneedle
acupuncture with a wavelength of 785 nm, a marked, but insignificant (p =
0.546) increase in vm in the OA during stimulus application occurred. Brief
stimulation (20 sec each) of the single points with a hand-held low level
laser (19 mW), did not reveal any significant (p = 0.939) differences in vm in
the OA, concerning the conditions before and after stimulation.
117
Ophthalmic artery (OA) Ophthalmic artery (OA) Ophthalmic artery (OA) Ophthalmic artery (OA)
vm (cm/s)
20 20
b 20 20
b
p=0.546 p=0.939
15 15 15 15
p=0.01* SE SE SE SE
10 10 b
p<0.01* 10 10
a c a c a c a c
b b
60 60
50
a c 40 a c
Fig. 10.2: Specific changes in mean blood flow velocity (vm) under laserneedle
acupuncture (from left to right: 685 nm, 685 nm with increased intensity (+ 30 %),
785 nm and 685 nm (19 mW)). Mean values and standard error (SE) before (a),
during (b) and after (c) stimulation are shown.
Figure 10.3 shows the changes in vm in the ACA and PCA when applying
different laser puncture schemes (A, B). When using laser puncture scheme
A, vm increased during stimulation (b - d) significantly in the ACA
(p < 0.001) and is still higher at the end of the experiment (e) than before
laser puncture (a). At the same time, insignificant changes in vm occurred in
the PCA. During optical stimulation of the acupuncture points in scheme B,
a significant increase (p < 0.002) in vm in the PCA took place although
simultaneously insignificant changes in the ACA were observed.
118
Volunteers n=22
12 female, 10 male, 21 - 29 years ( 24.4 + 2.6 years; x + SD )
R
49 51
48 *) 50
47 49
46 48
n.s.
45 47
a b c d e a b c d e
*) p < 0.001
Figure 10.6 at the left, shows the hypothetically assumed course of stimulus
intensity, in random units of a metal and laserneedle as a function of time. At
the middle and at the right, real time signals registered with NIRS and
bioelectric methods (EEG - BIS) are illustrated.
121
metal
100
metal needle
needle HHb
90
10 min
10 min
time [min]
laserneedle laserneedle 90
HHb
10 min
10 min
time [min]
Fig. 10.6: Stimulus intensity (SI) as a function of time. From left to right:
hypothesis, real measured cerebral reactions of near infrared spectroscopy
measurement parameters O2Hb (Oxyhaemoglobin) and HHb (Desoxyhaemoglobin),
as well as the bioelectric response (BIS = Bispectral index). Modified according to
[4,6,10].
10.4 Discussion
The term „laser“ is very fascinating for many people today. Innovation and
laser are nearly synonymous. Albert Einstein, already formulated the
physical foundation for so-called light intensification with stimulated
emission, in 1917. In the field of medicine, laser not only allows careful
treatment for patients, but also a manifold of selective therapies in nearly all
special fields. Laser has developed to be an important instrument in
acupuncture when considering the treatment of small children, or patients
with a phobia against needles.
One goal of this study is to give a summary about previous clinical
experimental studies dealing with this new method of optical acupuncture
stimulation. Since the test person or patient does not feel the intervention,
furthermore, the different acupuncture points can be stimulated continuously
and simultaneously, it was possible to perform these double-blind
randomised, controlled, cross-over studies for the first time. The studies
indicate that cerebral effects of this manner of stimulation are nearly
equivalent to that in needles. In addition to complex multi-directional
sonography, it was also possible to provide proof regarding cerebral
functional changes after laserneedle stimulation using functional magnetic
122
resonance imaging for the first time. At the same time, points “near the
head” could be stimulated during fMRI examination, which was not possible
thus far with acupuncture needles and hand-held laser instruments.
The new scientific results may be of great importance, not only for the field
of laser medicine, but also for acupuncture research in general.
10.5 Conclusion
For the first time, laserneedle acupuncture allows simultaneous optical
stimulation of individual puncture point combinations. Variations in
acupuncture on the body, ear or hand, as performed and described in these
studies are also possible. The studies were able to objectify and specify the
cerebral effects of laserneedle stimulation for the first time. The cerebral
effects triggered by this new, painless laserneedle technique are of similar
dimension to those evoked by manual needle acupuncture.
10.6 Acknowledgements
The authors would like to thank Ingrid Gaischek MSc (Biomedical
Engineering and Research in Anaesthesia and Intensive Care Medicine,
Medical University of Graz) for her valuable support in this study.
10.7 References
[1] Litscher G, Schikora D (2002) Cerebral effects of noninvasive
laserneedles measured by transorbital and transtemporal Doppler
sonography. Lasers Med Sci 17: 289-295
[2] Litscher G, Schikora D (2002) Neue Konzepte in der experimentellen
Akupunkturforschung - Computerkontrollierte Laserpunktur (CCL) mit
der Laserneedle® Technik. Der Akupunkturarzt / Aurikulotherapeut 28:
18-28
[3] Litscher G, Schikora D (2002) Effects of new noninvasive
laserneedles on brain function. In: Hutten H, Krösl K, editors. EMBEC
2002. Proceedings of the 2nd European Medical & Biological
Engineering Conference; 2002 Dec 4-8; Vienna, Austria. Graz; Verlag
der Technischen Universität Graz, 996-997
123
11.1 Introduction
Acupressure of points St.7 and SJ.22 can lead to significant, reversible ICP-
increases in intensive care patients with a priori elevated intracranial
pressure (ICP) [1]. Our study group already documented this in 1988. These
increases in intracranial pressure due to acupressure can reach a threatening
extent in isolated cases.
The following acupoints [2,3] were tested on each person, during three
partial unilateral (right) measurements (Fig. 11.1):
125
St.7
SJ.22
3 min
d
5 min
b a
1 min 1 min
Fig. 11.2: Measurement profile of the volunteer study. The measurement points were
determined before (b), during (d) and after (a) stimulation. The plateau increase
indicates the “active time” of acupressure, needle- and laserneedle acupuncture.
We evaluated the mean blood flow velocities (vm) in the right and left MCA
as well as the pulsatility index (PI = (systolic maximum value – end diastolic
maximum value)/mean value) in both cerebral vessels, before, during and
after the different stimulation techniques.
11.3 Results
Figure 11.3 exemplarily shows the registration of ICP and blood pressure (A.
radialis) during bilateral as well as unilateral acupressure in a 15-year-old
patient with severe head injury. During acupressure, significant and steep
increases in ICP occur, which first subside after terminating stimulation.
128
mmHg kPa
50 6.7
ICP
40 5.3
150 20
BP
80 11
10 min
Fig. 11.3: Time course of intracranial pressure (ICP) and blood pressure (BP) during
acupressure of points St.7 and SJ.22 in a 15-year-old patient after severe head injury.
Direction of recordings from right to left (arrow). Observe the ICP increase during
bilateral (b) and left (l) or right (r) acupressure.
80
60
a
40
20
left right
0
n=34 paired t-test
before during after before during after
Acupressure
vm (cm/s)
120
p = 0.231 (n.s.) p = 0.003
80
60 b
40
20
left right
0
n=34 paired t-test
before during after before during after
Needle Acupuncture
80
60 c
40
20
left right
Fig. 11.4: Box plot illustration of changes in mean blood flow velocity in the right
and left middle cerebral artery (MCA) in 34 healthy volunteers, before, during and
after acupressure (a), needle acupuncture (b) and laserneedle acupuncture (c). The
horizontal line in the box gives the position of the median. The end of the box
defines the 25th and 75th percentile; the error bars mark the 10th and 90th percentile.
130
p = 0.147 (n.s.)
PI p = 0.007
1,8
p = 0.162 (n.s.)
1,6
p = 0.007
1,4
1,2
a
1,0
0,8
0,6
PI p = 0.374 (n.s.)
1,6
p = 0.044
1,4
p = 0.231 (n.s.) p = 0.003
1,2
1,0
0,8 b
0,6
0,4
left right
0,2
0,0
n=34 paired t-test
before during after before during after
Needle Acupuncture
PI
1,6
p = 0.924 (n.s.)
p = 0.219 (n.s.)
p = 0.498 (n.s.)
1,4
p = 0.012
1,2
1,0
0,8
c
0,6
0,4
left right
0,2
Fig. 11.5: Box plot illustration of changes in pulsatility index (PI) in the right and
left middle cerebral artery before, during and after acupressure (a), needle
acupuncture (b) and laserneedle acupuncture (c). For further description see Fig.
11.4.
131
Regional cerebral oxygen saturation and blood pressure did not show any
significant stimulation-related changes (compare Tab. 11.1).
Tab. 11.1: Regional cerebral oxygen saturation (rSO2) and blood pressure (BP sys =
systolic, BP dia = diastolic and MAP = mean arterial pressure). Mean values (Cx)
and standard deviation (SD) under different test circumstances are noted.
11.4 Discussion
Intracranial pressure is defined as the pressure which the brain within the
skull (including the subarachnoid cavities), exerts on the surrounding dura
mater. This is particularly important under pathological circumstances, since
it influences cerebral perfusion as well as the oxygen and nutrient supply. An
increasing ICP consecutively leads to a decrease in cerebral perfusion. If
brain injury or damage by bleeding occurs, ICP can increase, however the
surrounding bones cannot give way. This finally can lead to further damage
of the brain reaching to transtentorial herniation or in extreme cases to brain
death.
TCD has its origin in the year 1842 with the discovery and description of the
Doppler effect by the Austrian physicist Christian Doppler. In the 80´s of the
past century, Aaslid et al. [10] used the temporal acoustic window to
overcome the barrier of cranial bones. As a result, TCD has become a non-
invasive method for evaluating blood flow velocity in intracranial vessels.
Cerebral blood flow parameters can either be determined mathematically
from the blood or cerebral pressure (cerebral perfusion pressure –
corresponds to the difference resulting from the mean arterial blood pressure
and transcranial pressure) or with TCD (blood flow velocity).
The close correlation between TCD parameters and intracranial pressure are
discussed and proven in several studies. In this manner, systemic-theoretical
approaches with simultaneous analysis of blood flow velocity and arterial
blood pressure enable transformation to the cerebral pressure curve with a
Dirac-impulse [11]. Clinical use of this non-invasive monitoring method is
being currently discussed.
Thus, the attributes “gentle, alternative and free of side effects”, which are
associated with TCM are not weakened inconsiderably. As the results from
this study show, there are some signs of possible connections to side effects
133
11.5 Acknowledgements
The authors thank Ms. Ingrid Gaischek MSc for her valuable help and for
writing the manuscript.
11.6 References
[1] Schwarz G, Pfurtscheller G, Tritthart H, List WF (1988)
Hirndruckanstieg beim Monitoring akustisch evozierter
Hirnstammpotentiale mittels Kopfhörer. Neurochirurgia (Stuttg) 31:
216-218
[2] König G, Wancura I (1989) Neue chinesische Akupunktur. Lehrbuch
und Atlas der Akupunktur-Punkte, 5. Auflage. Verlag Wilhelm
Maudrich, Wien-München-Bern
[3] Hecker U, Steveling A, Peuker E, Kastner J (2001) Lehrbuch und
Repetitorium Akupunktur. Hippokrates, Stuttgart
[4] Litscher G, Schikora D (2002) Cerebral effects of non-invasive
laserneedles measured by transorbital and transtemporal Doppler
sonography. Lasers Med Sci 17: 289-295
[5] Litscher G, Rachbauer D, Ropele S, Wang L, Schikora D, Fazekas F,
Ebner F (2004) Acupuncture using laserneedles modulates brain
function: First evidence from functional transcranial Doppler
sonography (fTCD) and functional magnetic resonance imaging
(fMRI). Lasers Med Sci 19: 6-11
[6] Litscher G, Schikora D (2002) Near-infrared spectroscopy for
objectifying cerebral effects of needle and laserneedle acupuncture.
Spectroscopy 16/3-4: 335-342
[7] Litscher G, Schikora D (Hrsg.) (2004) Lasernadel-Akupunktur.
Wissenschaft und Praxis. Pabst Science Publishers, Lengerich Berlin
Bremen
[8] Litscher G, Wang L, Schikora D, Rachbauer D, Schwarz G, Schöpfer
A, Ropele S, Huber E (2004) Biological effects of painless laserneedle
acupuncture. Medical Acupuncture 16(1): 24-29
[9] Schwarz G (1990) Dissoziierter Hirntod. Computergestützte Verfahren
in Diagnostik und Dokumentation. Springer, Berlin Heidelberg New
York
[10] Aaslid R, Markwalder TM, Nornes H (1982) Non-invasive transcranial
Doppler ultrasound recording of flow velocity in basal cerebral
arteries. J Neurosurg 57: 769-774
[11] Schmidt B (2003) Nichtinvasive Erfassung des Hirndrucks mittels des
transkraniellen Dopplersignals und der Blutdruckkurve unter
134
M. Weber
12.1 Introduction
For the first time, laserneedles using a high optical energy output were
applied at multiple points allowing painless and simultaneous 8-point
treatment in accordance with traditional Chinese acupuncture. The
laserneedles were developed by the German company Laserneedle® systems
[1] and were first introduced at the Medica-fair 2000 in Germany (Fig. 12.1).
Fig. 12.1: Front view of the laserneedle instrument with 8 optical energy outputs.
ranging from 0 - 100 were used. First the patients noted their level of
contentment and secondly their individual pain-level.
Fig. 12.3: Application of a laserneedle for ear acupuncture using a special headgear
for fixation.
Fig. 12.4: Typical ear acupuncture treatment after activating the laserneedle device.
138
Tab. 12.1: Summary of the treated illness in the different medical fields.
139
12.3 Results
12.3.1 Lumbar, thoracic and cervical spine syndromes as well as
post cervical and lumbar intervertebral disk prolapse
We treated local pain trigger points as well as the corresponding near points
(i.e. UB.10, 11 and 13 for cervical spine syndrome, or 50, 51 and 52 for
lumbar spine syndrome) and the distant acupuncture points such as UB.60
and 62, in addition, the over regional pain trigger points such as SI.3, LI.4,
SJ.5 and GB.41. In case of superimposed psychic symptoms, we also used
compensating points such as St.36 and Ki.6 and in stress symptoms often
Liv.3.
Case example
She was treated with laserneedles using the following point combination:
UB.34, 36, 37, 40, 60 and 62 as well as St.36 and Du 2. After a few minutes,
an intensive De-Qi sensation was built up during each session, and was
described as a pleasant, warm tingling feeling flowing into the entire leg.
After the 15-minute treatment period, pain was significantly reduced and
140
It is also interesting to note, that severe disorders like Morbus Bechterew and
fibromyalgia, as well as chronic polyarthritis responded exceptionally well
to treatment with laserneedles. In cases of year long impairment, great
importance was attributed to the additional treatment of relaxing, sedating,
stress relieving and energy stabilizing trigger points such as St.36, Ki.6, Ren
17, UB.60 and 62, SJ.5, GB.41, Lu.7, Liv.3 or Du 20, to compensate the
psychological and depressive symptoms.
In periarthritis of the shoulder, a long and impairing illness, the success rate
of treatment was significant and effects were of long duration.
Case example
Three patients who had suffered strokes with remaining paresis were treated
in the regions of the affected extremities. A blood-flow increasing and
muscle relaxing point combination was used with energy stabilizing points.
In all 3 cases, a significant increase in mobility was achieved by reducing
spasticity and improving the fine motor ability.
Case example
A 78-year-old female patient with painful, remaining paresis in her left arm
was treated using the following point combination: LI.4 and 11, SI.3, Pe.6,
SJ.5 and 15, Du 20 and St.36.
142
The elevation of her arm could be improved from 90 to 120 degrees after
only 5 sessions. The patient was able to pull a dress over her head for the
first time in 5 years. Pain reduction was achieved and fine motor ability was
greatly improved. The subjective patient satisfaction was 90 %.
Three patients suffering from tinnitus were treated. The results here were not
as impressive as in other disorders; often the tone/noise symptoms could be
reduced and sometimes stopped completely for a short time. Further long-
term studies still need to be evaluated.
Case example
Case example
Case example
Patients who had been treated with sedating and anti depressive points were
able to sleep better after only a few sessions. Their family life improved
greatly. Laserneedle acupuncture considerably reduced illness-related
absence from work.
Case example
She was treated with the following combination: He.9 and 7, Lu.7, UB.62,
Yintang, Liv.3, Du 20 and Ki.6. During the first session a soothing warmth
flowing through the whole body was sensed, she felt very relaxed and deeply
tired, which in turn led to a good night’s sleep. After only 3 sessions the
patient was able to resume her high-pressure job. The patient’s subjective
satisfaction was 100 %; the symptoms could be reduced by 90 %.
12.4 Discussion
In this report, more than 500 acupuncture treatments were performed with
the newly developed laserneedles. Limitations were reduced by using up to 8
stimulation points simultaneously on the body or ear so that all the principle
point combinations, either local, loco-regional and distant acupuncture
points could be activated with the laserneedles.
Treatment did not have any side effects, was extremely patient orientated,
pleasant and highly effective in all indications. During the study, the number
of patients asking for laserneedle treatment increased considerably. Because
treatment is more pleasant for the patient, no needle pricking is necessary,
and better results are achieved with laserneedles, acceptance is greater. Our
experience showed large groups of patients are willing to use the laserneedle
method. The advantages of laserneedle treatment in pediatrics are also
obvious: painlessness and the higher rate of achieved De-Qi sensations.
Lastly we would like to mention that remarkable results were achieved with
laserneedles in fields beyond normal usage of acupuncture. Dermatological
illnesses, such as crucial ulcers, chronic eczema and acute inflammation of
the skin and mucous membranes etc. were treated with great success. We
will report on these findings at a later date.
12.5 References
[1] Laserneedle systems GmbH (2001) Benutzerhandbuch zur
Akupunkturtherapie mit Lasernadeln. http://www.laserneedle.de
146
R. Helling
13.1 Introduction
The cases described in this chapter do not have the same value of an actual
study, however, clearly show the therapeutic effects of non-invasive
laserneedle acupuncture. The cases described, were solely treated with
laserneedle acupuncture.
13.3 Argumentation
In case of highly painful local processes, local points on contra lateral sides
are usually selected (St.2 – St.4 – SJ.21 ), in addition to distal points ipsi- or
bilateral:
LI.4: LI.4 is the so-called reference point for the large intestine meridian.
This is the most important distant acupuncture point for pain in the facial
149
Liv.3: is the reference point of the liver meridian. Combined with LI.4, this
point drives the wind out of the face [2,3].
reduction of about 30 %. Opiates did not show any effects, local anaesthetic,
paravertebral blocks caused additional pain.
According to TCM all points were located along the so-called Hua Tuo –
Line (one transverse finger paravertebral).
Treatment was performed once a week for 20 minutes. The weekly therapy
interval exists since 4 months and is still being performed currently. After
being completely free of pain for one week, massive pain of the previous
intensity builds up within 24 hours. Since all therapeutic methods performed
by several specialists were unable to achieve the effect of laserneedle
acupuncture, the patient has decided to buy her own therapy device.
According to the patient, she can achieve pain free intervals lasting one
week, with this painless therapy method and can live well this way.
13.4 Discussion
The two cases described here do not fulfil the criteria of a study. However,
they impressively show the effectiveness of laserneedle acupuncture in two
therapy resistant pain disorders.
Independent from the effectiveness of laserneedle acupuncture, the author
finds it very important to select the acupuncture points according to the
following three criteria, especially when treating pain disorders:
13.5 References
[1] Jiangping L, Yanliang C, Renhua S (1990) Chinese acupuncture and
moxibustion. Publishing House of Shanghai College of Traditional
Chinese Medicine, Shanghai
[2] Deadman P (1998) Großes Handbuch der Akupunktur. Verlag für
Ganzheitliche Medizin, Kötzting
[3] Maciocia G (1994) Die Grundlagen der Chinesischen Medizin. Verlag
für Traditionelle Chinesische Medizin, Kötzting
152
K. Kolitsch
14.1 Introduction
The largest joint of the body is the knee joint. Practically no other joint has
to endure greater daily stress. Complex rolling and sliding movements
guarantee high flexibility as well as stability. The required flexible
connection between different bones is guaranteed by the perfect cooperation
of muscles, tendons and ligaments. The knee joint consists of the articular
condyle and articular cavity, and is surrounded by the synovial capsule –
these establish the mobile connection between the upper and lower leg.
Stabilisation of the joint is secured on the side with ligaments, the meniscus
acts as shock absorbers. The synovioum, combined with synovial fluid and
articular cartilage provide optimum slidability. In case of arthrosis, the
articular cartilage is worn down, and in advanced stages, severe pain occurs,
due to friction between the bones.
Practical studies show that a dramatic deficit in caring for patients with
chronic pain exists. 75 % of osteoarthrosis/osteoarthritis patients are treated
by a general practitioner. About 60 % do not receive adequate pain therapy.
Effective pain treatment is still a foreign word for many older osteoarthrosis/
osteoarthritis patients. An untenable condition which risks the development
of a pain career. Frequent change in physicians, alternative methods without
competency and irregular medication are the result. In particular, modern
pain therapy methods offer a multi-modal pain therapy concept for patients
with chronic pain diseases. The qualified combination of drug and non-drug
treatment, in connection with psychotherapeutic strategies, leads to an
optimum of therapeutic results. Most important goal of treatment is the
mobilisation of patients with chronic pain diseases. Goal is a variety of
physical straining of the affected knee joint without repeated, one-sided
movement. Stressing of the knee joint should be avoided which doesn´t
follow the natural movement patters of this joint. In particular, torsional
movements should be regarded as dangerous for the knee joint. Modern pain
therapy offers patients a number of options within the multimodal treatment
concept.
Extra points:
Nu Xi Jan
Xiyan (Ex.32)
Heding (Ex.31)
Acupuncture points:
St.34 St.35
GB.43
Sp.10 Sp.9
14.3 Results
Evaluation of the treatment data after completing therapy showed pain
reduction of three graduation marks on the VAS (visual analog scale) in
65 % of the osteoarthrosis/osteoarthritis patients. After follow-up 4 weeks
after completing therapy the result improved to 70 %.
70 % of the patients registered a reduction pain of 3 graduation marks on the
VAS. 15 % of the osteoarthrosis/osteoarthritis patients showed a decrease in
pain of 2 graduation marks on the VAS.
14.4 Discussion
Evidence regarding efficiency is provided by the drug-free treatment with
the laserneedle system within a multimodal pain therapy concept under
remaining basis and or pain treatment (WHO – graduated scheme). As a
result of reduced pain intensity, an increase in mobility in chronic pain
patients was achieved with laserneedle therapy. Thereby this therapeutic
option achieves measurable improvement in the quality of life. Long-term
observations regarding the long-time effects of laserneedle therapy will
provide further effective data regarding the efficiency of this therapy.
155
14.5 References
[1] Litscher G (2003) Cerebral and peripheral effects of laserneedle®-
stimulation. Neurol Res 25: 722-728
[2] Litscher G, Schikora D (2002) Cerebral vascular effects of non-
invasive laserneedles measured by transorbital and transtemporal
Doppler sonography. Lasers Med Sci 17: 289-295
[3] Litscher G, Schikora D (2002) Near-infrared spectroscopy for
objectifying cerebral effects of needle and laserneedle acupuncture.
Spectroscopy 16: 335-342
156
15.1 Introduction
The laserneedle technique is a new, non-invasive method to stimulate
specific acupuncture points with laser light. The method and clinical effects
are described in more recent scientific literature >1@.
Unlike metal needles used in common acupuncture which are inserted into
the skin, Laserneedles are adhered to the desired acupoints points using
small adapters and a special adhesive technique.
After activating the device, continuous, visible red laser light with a
wavelength of 685 nm is applied via an optic fiber, directly to the acupoint
with the laserneedle. Intensity of the laserneedle is optimized in such a way,
that the patient barely feels the activation, however still builds up vegetative
stimulation at the acupuncture point. It has been documented, that
laserneedles at the acupoint trigger particular stimuli that is identical to the
Qi sensation of metal needles. The device has 8 exits with corresponding
cables. Therefore, laserneedle acupuncture makes the simultaneous
stimulation of individual point combinations possible. As a result, all
combinations of body, head, and ear acupuncture application are possible.
Laserneedles can be applied alone or in combination with additional
traditional acupuncture needles.
The acupoint is stimulated by the continuous photon flow from the
laserneedle. After subtraction of scattering losses, about 40 mW optic output
is achieved at the distal end of the laserneedle. The actual dose per
laserneedle at the skin during acupuncture treatment is 40 – 60 J >5@. The
157
Fig. 15.2: Induction of labor at points LI.4, St.36, GB.34 and Liv.3.
These are the common acupoints for inducing labor. Especially LI.4 (Fig.
15.3) is an important point to stimulate labor.
159
In this case, the patient delivered quickly and comfortably. Remarkable was
the short first phase of labor lasting only 3 hours.
The literature describes that emotional and physical stress for mother and
child has a clear influence on the length of childbirth. An „allowable
duration of childbirth“ in plurpara patients is usually 8 hours during the first
phase, 1 hour during the second phase and half an hour for bearing down.
Altogether childbirth takes 9 ½ hours >3@.
In our patient, childbirth only took 3 ½ hours. If this was due to the influence
of the laserneedles or if she would have delivered so well without this
measure remains a speculation. Noteworthy is the quick begin of labor after
laserneedle treatment, the brief first phase of childbirth and the subjectively
good feeling of having enough energy to achieve childbirth easily.
160
At that time, the symptoms increased after the first treatment, but improved
distinctly after the third treatment. Eight sittings using common acupuncture
with metal needles were performed, first 3 times a week, then once a week.
The patient experienced slight pain during needling.
After appropriate explanation, the patient wanted to try acupuncture with
laserneedles. Again the same two acupoints Pe.6 and Pe.7 at the inside of the
wrist were selected. The laserneedles were applied at these points and
illuminated with laser light for 30 minutes. Coincidently, 8 sittings were
161
A 40-year-old patient had breast cancer surgery on the left two years earlier.
Because of the tumor stage, a radical mastectomy and axillary
lymphadenectomy had to be performed. Histology showed an invasive
ductal breast cancer stage with neoplastic angiolysis and metastases in
lymph nodes, estrogen and progesterone receptor positive. Thereafter, she
had 6 cycles of chemotherapy as well as a anti-estrogen therapy with
Tamoxifen and Zoladex.
Her problem was a frozen shoulder on the left which severely restricted the
mobility of her arm. The skeletal scintigraphy and CT did not reveal any
metastasis. Arm movement was restricted and only sideward movement to
< 45° and towards the front to < 90° was possible. Shoulder pain caused by
tense muscles was rated with 7 on a 10 point pain scale. She had achieved
little improvement with physical therapy exercises.
In a sitting position, the patient was treated with laserneedles on both sides at
the body acupoints LI.14, SJ.15, GB.21, SI.11.
163
Fig. 15.5: Laserneedle treatment at acupoints LI.14, SJ.15, GB.21 and SI.11.
The scar on the knee was located somewhat lateral from the stomach
meridian. As we know, the stomach meridian runs directly over the breast.
Interestingly, the scar on the knee was on the right side, the mastectomy scar
on the left side of the body.
Whether energy from laserneedles flows further and is stopped at scars and
how far scars can be influenced with laserneedles should be discussed.
According to the interference field theory, scars are very important focuses
were energy is disturbed. Further studies to this topic should follow.
164
A 45-year-old patient came to the consultation hour and suffered from severe
pain in the lower abdomen during menstruation. Endometriosis AFS III was
documented in her medical records and she had several operations because
of endometriosis in the past. Dysmenorrhea was so severe, that she had to go
to the hospital for treatment with strong painkillers. Menstrual blood was
always clumpy and sluggish and dark in color. In addition, she had severe
back pain. She also complained about changing moods, loss of libido and
lack of energy.
Nine sittings with laserneedles were performed once a week. Different
acupoints on the body and ear were stimulated with laser light.
The time of treatment was selected in such a way, that it was briefly before
the beginning of menstruation.
During the nine treatments, the acupoints were stimulated with laser light.
After the treatment with laserneedles, the patient said that she hadn’t felt so
well in the last 2 years and that she was also emotionally better balanced.
She had much more energy and felt strong. Major changes had taken place
with positive effects on her body and emotional condition. She was
impressed. The changes in mood had also improved distinctly. Pain in the
lower abdomen was almost gone and she only needed a hot-water bottle on
the first day of menstruation. The color of menstrual blood was much lighter
and without clumps. As she was treated one day before the awaited
menstruation she reported that she already menstruated on the same day as
she was treated and that she didn’t experience any pain. The blood flow was
now much thinner and she didn’t experience clumpy or sluggish blood.
As the acupoint Yintang (comp. Chapter 7), a point on the forehead between
the eyebrows (Fig. 15.6) was treated, she described a pleasurable sensation
from the acupoint over the forehead, over the eyebrows, around the eyes and
to the nose.
165
It was a relaxing feeling. She had her eyes closed during the treatment.
Nevertheless, she reported feeling lightness within. After treatment, she was
full of energy and felt very well.
On the evening of the first treatment, she was very tired. Menstruation began
on the very next day. She reported that the blood flow wasn’t quite so
sluggish. The color of menstrual blood was still dark. During the course of
treatment, the color and consistence of blood changed. It was lighter red, not
as clumpy and more flowing. The menstrual cycle regulated itself to about
29 days. Pain in the lower abdomen was more tolerable. Remarkable is the
nearly picture-book like temperature curve with the typical increase at the
point of ovulation and the following plateau during the second cycle phase.
One day she came to my consultation hour and reported her positive
pregnancy test. The result was confirmed.
Scientific studies have shown that an increase in ATP takes place when
using the laserneedle method. I think that this ATP is very useful during
childbearing. Childbearing requires much energy from the mother and the
main supplier is definitely ATP.
In particular, the energy aspect is one major difference to common
acupuncture. In the approx. 300 patients we have treated with laser therapy,
nearly 80 % had the impression that they gained more energy through the
treatment.
Caution should be taken when treating patients with too much fullness or
heat. Even though the laserneedle method does not lead to an increase in
body temperature, one could observe that this method wasn’t appropriate for
such patients as described in the case study with hot flushes. One would be
cautious in patients with an already increased sympathicus. This also seems
logical. You should not give a person with too much fullness additional
energy.
It should be clearly stated that these are reports from experience in personal
treatment of patients. Further controlled studies to evaluate the effect of
laserneedles are necessary.
15.5 References
>1@ Litscher G, Schikora D (2002) Cerebral vascular effects of non
invasive laserneedles measured by transorbital and transtemporal
Doppler Sonography. Lasers Med Sci 17: 289-295
>2@ Litscher G, Schikora D (2002) Neue Konzepte in der experimentellen
Akupunkturforschung – Computerkontrollierte Laserpunktur (CCL) mit
der Laserneedle Technik. Der Akupunkturarzt / Aurikulotherapeut 28:
18-28
>3@ Martius G, Rath W (1998) Geburtshilfe und Perinatologie. Thieme
Verlag, Praxis der Frauenheilkunde Band II, 1998, S. 383-384
>4@ Schikora D.: European Patent Nr. PCT/EP 01/08504
>5@ Schikora D.: Physikalische und physiologische Eigenschaften der
Lasernadeln für Akupunktur, personal communication
169
16.1 Introduction
In the meantime, different descriptions regarding the use and effects of
laserneedle acupuncture can be found in literature [1]. Goal of this study was
to evaluate what patients experienced during and after treatment with
laserneedles and what they knew about the technique before treatment.
Using questionnaires, this current study compares the laserneedle-
acupuncture method with the common metal needle acupuncture method
based on the patients’ perception during and after treatment.
The mean age of patients in the metal needle group was 38 years (range from
18 to 73 years) and the mean age in the laserneedle group was 36 years
(range from 16 to 60 years). Assignment to the laserneedle or metal needle
treatment groups was done at random. Each patient took a random number
from 1 - 60. The patients with even numbers were treated with metal needle
acupuncture; those with uneven numbers were treated with laserneedle
acupuncture.
170
16.3 Method
The patients obtained questionnaires part 1 before the first treatment, part 2
after the first treatment and part 3 prior to the second treatment. The patients
filled out the questionnaires voluntarily and independently. In part 1, the
question “Do you know the method (metal needle acupuncture or laserneedle
acupuncture)?” was asked. Two answers were possible: either yes or no. The
second question was „Have you already been treated with acupuncture?”
Here also the answers yes and no could be selected. The third question was
“How would you evaluate your personal state of health at the moment?” The
following answers were possible: very good, good, satisfactory, poor and
very poor. The fourth question was „How strongly does your illness or
symptoms influence you in daily life?“ Here, 5 answers were possible as
follows: extremely, strongly, moderately, a little, not at all. The
questionnaires were given back for evaluation. Treatment was then
performed according to assignment either with metal needle or laserneedle
acupuncture.
Immediately after the first treatment, the patients filled out part 2 of the
questionnaire for evaluation. Again, the patients filled the questionnaire out
independently and without influence from others. In the second part of the
questionnaire, the patients were questioned regarding their perception during
treatment. The following questions were to be answered: “Did you
experience pain when the needle was applied?” - “Did you experience pain
during treatment?” - “Did you experience a feeling of warmth in the body
during treatment?” - “Did you experience an electrical tingling sensation
during treatment?” - “Did you feel something at the needle itself during
treatment?” - “Did you experience a sensation in the entire body during
treatment?” - “Did you experience tiredness during treatment?” - “Did you
feel relaxed, comfortable during the treatment?” The following answers were
possible for the questions above: extremely, strongly, moderately, a little,
none.
The third part of the questionnaire was filled out by the patients prior to the
second treatment. Questions regarding perception after treatment were
asked. The following questions were evaluated: “Did you experience pain
after the treatment?” - “Were you tired after treatment?” - “Did you feel
relaxed after treatment?” - “Did your symptoms improve after treatment?” -
“Did you feel well physically after treatment?” - “Did you feel well
emotionally after treatment?” - “Did your symptom improve with
treatment?” Again, several answers were possible: extremely, strongly,
moderately, a little, and none.
171
16.4 Results
After evaluating the question: “Do you know the method?” Thirty patients
answered “no” regarding the laserneedle method and 29 “yes” regarding the
acupuncture method. This shows that treatment with common metal needle
acupuncture is well known among the patients; however, they have not yet
been informed about laserneedle acupuncture. Already 13 of 30 patients
were treated with metal needle acupuncture whereas all 30 patients in the
laserneedle group had not yet been treated with this technique. The majority
of patients in both groups noted their current health condition as being good
to satisfactory (n=27 in the metal needle group and n=26 in the laserneedle
group) (Fig. 16.1). The symptoms they had influenced them very strongly to
moderately (Fig. 16.2).
The question whether they felt warmth during treatment was answered by 7
patients with extremely, 17 with strongly, 5 with moderately, 1 with little
and 0 with none in the laserneedle group (n=30). In the metal needle group
(n=30) only 1 patient answered with extremely, 4 with strongly, 7 with
moderately, 8 with a little and 10 with none (Fig. 16.5). In the laserneedle
group (n=30), the question regarding tiredness during treatment was
answered by 2 patients with extreme, 9 strong, 10 moderate, 6 a little and 3
none at all. In the metal needle group (n=30) 2 patients answered with
extremely, 12 strongly, 8 moderately, 2 a little and 6 with none at all (Fig.
16.6). In the laserneedle group no one answered the question regarding
tiredness after treatment with extreme, 1 with strong, 2 with moderate, 13
with a little and 14 with none. In the metal needle group, 4 patients were
extremely tired, 8 strongly, 4 moderately, 6 a little and 8 not at all (Fig.
16.7).
In the laserneedle group 2 patients said they were extremely relaxed during
treatment, 13 experienced strong relaxation. Six patients experienced
moderate, 6 little and 3 no relaxation. In the metal needle group, 4 noted
extreme, 17 strong, 5 moderate 4 little and 0 no relaxation (Fig. 16.8). The
question regarding relaxation after treatment showed similar results. In the
laserneedle group 8 answered with extreme, 14 with strong, 7 with moderate,
172
1 with little and no one with none and in the metal needle group 4 answered
with extreme, 18 with strong, 6 with moderate, 2 with little and no one with
none (Fig. 16.9). In both groups, the patients experienced a strong feeling of
relaxation during and after treatment.
20
16
15
15
11 11
10
5 3
2
1 1
0 0
0
very good good satisfactory poor very poor
Fig. 16.1: How would you evaluate your personal state of health at the moment?
16 15
14 12
12 10
10 8
8 7
6
6
4
2 1 1
0 0
0
extremely strongly moderately a little not at all
Fig. 16.2: How strongly does your illness or symptoms influence you in daily life?
173
Fig. 16.3: Did you experience pain when the needle was applied?
35
30
30
25 21
20
15
10
3 4
5 2
0 0 0 0 0
0
extreme strong moderate a little none
14
12
12
10
10 9
8
8
6 6
6
4 3
2 2 2
2
0
extreme strong moderate little none
18 17
16
number of patients (n=30) per group
14 13
12
10
8
6 6
6 5
4 4
4 3
2
2
0
0
extreme strong moderate little none
20
18
18
20 18
15
15
10 9
7
5 4
3
2 2
0 0
0
extremely strongly moderately a little not at all
15
10
5 6 5
4
5
1 1 0 0
0
very good good satisfactory poor very poor
16.5 Discussion
Our study shows that metal needle acupuncture is well known among
patients but that laserneedle acupuncture requires further explanation
regarding the method and possibilities of use.
With the exception of one patient, no one experienced any pain during
application of the needle or during treatment. The painless laserneedle
method has a clear advantage compared to common metal needle
acupuncture.
16.6 References
[1] Litscher G, Schikora D (Hrsg) (2004) Lasernadel-Akupunktur.
Wissenschaft und Praxis. Pabst Science Publishers, Lengerich Berlin
Bremen
179
K. Borer
17.1 Introduction
In addition to toothache and neuralgia, patients in dental practices often also
suffer from anxiety and needle phobia. Experienced dentists can achieve fast
relief with acupuncture therapy [1-4]. Laserneedle-technology allows new,
painless acupuncture stimulation.
This study is a report about the use of laserneedle acupuncture in daily
routine dentistry.
17.3 Results
17.3.1 Oral surgery
Post operative pain with lockjaw after surgical removal of wisdom tooth:
Daily treatment was done locally using the dermatologic hammer (Fig. 17.1)
with eight diodes for three sittings. After the first treatment, only minor pain
was present and after the third sitting, the patient could open his mouth
normally.
180
Local treatment with three diodes, every three days, resulted in immediate
painlessness after the first sitting, thereafter, to very rapid healing (gingiva
without necrotic coating, rapid resolution of the haematoma).
17.3.2 Endodontology
The affected tooth was treated daily, with two diodes, from the dental neck
to the apex. The patient was free of pain after two sittings with positive
vitality testing.
The corresponding area of the dental nerves were treated locally with one
diode, for one minute, thereafter, a dental wound bandage was applied. In
this manner, the possible death of dental nerves may be reduced.
181
The prepared teeth were treated with a diode for 2 minutes. As a result, later
death of the treated teeth may be avoided.
The dental neck to the apex was treated locally with 1 – 2 diodes for about
10 minutes, every 2 – 3 days (Fig. 17.2). The reaction time until pain ceased
was variable; usually 2 to 3 sittings were required.
17.3.5 Myoarthropathy
Fig. 17.3: Dermatologic hammer for the treatment of myoarthropathy and jaw
problems.
17.3.6 Neuralgia
Based on the affected areas of the head, diodes were applied at the classic
acupuncture points of the head and rest of the body. For example, Du 20 as
local point, and LI.4 and Liv.3 as distant points.
17.4 Discussion
Laserneedle-technology can be very well integrated into the routine dental
practice. The instrument is simple to handle and can be easily delegated. A
sterilizable dental adapter which survives repeated sterilization would be
desirable.
17.5 References
[1] Rosted P (2000) Introduction to acupuncture in dentistry. Br Dent J
189: 136-140
[2] Lu DP, LU GP (2003) Anatomical relevance of some acupuncture
points in the head and neck region that dictate medical or dental
application depending on depth of needle insertion. Acupunct
Electrother Res 28: 145-156
184
18.1 Introduction
The influence of post operative pain on the entire course of treatment was
underestimated for a very long time. The inadequate suppression of acute
postoperative pain has a negative influence on the subjective feeling,
compromises vegetative regulatory and control cycles and also plays an
important role in the risk of chronification. Innovative technical
developments such as laserneedle acupuncture (LNA) [1-4], provide the
foundation for new, potentially additive techniques in pain treatment. At the
Medical University Graz, initial indications for neuro-modulated effects of
LNA could be determined on healthy volunteers using non-invasive
neuromonitoring techniques and modern imaging modalities [1-4]. Goal of
these preliminary examinations was to document a possible influence of the
new laserneedle stimulation method on the subjective, individual need of
analgesics during post-operatively controlled analgesia, within a double-
blind, randomized study.
18.2 Method
18.2.1 Patients and procedure
LI.4 (Hegu) and UB.60 (Kunlun). A blind pain scale (VAS 0 - 10; 0 = free of
pain - 10 = maximum pain) was used for evaluation.
After cleaning the skin with alcohol, eight laserneedles were applied to the
acupoints with a special adhesive. A semi-conductor laser with an emitting
wave length of 680 nm was used as the light source. Output was 30 - 40 mW
per laserneedle. Duration of stimulation was 20 minutes, resulting in an
energy density ~ 4.6 kJ/cm² at each single acupoint, and an average total
187
value 36.8 kJ/cm² for all. Further details regarding the method can be found
in previous studies [1-4].
The determined data was presented graphically with box plots (SigmaStat,
Jandel Scientific Corp., Erkrath, Germany). The t-test was used for statistical
analysis. The level of significance was determined with p < 0.05.
18.3 Results
The results of the investigations are shown in Figure 18.2. The pilot study
indicated insignificant changes in the rating of subjective pain based on the
VAS before and after laserneedle acupuncture. It is noteworthy, that the use
of analgesics during postoperative observation was higher in the group
without activated laser stimulation (t-test; p = 0.09, n.s.). Clinical side effects
were not observed in any of the patients.
VAS use of
12 analgesics (O)
10
p = 0.09 (n.s.)
p=0.619
10 Boli
SE
8.0 + 1.1
8
n=19
6
4
SE
6.6 + 0.7
2
n=25
0
before after before after
n=25 laserneedle acupuncture
5
0 PE
1 2before OP
3 4 after OP
5 O
6 1 7POPD 8 with without
laserneedle acupuncture
Fig. 18.2: Box plots of changes in the values on the pain scale (VAS) at the
preliminary examination (PE), before and after surgery (OP), during postoperative
observation (O) and on the first post operative day (1 POPD).
188
18.4 Discussion
Adequate postoperative pain treatment fitted to the patients risks and needs
by the anesthesiologist, is an absolute necessity. Corresponding immediate
post and perioperative pain treatment not only helps the patient by relieving
pain, but also supports the stabilization of neuro-vegetative functions and
can also avoid the chronification of the pain process [5].
Dependent upon the extent and localization of surgery, postoperative pain is
expected in the majority of patients. However, the difference in individual
pain perception and the extent of side effects differs greatly from patient to
patient. Advances in pharmacological treatment have led to treatment
strategies which reduce postoperative pain to a minimum and in the best
case, avoid pain altogether. In addition to oral (tablets, drops) and
intramuscular administration of analgesic substances, other methods of pain
treatment should be mentioned, whereby drugs with analgesic potency
(opiates, local anesthetics) are applied via inserted special catheters (lumbar
or thoracic epidural catheters, arm plexus catheter etc.) or with long term
venous canules. These substances act either regionally or on the central
nervous system. Patient-controlled analgesia can be realized with
microprocessor controlled electronic perfusion and infusion devices.
Transcutaneous electrical nerve stimulation is another possibility for
suppressing post operative pain [6]. Moreover, scientific literature describes
the use of acupuncture for perioperative pain treatment in different types of
surgical interventions [7,8].
For the first time, this study applies the new laserneedle acupuncture method
as a possible additive method to pharmacologic pain treatment. The use of
laserneedles seems to achieve a subjective, additive suppression of pain and
leads to changes in the required pain medication within a 90 minute
postoperative observation period. Criterion for the required analgesics was
based on the patients rating of pain intensity on a visual pain analogue scale.
Non-invasive laserneedle stimulation can induce specific, reproducible
changes in the brain. This leads to changes in different parameters such as
cerebral blood flow velocity, and for the first time can be objectified with the
newest neuromonitoring methods [1-4]. This new method of painless
acupuncture has not yet been used experimentally or clinically in the field of
postoperative pain treatment.
18.5 Acknowledgements
The authors thank Ingrid Gaischek MSc for her valuable support in data
analysis and preparing the manuscript (Biomedical Engineering and
Research in Anaesthesia and Intensive Care Medicine, Medical University
Graz).
18.6 References
[1] Litscher G, Schikora D (2002) Cerebral vascular effects of non-
invasive laserneedles measured by transorbital and transtemporal
Doppler sonography. Lasers Med Sci 17: 289-295
[2] Litscher G, Schikora D (2002) Near-infrared spectroscopy for
objectifying cerebral effects of needle and laserneedle acupuncture.
Spectroscopy 16: 335-342
[3] Litscher G (2003) Cerebral and peripheral effects of laserneedle®-
stimulation. Neurol Res 25: 722-728
[4] Litscher G, Schikora D (Eds) (2004) Lasernadel-Akupunktur.
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190
G. Litscher
19.1 Introduction
In the past years, several new, technical advancements in laser acupuncture
have triggered an innovative jump in this field of study. In addition,
scientific studies have proven that laserneedle acupuncture can achieve
needle-equivalent, reproducible changes in cerebral parameters, that can be
registered with modern neuromonitoring techniques [1-5].
Laser light stimulation in the external auditory canal and its effects on early
(BAEP; latency: 1 - 10 ms) and very early auditory evoked potentials
(SAEP; latencies: < 1 ms) have not yet been scientifically investigated. In
this study, laserneedle-induced changes in biological factors of SAEP, could
be determined and registered for the first time in 23 healthy volunteers using
this measurement technique.
19.2 Methods
19.2.1 Laserneedle stimulation in the external auditory meatus
Fig. 19.1: Stimulation adapter for optical laser stimulation in the area of the external
acoustic meatus. A sound tube for acoustic stimulation between the 4 laserneedles is
implemented in the construction.
19.3 Results
The first five components of BAEP could be isolated and reproduced in all
test persons and corresponded with conventional standards [7]. One example
is shown in Fig. 19.3.
continuous laserstimulation
Fig. 19.3: Early auditory evoked potentials without (a), during continuous (b) and
during frequency-modulated (c) laser stimulation in a 24-year-old volunteer. Note
the occurrence of very early stimulus responses and the increase in stimulation
artefacts (see arrows) despite alternating stimulation modes during laser stimulation.
The tables show the absolute latencies of components I, III and V in milliseconds
(ms) as well as the interpeak latencies I-III, III-V and I-V in ms and the amplitude
relationships (I-I’)/(V-V’).
194
µV SAEP Ia (IV/V)a
0,4
p = 0.014 (s.)
n=23
p = 0.019 (s.)
0,3
n.s.
n.s.
0,2
0,1
0,0
R cw S1 R cw S1 R cw S1
LN LN LN LN LN LN
Fig. 19.4: Box-plot illustrations of very early auditory evoked potentials (SAEP),
amplitudes of the wave I (Ia) and amplitude of the IV/V-wave complex (IV/V)a in
µV under condition R (= resting, steady state, control measurement), cw LN
(continuous laserneedle stimulation) and S1 LN (2 Hz frequency-modulated
laserneedle stimulation). Note the significant increase in SAEP during laser
stimulation. The horizontal line in the box shows were the median is situated. The
ends of the box define the 25th and 75th percentile; error bars show the 10th and
90th percentile.
Whereas the amplitudes of wave I and those of the IV/V-complex did not
reveal significant changes during laser stimulation, the mean amplitude of
the stimulation artifact under continuous (p = 0.019), as well as during 2 Hz-
modulated stimulation (p = 0.014) show a significant increase.
°C
38,0
37,5
36,5
36,0
p < 0.001 (s.)
35,0
R cw S1
LN LN
Fig. 19.5: Laser stimulation related changes in temperature at the external auditory
meatus. The normal range for ear temperature given by the manufacturer is shown
on the right (R = resting, without stimulation; cw LN = continuous laser stimulation;
S1 LN = frequency-modulated laser stimulation). For further details, see Fig. 19.4.
19.4 Discussion
Laser has gained a permanent position in the field of acupuncture.
Corresponding to the desired solutions, the quality of different laser systems
must be applied. Future developments in laser technology will be based on
the new application of laser in the field of medicine in general, and its
specific use in acupuncture. Factors such as the better understanding of
working mechanisms, availability of technically perfected laser
constructions and the development of flexible optical transmitting systems
and optical fibers all lead to technically simpler systems and will play an
increasing role in the future [8].
Therefore auditory evoked potentials of very early latency were used. So-
called “clicks” (= rectangular impulses) with a duration of 200 µs were used
as stimulus impulses. Effects on latency, amplitudes and waveforms of early
auditory evoked potentials dependent on the polarity of electrical
stimulation, were investigated and described in detail in the literature [9-11].
If these stimuli are presented alternately, i.e. alternating once positive and
once negative, stimulus-related artifacts which occur during stimulus
presentation of one polarity are averaged in the signal response.
In the same manner, electro-cochleographic potentials originating in the pre-
synaptic region in the hair cells and their support structures, cochlear
microphonics and the summating potential are normally eliminated by
alternating the polarity of the stimulus.
Small blood vessels transport oxygen and nutrition and supply the sensory
cells responsible for hearing. In case of hypo-perfusion, cells are damaged
and their function is disturbed. Goal of standard medical treatment is to
avoid potential sudden deafness and improve the flowing characteristics of
blood. Other methods of blood cleansing or the so-called hyperbaric oxygen
therapy are further possibilities. Latter leads to an increase in oxygen in
blood and tissues which should result in an improved clinical picture.
a 10 µV
10 µV
b
CM
c CM
0,1 µV
N1
d AP
0,1 µV
1 ms
Fig. 19.6: Very early auditory evoked potentials (SAEP) in a 20-year-old volunteer
after performing positive (a) and negative (b) clicks; (c) shows microphonic
potentials (CM) and (d) the summating action potential (AP = N1).
The main component, the post synaptic wave N1 (compare Fig. 19.6),
represents a summating action potential of the auditory nerve and doesn’t
actually originate in the cochlea [12]. However, microphonic potentials
(CM) are considered as a cochlear event but do not play a major role in
clinical diagnostics [12].
A further hypothesis can be supposed for the arising changes in SAEP under
laser stimulation, which indicates that these stimulus-related depolarization
processes in extra cerebral areas of the auditory system underlie altered
conditions of impedance.
In order to get more exact results in the future, we could use a trans-
tympanic or extra tympanic technique to register the changes resulting from
laser stimulation instead of registering induced bioelectrical activity from the
mastoid, as performed in this study. The trans-tympanic technique requires
the application of a thin metal needle through the ear and eardrum to the
nearest area of the inner ear; the less invasive extra tympanic technique
allows the registration of changes in potential by applying a needle electrode
behind the ear and advancing it near the eardrum.
19.5 Acknowledgements
The author thanks Ms. Ingrid Gaischek MSc and Ms. Lu Wang MD (both
Biomedical Engineering and Research in Anaesthesia and Intensive Care
Medicine, Medical University of Graz) for their valuable support in data
registration and data analysis. The author thanks Dr. Detlef Schikora
(University of Paderborn) for the development of the ear adapter prototype.
199
19.6 References
21. Websites
Addendum
204
Laserneedle - Stimulation
205
Laserneedle - Acupuncture
Computer-
Computer-based Quantification
Laserneedle-
Laserneedle-Acupuncture Needle-
Needle-Acupuncture
Peripheral Central
Effects Effects
Multidirectional
Thermography Transcranial Ultrasound-
(surface temperature)
Doppler Sonography
(blood flow velocity)
Laser Doppler
Flowmetry Cerebral Near-infrared
(microcirculation)
Spectroscopy (changes of
Laser Doppler cerebral oxygen metabolism)
Imaging f MRI
+ Standard parameters
Bioelectrical Methods
(EEG, BIS, EP)
Laserneedle - Thermography
Laserneedle - Thermography
10:40 10:42
a b
10:44 10:46
c d
207
immediately
before after after
208
Laserneedle - Stimulation
Computer-
Computer-based Quantification
Cerebral Effects
209
Ophthalmic Artery
(OA)
210
Laserneedle – Stimulation
Neuromonitoring
Laserneedle - Acupuncture
as a potential additive method for post operative
pain treatment
LASERneedle® - History:
Second Generation
(2000)
The Laserneedle
Laserneedles were developed at the University of Paderborn (1997-1999)
[ Dr. D. Schikora, Dr. M. Bartels, R. Winterberg ]
Laserneedles are:
fiberoptic acupuncture needles
with non-invasive contact application
LASERneedle®-medical
LASERneedle®-frequency
LASERneedle® - applicators
I = 0° I = 20°
6 d = 1.02 * d0
6 d = d0
d = 1.01 * d0
d = 0.9996 * d0
4 d = d0
4 d = 0.9992 * d0
d = 0.9990 * d0 x (B) d = 0.99 * d0
2 2 d = 0.98 * d0
d = 0.9986 * d0
x / [mm]
x / [mm]
0 0 x (A)
-2 -2
-4 -4 x (C)
-6 -6
-6 -4 -2 0 2 4 6 -6 -4 -2 0 2 4 6
y / [mm] y / [mm]
217
LASERneedle®-dental
Parodontolology
Laserneedle-
surface-polishing procedure
For the first time, they allow painless and highly effective acupunc-
ture treatment according to traditional rules. Why this is possible is
discussed in this book.