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Evaluation of the Effects of Acupuncture on Blood Flow in Humans with Ultrasound Color Doppler Imaging

Evaluation of the Effects of Acupuncture on Blood Flow in Humans with Ultrasound Color Doppler... Hindawi Publishing Corporation Evidence-Based Complementary and Alternative Medicine Volume 2012, Article ID 513638, 8 pages doi:10.1155/2012/513638 Review Article Evaluation of the Effects of Acupuncture on Blood Flow in Humans with Ultrasound Color Doppler Imaging 1 1 1 2 1 Shin Takayama, Masashi Watanabe, Hiroko Kusuyama, Satoru Nagase, Takashi Seki, 3 1, 2 Toru Nakazawa, and Nobuo Yaegashi Department of Traditional Asian Medicine, Graduate School of Medicine, Tohoku University, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan Department of Ophthalmology and Visual Science, Graduate School of Medicine, Tohoku University, Sendai 980-8575, Japan Correspondence should be addressed to Shin Takayama, tatahara1492@gmail.com Received 23 February 2012; Revised 2 April 2012; Accepted 2 April 2012 Academic Editor: Gerhard Litscher Copyright © 2012 Shin Takayama et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Color Doppler imaging (CDI) can be used to noninvasively create images of human blood vessels and quantitatively evaluate blood flow in real-time. The purpose of this study was to assess the effects of acupuncture on the blood flow of the peripheral, mesenteric, and retrobulbar arteries by CDI. Statistical significance was defined as P values less than 0.05. Blood flow in the radial and brachial arteries was significantly lower during needle stimulation on LR3 than before in healthy volunteers, but was significantly higher after needle stimulation than before. LR3 stimulation also resulted in a significant decrease in the vascular resistance of the short posterior ciliary artery and no significant change of blood flow through the superior mesenteric artery (SMA) during acupuncture. In contrast, ST36 stimulation resulted in a significant increase in blood flow through the SMA and no significant change in the vascular resistance of the retrobulbar arteries. Additionally, acupuncture at previously determined acupoints in patients with open- angle glaucoma led to a significant reduction in the vascular resistance of the central retinal artery and short posterior ciliary artery. Our results suggest that acupuncture can affect blood flow of the peripheral, mesenteric, and retrobulbar arteries, and CDI can be useful to evaluate hemodynamic changes by acupuncture. 1. Introduction efficacy of those treatments, it is difficult to distinguish phys- iological reactions caused by acupuncture from those caused To date, no quantitative evaluation methods have been by the invasion necessary for examination. To determine the established for determining the physiological effectiveness efficacy of acupuncture in humans, it is important that the of acupuncture. Therefore, researchers conduct experiments examination method be noninvasive. We therefore used non- using a variety of approaches. In this study, we focused on invasive color Doppler imaging (CDI) with ultrasound to the physiological reactions to acupuncture and investigated evaluate blood flow. CDI is an examination technique that is blood flow changes that result from acupuncture [1–5]. widely used in the practice and research of Western medicine Many studies of acupuncture efficacy have been based [13–21]. CDI can quantitatively measure intravascular blood on the results of animal experiments with anesthesia. These flow in the extremities and in various organs in real-time. It is studies indicate that acupuncture works through physio- useful in the investigation of vessels, such as the peripheral, logical mechanisms that occur primarily in the autonomic coronary, splenic, adrenal, and superior mesenteric arteries nervous system [6–12]. When acupuncture is performed in (SMA) [22]. In addition, the reproducibility of real-time human clinical practice, the conditions are very different and noninvasive hemodynamic measurement with CDI is from those in animal experiments. Additionally, because reported elsewhere [23]. the invasive examination techniques that are often used to In traditional Chinese medicine, LR3 (Taichong, located evaluate the results of acupuncture treatments affect the on the foot, 1.5–2 units above the web between the 2 Evidence-Based Complementary and Alternative Medicine (a) (b) Figure 1: (a) Ultrasound measurement of the radial artery. 13 MHz linear transducer is fixed along radial artery with a special probe holder (MP-PH0001, Aloka Co., Ltd., Tokyo, Japan). (b) Display of CDI. Left: the vessel image and the position of the artery tracking gate. Right: changes in vessel diameter, Doppler flow, and flow velocity as determined by an automated edge-detection device and computer analysis software (e-Tracking system; Aloka Co., Ltd., Tokyo, Japan). (a) (b) Figure 2: (a) Ultrasound measurement of the brachial artery. 13 MHz linear transducer is fixed along brachial artery with a special probe holder (MP-PH0001, Aloka Co., Ltd., Tokyo, Japan). (b) Display of CDI. Left: image of the vessel image and position of the artery tracking gate. Right: changes in vessel diameter, Doppler flow, and flow velocity, as determined by an automated edge detection device and computer analysis software (e-Tracking system; Aloka Co., Ltd., Tokyo, Japan). first andsecondtoes[24]) is an acupoint on the liver 2. Materials and Methods meridian, which has the functions of “soothing the liver,” 2.1. Ultrasound Technique for Blood Flow Measurement. “regulating the blood,” and “opening into the eyes” [24]. We We measured circulation in the upper limb, SMA, and therefore hypothesized that LR3 acupuncture would affect retrobulbar vessels using an ultrasound system (Prosound hemodynamics in the peripheral arteries and the retrobulbar α10; Aloka Co., Ltd, Tokyo, Japan). The system had a 13 MHz arteries. ST36 (Zusanli, located on the lower leg, 3 units linear transducer and a 5 MHz convex transducer. We used below the lateral “eye” of the knee, approximately 1 finger the linear transducer to examine peripheral arteries and width lateral to the tibia [24]), in contrast, is an acupoint on the retrobulbar vessels. We used the convex transducer to the stomach meridian, and is associated with the functions measure SMA circulation. of gastrointestinal organs [25]. We therefore hypothesized The radial artery was examined just medial to the radial that ST36 acupuncture would affect hemodynamics in the styloid process (Figure 1). The brachial artery was monitored SMA. Because glaucoma prognosis and retrobulbar circu- immediately proximal to the elbow (Figure 2). The SMA lation are related [26–29], we also investigated the effects supplies blood to the whole small intestine, except for the of acupuncture on retrobulbar circulation in open-angle superior part of the duodenum. It also supplies blood to glaucoma (OAG) patients. In this study, we introduce the the cecum, the ascending colon, and most of the transverse noninvasive CDI with ultrasound to evaluate blood flow changes by acupuncture. colon. SMA measurements were acquired within 2-3 cm of Evidence-Based Complementary and Alternative Medicine 3 (a) (b) Figure 3: (a) Ultrasound measurement of the SMA. 5 MHz convex transducer is positioned on the abdomen. (b) Display of CDI. Left: image of the vessel and the position of the artery tracking. Right: Doppler flow and flow velocity. the artery origin (Figure 3)[30, 31]. Avoiding any pressure on the eye, CDI was performed for the retrobulbar vessels, including the ophthalmic artery (OA), central retinal artery (CRA), and nasal or temporal short posterior ciliary artery (Figures 4 and 5). The OA was examined approximately 20 mm behind the globe (Figure 5(b)), the CRA was exam- ined within 5 mm of the retrolaminar portion of the optic nerve (Figure 5(c)), and the nasal or temporal SPCA that Nasal SPCA obtained clear image was examined approximately 5–10 mm behind the globe (Figure 5(d)). Blood flow was monitored continuously [32, 33] and we employed a Doppler angle of 60 or less for each measurement [34, 35]. Each Doppler waveform was automatically drawn and calculated using the Temporal SPCA software included with the ultrasound system. The following calculations were used to determine the hemodynamic parameters at each site [30, 31]. CRA (i) Vessel diameter (VD). (ii) Cross-sectional area (CSA) = (VD/2) × π. (iii) Peak systolic velocity (PSV). OA (iv) End-diastolic velocity (EDV). (v) Resistive index (RI) = (PSV − EDV)/PSV. (vi) Mean flow velocity (MV). Figure 4: Schema of the retrobulbar arteries (OA: ophthalmic artery, CRA: central retinal artery, and SPCA: short posterior ciliary (vii) Blood flow volume = CSA × MV. artery). 2.2. Statistical Analysis. Statistical analysis was performed with SPSS software (version 16.0, SPSS Japan Inc., Tokyo, poster recruitment in Tohoku University. Eighteen healthy Japan). Repeated measure analysis of variance, followed by volunteers (mean age: 32 ± 5 years; 14 males and 4 females) Dunnett’s post hoc test, was used for statistical comparison were enrolled in this study. A disposable fine stainless- between the measure points. Comparison between rest and steel needle (diameter: 0.16 mm; length: 40 mm; Seirin Co., after acupuncture was done by paired t-test. Results are Ltd., Shizuoka, Japan) was inserted on LR3 bilaterally and presented as the mean ± SD and P< 0.05 was taken to maintained at a depth of 10 mm during the test. After indicate significance for all statistical analysis. the needle was inserted, stimulation (rotating the needles manually within an angle of 90 degrees) was performed 2.3. Experiment 1: Effects of LR3 Acupuncture on Upper for 18 seconds. The needles were removed 200 seconds Limb Circulation [1]. This study was employed to investi- after acupuncture. Radial and brachial CDI were performed gate the upper limb circulation after acupuncture at LR3 before acupuncture; during acupuncture treatment; 30, 60, acupoints on foot. The participants were recruited by the and 180 seconds after acupuncture. 4 Evidence-Based Complementary and Alternative Medicine (a) (b) (c) (d) Figure 5: (a) Ultrasound measurement of retrobulbar arteries. 13 MHz linier transducer is attached on the eyelid. Horizontal scans by CDI through the ocular globe showing the (b) ophthalmic artery (OA), (c) central retinal artery (CRA), and (d) temporal short posterior ciliary artery (SPCA). Left: image of the vessel and the position of the artery tracking. Right: Doppler flow and flow velocity (b, c, and d). 2.4. Experiment 2: Effects of LR3 Acupuncture on Blood disposable stainless steel needles (0.16 mm × 40 mm; Seirin Circulation to the Eye and through the SMA. This study Co. Ltd., Shizuoka, Japan) were kept in the same site for was employed to clarify the hemodynamic changes by 15 minutes. Retrobulbar vessels and SMA circulation were acupuncture in two different organs (intestine and eye) measured simultaneously at rest and 15 minutes after the with simultaneous evaluation by ultrasound. The partici- start of acupuncture using ultrasound. pants were recruited by the poster recruitment in Tohoku University. Thirteen healthy volunteers (mean age: 36 ± 2.6. Experiment 4: Effects of Acupuncture on Retrobulbar Cir- 9 years; 10 males and 3 females) were enrolled in this study. culation in OAG Patients [2]. The relation between glaucoma Acupuncture was performed bilaterally on LR3 with manual and retrobulbar circulation in the prognosis of the disease needle rotation and the disposable stainless steel needles has been indicated [26–29], therefore we investigated the (0.16 mm × 40 mm; Seirin Co. Ltd., Shizuoka, Japan) were effects of acupuncture on OAG patients by CDI. The patients kept at the same site for 15 minutes. Retrobulbar vessels and were recruited in the outpatient clinic of ophthalmology SMA circulation were measured simultaneously at rest and in Tohoku University Hospital. Eleven OAG patients (mean 15 minutes after the start of acupuncture using ultrasound. age: 63 ± 11 years; 1 male and 10 females; 20 eyes with OAG) were enrolled. All patients included in the study had 2.5. Experiment 3: Effects of ST36 Acupuncture Blood Cir- been treated with topical antiglaucoma medications for at culation to the Eye and through the SMA. This study was least 3 months prior to the study. As a control, the subjects also employed to clarify the hemodynamic changes by received the measurements of retrobulbar vessel hemody- acupuncture in two different organs (intestine and eye) with namics that were performed at rest and one hour after simultaneous evaluation by ultrasound. The participants the first measurement. One month later, they received the were recruited by the poster recruitment in Tohoku Uni- same measurements before and after acupuncture treatment. versity. Thirteen subjects (mean age: 36 ± 8 years; 10 males Acupuncture was performed once bilaterally at acupoints and 3 females) were enrolled in this study. Acupuncture was BL2, EX-HN5, ST2, ST36, SP6, KI3, LR3, GB20, BL18, and performed bilaterally on ST36 with manual rotation of the BL23 for 15 minutes using disposable stainless steel needles Evidence-Based Complementary and Alternative Medicine 5 Table 1: Hemodynamic parameters and blood flow volume of the radial and brachial arteries by acupuncture on LR3. The values represent ∗ ∗∗ the mean and SD. < 0.05, < 0.01 versus before acupuncture. Modified from [1]. P P Acupuncture on LR3 Parameters Before During 30 s after 60 s after 180 s after Systolic blood pressure (mmHg) 116.8 ± 10.1 114.5 ± 12.3 Diastolic blood pressure (mmHg) 67.3 ± 8.465.8 ± 7.3 Heart rate (beats/min) 67.3 ± 10.164.2 ± 8.865.8 ± 9.366.2 ± 9.366.9 ± 9.6 Blood flow volume of the radial artery (mL/min) 56.3 ± 33.525.4 ± 26.357.9 ± 47.567.7 ± 44.767.0 ± 36.5 Blood flow volume of the brachial artery (mL/min) 87.5 ± 56.465.7 ± 41.686.8 ± 53.790.1 ± 51.5 106.5 ± 59.8 Table 2: Hemodynamic parameters, blood flow volume of the SMA, and resistive index of retrobulbar arteries by acupuncture on LR3. The ∗ ∗∗ values represent the mean and SD. < 0.05, < 0.01 versus before acupuncture. P P Acupuncture on LR3 Parameters Before After Systolic blood pressure (mmHg) 119.6 ± 12.8 116.7 ± 11.1 Diastolic blood pressure (mmHg) 77.7 ± 9.476.5 ± 9.3 ∗∗ Heart rate (beats/min) 66.8 ± 7.163.3 ± 4.6 Blood flow volume of the SMA (mL/min) 734.8 ± 312.9 704.4 ± 328.1 RI in OA 0.719 ± 0.097 0.707 ± 0.089 RI in CRA 0.661 ± 0.088 0.644 ± 0.052 RI in SPCA 0.624 ± 0.057 0.580 ± 0.037 (0.16 mm or 0.20 mm × 40 mm; Seirin Co. Ltd., Shizuoka, Japan). Retrobulbar circulation was measured using CDI at rest prior to treatment and 1 hour later, or after acupuncture. 3. Results and Discussion 3.1. Experiment 1: Effects of LR3 Acupuncture on Upper Limb Circulation [1]. Hemodynamic parameters including blood pressure, heart rate, and blood flow volume in the radial ∗∗ and brachial arteries are summarized in Table 1. Figure 6 illustrates the profile of the percent changes in blood flow volume in the radial and brachial arteries. The blood flow Before AP During AP 30s 60s 180s volume in the radial artery decreased significantly during after AP after AP after AP acupuncture (P< 0.01), but showed a significant increase at 180 seconds after acupuncture (P< 0.05) (Figure 6). Radial artery In the brachial artery, the blood flow volume also showed Brachial artery a significant increase at 180 seconds after acupuncture Figure 6: Percent changes in blood flow volume in the radial and (P< 0.05) (Figure 6). The physiological mechanisms of brachial arteries before, during, and after acupuncture treatment. decrease and increase blood flow volume in upper limb are Values are presented as a percentage of the pretreatment blood flow. presumably related to a peripheral vascular resistance due to Values represent the mean and SD. AP: acupuncture. < 0.05, an instantaneous increase and decrease in sympathetic tone ∗∗ P < 0.01 versus before acupuncture. Modified from [1]. [1]. The present result suggests that LR3 located on the foot and apart from the upper limb can affect the circulation in the upper limb. we observed indicates that acupuncture on LR3 results in an increase of the blood flow to the choroid. It has been reported 3.2. Experiment 2: Effects of LR3 Acupuncture on Blood that the blood flow in the eye is controlled by sympathetic Circulation to the Eye and through the SMA. TheRIofthe and parasympathetic nerves, and it is related with the SPCA was significantly lower after acupuncture than before release of nitric oxide or calcitonin gene-related peptide (P< 0.05; Table 2). However, blood flow volume in the [33, 34]; it has also been reported that the regulation of SMA was not significantly changed after acupuncture than regional blood flow by somatic afferent stimulation is based before (Table 2). The SPCA is the ocular branches of the OA on somatoautonomic reflex mechanisms in the choroidal and it supplies blood to the choroid (Figure 4)[32]. The blood flow of the eyeball [34]. The hemodynamic changes decrease of the distal vascular resistance in the SPCA that in the SPCA by acupuncture may be related with these Blood flow volume in the radial and bradhial artery (%) 6 Evidence-Based Complementary and Alternative Medicine Table 3: Hemodynamic parameters, blood flow volume of the SMA, and resistive index of retrobulbar arteries by acupuncture on ST36. The ∗ ∗∗ values represent the mean and SD. < 0.05, < 0.01 versus before acupuncture. P P Acupuncture on ST36 Parameters Before After Systolic blood pressure (mmHg) 121.7 ± 11.8 120.7 ± 10.9 Diastolic blood pressure (mmHg) 77.8 ± 9.477.6 ± 7.6 Heart rate (beats/min) 61.9 ± 6.661.5 ± 7.4 Blood flow volume of the SMA (mL/min) 549.8 ± 192.2 620.2 ± 188.1 RI in OA 0.736 ± 0.07 0.728 ± 0.070 RI in CRA 0.617 ± 0.065 0.631 ± 0.043 RI in SPCA 0.600 ± 0.030 0.580 ± 0.06 Table 4: Hemodynamic parameters and resistive index of retrobulbar arteries in control and acupuncture therapy. The values represent the ∗ ∗∗ † †† mean and SD. < 0.05, < 0.01 versus rest or before acupuncture. < 0.05, < 0.01 versus control. Modified from [2]. P P P P Control Acupuncture Parameters Rest After 1 hour Before After Systolic blood pressure (mmHg) 116.4 ± 10.0 119.8 ± 7.6 124.5 ± 12.9 122.6 ± 9.7 Diastolic blood pressure (mmHg) 69.8 ± 6.568.6 ± 3.974.5 ± 5.472.0 ± 2.9 Heart rate (beats/min) 61.5 ± 7.360.1 ± 8.161.7 ± 8.5 60.3 ± 10.4 RI in OA 0.74 ± 0.04 0.75 ± 0.05 0.74 ± 0.04 0.74 ± 0.04 RI in CRA 0.75 ± 0.09 0.72 ± 0.03 0.72 ± 0.05 0.68 ± 0.04 ∗†† RI in SPCA 0.68 ± 0.05 0.68 ± 0.04 0.67 ± 0.04 0.64 ± 0.06 mechanisms. The present result suggests that LR3 located on physiological mechanisms of increase blood flow in eye has the foot and apart from the eye can affect the circulation in already described in the discussion of Experiment 2. The the retrobulbar arteries. present result suggests that acupuncture can improve the retrobulbar circulation in the patients of OAG with standard medication. 3.3. Experiment 3: Effects of ST36 Acupuncture on Blood Circulation to the Eye and through the SMA. RI in the 4. Ultrasound and CDI retrobulbar vessels was not changed by ST36 acupuncture treatment. However, the blood flow volume in the SMA 4.1. Advantage. We focused on the evaluation of CDI by was significantly greater after acupuncture than before ultrasound. Noninvasive and real-time measure of CDI was (P< 0.05; Table 3). Acupuncture on the limbs was also applied to assess circulation in organs after acupuncture. demonstrated to elicit systemic visceral responses via the The continuous method of CDI was used to assess the supraspinal reflexes in animal models [9, 36, 37]. According brief effects of circulation in the arm (Experiment 1). The to several reports, blood flow volume in the SMA increased simultaneous evaluation by CDI was applied to assess the significantly after stimulation of the lower limbs [9, 36–38]. circulation in two different organs (Experiments 2 and 3). We speculate that this increase is caused by excitation of the Resistive index measured by CDI is measured in the small parasympathetic system and inhibition of the sympathetic vessels as retrobulbar arteries (Experiment 4). Acupuncture system via supraspinal reflexes. The present result suggests affects the autonomic nervous system via the somatic nerves. that ST36 located on the lower limb and apart from the Invasive evaluation also affects these systems and reflex. abdomen can affect the circulation in the SMA. Therefore, invasive evaluation might not correctly evaluate the physiological effects of acupuncture therapy. We suggest that real-time and noninvasive hemodynamic measurement 3.4. Experiment 4: Effects of Acupuncture on Retrobulbar as CDI is suitable to measure the physiological effects in Circulation in OAG Patients. RI in the CRA and SPCA humans. were significantly lower after acupuncture than it was before acupuncture treatment (CRA; P< 0.05, SPCA; P< 0.05; Table 4). RI in the SPCA was also significantly lower after 4.2. Limitation. While CDI provides detailed images of acupuncture than when no treatment was given (SPCA; blood vessels in real-time, there are limits to the hemody- P< 0.01; Table 4). The CRA supplies blood to the retina namic measurements that can be made using this technique. and SPCA, to the choroid (Figure 4). The decrease of the In addition, while CDI is useful for the measurement of distal vascular resistance in the CRA and SPCA that we blood flow in various vessels in real time, it does not have observed indicates that acupuncture results in an increase sufficient resolution to determine the diameter of very small of the blood flow to the retina and choroid. The possible retrobulbar vessels such as OA, CRA, and SPCA. Therefore, Evidence-Based Complementary and Alternative Medicine 7 CDI cannot be used to measure blood flow volume in References these vessels. However, it can provide an index of vascular [1] S. Takayama, T. Seki, M. Watanabe et al., “Brief effect of resistance such as RI. A decrease in the distal vascular acupuncture on the peripheral arterial system of the upper resistance in the small vessels indicates an increase in the limb and systemic hemodynamics in humans,” Journal of blood flow in the distal part of the vessels. 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Evaluation of the Effects of Acupuncture on Blood Flow in Humans with Ultrasound Color Doppler Imaging

Evidence-based Complementary and Alternative Medicine : eCAM , Volume 2012 – Jun 21, 2012

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Copyright © 2012 Shin Takayama et al.
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Hindawi Publishing Corporation Evidence-Based Complementary and Alternative Medicine Volume 2012, Article ID 513638, 8 pages doi:10.1155/2012/513638 Review Article Evaluation of the Effects of Acupuncture on Blood Flow in Humans with Ultrasound Color Doppler Imaging 1 1 1 2 1 Shin Takayama, Masashi Watanabe, Hiroko Kusuyama, Satoru Nagase, Takashi Seki, 3 1, 2 Toru Nakazawa, and Nobuo Yaegashi Department of Traditional Asian Medicine, Graduate School of Medicine, Tohoku University, 2-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan Department of Ophthalmology and Visual Science, Graduate School of Medicine, Tohoku University, Sendai 980-8575, Japan Correspondence should be addressed to Shin Takayama, tatahara1492@gmail.com Received 23 February 2012; Revised 2 April 2012; Accepted 2 April 2012 Academic Editor: Gerhard Litscher Copyright © 2012 Shin Takayama et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Color Doppler imaging (CDI) can be used to noninvasively create images of human blood vessels and quantitatively evaluate blood flow in real-time. The purpose of this study was to assess the effects of acupuncture on the blood flow of the peripheral, mesenteric, and retrobulbar arteries by CDI. Statistical significance was defined as P values less than 0.05. Blood flow in the radial and brachial arteries was significantly lower during needle stimulation on LR3 than before in healthy volunteers, but was significantly higher after needle stimulation than before. LR3 stimulation also resulted in a significant decrease in the vascular resistance of the short posterior ciliary artery and no significant change of blood flow through the superior mesenteric artery (SMA) during acupuncture. In contrast, ST36 stimulation resulted in a significant increase in blood flow through the SMA and no significant change in the vascular resistance of the retrobulbar arteries. Additionally, acupuncture at previously determined acupoints in patients with open- angle glaucoma led to a significant reduction in the vascular resistance of the central retinal artery and short posterior ciliary artery. Our results suggest that acupuncture can affect blood flow of the peripheral, mesenteric, and retrobulbar arteries, and CDI can be useful to evaluate hemodynamic changes by acupuncture. 1. Introduction efficacy of those treatments, it is difficult to distinguish phys- iological reactions caused by acupuncture from those caused To date, no quantitative evaluation methods have been by the invasion necessary for examination. To determine the established for determining the physiological effectiveness efficacy of acupuncture in humans, it is important that the of acupuncture. Therefore, researchers conduct experiments examination method be noninvasive. We therefore used non- using a variety of approaches. In this study, we focused on invasive color Doppler imaging (CDI) with ultrasound to the physiological reactions to acupuncture and investigated evaluate blood flow. CDI is an examination technique that is blood flow changes that result from acupuncture [1–5]. widely used in the practice and research of Western medicine Many studies of acupuncture efficacy have been based [13–21]. CDI can quantitatively measure intravascular blood on the results of animal experiments with anesthesia. These flow in the extremities and in various organs in real-time. It is studies indicate that acupuncture works through physio- useful in the investigation of vessels, such as the peripheral, logical mechanisms that occur primarily in the autonomic coronary, splenic, adrenal, and superior mesenteric arteries nervous system [6–12]. When acupuncture is performed in (SMA) [22]. In addition, the reproducibility of real-time human clinical practice, the conditions are very different and noninvasive hemodynamic measurement with CDI is from those in animal experiments. Additionally, because reported elsewhere [23]. the invasive examination techniques that are often used to In traditional Chinese medicine, LR3 (Taichong, located evaluate the results of acupuncture treatments affect the on the foot, 1.5–2 units above the web between the 2 Evidence-Based Complementary and Alternative Medicine (a) (b) Figure 1: (a) Ultrasound measurement of the radial artery. 13 MHz linear transducer is fixed along radial artery with a special probe holder (MP-PH0001, Aloka Co., Ltd., Tokyo, Japan). (b) Display of CDI. Left: the vessel image and the position of the artery tracking gate. Right: changes in vessel diameter, Doppler flow, and flow velocity as determined by an automated edge-detection device and computer analysis software (e-Tracking system; Aloka Co., Ltd., Tokyo, Japan). (a) (b) Figure 2: (a) Ultrasound measurement of the brachial artery. 13 MHz linear transducer is fixed along brachial artery with a special probe holder (MP-PH0001, Aloka Co., Ltd., Tokyo, Japan). (b) Display of CDI. Left: image of the vessel image and position of the artery tracking gate. Right: changes in vessel diameter, Doppler flow, and flow velocity, as determined by an automated edge detection device and computer analysis software (e-Tracking system; Aloka Co., Ltd., Tokyo, Japan). first andsecondtoes[24]) is an acupoint on the liver 2. Materials and Methods meridian, which has the functions of “soothing the liver,” 2.1. Ultrasound Technique for Blood Flow Measurement. “regulating the blood,” and “opening into the eyes” [24]. We We measured circulation in the upper limb, SMA, and therefore hypothesized that LR3 acupuncture would affect retrobulbar vessels using an ultrasound system (Prosound hemodynamics in the peripheral arteries and the retrobulbar α10; Aloka Co., Ltd, Tokyo, Japan). The system had a 13 MHz arteries. ST36 (Zusanli, located on the lower leg, 3 units linear transducer and a 5 MHz convex transducer. We used below the lateral “eye” of the knee, approximately 1 finger the linear transducer to examine peripheral arteries and width lateral to the tibia [24]), in contrast, is an acupoint on the retrobulbar vessels. We used the convex transducer to the stomach meridian, and is associated with the functions measure SMA circulation. of gastrointestinal organs [25]. We therefore hypothesized The radial artery was examined just medial to the radial that ST36 acupuncture would affect hemodynamics in the styloid process (Figure 1). The brachial artery was monitored SMA. Because glaucoma prognosis and retrobulbar circu- immediately proximal to the elbow (Figure 2). The SMA lation are related [26–29], we also investigated the effects supplies blood to the whole small intestine, except for the of acupuncture on retrobulbar circulation in open-angle superior part of the duodenum. It also supplies blood to glaucoma (OAG) patients. In this study, we introduce the the cecum, the ascending colon, and most of the transverse noninvasive CDI with ultrasound to evaluate blood flow changes by acupuncture. colon. SMA measurements were acquired within 2-3 cm of Evidence-Based Complementary and Alternative Medicine 3 (a) (b) Figure 3: (a) Ultrasound measurement of the SMA. 5 MHz convex transducer is positioned on the abdomen. (b) Display of CDI. Left: image of the vessel and the position of the artery tracking. Right: Doppler flow and flow velocity. the artery origin (Figure 3)[30, 31]. Avoiding any pressure on the eye, CDI was performed for the retrobulbar vessels, including the ophthalmic artery (OA), central retinal artery (CRA), and nasal or temporal short posterior ciliary artery (Figures 4 and 5). The OA was examined approximately 20 mm behind the globe (Figure 5(b)), the CRA was exam- ined within 5 mm of the retrolaminar portion of the optic nerve (Figure 5(c)), and the nasal or temporal SPCA that Nasal SPCA obtained clear image was examined approximately 5–10 mm behind the globe (Figure 5(d)). Blood flow was monitored continuously [32, 33] and we employed a Doppler angle of 60 or less for each measurement [34, 35]. Each Doppler waveform was automatically drawn and calculated using the Temporal SPCA software included with the ultrasound system. The following calculations were used to determine the hemodynamic parameters at each site [30, 31]. CRA (i) Vessel diameter (VD). (ii) Cross-sectional area (CSA) = (VD/2) × π. (iii) Peak systolic velocity (PSV). OA (iv) End-diastolic velocity (EDV). (v) Resistive index (RI) = (PSV − EDV)/PSV. (vi) Mean flow velocity (MV). Figure 4: Schema of the retrobulbar arteries (OA: ophthalmic artery, CRA: central retinal artery, and SPCA: short posterior ciliary (vii) Blood flow volume = CSA × MV. artery). 2.2. Statistical Analysis. Statistical analysis was performed with SPSS software (version 16.0, SPSS Japan Inc., Tokyo, poster recruitment in Tohoku University. Eighteen healthy Japan). Repeated measure analysis of variance, followed by volunteers (mean age: 32 ± 5 years; 14 males and 4 females) Dunnett’s post hoc test, was used for statistical comparison were enrolled in this study. A disposable fine stainless- between the measure points. Comparison between rest and steel needle (diameter: 0.16 mm; length: 40 mm; Seirin Co., after acupuncture was done by paired t-test. Results are Ltd., Shizuoka, Japan) was inserted on LR3 bilaterally and presented as the mean ± SD and P< 0.05 was taken to maintained at a depth of 10 mm during the test. After indicate significance for all statistical analysis. the needle was inserted, stimulation (rotating the needles manually within an angle of 90 degrees) was performed 2.3. Experiment 1: Effects of LR3 Acupuncture on Upper for 18 seconds. The needles were removed 200 seconds Limb Circulation [1]. This study was employed to investi- after acupuncture. Radial and brachial CDI were performed gate the upper limb circulation after acupuncture at LR3 before acupuncture; during acupuncture treatment; 30, 60, acupoints on foot. The participants were recruited by the and 180 seconds after acupuncture. 4 Evidence-Based Complementary and Alternative Medicine (a) (b) (c) (d) Figure 5: (a) Ultrasound measurement of retrobulbar arteries. 13 MHz linier transducer is attached on the eyelid. Horizontal scans by CDI through the ocular globe showing the (b) ophthalmic artery (OA), (c) central retinal artery (CRA), and (d) temporal short posterior ciliary artery (SPCA). Left: image of the vessel and the position of the artery tracking. Right: Doppler flow and flow velocity (b, c, and d). 2.4. Experiment 2: Effects of LR3 Acupuncture on Blood disposable stainless steel needles (0.16 mm × 40 mm; Seirin Circulation to the Eye and through the SMA. This study Co. Ltd., Shizuoka, Japan) were kept in the same site for was employed to clarify the hemodynamic changes by 15 minutes. Retrobulbar vessels and SMA circulation were acupuncture in two different organs (intestine and eye) measured simultaneously at rest and 15 minutes after the with simultaneous evaluation by ultrasound. The partici- start of acupuncture using ultrasound. pants were recruited by the poster recruitment in Tohoku University. Thirteen healthy volunteers (mean age: 36 ± 2.6. Experiment 4: Effects of Acupuncture on Retrobulbar Cir- 9 years; 10 males and 3 females) were enrolled in this study. culation in OAG Patients [2]. The relation between glaucoma Acupuncture was performed bilaterally on LR3 with manual and retrobulbar circulation in the prognosis of the disease needle rotation and the disposable stainless steel needles has been indicated [26–29], therefore we investigated the (0.16 mm × 40 mm; Seirin Co. Ltd., Shizuoka, Japan) were effects of acupuncture on OAG patients by CDI. The patients kept at the same site for 15 minutes. Retrobulbar vessels and were recruited in the outpatient clinic of ophthalmology SMA circulation were measured simultaneously at rest and in Tohoku University Hospital. Eleven OAG patients (mean 15 minutes after the start of acupuncture using ultrasound. age: 63 ± 11 years; 1 male and 10 females; 20 eyes with OAG) were enrolled. All patients included in the study had 2.5. Experiment 3: Effects of ST36 Acupuncture Blood Cir- been treated with topical antiglaucoma medications for at culation to the Eye and through the SMA. This study was least 3 months prior to the study. As a control, the subjects also employed to clarify the hemodynamic changes by received the measurements of retrobulbar vessel hemody- acupuncture in two different organs (intestine and eye) with namics that were performed at rest and one hour after simultaneous evaluation by ultrasound. The participants the first measurement. One month later, they received the were recruited by the poster recruitment in Tohoku Uni- same measurements before and after acupuncture treatment. versity. Thirteen subjects (mean age: 36 ± 8 years; 10 males Acupuncture was performed once bilaterally at acupoints and 3 females) were enrolled in this study. Acupuncture was BL2, EX-HN5, ST2, ST36, SP6, KI3, LR3, GB20, BL18, and performed bilaterally on ST36 with manual rotation of the BL23 for 15 minutes using disposable stainless steel needles Evidence-Based Complementary and Alternative Medicine 5 Table 1: Hemodynamic parameters and blood flow volume of the radial and brachial arteries by acupuncture on LR3. The values represent ∗ ∗∗ the mean and SD. < 0.05, < 0.01 versus before acupuncture. Modified from [1]. P P Acupuncture on LR3 Parameters Before During 30 s after 60 s after 180 s after Systolic blood pressure (mmHg) 116.8 ± 10.1 114.5 ± 12.3 Diastolic blood pressure (mmHg) 67.3 ± 8.465.8 ± 7.3 Heart rate (beats/min) 67.3 ± 10.164.2 ± 8.865.8 ± 9.366.2 ± 9.366.9 ± 9.6 Blood flow volume of the radial artery (mL/min) 56.3 ± 33.525.4 ± 26.357.9 ± 47.567.7 ± 44.767.0 ± 36.5 Blood flow volume of the brachial artery (mL/min) 87.5 ± 56.465.7 ± 41.686.8 ± 53.790.1 ± 51.5 106.5 ± 59.8 Table 2: Hemodynamic parameters, blood flow volume of the SMA, and resistive index of retrobulbar arteries by acupuncture on LR3. The ∗ ∗∗ values represent the mean and SD. < 0.05, < 0.01 versus before acupuncture. P P Acupuncture on LR3 Parameters Before After Systolic blood pressure (mmHg) 119.6 ± 12.8 116.7 ± 11.1 Diastolic blood pressure (mmHg) 77.7 ± 9.476.5 ± 9.3 ∗∗ Heart rate (beats/min) 66.8 ± 7.163.3 ± 4.6 Blood flow volume of the SMA (mL/min) 734.8 ± 312.9 704.4 ± 328.1 RI in OA 0.719 ± 0.097 0.707 ± 0.089 RI in CRA 0.661 ± 0.088 0.644 ± 0.052 RI in SPCA 0.624 ± 0.057 0.580 ± 0.037 (0.16 mm or 0.20 mm × 40 mm; Seirin Co. Ltd., Shizuoka, Japan). Retrobulbar circulation was measured using CDI at rest prior to treatment and 1 hour later, or after acupuncture. 3. Results and Discussion 3.1. Experiment 1: Effects of LR3 Acupuncture on Upper Limb Circulation [1]. Hemodynamic parameters including blood pressure, heart rate, and blood flow volume in the radial ∗∗ and brachial arteries are summarized in Table 1. Figure 6 illustrates the profile of the percent changes in blood flow volume in the radial and brachial arteries. The blood flow Before AP During AP 30s 60s 180s volume in the radial artery decreased significantly during after AP after AP after AP acupuncture (P< 0.01), but showed a significant increase at 180 seconds after acupuncture (P< 0.05) (Figure 6). Radial artery In the brachial artery, the blood flow volume also showed Brachial artery a significant increase at 180 seconds after acupuncture Figure 6: Percent changes in blood flow volume in the radial and (P< 0.05) (Figure 6). The physiological mechanisms of brachial arteries before, during, and after acupuncture treatment. decrease and increase blood flow volume in upper limb are Values are presented as a percentage of the pretreatment blood flow. presumably related to a peripheral vascular resistance due to Values represent the mean and SD. AP: acupuncture. < 0.05, an instantaneous increase and decrease in sympathetic tone ∗∗ P < 0.01 versus before acupuncture. Modified from [1]. [1]. The present result suggests that LR3 located on the foot and apart from the upper limb can affect the circulation in the upper limb. we observed indicates that acupuncture on LR3 results in an increase of the blood flow to the choroid. It has been reported 3.2. Experiment 2: Effects of LR3 Acupuncture on Blood that the blood flow in the eye is controlled by sympathetic Circulation to the Eye and through the SMA. TheRIofthe and parasympathetic nerves, and it is related with the SPCA was significantly lower after acupuncture than before release of nitric oxide or calcitonin gene-related peptide (P< 0.05; Table 2). However, blood flow volume in the [33, 34]; it has also been reported that the regulation of SMA was not significantly changed after acupuncture than regional blood flow by somatic afferent stimulation is based before (Table 2). The SPCA is the ocular branches of the OA on somatoautonomic reflex mechanisms in the choroidal and it supplies blood to the choroid (Figure 4)[32]. The blood flow of the eyeball [34]. The hemodynamic changes decrease of the distal vascular resistance in the SPCA that in the SPCA by acupuncture may be related with these Blood flow volume in the radial and bradhial artery (%) 6 Evidence-Based Complementary and Alternative Medicine Table 3: Hemodynamic parameters, blood flow volume of the SMA, and resistive index of retrobulbar arteries by acupuncture on ST36. The ∗ ∗∗ values represent the mean and SD. < 0.05, < 0.01 versus before acupuncture. P P Acupuncture on ST36 Parameters Before After Systolic blood pressure (mmHg) 121.7 ± 11.8 120.7 ± 10.9 Diastolic blood pressure (mmHg) 77.8 ± 9.477.6 ± 7.6 Heart rate (beats/min) 61.9 ± 6.661.5 ± 7.4 Blood flow volume of the SMA (mL/min) 549.8 ± 192.2 620.2 ± 188.1 RI in OA 0.736 ± 0.07 0.728 ± 0.070 RI in CRA 0.617 ± 0.065 0.631 ± 0.043 RI in SPCA 0.600 ± 0.030 0.580 ± 0.06 Table 4: Hemodynamic parameters and resistive index of retrobulbar arteries in control and acupuncture therapy. The values represent the ∗ ∗∗ † †† mean and SD. < 0.05, < 0.01 versus rest or before acupuncture. < 0.05, < 0.01 versus control. Modified from [2]. P P P P Control Acupuncture Parameters Rest After 1 hour Before After Systolic blood pressure (mmHg) 116.4 ± 10.0 119.8 ± 7.6 124.5 ± 12.9 122.6 ± 9.7 Diastolic blood pressure (mmHg) 69.8 ± 6.568.6 ± 3.974.5 ± 5.472.0 ± 2.9 Heart rate (beats/min) 61.5 ± 7.360.1 ± 8.161.7 ± 8.5 60.3 ± 10.4 RI in OA 0.74 ± 0.04 0.75 ± 0.05 0.74 ± 0.04 0.74 ± 0.04 RI in CRA 0.75 ± 0.09 0.72 ± 0.03 0.72 ± 0.05 0.68 ± 0.04 ∗†† RI in SPCA 0.68 ± 0.05 0.68 ± 0.04 0.67 ± 0.04 0.64 ± 0.06 mechanisms. The present result suggests that LR3 located on physiological mechanisms of increase blood flow in eye has the foot and apart from the eye can affect the circulation in already described in the discussion of Experiment 2. The the retrobulbar arteries. present result suggests that acupuncture can improve the retrobulbar circulation in the patients of OAG with standard medication. 3.3. Experiment 3: Effects of ST36 Acupuncture on Blood Circulation to the Eye and through the SMA. RI in the 4. Ultrasound and CDI retrobulbar vessels was not changed by ST36 acupuncture treatment. However, the blood flow volume in the SMA 4.1. Advantage. We focused on the evaluation of CDI by was significantly greater after acupuncture than before ultrasound. Noninvasive and real-time measure of CDI was (P< 0.05; Table 3). Acupuncture on the limbs was also applied to assess circulation in organs after acupuncture. demonstrated to elicit systemic visceral responses via the The continuous method of CDI was used to assess the supraspinal reflexes in animal models [9, 36, 37]. According brief effects of circulation in the arm (Experiment 1). The to several reports, blood flow volume in the SMA increased simultaneous evaluation by CDI was applied to assess the significantly after stimulation of the lower limbs [9, 36–38]. circulation in two different organs (Experiments 2 and 3). We speculate that this increase is caused by excitation of the Resistive index measured by CDI is measured in the small parasympathetic system and inhibition of the sympathetic vessels as retrobulbar arteries (Experiment 4). Acupuncture system via supraspinal reflexes. The present result suggests affects the autonomic nervous system via the somatic nerves. that ST36 located on the lower limb and apart from the Invasive evaluation also affects these systems and reflex. abdomen can affect the circulation in the SMA. Therefore, invasive evaluation might not correctly evaluate the physiological effects of acupuncture therapy. We suggest that real-time and noninvasive hemodynamic measurement 3.4. Experiment 4: Effects of Acupuncture on Retrobulbar as CDI is suitable to measure the physiological effects in Circulation in OAG Patients. RI in the CRA and SPCA humans. were significantly lower after acupuncture than it was before acupuncture treatment (CRA; P< 0.05, SPCA; P< 0.05; Table 4). RI in the SPCA was also significantly lower after 4.2. Limitation. While CDI provides detailed images of acupuncture than when no treatment was given (SPCA; blood vessels in real-time, there are limits to the hemody- P< 0.01; Table 4). The CRA supplies blood to the retina namic measurements that can be made using this technique. and SPCA, to the choroid (Figure 4). The decrease of the In addition, while CDI is useful for the measurement of distal vascular resistance in the CRA and SPCA that we blood flow in various vessels in real time, it does not have observed indicates that acupuncture results in an increase sufficient resolution to determine the diameter of very small of the blood flow to the retina and choroid. The possible retrobulbar vessels such as OA, CRA, and SPCA. Therefore, Evidence-Based Complementary and Alternative Medicine 7 CDI cannot be used to measure blood flow volume in References these vessels. However, it can provide an index of vascular [1] S. Takayama, T. Seki, M. Watanabe et al., “Brief effect of resistance such as RI. A decrease in the distal vascular acupuncture on the peripheral arterial system of the upper resistance in the small vessels indicates an increase in the limb and systemic hemodynamics in humans,” Journal of blood flow in the distal part of the vessels. 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