EXPERIMENTAL
NEUROLOGY
49,
Acupuncture C. L. Lr, D.
and
AHLBERG,
C. Y. National
Institute
of
TING,
272-280 (1975)
Hypnosis:
Effects
H. LANSDELL, A. F. BAK,
Neurological Bethesda Received
on Induced
M. A. GRAVITZ, D. BLESSING
AND
and Commmicative Maryland 20014
Disorders
Pain
T. C.
CHEN,
l and Stroke,
May 9,1975
The reactions of 14 volunteers to electrical stimulation near the supraorbital nerve were studied under acupuncture, placebo-acupuncture, and hypnosis. As the intensity of stimulation increased, a minimum sensation, a minimum pain, and then a maximum or intolerable pain sensation were produced. Under hypnosis the average intensity of the stimulus for producing these sensations was higher than before the trance induction. Under acupuncture and placebo-acupuncture no clear increase in current intensity was observed. Acupunctuw, as well as hypnosis, did not consistently change the blood, blood pressure, pulse rate, EKG, respiratory rate, or EEG.
INTRODUCTION Questions of how and why acupuncture-analgesia works remain to be answered (5, 21, 23, 26). Whether it is a separate treatment entity or similar to the use of hypnosis is still being debated (17-19, 27, 31). There are also reports that acupuncture changes the blood picture and influences the functions of the somatosensory and autonomic nervous systems (1, 16, 2.5, 32). These matters were investigated in the present study with experimental pain in selected subjects under acupuncture, hypnosis, and a form of placeb+acupuncture. METHODS Subjects. Forty-five paid volunteers were recruited by the Normal Volunteer Office of the National Institutes of Health and they were screened for admission to the study by a personality questionnaire. They 1 We thank Charles Sartor, George Norris, Joseph M. Bucolo, and William Sheriff for their technical assistance; the staff members under Dr. Donald Young, who did all the blood studies in this project; Delbert Nye and Esther Taylor of the Normal Volunteer Office of the Clinical Center at NIH. 212 Copyright All rights
fQ 1975 by Academic Press, Inc. of reproduction in any form reserved.
ACUPUNCTUKE.4KD
HYPNOSIS
273
were all Caucasians between 18 and 40 years old and had no history of chronic disease. After taking the medical history, an investigator described to the subject the experimental procedures and possible hazards (14)) and asked the subject to sign a consent form, which stated that the subject was free to discontinue participation in the study at any time. The psychological screening was done in the same room as the subsequent research and it was based on scores obtained on the tape-recorded version of the Minnesota Multiphasic Personality Inventory or “MMPI” (13, 30). The criteria (20) for accepting a volunteer were: that the test scores indicate it was a “valid” record, that no standard scores on the MMPI clinical scales were above 70 (a traditional level for concern) : and (i.e., K score minus F score that it show no sign of having been “faked,” not greater than 17). Twenty-nine voluteers were rejected on the basis of the MMPI scores, another was rejected for clinical reasons, and one declined to participate after being accepted. The qualifying subjects used in the study were eight men and six women with an average age of 27.6 (SD = 7.8) years. They were all college graduates or undergraduates with an average IQ of 118.9 (SD = 8.0). Procedure. After qualifying for the study, each subject was assigned, according to a predetermined schedule, to return to the laboratory for one of the six possible sequences of the three treatments of acupuncture, hypnosis, and placebo-acupuncture. The three sessions for each subject took place on a different day, at intervals from 1 to 47 days. The mean interval between first and second sessions was 20.5 (SD = 16.3) days; between second and third sessions, 13.4 (SD = 12.1) days. During each session the subject lay on a stretcher. In most of the sessions, an initial blood sample was obtained either before or after a general physical and neurological examination. The EKG, respiratory movement, and EEG (over the posterior temporal and inferior parietal regions bilaterally) were recorded, and the recordings were made almost continuously throughout the session. A magnetic tape recorder was used to record these parameters, and the voices of the investigators or the subject. The EEG was analyzed on a later day with a computer and a digital plotter. In addition to monitoring by oscilloscopes, there was another display of the physiological parameters on paper. This paper recorder was near the subject and its noise, particularly when switched to higher speed to provide space to record threshold data, tended to mask other sounds in the room. After the baseline recording of 8-10 min, a stimulating electrode, which was insulated except at the tip, was inserted near the supraorbital branch of the left trigeminal nerve. Biphasic pulses of l-2 msec in duration at a frequency of l-2 Hz were delivered through a stimulus isolation unit, and
274
LI
ET AL.
the pulses were recorded through a current probe on a storage oscilloscope. As the intensity of the stimulating current was increased, the subject began to detect a sensation in the forehead and raised his or her fingers, or said “Now.” This was recorded as the minimum sensation (MIS) of the subject. As the intensity of the stimulating current continued to rise, it reached a point that became painful to the subject, who then signalled again, and the stimulation was terminated. This intensity was recorded as the minimum pain sensation (MIP). This procedure was repeated five more times. Then the strength of the current was further increased to the maximum that the subject could endure, and six values of this maximum level of tolerance to pain (MAP) were obtained. After determining MIS, MIP, and MAP, a second neurological examination was made and a second blood sample was taken. After a short rest period the investigator who administered the treatment, either acupuncture, hypnosis, or placebo-acupuncture, entered the laboratory. This was the occasion when the subject met for the first time the hypnotist or the professional acupuncturist. The acupuncturist applied, in five subjects, one needle to right Ho-Ku (a point on the dorsum of the hand between the first and second metacarpals) ; in one subject, two needles: one to right Ho-Ku and one to left T’ai Ch’ung (a point over the dorsum of the foot between the first and second metatarsals) ; in four subjects, three needles: one to right Ho-kg one to left Ho-ku and one to left T’ai Ch’ung or left ChGan Liao (a point on the face just inferior to the zygoma) ; and in four subjects, five needles : one to right Ho-ku, one to left Ho-Ku, one to left Chiian-L&o, one to right T’ai-Ch’ung and one to left T’ai-Ch’ung. Since acupuncture for pain relief and for surgical procedures (22) was originally achieved by manual manipulation of the needles, in the present experiment electro-acupuncture (2, 8) was not used. Figure 1 shows the tine needles and puncture points. In the original design of the experiment, only Ho-Ku was to be needled since, according to our reading of the literature, it is the most powerful point for relief of contralateral pain in the face. Also, in the original design, no conversation was to take place between the acupuncturist and the subject. After finding no obvious changes in the results obtained from the first five subjects, we applied two needles to the sixth subject. Again, finding no changes, we then applied three needles to the next four subjects; and, finally, five needles to the remaining four subjects. With the last eight subjects, the acupuncturist was asked to converse with them as in a clinic, and this entailed queries about the presence of soreness and other sensations, or Te Ch’i (6, 7, 9, IO). At this time, the acupuncturist traditionally encounters increased resistance to manipulation of the needles. The needles were manipulated by the acupuncturist almost continuously, and on the
ACUPUNCTUREANDHYPNOSIS
275
FIG. 1. T’ni-Ch’mrg
Acupuncture and placebo-acupuncture. Needles shown in HO-KM (A), (B), ChiiawLiao (C), and placebo point (D). The stimulating electrode in the forehead is also seen in C.
average for 27.6 (SD = 5.7) min. After these induction periods, another investigator obtained a second set of responsesto the electrical stimulation, a third blood sample and gave a third neurological examination. The acupuncture needle or needles were then removed and the subject rested for about 20 min. Thereafter, a third set of responsesto electrical stimulation and another blood sample were obtained. During the sessions for placebo-acupuncture, the same experimental procedures were repeated, except that in all casesthe subject received only one needle at a point about 3-4 cm away from the Ho-Ku point in the right hand (Fig. 1) , and the needle was applied and manipulated by a physician who was not a professional acupuncturist. The induction period lasted for 23.4 (SD = 3.3) min on the average. The hypnosis used in the other sessionswas based on the traditional methods (11, 29) of eye fixation, arm levitation and suggestions for relaxation. After trance behavior was clearly observed, suggestions were added that the subject would not experience discomfort in what was to follow. Suggestions were also given that the pain in the forehead would be “far away,” or could be endured. These suggestions continued during the determination of reactions to the electrical stimulation. The induction period lasted for a mean of 27.1 (SD = 4.8) min.
MIS MIP MAP MIS MIP MAP MIS MIP MAP MIS MIP MAP MIS MIP MAP
6
4
4
14
14
Acupuncture 3 needles
Acupuncture 5 needles
Placebo-acupuncture
Hypnosis
0.86 2.65 9.53 0.80 3.72 8.27 0.62 2.09 9.04 0.61 2.00 8.07 0.82 3.02 8.09
1.10 2.76 8.59 0.81 3.61 8.19 0.61 2.80 9.94 0.68 2.49 8.20 1.05 4.12 9.73
Mean current (ma) Baseline treatment 0.24 0.11 -0.94 0.01 -0.11 -0.08 -0.01 0.71 0.90 0.07 0.49 0.13 0.23 1.10 1.64
f f f f f f f f f f zt f f f f
0.12 0.23 0.45 0.14 0.29 0.56 0.14 0.29 0.56 0.04 0.21 0.30 0.06 0.49 0.72
Difference (X f SE)
AND MAXIMUM AND HYPNOSIS
PAIN
9)”
= 2.10
P = 0.005
P = 0.22 F(3, 11) = 7.61
P = 0.09 F(3, 11) = 1.70
P = 0.95 F(3, 9) = 3.00
P = 0.13 F(3, 9) = 0.10
F(3,
Hotelling T2 test
TOLERATED,
a MIS = minimum sensation; MIP = minimum pain sensation; MAP = maximum tolerance to pain. “The larger degree of freedom of the F-statistic for the three acupuncture groups was evaluated on the basis of the pooled variancecovariance matrix over the three groups after the equality of the individual variance-covariance matrices was examined (24, p. 120).
Treatment
1
FOR MINIMUM SENSATION, MINIMUM PAIN WITH ACUPUNCTURE, PLACEBO-ACUPUNCTURE
Acupuncture 1 & 2 needles
IN MILLIAMPERES AND CHANGES Reaction5
CURRENT
N
MEAN
TABLE
ACUPUNCTURE
AND
HYPNOSIS
277
In almost all the sessions the initial blood samples were obtained soon after the subject entered the laboratory; and the second samples, about 85 min later during the baseline recording of the physiologic parameters. The third samples, obtained during the treatment, were taken on an average of 34.1 min later (SD = 16.5 min), and final samples were taken 32.7 min later (SD = 10.2 min). While blood studies were done in all sessions with acupuncture, they were done only in six of 14 sessions with placebo-acupuncture and in four of the sessions with hypnosis. For each blood sample, values were obtained for hemoglobin, hematocrit, white blood corpuscles, platelets, sedimentation rate, prothrombin time, thrombin time, partial thromboplastin time. h‘a, IX, Chloride, bicarbonate, glucose, alkaline phosphatase, serum glutamic oxyloacetic transaminase, serum glutamic pyruvic transaminase, lactic dehydrogenase, and cortisol. RESULTS In a given subject in a test stage of a session, the six measurements of the intensity of current for minimum nonpainful (MIS), minimum painful (MIP), and maximum painful sensations (MAP) were fairly consistent. From subject to subject and from session to session, the measurements varied, probably due to variation in the distance from the stimulating electrode to the supraorbital nerve. Table 1 shows the mean values of electrical current recorded for the baseline measurements and during treatments for the three reactions (MIS, MIP, and MAP), and the mean differences for hypnosis, placebo-acupuncture, and acupuncture with the different numbers of needles. The significance of these differences, regarding MIS, MIP and MAP as trivariate data, was tested by Hotelling T2 test (24) for each treatment group. Since the electrical current measurements were recorded on each subject for all three treatments, the Hotelling T? test results may not be completely independent. However, from the practical point of view the problem with a Type I error is not crucial here. Both acupuncture and placebo-acupuncture produced no significant changes in the reactions to the electrical stimulation, although there was some borderline indication that using five needles in the last four subjects might have raised the intensity of the applied current. In contrast, hypnosis consistently raised the intensity of the applied current for the same responses. Between acupuncture (pooling all groups together) and hypnosis, there was a significant difference in the number of cases (six and 13 cases, respectively) showing increased intensity of the stimulation for maximum pain sensations during treatment; the chi-square was 5.14, p < 0.025 (24). In all the measures of response to the electrical stimulation, the increase in average values of
278
LI ET AL.
the applied current was greater for hypnosis than for the other two treatments. No consistent changes were observed in EKG, blood pressure, pulse rate, or respiratory rate during the different sessions. No consistent changes were found in the blood. In all instances, sensory deficit was not detected on the face ; pupils were reactive and equal on both sides. Alpha activity was dominant in the EEGs recorded from seven subjects under acupuncture, nine subjects under placebo-acupuncture and ten subjects under hypnosis. The alpha activity recorded from other subjects under these three conditions was not prominent until the end of the induction period; and in some instances, different frequencies were dominant at different times. In 33 of 4.2 experimental sessions, there was no change in the EEG throughout the procedure. Of these 33 sessions, ten were obtained during acupuncture, 12 during placebo-acupuncture, and 11 during hypnosis. DISCUSSION The increased endurance to pain in response to electrical stimulation of a nerve was to be expected in these volunteers under hypnosis (3, 15). The absence of significant changes in the reaction to the painful stimulation during acupuncture and placebo-acupuncture could have resulted from using subjects who were not patients seeking help; it could have resulted also from having to use an artificially induced pain, which is known to be different from pain of pathological origin (4, 12). Furthermore, our volunteers were carefully selected, and pain reactions appear to vary with psychological state and other characteristics such as age, sex, and race (4, 12, 28, 33). Undoubtedly the present findings cannot be taken as evidence that acupuncture is ineffective as an analgesic; they indicate merely that we have yet to succeed in defining the circumstances or the type of medical situation where it may prove to be useful. Further study of acupuncture in patients with pain syndromes appears to be needed. In this study, we were unable to confirm that acupuncture causes changes in blood, blood pressure, EEG, or EKG, and we believe that further investigation will be necessary to substantiate such claims. REFERENCES 1. ACUPUNCTURE ANESTHESIA RESEARCH GROUP, Hunan Medical College Changsha. 1973. The relation between acupuncture analgesia and neurotransmitters in rabbit brain. Chin. Med. 1. 8 : 478-486. 2. ANDERSON, S. A., T. ERICSON, E. HOLMGREN, and G. LINDQVIST. 1973. Electroacupuncture and pain threshold. Lancet 1: ,564.
ACUPUNCTURE
AND
HYPNOSIS
279
3. BARBER, T. X., and K. W. HAHN, JR. 1962. Physiological and subjective responses to pain producing stimulation under hypnotically-suggested and waking-imagined “analgesia.” J. Abnornz. Sot. Psychol. 65 : 411-418. 4. BEECHER, H. K. 1959. “Measurement of Subjective Response: Quantitative Effects of Drugs.” Oxford Univ. Press, New York. 5. CHANG, H. T. 1973. Integrative action of thalamus in the progress of acupuncture for analgesia. Scicr~tia Sinica 16 : 25-60. 6. CHIANG-SU NEW MEDICAL COLLEGE. 1973. “ChPn Chiu Hsiieh” (“Plcupuncturology”). People’s Republic Published, Shanghai. 7. CHU, L. 1954. “Sin Chtn Chiu Hsiieh” (“Modern Acupuncturology”). Peoples’ Health Publisher, Peking. 8. CLARK, W. C., and J. C. YOUNG. 1974. Acupunctural analgesia? Evaluation by signal detection theory. Science 184 : 10961098. 9. DEPARTMENT OF ACUPUNCTURE, Chinese Traditional Medical Institute, Shanghai. 1960. “Chen Chui Hsiieh Chien I” (“Textbook of Acupuncture”). I-Ling Puhl. Co., Hong Kong. 10. DEPARTMENT OF PHYSIOLOGY OF SHANGHAI FIRST MEDICAL COLLEGE AND AcuPUNCTURE ANESTHESIA CO-ORDINATING GROUP OF HUA SHAN HOSPITAL, Shanghai. 1973. Acupuncture sensation (Te C/t’;) and electromyogram of the needle point in patients with nervous diseases. Chin. Med. J. 10: 619-622. 11. GRAVITZ. M. A., and M. F. KRAMER. 1967. A study of some factors associated with hypnotic-like experience. Amer. J. Clin. Hyps. 10: 48-51. 12. HARDY, D. J., H. G. WOLFF, and H. GOODELL. 1952. “Pain Sensations and Reactions.” Williams & Wilkins, Baltimore. 13. HATHAWAY, S. R., and J. C. MCKINLEY. 1942. “Minnesota Multiphasic Personality Inventory.” University of Minnesota Press, Minneapolis. 14. HILGARD, E. R. 196.5. “Hypnotic Suggestibility.” Harcourt, Brace & World, New York. 15. HILGARD, E. R. 1971. Pain: Its reduction and production hypnosis. Proc. .4mw. Philos. Sot. 115 : 470-476. 16. HOPEI MEDICAL COLLEGE, Pathophysiology Research Group. 1958. The influence of acupuncture on the central nervous system. Chi. Med. J. 5: 167. 17. KATZ, R. L., C. Y. KAO, H. SPIEGEL, and G. J. KATZ. 1974. Pain, acupuncutre, hypnosis, pp. 819-825. In “Advances in Neurology.” Vol. 4. J. J. Bonica [Ed.]. Raven Press, New York. 18. KROGER, W. S. 1972. Hypnotism and acupuncture. J. Amer. Med. Ass. 220: 10121013. 19. KROGER, W. S. 1973. Acupuncture analgesia: Its explanation by conditioning dmer. J. Ps)‘chiat. 130: 855-860. theory, autogenic training and hypnosis. 20. LANSDELL, H. 1968. Effect of extent of temporal lobe surgery and neuropathology on the MMPI. 1. Clin. Ps~jchol. 24: 406-412. 21. LI, C. L. 1973. Neurological basis of pain and its possible relationship to acupuncture-analgesia. Anzcr. J. Chin. Med. 1 : 61-72. 22. LI, C. L. 1974. A brief outline of Chinese medical history with particular reference to acupuncture. Perspect. Biol. Med. 18: 132-143. 23. MELZACK, R. 1973. “The Puzzle of Pain.” Basic Books, New York. 24. MORRISON, D. F. 1967. “Multivariate Statistical Methods.” McGraw-Hill, New York. 25. RESEARCH GROUP OF ACUPUNCTURE ANESTHESIA, Peking Medical College, Peking. 1974. The role of some neurotransmitters of brain in finger-acupuncture analgesia, $&es& Sinica I7 : 112-130.
280 26. 27.
28. 29. 30. 31.
32. X3.
LI ET AL. SHANGHAI INSTITUTE OF PHYSIOLOGY, Shanghai. 1973. Why can acupuncture suppress pain? Ke Xue Shi Yuan (Scientific Experimentation) 7: 241-242. WALL, P. D. 1972. An eye on the needle. New Sci. 55: 129-131. WALTERS, A. 1973. Psychiatric considerations of pain, pp. 1615-1645. ln “Neurological Surgery.” Vol. 3. J. R. Youmans [Ed.]. W. B. Saunders, Philadelphia. WEITZENROFFER, A. M. 1957. “General Techniques of Hypnotism.” Grune & Stratton, New York. WOLF, S., W. R. FREINEK, and J. W. SHAFFER. 1964. Comparability of complete oral and booklet forms of the MMPI. J. Clin. Psycho/. 20: 375-378. WOLFFENB~~TTEL, E. 1968. Hypnosis and acupuncture. XI. Rev. Bras. Med. 25: 441-443. Wu, W. Y., H. J. Du, and E. SHEN. 1962. Experimental referred tender spots on the pinna of monkey. Acta Physiol. Sinica 25: 78-85. ZBROWSKI, W. 1952. Cultural components in responses to pain. J. Sot. Issues 8: 16-30.
NEUROLOGY
49,
Acupuncture C. L. Lr, D.
and
AHLBERG,
C. Y. National
Institute
of
TING,
272-280 (1975)
Hypnosis:
Effects
H. LANSDELL, A. F. BAK,
Neurological Bethesda Received
on Induced
M. A. GRAVITZ, D. BLESSING
AND
and Commmicative Maryland 20014
Disorders
Pain
T. C.
CHEN,
l and Stroke,
May 9,1975
The reactions of 14 volunteers to electrical stimulation near the supraorbital nerve were studied under acupuncture, placebo-acupuncture, and hypnosis. As the intensity of stimulation increased, a minimum sensation, a minimum pain, and then a maximum or intolerable pain sensation were produced. Under hypnosis the average intensity of the stimulus for producing these sensations was higher than before the trance induction. Under acupuncture and placebo-acupuncture no clear increase in current intensity was observed. Acupunctuw, as well as hypnosis, did not consistently change the blood, blood pressure, pulse rate, EKG, respiratory rate, or EEG.
INTRODUCTION Questions of how and why acupuncture-analgesia works remain to be answered (5, 21, 23, 26). Whether it is a separate treatment entity or similar to the use of hypnosis is still being debated (17-19, 27, 31). There are also reports that acupuncture changes the blood picture and influences the functions of the somatosensory and autonomic nervous systems (1, 16, 2.5, 32). These matters were investigated in the present study with experimental pain in selected subjects under acupuncture, hypnosis, and a form of placeb+acupuncture. METHODS Subjects. Forty-five paid volunteers were recruited by the Normal Volunteer Office of the National Institutes of Health and they were screened for admission to the study by a personality questionnaire. They 1 We thank Charles Sartor, George Norris, Joseph M. Bucolo, and William Sheriff for their technical assistance; the staff members under Dr. Donald Young, who did all the blood studies in this project; Delbert Nye and Esther Taylor of the Normal Volunteer Office of the Clinical Center at NIH. 212 Copyright All rights
fQ 1975 by Academic Press, Inc. of reproduction in any form reserved.
ACUPUNCTUKE.4KD
HYPNOSIS
273
were all Caucasians between 18 and 40 years old and had no history of chronic disease. After taking the medical history, an investigator described to the subject the experimental procedures and possible hazards (14)) and asked the subject to sign a consent form, which stated that the subject was free to discontinue participation in the study at any time. The psychological screening was done in the same room as the subsequent research and it was based on scores obtained on the tape-recorded version of the Minnesota Multiphasic Personality Inventory or “MMPI” (13, 30). The criteria (20) for accepting a volunteer were: that the test scores indicate it was a “valid” record, that no standard scores on the MMPI clinical scales were above 70 (a traditional level for concern) : and (i.e., K score minus F score that it show no sign of having been “faked,” not greater than 17). Twenty-nine voluteers were rejected on the basis of the MMPI scores, another was rejected for clinical reasons, and one declined to participate after being accepted. The qualifying subjects used in the study were eight men and six women with an average age of 27.6 (SD = 7.8) years. They were all college graduates or undergraduates with an average IQ of 118.9 (SD = 8.0). Procedure. After qualifying for the study, each subject was assigned, according to a predetermined schedule, to return to the laboratory for one of the six possible sequences of the three treatments of acupuncture, hypnosis, and placebo-acupuncture. The three sessions for each subject took place on a different day, at intervals from 1 to 47 days. The mean interval between first and second sessions was 20.5 (SD = 16.3) days; between second and third sessions, 13.4 (SD = 12.1) days. During each session the subject lay on a stretcher. In most of the sessions, an initial blood sample was obtained either before or after a general physical and neurological examination. The EKG, respiratory movement, and EEG (over the posterior temporal and inferior parietal regions bilaterally) were recorded, and the recordings were made almost continuously throughout the session. A magnetic tape recorder was used to record these parameters, and the voices of the investigators or the subject. The EEG was analyzed on a later day with a computer and a digital plotter. In addition to monitoring by oscilloscopes, there was another display of the physiological parameters on paper. This paper recorder was near the subject and its noise, particularly when switched to higher speed to provide space to record threshold data, tended to mask other sounds in the room. After the baseline recording of 8-10 min, a stimulating electrode, which was insulated except at the tip, was inserted near the supraorbital branch of the left trigeminal nerve. Biphasic pulses of l-2 msec in duration at a frequency of l-2 Hz were delivered through a stimulus isolation unit, and
274
LI
ET AL.
the pulses were recorded through a current probe on a storage oscilloscope. As the intensity of the stimulating current was increased, the subject began to detect a sensation in the forehead and raised his or her fingers, or said “Now.” This was recorded as the minimum sensation (MIS) of the subject. As the intensity of the stimulating current continued to rise, it reached a point that became painful to the subject, who then signalled again, and the stimulation was terminated. This intensity was recorded as the minimum pain sensation (MIP). This procedure was repeated five more times. Then the strength of the current was further increased to the maximum that the subject could endure, and six values of this maximum level of tolerance to pain (MAP) were obtained. After determining MIS, MIP, and MAP, a second neurological examination was made and a second blood sample was taken. After a short rest period the investigator who administered the treatment, either acupuncture, hypnosis, or placebo-acupuncture, entered the laboratory. This was the occasion when the subject met for the first time the hypnotist or the professional acupuncturist. The acupuncturist applied, in five subjects, one needle to right Ho-Ku (a point on the dorsum of the hand between the first and second metacarpals) ; in one subject, two needles: one to right Ho-Ku and one to left T’ai Ch’ung (a point over the dorsum of the foot between the first and second metatarsals) ; in four subjects, three needles: one to right Ho-kg one to left Ho-ku and one to left T’ai Ch’ung or left ChGan Liao (a point on the face just inferior to the zygoma) ; and in four subjects, five needles : one to right Ho-ku, one to left Ho-Ku, one to left Chiian-L&o, one to right T’ai-Ch’ung and one to left T’ai-Ch’ung. Since acupuncture for pain relief and for surgical procedures (22) was originally achieved by manual manipulation of the needles, in the present experiment electro-acupuncture (2, 8) was not used. Figure 1 shows the tine needles and puncture points. In the original design of the experiment, only Ho-Ku was to be needled since, according to our reading of the literature, it is the most powerful point for relief of contralateral pain in the face. Also, in the original design, no conversation was to take place between the acupuncturist and the subject. After finding no obvious changes in the results obtained from the first five subjects, we applied two needles to the sixth subject. Again, finding no changes, we then applied three needles to the next four subjects; and, finally, five needles to the remaining four subjects. With the last eight subjects, the acupuncturist was asked to converse with them as in a clinic, and this entailed queries about the presence of soreness and other sensations, or Te Ch’i (6, 7, 9, IO). At this time, the acupuncturist traditionally encounters increased resistance to manipulation of the needles. The needles were manipulated by the acupuncturist almost continuously, and on the
ACUPUNCTUREANDHYPNOSIS
275
FIG. 1. T’ni-Ch’mrg
Acupuncture and placebo-acupuncture. Needles shown in HO-KM (A), (B), ChiiawLiao (C), and placebo point (D). The stimulating electrode in the forehead is also seen in C.
average for 27.6 (SD = 5.7) min. After these induction periods, another investigator obtained a second set of responsesto the electrical stimulation, a third blood sample and gave a third neurological examination. The acupuncture needle or needles were then removed and the subject rested for about 20 min. Thereafter, a third set of responsesto electrical stimulation and another blood sample were obtained. During the sessions for placebo-acupuncture, the same experimental procedures were repeated, except that in all casesthe subject received only one needle at a point about 3-4 cm away from the Ho-Ku point in the right hand (Fig. 1) , and the needle was applied and manipulated by a physician who was not a professional acupuncturist. The induction period lasted for 23.4 (SD = 3.3) min on the average. The hypnosis used in the other sessionswas based on the traditional methods (11, 29) of eye fixation, arm levitation and suggestions for relaxation. After trance behavior was clearly observed, suggestions were added that the subject would not experience discomfort in what was to follow. Suggestions were also given that the pain in the forehead would be “far away,” or could be endured. These suggestions continued during the determination of reactions to the electrical stimulation. The induction period lasted for a mean of 27.1 (SD = 4.8) min.
MIS MIP MAP MIS MIP MAP MIS MIP MAP MIS MIP MAP MIS MIP MAP
6
4
4
14
14
Acupuncture 3 needles
Acupuncture 5 needles
Placebo-acupuncture
Hypnosis
0.86 2.65 9.53 0.80 3.72 8.27 0.62 2.09 9.04 0.61 2.00 8.07 0.82 3.02 8.09
1.10 2.76 8.59 0.81 3.61 8.19 0.61 2.80 9.94 0.68 2.49 8.20 1.05 4.12 9.73
Mean current (ma) Baseline treatment 0.24 0.11 -0.94 0.01 -0.11 -0.08 -0.01 0.71 0.90 0.07 0.49 0.13 0.23 1.10 1.64
f f f f f f f f f f zt f f f f
0.12 0.23 0.45 0.14 0.29 0.56 0.14 0.29 0.56 0.04 0.21 0.30 0.06 0.49 0.72
Difference (X f SE)
AND MAXIMUM AND HYPNOSIS
PAIN
9)”
= 2.10
P = 0.005
P = 0.22 F(3, 11) = 7.61
P = 0.09 F(3, 11) = 1.70
P = 0.95 F(3, 9) = 3.00
P = 0.13 F(3, 9) = 0.10
F(3,
Hotelling T2 test
TOLERATED,
a MIS = minimum sensation; MIP = minimum pain sensation; MAP = maximum tolerance to pain. “The larger degree of freedom of the F-statistic for the three acupuncture groups was evaluated on the basis of the pooled variancecovariance matrix over the three groups after the equality of the individual variance-covariance matrices was examined (24, p. 120).
Treatment
1
FOR MINIMUM SENSATION, MINIMUM PAIN WITH ACUPUNCTURE, PLACEBO-ACUPUNCTURE
Acupuncture 1 & 2 needles
IN MILLIAMPERES AND CHANGES Reaction5
CURRENT
N
MEAN
TABLE
ACUPUNCTURE
AND
HYPNOSIS
277
In almost all the sessions the initial blood samples were obtained soon after the subject entered the laboratory; and the second samples, about 85 min later during the baseline recording of the physiologic parameters. The third samples, obtained during the treatment, were taken on an average of 34.1 min later (SD = 16.5 min), and final samples were taken 32.7 min later (SD = 10.2 min). While blood studies were done in all sessions with acupuncture, they were done only in six of 14 sessions with placebo-acupuncture and in four of the sessions with hypnosis. For each blood sample, values were obtained for hemoglobin, hematocrit, white blood corpuscles, platelets, sedimentation rate, prothrombin time, thrombin time, partial thromboplastin time. h‘a, IX, Chloride, bicarbonate, glucose, alkaline phosphatase, serum glutamic oxyloacetic transaminase, serum glutamic pyruvic transaminase, lactic dehydrogenase, and cortisol. RESULTS In a given subject in a test stage of a session, the six measurements of the intensity of current for minimum nonpainful (MIS), minimum painful (MIP), and maximum painful sensations (MAP) were fairly consistent. From subject to subject and from session to session, the measurements varied, probably due to variation in the distance from the stimulating electrode to the supraorbital nerve. Table 1 shows the mean values of electrical current recorded for the baseline measurements and during treatments for the three reactions (MIS, MIP, and MAP), and the mean differences for hypnosis, placebo-acupuncture, and acupuncture with the different numbers of needles. The significance of these differences, regarding MIS, MIP and MAP as trivariate data, was tested by Hotelling T2 test (24) for each treatment group. Since the electrical current measurements were recorded on each subject for all three treatments, the Hotelling T? test results may not be completely independent. However, from the practical point of view the problem with a Type I error is not crucial here. Both acupuncture and placebo-acupuncture produced no significant changes in the reactions to the electrical stimulation, although there was some borderline indication that using five needles in the last four subjects might have raised the intensity of the applied current. In contrast, hypnosis consistently raised the intensity of the applied current for the same responses. Between acupuncture (pooling all groups together) and hypnosis, there was a significant difference in the number of cases (six and 13 cases, respectively) showing increased intensity of the stimulation for maximum pain sensations during treatment; the chi-square was 5.14, p < 0.025 (24). In all the measures of response to the electrical stimulation, the increase in average values of
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the applied current was greater for hypnosis than for the other two treatments. No consistent changes were observed in EKG, blood pressure, pulse rate, or respiratory rate during the different sessions. No consistent changes were found in the blood. In all instances, sensory deficit was not detected on the face ; pupils were reactive and equal on both sides. Alpha activity was dominant in the EEGs recorded from seven subjects under acupuncture, nine subjects under placebo-acupuncture and ten subjects under hypnosis. The alpha activity recorded from other subjects under these three conditions was not prominent until the end of the induction period; and in some instances, different frequencies were dominant at different times. In 33 of 4.2 experimental sessions, there was no change in the EEG throughout the procedure. Of these 33 sessions, ten were obtained during acupuncture, 12 during placebo-acupuncture, and 11 during hypnosis. DISCUSSION The increased endurance to pain in response to electrical stimulation of a nerve was to be expected in these volunteers under hypnosis (3, 15). The absence of significant changes in the reaction to the painful stimulation during acupuncture and placebo-acupuncture could have resulted from using subjects who were not patients seeking help; it could have resulted also from having to use an artificially induced pain, which is known to be different from pain of pathological origin (4, 12). Furthermore, our volunteers were carefully selected, and pain reactions appear to vary with psychological state and other characteristics such as age, sex, and race (4, 12, 28, 33). Undoubtedly the present findings cannot be taken as evidence that acupuncture is ineffective as an analgesic; they indicate merely that we have yet to succeed in defining the circumstances or the type of medical situation where it may prove to be useful. Further study of acupuncture in patients with pain syndromes appears to be needed. In this study, we were unable to confirm that acupuncture causes changes in blood, blood pressure, EEG, or EKG, and we believe that further investigation will be necessary to substantiate such claims. REFERENCES 1. ACUPUNCTURE ANESTHESIA RESEARCH GROUP, Hunan Medical College Changsha. 1973. The relation between acupuncture analgesia and neurotransmitters in rabbit brain. Chin. Med. 1. 8 : 478-486. 2. ANDERSON, S. A., T. ERICSON, E. HOLMGREN, and G. LINDQVIST. 1973. Electroacupuncture and pain threshold. Lancet 1: ,564.
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3. BARBER, T. X., and K. W. HAHN, JR. 1962. Physiological and subjective responses to pain producing stimulation under hypnotically-suggested and waking-imagined “analgesia.” J. Abnornz. Sot. Psychol. 65 : 411-418. 4. BEECHER, H. K. 1959. “Measurement of Subjective Response: Quantitative Effects of Drugs.” Oxford Univ. Press, New York. 5. CHANG, H. T. 1973. Integrative action of thalamus in the progress of acupuncture for analgesia. Scicr~tia Sinica 16 : 25-60. 6. CHIANG-SU NEW MEDICAL COLLEGE. 1973. “ChPn Chiu Hsiieh” (“Plcupuncturology”). People’s Republic Published, Shanghai. 7. CHU, L. 1954. “Sin Chtn Chiu Hsiieh” (“Modern Acupuncturology”). Peoples’ Health Publisher, Peking. 8. CLARK, W. C., and J. C. YOUNG. 1974. Acupunctural analgesia? Evaluation by signal detection theory. Science 184 : 10961098. 9. DEPARTMENT OF ACUPUNCTURE, Chinese Traditional Medical Institute, Shanghai. 1960. “Chen Chui Hsiieh Chien I” (“Textbook of Acupuncture”). I-Ling Puhl. Co., Hong Kong. 10. DEPARTMENT OF PHYSIOLOGY OF SHANGHAI FIRST MEDICAL COLLEGE AND AcuPUNCTURE ANESTHESIA CO-ORDINATING GROUP OF HUA SHAN HOSPITAL, Shanghai. 1973. Acupuncture sensation (Te C/t’;) and electromyogram of the needle point in patients with nervous diseases. Chin. Med. J. 10: 619-622. 11. GRAVITZ. M. A., and M. F. KRAMER. 1967. A study of some factors associated with hypnotic-like experience. Amer. J. Clin. Hyps. 10: 48-51. 12. HARDY, D. J., H. G. WOLFF, and H. GOODELL. 1952. “Pain Sensations and Reactions.” Williams & Wilkins, Baltimore. 13. HATHAWAY, S. R., and J. C. MCKINLEY. 1942. “Minnesota Multiphasic Personality Inventory.” University of Minnesota Press, Minneapolis. 14. HILGARD, E. R. 196.5. “Hypnotic Suggestibility.” Harcourt, Brace & World, New York. 15. HILGARD, E. R. 1971. Pain: Its reduction and production hypnosis. Proc. .4mw. Philos. Sot. 115 : 470-476. 16. HOPEI MEDICAL COLLEGE, Pathophysiology Research Group. 1958. The influence of acupuncture on the central nervous system. Chi. Med. J. 5: 167. 17. KATZ, R. L., C. Y. KAO, H. SPIEGEL, and G. J. KATZ. 1974. Pain, acupuncutre, hypnosis, pp. 819-825. In “Advances in Neurology.” Vol. 4. J. J. Bonica [Ed.]. Raven Press, New York. 18. KROGER, W. S. 1972. Hypnotism and acupuncture. J. Amer. Med. Ass. 220: 10121013. 19. KROGER, W. S. 1973. Acupuncture analgesia: Its explanation by conditioning dmer. J. Ps)‘chiat. 130: 855-860. theory, autogenic training and hypnosis. 20. LANSDELL, H. 1968. Effect of extent of temporal lobe surgery and neuropathology on the MMPI. 1. Clin. Ps~jchol. 24: 406-412. 21. LI, C. L. 1973. Neurological basis of pain and its possible relationship to acupuncture-analgesia. Anzcr. J. Chin. Med. 1 : 61-72. 22. LI, C. L. 1974. A brief outline of Chinese medical history with particular reference to acupuncture. Perspect. Biol. Med. 18: 132-143. 23. MELZACK, R. 1973. “The Puzzle of Pain.” Basic Books, New York. 24. MORRISON, D. F. 1967. “Multivariate Statistical Methods.” McGraw-Hill, New York. 25. RESEARCH GROUP OF ACUPUNCTURE ANESTHESIA, Peking Medical College, Peking. 1974. The role of some neurotransmitters of brain in finger-acupuncture analgesia, $&es& Sinica I7 : 112-130.
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