50

ORIGINAL ARTICLE

Bilateral Effects of 6 Weeks Unilateral Acupuncture and

Electroacupuncture on Ankle Dorsiflexors Muscle Strength:
A Pilot Study
Shi Zhou, PhD, Li-Ping Huang, PhD, Jun Liu, MSc, Jun-Hai Yu, MSc, Qiang Tian, MSc, Long-Jun Cao, MSc
ABSTRACT. Zhou S, Huang L-P, Liu J, Yu J-H, Tian Q,
Cao L-J. Bilateral effects of 6 weeks unilateral acupuncture
and electroacupuncture on ankle dorsiflexors muscle strength:
a pilot study. Arch Phys Med Rehabil 2012;93:50-5.
Objectives: To determine the effect of unilateral manual
acupuncture at selected acupoints on ankle dorsiflexion
strength of both limbs, and compare the effect with that of
electroacupuncture at the same acupoints and sham points.
Design: Randomized controlled trial.
Setting: Rehabilitation laboratory of a university.
Participants: Young men (N43) were randomly allocated
into 4 groups: control; manual acupuncture and electroacupuncture on 2 acupoints (ST-36 and ST-39); and electroacupuncture on 2 nonacupoints. These points were located on the
tibialis anterior muscle.
Interventions: The participants in the experimental groups
received 15 to 30 minutes of acupuncture or electroacupuncture
on the right leg in each session, 3 sessions per week for 6
weeks.
Main Outcome Measures: The maximal strength in isometric
ankle dorsiflexion of both legs was assessed before and after
the experimental period.
Results: Repeated-measures analysis of variance identified
significant and similar strength gains (range, 35% 64% in the
right leg and 32% 49% in the left leg; P.01) in all acupuncture groups, but not in the control group (2% to 2%, P.05).
Conclusions: Unilateral manual acupuncture and electroacupuncture at the acupoints can improve muscle strength in
both limbs, and electroacupuncture at the nonacupoints as used
in this study can also induce similar strength gains.
Key Words: Acupuncture; Electric stimulation; Functional
laterality; Muscle strength; Rehabilitation.
2012 by the American Congress of Rehabilitation
Medicine

T HAS BEEN REPEATEDLY reported that single-limb

Imuscle
resistance exercise can affect muscle strength in both the
under training and the homologous muscle in the con-

myostimulation (EMS)7-12 or electroacupunture13 may also induce cross education, with the magnitude similar to that found
in resistance training.
It has been suggested that cross education can be used as a
means of therapy or rehabilitation for certain neuromuscular
disorders.2,14-16 Interestingly, the practice of unilateral therapy
for conditions on the contralateral side has been used in traditional Chinese medicine (TCM) for centuries.17 One particular
type of treatment, termed Juci, is to perform acupuncture on the
unaffected side of the body for treatment of certain disorders on
the contralateral side.18 There have been reports that acupuncture can increase muscle strength.13,19,20 For example, the
muscle strength of the knee extensors was found to be increased after a single session of bilateral manual acupuncture in
a randomized, placebo-controlled trial in recreational athletes.19 However, the effect of unilateral manual acupuncture
on muscle strength of the contralateral side of the body has
rarely been critically examined.
With the development of technology, electroacupuncture
became available several decades ago.21,22 Electroacupuncture
involves applying acupuncture at selected acupoints with
electrical pulses delivered to the needles. Both manual acupuncture and electroacupuncture techniques are receiving
recognition in the West, but they are recommended primarily for pain modulation.23 There has been increased interest
on the effect of acupuncture on muscle function and sports
performance; however, the published work in this area is
still very limited.19,20,24-26
For the purpose of developing optimal therapeutic, rehabilitation, and strength training programs, in relation to crosseducation effect, it would be interesting to investigate whether
unilateral manual acupuncture can also induce a similar contralateral effect on muscle strength as that caused by electroacupuncture, and whether the effect occurs only when the needles are applied to specific acupoints. Therefore, the aim of this
study was to determine the effect of 6 weeks of unilateral
manual acupuncture at selected acupoints on muscle strength in
ankle dorsiflexion of both limbs, and compare the effect with
that of electroacupuncture at the same acupoints, and electroa-

tralateral limb, a phenomenon known as cross education.1-6

Furthermore, there have been reports that unilateral electro-

List of Abbreviations
From the Department of Health and Exercise Science, Tianjin University of Sport,
Tianjin, China (Zhou, Huang, Liu, Yu, Tian, Cao); and the School of Health and
Human Sciences, Southern Cross University, Lismore, NSW, Australia (Zhou).
Supported by Tianjin Scientific Research Foundation (grant no. 05YFGDSF02100)
and Internal Research Grant of Southern Cross University, Australia.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
Correspondence to Li-Ping Huang, PhD, Dept of Health and Exercise Science,
Tianjin University of Sport, 51 Weijin South Rd, Hexi District, Tianjin 300381, P. R.
China, e-mail: hlping36@yahoo.com.cn. Reprints are not available from the authors.
0003-9993/12/9301-00356$36.00/0
doi:10.1016/j.apmr.2011.08.010

Arch Phys Med Rehabil Vol 93, January 2012

CON
EAcu
EMS
ESham
fMRI
H-reflex
MAcu
MVC
RMANOVA
TCM

control group
electroacupuncture
electromyostimulation
electroacupuncture at sham point
functional magnetic resonance imaging
Hoffmanns reflex
manual acupuncture
maximal voluntary contraction
analysis of variance with repeated
measures
traditional Chinese medicine

51

ACUPUNCTURE AND MUSCLE STRENGTH, Zhou

Table 1: Physical Characteristics of Participants
Characteristic

CON (n10)

MAcu Group (n11)

EAcu Group (n11)

ESham Group (n11)

Total (N43)

Age (y)
Mass (kg)
Height (cm)

21.61.4
68.85.3
175.17.1

19.50.9
64.36.6
171.84.1

21.63.4
69.411.5
172.85.4

19.61.3
62.510.3
169.43.9

20.62.2
66.29.1
172.25.5

NOTE. Values are mean SD.

cupuncture at nonacupoints (sham points). The dorsiflexion

muscle group was chosen because its normal function is essential to walking, and the dorsiflexors are often more significantly impaired than the plantar flexors in patients with hemiparesis.27-29
METHODS
Participants
Forty-three male university students with a mean age of 20.6
years (range, 18 29y) volunteered for the study. The sample
size was determined by a priori estimation based on the effect
size of 0.8, power of .95, and level of .05, using the G*Power
3 program (version 3.0.3).30,a It was estimated that to detect
between-factor differences using analysis of variance with repeated measures (RMANOVA), a minimum of 7 participants
in each group would be required. Therefore, 10 participants in
each group were thought to have sufficient statistical power to
determine the effect of treatment in the present study.
Participants had no musculoskeletal or neurologic disorders,
had not been involved in regular strength training during the 6
months before the study, and had no previous experience with
acupuncture or EMS. All participants were right foot dominant
as identified using an established questionnaire.31 Participants
were first given an individual registration number, then randomly allocated into 4 groups according to a random number
table: control group (CON) (n10), manual acupuncture on
acupoints (MAcu) group (n11), electroacupuncture on acupoints (EAcu) group (n11), and electroacupuncture on sham
points (ESham) group (n11). The physical characteristics of
the participants are presented in table 1. The experimental
procedures obtained approval by the human research ethics
committee of the university and were conducted in compliance
with the Declaration of Helsinki. Consent was obtained from
all participants before commencement of the study.
Procedures
Participants in the MAcu, EAcu, and ESham groups received
acupuncture on the right leg, 3 sessions per week, for 6 weeks.
All participants were given 1 minute of ankle exercise at a
comfortable intensity before each session as warm-up, and
similar exercise after each session as cool-down.
The MAcu and EAcu groups received manual acupuncture
or electroacupuncture at the acupoints of Zusanli (ST-36) and
Xiajuxu (ST-39)32 (fig 1). The locations of these acupoints have
been described in a previous report.13 For the ESham group,
acupuncture needles were applied to a point at the top one third
and a point at the lower one third length of muscle belly of the
tibialis anterior, respectively, and 3cm laterally to the anterior
crest of the tibia, avoiding any known TCM meridian channels
and acupoints (see fig 1).
For all participants in the 3 intervention groups, a stainless
steel acupuncture needle (GB2024-94)b with a diameter of
0.3mm and length of 50mm was inserted vertically into the
muscle at the selected point to a depth of 20 to 30mm. At the
acupoints, a feeling of Deqi (ie, needle sensationa soreness

and numbness sensation but not a sharp pain) was experienced

by the participants. At the sham point, the needle was inserted
to a similar depth as that for the acupoint; however, it was not
necessary to experience Deqi but instead only a level of pain.
The acupuncture was performed by a qualified acupuncturist
who had a bachelors degree in TCM and practiced acupuncture in hospital for 10 years.
The treatment time in each session was 15 minutes in the
first week, 20 minutes in week 2, and 30 minutes in weeks 3
through 6. For the MAcu group, twirling and lift-thrusting
techniques were applied for 15 seconds every 5 minutes. For
the EAcu and ESham groups, an electroacupuncture apparatus
(SDZ-II)b was used to deliver constant-current square-wave
pulses at a frequency of 40Hz and a pulse width of 1ms, with
a gradually increased intensity up to the maximal level the

Fig 1. Locations of ST-36, ST-39 acupoints and sham points. Cun is

a unit for relative length used in TCM. Three cun is the breadth of
participants index, middle, ring, and little fingers at the level of the
proximal interphalangeal joint at the dorsum of the middle finger.
Sham points are located at the top one third and lower one third
length of the muscle belly of the tibialis anterior muscle, and 3cm
lateral to the anterior crest of the tibia.

Arch Phys Med Rehabil Vol 93, January 2012

52

ACUPUNCTURE AND MUSCLE STRENGTH, Zhou

Fig 2. The maximum isometric ankle dorsiflexion strength (newtons)

of the left (L, circles) and right (R,
squares) leg before (Pre, unfilled)
and after (Post, filled) 6 weeks of
MAcu and EAcu on acupoints of
ST-36 and ST-39, and ESham.
*P<.05 compared with CON;

P<.000, Pre vs Post.

participants could tolerate. The cathode of the stimulator was

connected to the proximal needle and the anode to the distal
needle. The stimulation was applied continuously for the same
period during each session as that for the MAcu group. Participants took a supine position and were instructed not to voluntarily contract the muscle during the acupuncture. For safety
considerations, dorsiflexion force was not monitored when
acupuncture needles were in the muscle. The electroacupuncture induced visible contractions, while manual acupuncture
did not induce any visible muscle contraction.
Participants in the CON continued with their normal daily
activities without engaging in any specific physical training.
For a more appropriate control of the potential effects from the
experimental environment, all participants in the CON also
visited the laboratory 3 times per week. They participated in
the warm-up and cool-down activities but otherwise rested
during the session.
Before and after the 6 weeks of intervention, all participants
were tested for their maximal voluntary contraction (MVC)
strength in isometric dorsiflexion contractions on a custombuilt device. During the test, participants were supine with the
nontested leg fully extended and relaxed. The leg for testing
was strapped to the testing device by Velcro belts at the foot,
leg, and the thigh, with the ankle joint at 15 plantar flexion and
the knee joint angle at full extension. The force transducer
(MCL-S)c was mounted on a metal bar with foam padding that
was placed on the back of the foot at the level of the metatarsophalangeal joint. With the heel supported and rotation axis of
the device and ankle joint aligned, the location of the metal bar
was adjusted according to the foot size. This location was
recorded for each individual for repeated testing. The signals
collected from the force transducer were fed into a Medlab data
acquisition system (Medlab-U8C)d at the analog-to-digital conversion rate of 500Hz. The participant was asked to perform at
least 3 maximal dorsiflexions against the force transducer.
Each contraction was maintained for 3 to 5 seconds followed
by 1 minute of recovery. Strong verbal encouragement was
given to the participants during the contraction, and 1 or 2
additional trials were allowed if participants thought they could
do better.33 The research assistant who performed the strength
test was not aware of which group the participants were from,
and the data analysis was performed offline after completion of
the experimental period by a research assistant who was also
blinded to participants groups and the time (pre or post) of the
Arch Phys Med Rehabil Vol 93, January 2012

tests. The highest force value of the successful contractions

from each participant was used in statistical analysis.
Statistical Analysis
A 3-way RMANOVA (intervention leg, with the group as
the between-subject factor) was performed to detect the main
effect of intervention, leg, and group; and interactions between
preintervention and postintervention, left and right legs, and the
groups. If a significant effect or interaction was detected,
Bonferroni adjustment was applied in post hoc analysis to
compare the mean values, with an level of .05 set for
statistical significance. These statistical analyses were performed using SPSS statistical package (Version 17).e
RESULTS
All participants successfully completed the study, except
that the postintervention data of 2 participants in the MAcu
group were invalid because of errors in recording. The results
of RMANOVA indicated that there was a significant main
effect of intervention (F132.5, P.000), and interaction of
intervention by group (F19.6, P.000). Post hoc analyses
indicated that the 6 weeks of intervention significantly improved dorsiflexion MVC in both legs in the MAcu, EAcu, and
ESham groups (all P.01), while the CON showed no change
in MVC of both legs during the same period (fig 2). There were
no significant differences in MVC between the 2 legs in either
the preintervention or the postintervention test in all groups.
There were no significant differences in MVC between the
CON and other groups before the intervention. However, in the
postintervention test, the right leg strength of the EAcu and
ESham groups, and the left leg strength of all 3 acupuncture
groups became significantly higher than that of the CON
(P.05) (see fig 2).
DISCUSSION
There have been reports that 1 session of bilateral acupuncture or electrical stimulation at selected acupoints may have an
acute effect on muscle strength.20,34 A previous study13 in our
laboratory has also demonstrated that 4 weeks of unilateral
electroacupuncture can improve muscle strength bilaterally.
The present study demonstrated, for the first time, that 6 weeks
of unilateral manual acupuncture can also have bilateral effects
on muscle strength, while the outcomes of electroacupuncture

ACUPUNCTURE AND MUSCLE STRENGTH, Zhou

intervention underscored our previous finding. The 18 sessions

of electroacupuncture at the acupoints resulted in a 35%
strength gain in the stimulated leg and 32% in the contralateral
leg, and at the sham points resulted in a 64% and 55% strength
gain, respectively, which appeared to be greater than the 21.3%
and 15.2% strength gain found in our previous investigation13
on the effects of 4 weeks (12 sessions) of electroacupuncture.
Whether the greater strength gain in the present study was due
to the longer period of intervention would be an interesting
question for future study. More interestingly, the MAcu group
also demonstrated a significant strength gain, with 46% and
49% in the right and the left legs, respectively, while the CON
showed no change in strength of both legs.
These findings may have clinical implications. Although
acupuncture has been practiced for centuries, only during the
past several decades has its effectiveness for specific conditions
been examined in randomized, controlled clinical trials.17,23,35
For example, a recent systematic review and meta-analysis17 of
randomized clinical trials on the effect of acupuncture for poststroke rehabilitation indicated that contralateral treatment might
have a superior effect compared with ipsilateral treatment for
cerebral infarction. Acupuncture has also been used as an ergogenic aid for enhancing sports performance, with some evidence of improved muscle strength and power and hemodynamic parameters, although a larger number of randomized
controlled trials are needed to confirm these effects.24
It has been reported that 50% of the acupoints are directly
above major nerve trunks, and other acupoints are located
within 0.5cm of the nerve trunks or are identical to the motor
points.36 Sham points have been used as a control for the
effect of acupuncture.35,37,38 In a recent literature review38 on
the specificity of acupoints, it was reported that nearly 60% of
the trials did not find a significant difference in the outcomes
between acupuncture at acupoints and sham points. The present
study also found no significant difference in the strength gains
between the EAcu and ESham groups. However, the results
should be interpreted with caution because the acupoints and
sham points selected in this study might be in the same vicinity
of the deep peroneal nerve (see fig 1), and electrical stimulation
at these points could have stimulated the same nerve. Further
studies may use other means of control, such as manual
acupuncture on sham points, no needle insertion, or insertion at
various depths, to provide alternative evidence.23 It is difficult
to perform placebo-controlled trials for acupuncture because of the difficulty in finding an adjacent point that is far
enough away from the acupoint without overlapping with
another acupoint or a meridian channel,23 and because electroacupuncture and manual acupuncture at both acupoints or sham
points cause a level of pain that may produce a placebo effect.37,38 A limitation of this pilot study was that additional
control groups were not included to address these aspects.
Nevertheless, the results of the present study appear to indicate
that the 3 types of interventions as used in this study all can
induce a significant bilateral effect on muscle strength.
It is beyond the objectives of this study to discuss the
possible mechanisms of acupuncture-induced cross education
within the theoretic framework of TCM. We adopt the viewpoint that the bilateral effects of acupuncture and electrical
stimulation are induced by plasticity of the nervous system,23,36
although the possibility of peripheral adaptations should not be
excluded.4,5,12,39 It has been hypothesized that at the supraspinal levels, the contralateral strength gain in adaptation to resistance training could be due to either crossed activation
(eg, activation of neural circuits on 1 side that chronically
modifies the efficacy of motor pathways that project to the
opposite untrained limb) or bilateral access (ie, the untrained

53

limb may access these modified neural circuits during training),

which may subsequently lead to an increased capacity to drive
the untrained muscles and thus result in increased strength.6,39
However, whether and how the contralateral strength gain
induced by electrical stimulation or acupuncture can be manifested via these proposed cortical mechanisms are unknown.
The principle of electrical stimulation training is to deliver
electrical pulses to the target peripheral nerve to activate the
muscle. Because the excitation threshold of the nerve fibers is
significantly lower than that of the muscle fibers, transcutaneous stimulation, and perhaps electroacupuncture as well, will
preferentially activate the nerve fibers.40 When the stimulation
intensity is progressively increased, the nerve fibers that have a
lower threshold (eg, the large Ia afferent fibers from muscle
spindles) are activated before those with higher thresholds (eg,
large Ia motor nerve fibers and small IV fibers from the pain
and thermal receptors).41,42 It can be predicted that at the
maximal stimulation intensity, all the sensory and motor nerve
fibers in the nerve trunk will be activated. However, subject to
participants tolerance to discomfort and pain, submaximal
stimulation intensities are normally used in electrical stimulation training,41 and that was also the case for electroacupuncture as experienced in this study. Nevertheless, the sensory
pathways are activated during the electrical stimulation and
electroacupuncture, as the participants have perceived pain,
indicating even the smallest nerve fibers are activated.
The sensory afferents associated with electrical stimulation
have been shown to cause cortical adaptations and improve
MVC and muscle activation without significant muscle hypertrophy.41 There has been evidence from studies43,44 that used
transcranial magnetic stimulation that peripheral electrical
stimulation can result in rapid plastic change in the corticomotor pathway. A study45 that used functional magnetic resonance
imaging (fMRI) technique showed that electrical stimulation
applied to the tibialis anterior muscle of 1 side induced a
widespread activation in the brain. The fMRI signals were
stronger in voluntary ankle dorsiflexion than that in electrical
stimulation-induced contractions in brain areas responsible for
motor planning, execution, and visuomotor coordination, while
the electrical stimulation-induced activity was stronger in bilateral secondary somatosensory areas and the insula, possibly
because of increased sensory integration or nociceptive inputs.
How these changes in brain activities are related to plasticity in
motor function is still subject to elucidation. However, it can be
speculated that the sensory afferents may play an important
role in mediating the cross education associated with electrical
stimulation training.
The essential role of sensory afferents in mediating cross
education is further supported by the effect of manual acupuncture as found in this study. The manual acupuncture did not
appear to effectively activate the motor nerve because no
visible muscle contraction was observed. Therefore, the crosseducation effect caused by acupuncture does not seem to be
related to the contraction intensity, but must be related to the
sensory inputs. The practice of traditional acupuncture is to
manually manipulate the needle that results in Deqi, which is a
mixture of aching, pressure, soreness, heaviness, fullness,
warmth, cooling, numbness, tingling, and dull pain, but not
sharp pain.46 These sensory inputs are conducted by type II, III,
and IV fibers.46 Further research is needed to determine how
these sensory inputs are related to cortical plasticity in motor
performance.
Spinal mechanisms may also be involved in cross education. It
has been reported that unilateral voluntary dorsiflexion exercise
increased dorsiflexion strength of both limbs, while the H-reflex at
the threshold stimulation was increased in both the tibialis anterior
Arch Phys Med Rehabil Vol 93, January 2012

54

ACUPUNCTURE AND MUSCLE STRENGTH, Zhou

and soleus muscles of the trained limb, indicating that more lowthreshold motoneurons were recruited. Furthermore, the H-reflex at
maximum (H@max) of the antagonist (soleus) in both limbs decreased after 5 weeks of training.29 Equivocal evidence has been
reported for the effect of acupuncture on the H-reflex. Electroacupuncture at Hegu (LI-4) acupoint (in the hand) has been
shown to increase H-reflex amplitude, while manual acupuncture did not have a significant effect.47
Study Limitations
A limitation of this pilot study was not including additional
control groups for manual acupuncture on sham points or at
various depths to address the potential placebo effects. The
findings of the present study were from a healthy, young
population with participants who had not participated in specific resistance training for the previous 6 months. It is known
that muscle strength can improve quickly at the beginning of a
training program because of neural adaptations, particularly in
previously untrained individuals.48 Whether the strength gain
induced by the acupuncture relies on the same neural mechanism
is unknown. Furthermore, it is speculated that the contralateral
effect of unilateral acupuncture on neuromuscular function might
have clinical implicationsfor instance, in rehabilitation for
single-limb injuries or hemiparesis, or as an ergogenic aid for
enhancement of motor performance. Further studies are needed to
confirm the therapeutic effect in patients or ergogenic effect in
resistance-trained individuals such as athletes.
CONCLUSIONS
The present study demonstrated that dorsiflexion muscle
strength was significantly improved in response to 6 weeks of
unilateral manual acupuncture in healthy young men. The
results also showed that the bilateral strength gain induced by
electroacupuncture was not different when the stimulation was
applied to ST-36 and ST-39 compared with that to the 2
nonacupoints on the leg.
Acknowledgments: We thank Qing-Wen Li, PhD, for her guidance on acupuncture, and Ming Ao, BSc, and Wen-Long Wang, BEd,
Tianjin University of Sport, for data collection and analysis.
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Suppliers
a. G*Power. Free software. Available for downloading at: http://
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b. Suzhou Medical Appliance Factory, Ltd, 12-14 W Qiling Ln,
Suzhou, Jiangsu Province 215005, P.R. China.
c. Beijing Zhengkai Instruments Co, Ltd, 10 Xinkangyuan, Xisanqi E
Rd, Haidian District, Beijing 100096, P.R. China.
d. Nanjing MedEase Science and Technology Co, Ltd, 119 Jinghuai
St, Jiangning Economic and Technology Development Zone, Nanjing, Jiangzu Province, P.R. China.
e. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

Arch Phys Med Rehabil Vol 93, January 2012