Effect of Acupuncture-Point Stimulation on Diastolic

Blood Pressure in Hypertensive Subjects: A

Preliminary Study
Tim Williams, Karen Mueller and Mark W Cornwall
PHYS THER. 1991; 71:523-529.

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Research Report

Effect of Acupuncture-Point Stimulation on Diastolic

Blood Pressure in Hypertensive Subjects:
A Preliminary Study

Electrical stimulation of four specijic acupuncture points (Liver 3, Stomach 36, Tim Wllllams
Large lntestine 11, and the Groovefor Lowering Blood Pressure) was examined Karen Mueller
in order to determine the effect of thb stimulation o n diastolic blood pressure in Mark W Cornwall
10 subjects with diastolic hypertension. Subjects were randomly divided into two
groups: (1) a n Acu-ES group, which received electrical stimulation applied to the
four antihypertensive acupuncture points, and (2) a Sham-ES group, which re-
ceived electrical stimulation applied to non-acupuncture-point areas. A repeated-
measures analysis of variance revealed a sign$cant, immediate poststimulation
reduction of diastolic blood pressure for the Acu-Es group versus the Sham-ES
group. Further studies are needed to determine whether there are other acupunc-
ture points, stimulation characteristics, or modalities that can enhance this treat-
ment effect and whether the treatment effect can last for a clinically signijicant
period of time. W i l l i a m T, Mueller 4 Cornwall MW: Effect of acupuncture-point
stimulation o n diastolic blood pressure in hypertensive subjects: a preliminary
study. Phys T h e 1991;71:523-529.1

Key Words: Acupuncture/acupressure;Blood pressure; Electrotherapy, electrical

stimulation; Hypertension.

Research exploring the physiologic has facilitated an increasing accept- disorders such as angina pectoris and
mechanisms underlying acupuncture ance of acupuncture in western medi- hypertension.'-5
suggests that somatic processes may cine, in which it has been used suc-
be altered through the production of cessfully for the production of Traditional acupuncture involves the
systemic vasodilation, increased en- analgesia during surgery, pain control use of small-diameter needles, which
dorphin release, and alterations in in conditions such as migraine head- are inserted into the skin. The litera-
hormonal secretion.' Such research ache, and treatment of cardiovascular ture suggests that effective stimulation
of acupuncture points may also be
produced through direct pressure:
T Williams, BS, FT,is Staff Physical Therapist, Havasu Samaritan Regional Hospital, Lake Havasu the use of ultrasound7~fjand helium-
City, AZ 86403. He was a senior physical therapy student at Northern Arizona University, Flagstaff, neon lasers,"" and the application of
AZ,when this article was written. electric currents via the use of surface
K Mueller, MS, PT, is Assistant Professor, Department of Physical Therapy, Northern Arizona Univer- o r implanted electr0des.'2-'~
sity, PO Box 15105, Flagstaff, AZ 86011-5105 (USA). Address all correspondence to Ms Mueller.

MW Cornwall, PhD, FT,is Assistant Professor, Department of Physical Therapy, Northern Arizona
The effective use of acupuncture,
University regardless of the method used, in-
volves the accurate detection of acu-
The results of this study were presented in poster format at the Annual Conference of the Ameri-
can Physical Therapy Association, June 11-15, 1989, Nashville, TN. puncture points on the body surface.
Previous studies17-19 have shown acu-
This study was approved by the Northern Arizona University Human Subjects Institutional Review puncture points to have a markedly
Board.
lower electrical resistance than the
This article was submitted July 31, 1989, and was accepted March 6 1991

34 / 523 Physical Therapy /Volume 71, Number 7 /July 1991

Downloaded from http://ptjournal.apta.org/ by guest on October 23, 2012
skin around them. This finding has
allowed clinicians to use devices such
as an ohmmeter to accurately locate
acupuncture points.
Hypertension is a major risk factor
for coronary artery disease and
stroke, which are, respectively, the
first and third highest causes of
mortality in the United States.20Cur-
rent treatment for hypertension in-
cludes sodium restriction, pharma-
cologic management, and lifestyle
modifications such as stress manage-
ment ancl e ~ e r c i s e . 2Although
~ these
methods of treatment are generally
considered to be effective, they fre-
quently require permanent lifestyle
changes. Thus, poor patient compli-
ance is common. The drawbacks of
antihypertensive medication include
side effects, such as fatigue, electro-
lyte imbalance, and impotence,
which ofi.en result in patient intoler-
ance.21 The substantial cost of long-
term medication can also be prob-
lematic. These disadvantages suggest
a need for alternative strategies in
the management of hypertension.
The use of needle acupuncture as a
method of treatment for hypertension
has been explored in both western
and Chinese literature. Tam and YiuZ2
found that acupuncture produced a
significant reduction in systolic and
diastolic blood pressure (BP) immedi-
ately upon stimulation. In a study ex-
ploring the physiologic mechanisms
of this effect, Omural measured circu-
latory changes during acupuncture in
400 patients and reported a general-
ized vasodilation response, which co-
incided with a decrease in systolic
and diastolic BP. He also found that
slight decreases in BP often occurred
in patient,^ receiving acupuncture,
regardless of the condition treated.
Furthermore, the most dramatic de-
creases were found in patients with
essential hyperten~ion.~ Peng23 sug-
gested that acupuncture stimulation
may cause vasodilation.
There is little research on the effect of
electrical stimulation of acupuncture
points on systolic and diastolic BP.
Studies by Yao et a12*and Hoffman
and Thon:n25 have demonstrated a
Physical Therapy /Volume 71, Number
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significant reduction of systolic and
diastolic BP in hypertensive rats fol-
lowing the application of low-
frequency electrical stimulation to
the sciatic nerve.
The purpose of this study was to de-
termine the effect of electrical stimula-
tion of selected acupuncture points
on diastolic BP in hypertensive sub-
jects immediately following and 5
minutes after stimulation. We hypoth-
esized that hypertensive subjects who
received electrical stimulation of four
selected acupuncture points would
show a significant decrease in dia-
stolic BP immediately following treat-
ment, whereas there would be no
immediate posttreatment change in a
group of hypertensive subjects who
received electrical stimulation applied
to non-acupuncture-point areas.
Method
Subjects
Subjects were selected on the basis of
two inclusion criteria: (1) a resting
diastolic BP between 90 and 120 mm
Hg and (2) no past o r present use of
antihypertensive medication.
All subjects were patients under the
care of two physicians with a specialty
in family practice. In addition, all sub-
jects had been diagnosed with border-
line hypertension within the previous
6 months. The diagnosis of borderline
hypertension was assigned by these
physicians to any patient with a dia-
stolic BP greater than 90 mm Hg dur-
ing two consecutive office visits. Pa-
tients diagnosed with borderline
hypertension were counseled by the
physicians about dietary modifications
and exercise and were instructed to
monitor their BP at home. Subse-
quently, if these patients reported
three consecutive at-home diastolic BP
readings above 90 mm Hg, their diag-
nosis was changed from borderline to
essential hypertension. AU subjects
who participated in this study were
still considered by these physicians to
be borderline hypertensive.
The two physicians contacted 22 sub-
jects who met the study's inclusion
criteria, 12 of whom agreed to partici-
pate (2 subjects showed normotensive
diastolic BPS when they arrived for
the first data-collection session and
were excluded from the study). Of
the 10 subjects who completed the
study, 2 were female and 8 were
male. Their mean age was 46 years
(range= 27-72 years). All subjects
gave written informed consent.
Test Environment
The testing environment was carefully
controlled in order to minimize fac-
tors that could influence diastolic
BP.26127All testing was performed in
an acoustically insulated audiology
booth in which the temperature was
maintained between 23" and 25C.
In order to minimize psychological
factors affecting diastolic BP, the fol-
lowing steps were taken to ensure a
relaxed atmosphere during testing.
Subjects were instructed to wear
loose and comfortable clothing. The
investigators refrained from wearing
laboratory coats during all sessions,
because the use of such apparel has
been associated with increased BP
("white-coat hypertension") in some
patients.28Except for a standing mer-
cury column sphygmomanometer and
a stethoscope, the testing equipment
was placed away from the subject's
view. Finally, a large poster of a pleas-
ant outdoor scene was placed on the
wall facing the subject.
Procedure
Subjects were randomly divided
into two groups by the use of a coin
toss. Four subjects comprised the
Acu-Es group (test group), which
received electrical stimulation ap-
plied to the four acupuncture
points, and six subjects formed the
Sham-ES group (control group),
which received electrical stimulation
applied to non-acupuncture-point
areas. The two subjects who were
excluded from the study had previ-
ously been assigned to the Acu-ES
group. Because they were the last two
subjects scheduled for data collection,
an uneven distribution of subjects
resulted.
All diastolic BP measurements were
performed by one investigator (KM),
who was blinded as to the subject's
group assignment. Prior to the study,
this investigator established a test-
retest reliability of .99 for diastolic BP
using an intraclass correlation coeffi-
cient (ICC[l,k])*9as the index of reli-
ability. The diastolic BP of 10 subjects
was measured twice, with a 1-minute
interval between the first and second
measurements, and the measurements
were compared for consistency. Dia-
stolic BP was measured according to
American Heart Association guide-
lines.3O All electrical stimulation was
performed by one investigator (TW)
as well.
A Neuroprobea System lV stimulator*
was used to detect acupuncture points
and to provide electrical stimulation.
We used a remote hand-held treat-
ment probe with a metal tip measur-
ing 22 mm long and 3 mm wide. No
conductive medium was used.
The NeuroprobeB System IV provides
both audtory and visual signals when
the active hand-held treatment probe
is in contact with skin areas of low
resistance. As previously mentioned,
these areas correspond to acupunc-
ture points.
The Neuroprobea System lV provides
a medium-frequency sinusoidal signal
of 10,000 Hz. All subjects in the study
received continuous electrical stimula-
tion at 10,000 Hz (the "MF continu-
ous" pulse-rate setting on the Neuro-
probe@' System N). This stimulation
was divided into two 30-second doses
applied to each selected acupuncture
point, with a 5- to 7-second interval
between each dose. The output inten-
sity of each dose was set at the lowest
point at which the subject could de-
tect the stimulation.
The test procedure for each subject
was as follows. The subject was seated
in a comfortable chair inside the treat-
ment booth. The Neuroprobea Sys-
'Physio Technology Inc, 1505 SW 42nd St, Topeka, KS 66609.
+ ~ e u r Division,
o Medrronic Inc, 7000 Central Ave IYE, Minneapolis, MN 55440
36 / 525
Downloaded from http://ptjournal.apta.org/ by guest on October 23, 2012
tem lV setup began with the applica-
tion of a NeuroAid 3.5 model 7 7 9 P
disposable gel electrodet on the volar
surface of the subject's right forearm.
The subject was fitted with a BP cuff
on the right arm and allowed to sit
quietly for 5 minutes. Following this
5-minute period, a pretreatment dia-
stolic BP measurement was taken.
Immediately after the pretreatment
diastolic BP measurement, the groups
received their respective treatments. A
second diastolic BP measurement was
taken immediately after treatment.
The subjects remained seated for an
additional 5 minutes, whereupon the
final diastolic BP measurement was
taken.
Treatment for subjects in the Acu-ES
group consisted of electrical stimula-
tion of four selected acupuncture
points. Selection of these points was
based on acupuncture texts1-5 and
discussions with three certified acu-
puncture practitioners. The four acu-
puncture points selected received the
highest number of recommendations
from these sources.
Electrical stimulation was applied to
acupuncture points on the left side of
all subjects in the Acu-ES group.
Figure 1 illustrates the anatomical lo-
cations of the four acupuncture
points. These anatomical locations
were used to detect the general area
of the acupuncture points, and the
hand-held treatment probe was used
to determine the exact area for elec-
trical stimulation. The first point stim-
ulated was Liver 3, located on the
dorsal surface of the foot, between
the first and second metatarsals, at the
metatarsophalangeal joints. The sec-
ond point stimulated was Stomach 36.
This point is located 3.8 cm (1.5 in)
distal to the lower border of the pa-
tella and 1.3 cm (0.5 in) lateral to the
anterior tibia1 ridge. The third point
stimulated was Large Intestine 11.
This point is located at the lateral end
of the elbow flexion fold. The fourth
point is known as the Groove for
Physical Therapy /Volume 71, Number 7 /July 1991
Lowering Blood Pressure. This is the
groove that is found behind the ear
when the auricle is folded down. This
order was followed for all subjects.
The exact location of the acupuncture
points in Acu-ES group subjects was
determined by using the hand-held
treatment probe to find the area in
the region of the acupuncture point
with the lowest electrical resistance.
Subjects in the Sham-ES group re-
ceived a control treatment using elec-
trical stimulation characteristics identi-
cal to those used for the Acu-ES
group; however! this stimulation was
applied to non-acupuncture-point
areas. 'These non-acupuncture-point
areas were located by placing the
probe over the general anatomical
area of the acupuncture point as de-
scribed previously, then moving the
probe approximately 15 cm (6 in)
away to an area at which a high elec-
trical resistance was encountered.
These areas were also stimulated on
the subjects' left side in the same or-
der as for the Acu-ES group.
Data Analysis
The test for differences in diastolic BP
between immedate posttreatment and
5-minute posttreatment measurements
as well as for differences in diastolic
BP between the two experimental
groups was performed using a mixed
two-way analysis of variance (ANOVA).
The factor of time (pretreatment-
immediately after treatment versus
pretreatment-5 minutes after treat-
ment) was designated as the repeated-
measures variable. An alpha level of
.05 was used for the determination of
significant differences.
Table 1 shows the diastolic BP read-
ings of each subject before, immedi-
ately after, and 5 minutes following
electrical stimulation. The results of
an independent Student's t test re-
vealed no statistically significant differ-
ence (t=-.93, df=8, P>.05) for the
pretreatment measurements of the
Acu-ES and Sham-ES groups. Table 2
shows the between-group means and
standard deviations of the diastolic

Flgure l. Anatomical locations of the four acupuncture points used in this study.
changes between immediate posttreat-
ment and. pretreatment measurements
and between 5-minute posttreatment
and pretreatment measurements.
Table 3 shows the ANOVA results,
which demonstrate a significant differ-
ence (df== 1,Pe.05) between treat-
ment groups and between the two
posttreatment measurement sessions.
No signiEicant interaction (P>.05) was
found between the treatment groups
and the rwo posttreatment measure-
ment sessions. Figure 2 graphically
illustrates the mean changes in dia-
stolic BP over time for the two
groups.
Discussion
The results of this preliminary study
support the hypothesis that medium-
frequency electrical stimulation of se-
lected acupuncture points results in a
significant reduction in diastolic BP.
Physical Therapy /Volume 71, Number 7/July 1991
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The magnitude and duration of this
reduction, however, are insufficient for
such stimulation to be of current clini-
cal value as a means of treatment for
hypertension. Nonetheless, the results
of this study suggest the possibility that
further research may lead to the dis-
covery of stimulation characteristics,
modalities, and acupuncture points
that will promote a sustained reduc-
tion of diastolic BP into the therapeutic
range. The discovery of such factors
could, in turn, result in the use of elec-
trical stimulation of acupuncture points
as a viable method of treatment for
hypertension.
A major limitation of this study was
the small number of subjects. Because
of the risk for stroke and heart dis-
ease associated with untreated hyper-
tension, however, many physicians
choose not to delay the prescription
of antihypertensive medication. For
this reason, we were only able to re-
cruit a small group of subjects who
met the inclusion criteria for our
study. In spite of the difficulty of re-
cruiting appropriate subjects, we
based our selection criteria on the
work of Tam and Y ~ uwho , ~ sug-
~
gested that acupuncture is more effec-
tive in lowering BP in subjects who
have no history of antihypertensive
medication use than in subjects with a
history of antihypertensive medication
use. These investigators also found
that results are even greater when the
diagnosis of hypertension has been
Results of studies investigating the use
of acupuncture on pharmacologically
managed hypertensive subjects sug-
gest that antihypertensive medication
may interfere with the effects of acu-
puncture treatment. Sugioka et a131
found that the use of acupuncture had
no effect on patients who had just
completed a course of antihyperten-
sive medication. Clearly, there is a
need for further studies to explore
how antihypertensive medications and
length of time since the diagnosis of
hypertension interact with the electri-
cal stimulation of acupuncture points.
Another limitation of this study was
the transient duration of the reduc-
tion in diastolic BP. In designing a
preliminary study, our objective was
to determine the efficacy of electrical
stimulation as a means of lowering
diastolic BP. Because environmental
factors can have a profound effect on
BP, major emphasis was given to the
reduction of patient anxiety. Accord-
ingly, we selected electrical stimula-
tion characteristics that would pro-
duce the most immediate treatment
effect. These stimulation characteris-
tics resulted in an average treatment
time of about 5 minutes. As previ-
ously mentioned, the literature sug-
gests that a frequency of 10,000 Hz
produces an immediate, but short-
lasting, treatment effect.32.33 The re-
sults of our study support this litera-
ture, because the differences in
diastolic BP between the Acu-ES and
Sham-ES groups were no longer
significant 5 minutes posttreatment.
Further studies are needed to deter-
Table 1. Diastolic Blood Pressure Measurements (in Millimeters of Mercury)

Measurement
Age lmmedlate 5-Minute
Groupa Sex (Y) Pretreatment Posttreatment Posttreatment

ACU-ES
ACU-ES
ACU-ES
-
X
SD
Range
Sham-ES
Sham-ES
Sham-ES
Sham-ES
Sham-ES
Sham-ES
-
X
SD
Range

"Acu-ES group received electrical stimulation of four antihypertensive acupuncture points; Sham-ES group rece~vedelectrical stimulation of four nun-
acupuncture-point areas.

mine whether longer treatment du-
rations at a frequency of 10,000 Hz
will result in longer periods of
treatment effectiveness.
Although our study involved the use
of 10,000-Hz electrical current, hrther
research involving lower frequencies
may prove beneficial. Research by Fox
and Melzack13suggests that a lower-
frequency, long-duration current
(such as that used in transcutaneous
electrical nerve stimulation) may pro-
duce longer-lasting treatment effects.
Electrotherapeutic modalities are
widely used by physical therapists for
the treatment of musculoskeletal prob-
lems. The acupuncture points used to
treat musculoskeletal problems are
different from those used to reduce
BP. Whether an indirect antihyperten-
sive effect results from such treatment,
however, remains to be determined.
Further research on the indirect effects
of electrical stimulation of acupuncture
points for the treatment of muscu-
loskeletal problems in normotensive
and hypertensive subjects may prove
to be enlightening. Perhaps it is possi-
ble that desirable reductions in BP

Table 2. Means and Standard Deviations of Changes Between Diastolic Blood Pressure Measurements

Measurement
Pretreatment Versus lmmedlate Pretreatment Versus 5-Minute
Posttreatment Posttreatment
- -
X SD X SD

"Acu-ES group received electrical stimulation of four antihypenensive acupuncture points; Sham-ES group received electrical stimulation of four non-
acupuncture-point areab.
h~ignificantlydifferent (+I, P<.05).
"Not significantly different ( P > . 0 5 ) .
1

38 / 527 Physical Therapy/Volume 71, Number 7IJuly 1991

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-
Table 3.
Source of
Varlatlon
Results of Analysis of Variance
Group
Error 1
Time
Groupxtime
Error 2
occur in hypertensive patients receiv-
ing electrotherapy for musculoskeletal
problems.
The four acupuncture points used in
this study are among several that are
stated in the acupuncture literature to
have an antihypertensive effect. Peri-
cardium ti; Gall Bladder 20, 21, and
41; Stomach 9 and 37; Kidney 1;
Spleen 1 and 2; and Heart 7 are other
acupuncture points that can be used
to lower 13P.l-5 We suggest that future
studies be conducted using one or
more of tlhese alternative acupuncture
points. Bilateral stimulation to se-
lected acupuncture points may also
prove to be effective.
80 t'
Pretreatment Immediate Posttreatment
Measurement
Flgure 2. Mean changes in diastolic blood pressure (in millimeters of mercuty)
over time &or Acu-ES and Sham-ES groups. (O=Sham-ESgroup, X=Acu-ES group,)
Physical Therapy /Volume 71, Number 7IJuly 1991
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In summary, the results of this study
suggest numerous possibilities for
future research. We suggest several
replications of this study, manipulat-
ing the variables of treatment dura-
tion, electrical modality used, stimula-
tion characteristics, and acupuncture
points selected.
Conclusion
This study was designed to validate
the current literature concerning the
electrical stimulation of acupuncture
points affecting diastolic BP and to
provide a basis for future research.
Thus, we designed a preliminary
study, with an emphasis on accuracy
of acupuncture-point detection, using
a clinically available modality that pro-
5-Minute
Posttreatment
duces a quick, but short-lasting, thera-
peutic effect. The results of our study
indicate that stimulation of four se-
lected acupuncture points with a cur-
rent of 10,000 Hz produces a signifi-
cant reduction in diastolic BP in
hypertensive subjects. Although the
duration and magnitude of this effect
were insufficient to be of clinical
value, the results of this study support
the efficacy of electrical stimulation as
a means of lowering diastolic BP.
Acknowledgments
We would like to express our thanks
to the following individuals: Michael
Ryan, MD, and Corwin Demarse, MD,
for their assistance in locating sub-
jects; Kay Evje and Susan Nassan, li-
censed acupuncturists, for their ad-
vice; Graydon Bell, PhD, for his
contribution to our statistical analysis;
and Paul Hansen, PhD, PT, for his edi-
torial comments. Finally, we extend
special thanks to all of our subjects.
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40 / 529 Physical Therapy /Volume 71, Number 7 /July 1991

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 Effect of Acupuncture-Point Stimulation on Diastolic
Blood Pressure in Hypertensive Subjects: A
Preliminary Study
Tim Williams, Karen Mueller and Mark W Cornwall
PHYS THER. 1991; 71:523-529.

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