# Laser Acupuncture

Lasers Med Sci. 2016 Dec 10. [Epub ahead of print]

# Efficacy of femtosecond lasers for application of acupuncture therapy.

Ohta M1,2, Hosokawa Y3, Hatano N4, Sugano A1,2, Ito A5, Takaoka Y6,7.

### Author information

• 1Division of Medical Informatics and Bioinformatics, Kobe University Hospital, Kobe, 650-0017, Japan.
• 2Genome Science Research Unit, Life Science Research Center, Kobe Tokiwa University, Kobe, 653-0838, Japan.
• 3Graduate School of Materials Science, Nara Institute of Science and Technology, Nara, 630-0912, Japan.
• 4The Integrated Center for Mass Spectrometry, Kobe University Graduate School of Medicine, Kobe, 650-0017, Japan.
• 5Department of Pathology, Kindai University Faculty of Medicine, Osaka, 589-8511, Japan.
• 6Division of Medical Informatics and Bioinformatics, Kobe University Hospital, Kobe, 650-0017, Japan. ytakaoka@med.kobe-u.ac.jp.
• 7Genome Science Research Unit, Life Science Research Center, Kobe Tokiwa University, Kobe, 653-0838, Japan. ytakaoka@med.kobe-u.ac.jp.

### Abstract

Acupuncture treatment utilizes the stimulation of metal acupuncture needles that are manually inserted into a living body. In the last decades, laser light has been used as an alternative to needles to stimulate acupuncture points. We previously reported suppression of myostatin (Mstn) gene expression in skeletal muscle by means of femtosecond laser (FL) irradiation, after electroacupuncture, in which acupuncture needles are stimulated with a low-frequency microcurrent. The purpose of the study here was to investigate the efficacy of FL irradiation in mouse skeletal muscle with regard to protein synthesis. After irradiation of the hindlimbs, we first analyzed Mstn gene expression and Mstn protein level in the skeletal muscle. We then evaluated phosphorylation of the mammalian target of rapamycin (mTOR) and its downstream target 70-kDa ribosomal protein S6 kinase (p70S6K). The results showed that FL irradiation significantly reduced the amount of Mstn protein and enhanced the phosphorylation of p70S6K in of the mTOR/S6K signaling pathway. We suggest that FL irradiation activated the protein synthetic pathway in the skeletal muscle. In conclusion, we determined that FL irradiation can serve as an alternative for acupuncture needles and has the potential of being a new non-invasive acupuncture treatment of skeletal muscle.

Acupunct Med. 2016 Sep 9. pii: acupmed-2016-011112. doi: 10.1136/acupmed-2016-011112. [Epub ahead of print]

# Laser acupuncture attenuates oxaliplatin-induced peripheral neuropathy in patients with gastrointestinal cancer: a pilot prospective cohort study.

Hsieh YL1, Chou LW2, Hong SF3, Chang FC4, Tseng SW5, Huang CC6, Yang CH1, Yang CC7, Chiu WF7.

### Author information

• 1Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung, Taiwan.
• 2Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung, Taiwan Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung, Taiwan.
• 3Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung, Taiwan Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital Chung Shing Branch, Taichung, Taiwan.
• 4Nursing Department, Chung Shan Medical University Hospital, Taichung, Taiwan.
• 5Department of Internal Medicine, Division of Medical Oncology, Chung Shan Medical University Hospital, Taichung, Taiwan.
• 6School of Medicine, Chung Shan Medical University, Taichung, Taiwan Department of Surgery, Division of Colon and Rectum, Chung Shan Medical University Hospital, Taichung, Taiwan.
• 7Department of Physical Medicine and Rehabilitation, Cheng Ching General Hospital, Taichung, Taiwan.

### Abstract

#### BACKGROUND:

Oxaliplatin is a platinum compound that is widely used in the treatment of some solid tumours. Oxaliplatin-induced peripheral neuropathy (OIPN) in the upper and lower extremities is the major adverse side effect and represents the main dose-limiting factor of this drug. The aim of this single-arm study was to evaluate the feasibility and effects of laser acupuncture (LA) in the treatment of OIPN in patients with advanced gastrointestinal cancers.

#### METHODS:

17 gastrointestinal cancer survivors (14 colorectal and 3 gastric cancers), who had been treated with oxaliplatin-based chemotherapies, were recruited. Low-level laser stimulation (50?mW) bilaterally at PC6, PC7, PC8, P9, LU11, SP6, KI3, BL60, KI1, and KI2 was administered for 20?min/point for 12 sessions over 4?weeks. The pain quality assessment scale (PQAS), chemotherapy-induced neurotoxicity questionnaire (CINQ), oxaliplatin-specific neurotoxicity scale (OSNS), quantitative touch-detection threshold (using von Frey filaments), and cold-triggered pain withdrawal latency (using the cold-water immersion test) were measured before and after completion of the 12 treatment sessions.

#### RESULTS:

PQAS, CINQ, and OSNS scores, as well as touch-detection threshold and cold-trigger pain withdrawal latency all improved significantly after LA in the cancer patients with OIPN (p<0.05). LA significantly relieved both oxaliplatin-induced cold and mechanical allodynia and also decreased the incidence and severity of neurotoxicity symptoms in the patients’ upper and lower extremities and impact on their daily activities (all p<0.05).

#### CONCLUSIONS:

Following treatment with LA, neurotoxicity symptoms were significantly improved in cancer patients with OIPN. Further randomised controlled trials are needed to evaluate the role of LA as a therapeutic option in the management of OIPN.

Journal of Acupuncture and Meridian Studies
February 2015 Volume 8, Issue 1, Pages 2–16

# Laser Acupuncture for Treating Musculoskeletal Pain: A Systematic Review with Meta-analysis.

Dina Law correspondence email, Susan McDonough, Chris Bleakley, George David Baxter, Steve Tumilty
Received: January 13, 2014; Received in revised form: June 18, 2014; Accepted: June 25, 2014; Published Online: July 24, 2014.
DOI: http://dx.doi.org/10.1016/j.jams.2014.06.015 |

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Abstract
Laser acupuncture has been studied extensively over several decades to establish evidence-based clinical practice. This systematic review aims to evaluate the effects of laser acupuncture on pain and functional outcomes when it is used to treat musculoskeletal disorders and to update existing evidence with data from recent randomized controlled trials (RCTs). A computer-based literature search of the databases MEDLINE, AMED, EMBASE, CINAHL, SPORTSDiscus, Cochrane Library, PubMed, Current Contents Connect, Web of Science, and SCOPUS was used to identify RCTs comparing between laser acupuncture and control interventions. A meta-analysis was performed by calculating the standardized mean differences and 95% confidence intervals, to evaluate the effect of laser acupuncture on pain and functional outcomes. Included studies were assessed in terms of their methodological quality and appropriateness of laser parameters. Forty-nine RCTs met the inclusion criteria. Two-thirds (31/49) of these studies reported positive effects, were of high methodological quality, and reported the dosage adequately. Negative or inconclusive studies commonly failed to demonstrate these features. For all diagnostic subgroups, positive effects for both pain and functional outcomes were more consistently seen at long-term follow-up rather than immediately after treatment. Moderate-quality evidence supports the effectiveness of laser acupuncture in managing musculoskeletal pain when applied in an appropriate treatment dosage; however, the positive effects are seen only at long-term follow-up and not immediately after the cessation of treatment.Keywords:
acupuncture therapy, low-level laser therapy, pain, review1. Introduction

Musculoskeletal disorders represent a significant cost to the health care system [1]. A recent report estimated that 1.7 billion individuals globally are affected by various kinds of musculoskeletal problems, and highlighted the considerable impact of chronic pain and disabilities upon individuals [2]. Coupled with the increasing risk factors such as obesity, sedentary lifestyles, and aging populations in the modern world [[3], [4]], increasing prevalence of musculoskeletal disorders is foreseeable, exacerbating the health care burden.Recent research confirms that treatments such as physical therapy, acupuncture, and massage remain popular with pain sufferers. A survey conducted in 16 European countries showed that 70% of participants who suffered from musculoskeletal pain sought other forms of treatment apart from medication [5]. Acupuncture is one of the most common types of alternative treatments for patients looking for long-term pain management [6], which is a relatively safe procedure with minimal side effects. Growing demand for, and provision of, acupuncture services have been seen in different countries [[5], [7], [8]], resulting an interest in, and rapid development of, acupuncture research in order to establish a more solid evidence-based practice [9].

Such research development extends to other forms of acupuncture apart from the traditional needling method. The use of low-level laser to stimulate acupuncture points is suggested to be a safer technique due to its noninvasive nature and its acceptability to people with needle phobia [10]. Laser acupuncture is considered to be an effective alternative to traditional needling, is useful in patients who are needle phobic, or can be used at acupuncture points that require complicated application of the needle [[10], [11]].

Ever since laser acupuncture studies were conducted in the 1970s [[12], [13]], researchers have focused on the underlying mechanism of laser acupuncture to build the scientific basis for clinical practice. Controversy remains concerning the mechanisms of laser acupuncture, which, being free from any mechanical stimulation, do not share similar pain modulation pathways to those of traditional needling acupuncture [10]. Rather than producing a “needling sensation,” the acupuncture point irradiated by the laser needs to receive sufficient energy to elicit the physiological effect at the cellular level, based upon the wider principle of “photobiomodulation” [[14], [15], [16]]. A key point to determine the effectiveness of laser acupuncture is the dosage applied: this issue has been stressed in several recent papers [[16], [17]]. The development of dosage guidelines for laser acupuncture is confounded by the lack of a clear understanding of the mechanisms underpinning such treatment, as dosage dependency is normally explored during the stage of in vitro and animal studies [10]. At present, the World Association for Laser Therapy guidelines for low-level laser therapy published in 2010 provide recommendations for general laser treatment for different conditions only; no specific guidelines have been developed for laser acupuncture [[18], [19]]. Hence, selection of laser parameters and dosage is often subjective or based on clinical experience. Studies may involve the use of an inappropriate dosage or report the parameters inadequately; hence, the results of these studies would be difficult to replicate or provide data to formulate the most efficacious dose [[20], [21], [22]].

More recent evidence supports the physiological effects of laser acupuncture, including anti-inflammatory [23] and antinociceptive effects [24]. Such studies highlight the potential effect of laser acupuncture under well-controlled conditions; however, whether or not these results can be extrapolated to the clinical setting remains unclear. It is critically important to understand the relevance of laser irradiation parameters, together with the appropriate selection of acupoints, to the effectiveness of laser acupuncture for musculoskeletal conditions.

Despite the growth of evidence in the field of laser acupuncture, its effectiveness for musculoskeletal condition remains unclear because of inconclusive results from different studies [[14], [20], [22]]. This expansion may suggest a shift in the evidence base; therefore, it is timely to review the results from recent studies to confirm the current evidence base for laser acupuncture. A systematic review with meta-analysis was, therefore, conducted to update the previous review in this area [17], with the following aims: (a) to assess the clinical effectiveness of laser acupuncture for relieving pain and improving functional outcomes when used for treating musculoskeletal conditions; (b) to explore the relationship between parameter choice and outcomes; and (c) to establish the level of evidence of the effectiveness of laser acupuncture with an update of the current literature.

2. Methods

2.1. Protocol and registration
This systematic review was conducted and reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline [25]; a pre-registered protocol was not used.

2.2. Selection criteria
Studies included for this review had to meet the following criteria.

2.2.1. Types of studies
Randomized controlled trials (RCTs) and controlled clinical trials published in peer-reviewed journals were included. In addition, studies published in databases since their inception to March 1, 2013 were included, in order not to miss any records and to update the findings of our previous systematic review [17] by the inclusion of more current publications. Due to resource limitations, this review excluded non-English-language publications.

2.2.2. Types of participants
Human participants with musculoskeletal diseases or injuries, and presenting with pain were included. Those with systemic illness and headache were not included. There were no restrictions based on age, gender, or physical activity status.

2.2.3. Types of intervention
Studies evaluating laser acupuncture as the primary intervention were included. Such intervention needed to include application of active low-level laser therapy to traditional Chinese medicine acupuncture points, trigger points, or tender points. Studies involving a primary intervention using needling or other forms of stimulation on acupuncture points, or those involving application of laser therapy to nonacupuncture points were not considered. In addition, those studies were included that compared laser acupuncture with one of the following as a control intervention: placebo or sham laser, no treatment, or other treatments, such as medication, exercise therapy, or other electrotherapy modalities.

2.2.4. Types of outcome measures
These studies included those that assessed pain or function using at least one of the following as primary outcomes: pain level (visual analog scale), global assessment of participants’ improvement (subjective improvement, proportion of objective measures improvement, overall improvement), or a functional outcome measure (validated questionnaire or functional scale specific to the presenting condition).

2.2.5. Length of follow-up
No restriction was applied to the length of follow-up.

2.3. Search strategy
Studies were identified by an electronic search of the following databases: MEDLINE (from 1946 to March 1, 2013), AMED (from 1985 to March 1, 2013), EMBASE (from 1947 to March 1, 2013), CINAHL (from 1981 to March 1, 2013), SPORTSDiscus (from 1960 to March 1, 2013), Cochrane Library, PubMed (from 1950 to March 1, 2013), Current Contents Connect (from 1998 to March 1, 2013), Web of Science (from 1900 to March 1, 2013), and SCOPUS (from 1960 to March 1, 2013). The same search strategy was used in subject-based databases, as shown in Appendix 1. In addition, Google Scholar (from January 1, 2013 to March 1, 2013), Physiotherapy Evidence Database (PEDro; from 1966 to March 1, 2013), and two key journals (Lasers in Surgery and Medicine, from 2005 to March 1, 2013; and Photomedicine and Laser Surgery, from 2005 to March 1, 2013) were searched manually to cover recent studies, which may have not been included in other databases. Two independent reviewers ran the search independently on March 1, 2013.

2.4. Selection of studies
Two independent reviewers assessed the eligibility of all studies independently by screening the titles and abstracts with the above selection criteria. Full-text articles were retrieved if there was any uncertainty. When there was a disagreement between the two reviewers, the study was reassessed using the selection criteria as a basis for consideration of its eligibility until consensus was achieved. Relevant studies were retrieved as full-text articles, either from the databases or from the study authors, for final assessment of inclusion or exclusion. Reference lists of retrieved articles were checked for any missing relevant articles.

2.5. Assessment of methodological quality
All included studies were assessed for methodological quality using the PEDro scale [26]. Two reviewers performed the assessment independently in a standardized manner; they were not blinded to the details of the studies. Disagreements between reviewers were resolved by consensus, and a third reviewer was consulted if disagreements persisted. Methodological qualities of the included studies were rated from 1 to 10 on a 10-item PEDro scale. All included studies were also assessed for their level of risk of bias by two independent reviewers. The risk of bias assessment helps identify any major methodological flaws from different domains of the included studies [27]. Further subgroup analyses related to bias assessment were planned where appropriate.

2.6. Data extraction
Two independent reviewers extracted data from included studies. Disagreements were resolved by discussion; if no agreement could be reached, a third reviewer was available for cross-referral.

Data were extracted from each included trial on: study population; details of interventions; types of outcome measures; and laser acupuncture dosage (including parameters recommended by the World Association for Laser Therapy [28] or calculation of missing data if possible).

2.7. Outcome measures
Data from included studies were pooled for further meta-analysis where appropriate. If available, means and standard deviations for outcome measures were extracted or calculated using published relevant data with Review Manager (RevMan) software, version 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012 [29]. Unpublished data were not sought from authors because of time limitations. Data were categorized and analyzed based on the following parameters, (1) Pain score—using a visual analogue scale and expressing the raw score on a 0–10 scale. Change in scores (difference between various time points in a study) were also considered but grouped separately. (2) Pressure pain threshold—algometric measurement expressed in kg/cm2. (3) Functional score—using validated functional scales, measuring grip strength, or comparing the difference in functional scores prior to and after the intervention.

2.8. Statistical analysis
Dichotomous outcomes were expressed as relative risks, and continuous outcomes were expressed as the standardized mean difference (SMD); both were presented with 95% confident intervals [27]. A negative SMD was defined to indicate favorable effects of laser acupuncture to the control intervention and vice versa. Magnitudes of the overall effect size were classified as small (0.2–0.5), moderate (0.5–0.8), and large (>0.8) according the value of SMD using the Cohen’s categories [30]. Qualitative analysis was performed if studies failed to provide data to be pooled for analysis. Studies were assessed for heterogeneity using the Chi-square test to decide whether a random or fixed effect model was used; Chi-square test with a p ? 0.05 indicates a significant heterogeneity [27]. I2 value quantifies the degree of heterogeneity: moderate (I2 > 30%), substantial (I2 > 50%), and considerable (I2 > 75%) [27].

2.9. Subgroup and sensitivity analyses
Subgroup analyses were conducted to evaluate the following overall effects: (1) diagnosis; (2) control intervention; (3) follow-up period—measures taken immediately at the end of the intervention (short-term effect) or from 6 weeks to 26 weeks postrandomization (long-term effect); and (4) site of laser acupuncture application—acupuncture point, trigger point, or tender point.

Sensitivity analyses were conducted for testing the robustness of the pooled effect size. Effects were examined according to risk of bias, to ensure that the analysis was not biased by any study with a large number of methodological flaws.

2.10. Risk of bias across studies
The risk of publication bias was assessed by analyzing the symmetry of the funnel plots generated by RevMan (The Cochrane Collaboration). Symmetrical funnel plots represented lower risk of bias, whereas higher risk of bias was demonstrated by increased asymmetry [31].

2.11. Quality of evidence
The Grading of Recommendations Assessment, Development, and Evaluation approach was used to judge and categorize the quality of evidence for the primary outcomes [32]. This reflects the extent of confidence of the estimated effects by considering the study design and other confounding factors that may affect the judgment. The following quality grades used were used. (1) High quality: “We are very confident that the true effect lies close to that of the estimate of the effect”. (2) Moderate quality: “We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different”. (3) Low quality: “Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect”. (4) Very low quality: “We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of the effect”.3. Results3.1. Study selection
Fig. 1 depicts the process of study selection with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. The search was conducted on March 1, 2013, and a total of 2093 potential relevant records were retrieved. After adjusting for duplicates, 1432 records remained. One additional study was retrieved from Google Scholar. A total of 49 studies met the inclusion criteria and were included in the current review.Thumbnail image of Figure 1. Opens large image
Figure 1
PRISMA flow diagram. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.View Large Image | View Hi-Res Image | Download PowerPoint Slide

3.2. Study characteristics
Table 1 [[33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74], [75], [76], [77], [78], [79], [80], [81]] summarizes the characteristics of all 49 included studies. All studies were RCTs published in English. A total of 2360 participants, aged ? 18 years, were involved. All trials were conducted in either a primary or a secondary health care setting. Participants received from three to 15 treatment sessions over a period of 1–12 weeks. Laser acupuncture was performed by physiotherapists or other trained health care professionals in most of the trials; however, half of the studies failed to report this clearly.

Table 1
Characteristics of the included studies.?
Authors Year Diagnosis n Interventions Follow-up

Ferreira et al [33] 2013 Temporomandibular joint disorder 40 Laser acupuncture (20) versus placebo (20) Monthly until intervention completed
Kannan [34] 2012 Myofascial pain 45 Ultrasound (15) versus laser (15) versus ischemic compression (15) End of intervention
Lin et al [35] 2012 Low back pain 60 Laser acupuncture (21) versus placebo (21) After each session
Sattayut and Bradley [36] 2012 Temporomandibular joint disorder 30 Low-energy-density laser (10) versus high-energy-density laser (10) versus placebo (10) After each session
Skorupska et al [37] 2012 Lateral epicondylitis 80 LLLT (40) versus ultrasound (40) (trigger point application versus anatomical site application; 20 in each subgroup) End of intervention; 12 mo
Lee and Han [38] 2011 Myofascial trigger point pain 24 Laser (12) versus placebo (12) End of intervention
Rayegani et al [39] 2011 Myofascial pain 49 Laser (17) versus ultrasound (16) versus placebo laser (16) 6 wk
Emanet et al [40] 2010 Lateral epicondylitis 47 Laser acupuncture (24) versus placebo (23) End of intervention; 12 wk after intervention
Glazov [41] 2010 Low back pain 100 Laser acupuncture (45) versus placebo (45) After each session; 6 wk after intervention; 6 mo after intervention
Katsoulis et al [42] 2010 Tendomyopathy 11 Laser (7) versus placebo (4) 3 mo after intervention
Öz et al [43] 2010 Myofascial pain 40 Laser (20) versus occlusal splint (20) End of intervention
Zhao et al [44] 2010 Knee osteoarthritis 40 Laser on acupuncture point (19) versus laser on sham point (17) 2 wk; 4 wk
Carrasco et al [45] 2009 Myofascial pain 60 Laser (30) versus placebo (30)—three-parameter groups; 10 in each group After four sessions; after eight Rx; 15 d after intervention; 1 mo after intervention
Glazov et al [46] 2009 Low back pain 100 Laser acupuncture (45) versus placebo (45) After each session; 6 wk after intervention; 6 mo after intervention
Shen et al [47] 2009 Knee osteoarthritis 40 Laser acupuncture (20) versus placebo (20) 2 wk; 4 wk
Shirani et al [48] 2009 Myofascial pain 16 Laser acupuncture (8) versus placebo (8) After first session; 1 wk; the day with complete pain relief
Shen et al [49] 2008 Knee osteoarthritis 48 Laser acupuncture (24) versus placebo (24) 2 wk; 4 wk
Dundar et al [50] 2007 Myofascial pain 64 Laser acupuncture (32) versus placebo (32) 4 wk
Lam and Cheing [51] 2007 Lateral epicondylitis 39 Laser acupuncture (21) versus placebo (18) After five sessions; end of intervention; 3 mo after intervention
Matsutani et al [52] 2007 Fibromyalgia 20 Laser (10) versus no laser (10) End of intervention
Mazzetto et al [53] 2007 Temporomandibular joint disorder 48 Laser (24) versus placebo (24) After four sessions; after eight sessions; 30 d after intervention
Yurtkuran et al [54] 2007 Knee osteoarthritis 55 Laser (27) versus placebo (25) 2 wk; 12 wk
Aigner et al [55] 2006 Whiplash injury 50 Laser acupuncture (23) versus placebo (22) After each session; end of intervention; 8–12 mo after injury
Armagan et al [56] 2006 Fibromyalgia 32 LLLT (16) versus placebo (16) End of intervention; 6 mo after intervention
Chow et al [57] 2006 Chronic neck pain 90 Laser (45) versus placebo (45) 7 wk; 12 wk
Kiralp et al [58] 2006 Myofascial pain 43 Laser (23) versus trigger point injection (20) End of intervention; 6 mo after intervention
Altan et al [59] 2005 Myofascial pain 53 Laser (23) versus placebo (25) 2 wk; 12 wk after intervention
Tam [60] 2005 Periarthritis of shoulder 60 Corticosteroid injection (20) versus LLLT (21) versus wait-and-see policy (18) 3 wk; 6 wk; 12 wk; 26 wk; 52 wk
Ceylan et al [61] 2004 Myofascial pain 46 Laser (19) versus placebo (20) End of intervention
Chow et al [62] 2004 Chronic neck pain 20 Laser (10) versus placebo (10) 7 wk; 12 wk
Gur et al [63] 2004 Myofascial pain 60 Laser (30) versus placebo (30) 2 wk; 3 wk; 12 wk
Ilbuldu et al [64] 2004 Trigger point pain 60 Placebo laser (20) versus dry needling (20) versus laser (20) End of intervention; 6 mo
Al-Shenqiti and Oldham [65] 2003 Rotator cuff tendinitis 55 Laser (26) versus placebo (29) End of intervention; 3 mo
Hakgüder et al [66] 2003 Myofascial pain 62 Laser (31) versus no laser (31) End of intervention; 3 wk after intervention
Gür et al [67] 2002 Fibromyalgia 40 Laser (20) versus placebo (20) End of intervention
Wong et al [68] 2001 Carpal tunnel syndrome 12 Laser (12) versus placebo (12) End of intervention
Chen et al [69] 1997 Myofascial pain 21 Placebo (5) versus continuous laser (7) versus pulsed laser (9) End of intervention
Conti [70] 1997 Temporomandibular joint disorder 20 Laser (10) versus placebo (10) After each session
Laaskso et al [71] 1997 Myofascial trigger point pain 41 Red laser (15) versus IR laser (16) versus placebo (10) Prior to each session; after each session
Lögdberg-Andersson et al [72] 1997 Tendinitis and myofascial pain 176 Laser (92) versus placebo (84) End of intervention; 4 wk after intervention
Papadopoulos et al [73] 1996 Lateral epicondylitis 29 Laser (14) versus placebo (15) After four sessions; after six sessions
Vecchio et al [74] 1993 Rotator cuff tendinitis 35 Laser (19) versus placebo (16) 2 wk; 4 wk; 8 wk
Haker and Lundeberg [75] 1991 Lateral epicondylitis 60 Laser (29) versus placebo (29) End of intervention; 3 mo; 6 mo; 12 mo
Haker and Lundeberg [76] 1990 Lateral epicondylitis 49 Laser acupuncture (23) versus placebo (26) End of intervention; 3 mo; 12 mo
Ceccherelli et al [77] 1989 Myofascial pain 27 Laser (13) versus placebo (14) End of intervention; 3 mo after intervention
Snyder-Mackler et al [78] 1989 Myofascial trigger point pain 24 Laser (13) versus placebo (11) Prior to each session; after each session
Waylonis et al [79] 1988 Fibromyalgia/chronic myofascial pain 55 Placebo versus laser acupuncture 6 wk after each round of intervention; 60 d; 120 –d
Lundeberg et al [80] 1987 Lateral epicondylitis 57 Placebo (19) versus GaAs laser (19) versus HeNe laser (19) Every 2 wk; end of intervention; 3 mo; 6 mo
Snyder-Mackler et al [81] 1986 Musculoskeletal trigger point pain 27 Laser (13) versus placebo (11) Prior to each session; after each session
?See Appendix 2 for the outcome measures and summarized results of individual studies.IR = infrared; LLLT = low-level laser therapy.3.3. Quality assessment of included studies
Appendix 3 shows the methodological assessment of the included studies using the PEDro scale [26]. Thirty studies (61%) were considered to be of high methodological quality with a moderate cut-off score of 6 [82]. The most common flaws were inadequate allocation concealment (78%), lack of blinded therapists (63%), and lack of intention-to-treat analysis (71%). Despite the possible bias related to these flaws, other criteria were adequately addressed to minimize the risk of bias. Almost all the studies (94%) performed adequate randomization, thereby reducing possible selection bias. In most of the studies, patients (81%) and assessors (63%) were blinded successfully. Almost three-quarters (73%) of the studies provided adequate follow-up data with < 15% dropout rate; therefore, attrition bias was lowered. Inter-rater agreement was at an acceptable level, and disagreements were resolved by consensus.Evaluation of the included studies using the risk of bias assessment tool provided by the Cochrane collaboration [27] showed similar results to that using the PEDro score (see Fig. 2). Risks of selection bias and performance bias were mixed, as risks of some of the studies were unclear due to insufficient description. Other domains remained at low risk in all the included studies, except for 20% of the studies that exhibited high risk in attrition due to high dropout rates or nondescription of reasons for withdrawals.Thumbnail image of Figure 2. Opens large image
Figure 2
Risk of bias—graphical distribution of the judgments across all included studies.

3.4. Effects of laser acupuncture
Thirty-three studies provided sufficient data to calculate effect sizes for key outcome measures using RevMan (The Cochrane Collaboration) and were included in the meta-analysis. These studies showed mixed results, as reported by the authors, with two-thirds reporting positive effects favoring laser acupuncture, and one-third inconclusive or no effect.

3.4.1. Pain
All 33 studies assessed pain as one of the primary outcome measures. However, due to the heterogeneous characteristics of studies, results for pain scores were subcategorized into laser acupuncture versus placebo or laser acupuncture versus other interventions. To account for possible variation among different studies, the random effects model was used and the pooled effects were expressed as the SMD.

When compared with the placebo intervention, the overall effect for pain favored laser acupuncture, both at the end of intervention (SMD ?0.43; ?0.74 to ?0.12) and at the follow-up period (SMD ?0.61; ?1.12 to ?0.10). The pooled effect sizes of laser acupuncture for pain were considered to be small at short-term follow-up, but showed a moderate effect at long-term follow-up (see Appendix 4). Other studies [[40], [41], [44], [47], [48], [50], [54], [57], [61], [62], [74], [80]] expressed the pain change scores from baseline, and showed a similar effect on pain relief at both short-term (SMD ?0.53; ?0.95 to ?0.10) and long-term follow-ups (SMD ?0.77; ?1.25 to ?0.29). When compared with other interventions, results of pain scores were mixed. Laser acupuncture failed to show significant favorable effects on pain scores at any time point compared to the control treatment (SMD ?0.23; ?1.00–0.54; SMD ?1.43; ?3.84–0.98).

Nine studies investigated pain by measuring the pressure pain threshold [[36], [38], [39], [43], [51], [58], [59], [64], [69]]. A positive effect indicates the beneficial effects of laser acupuncture as compared to control interventions. Similarly, compared with a placebo group, results showed a strong positive effect in favor of the experimental group at the end of intervention (SMD 1.02; 0.72–1.33) and during the follow-up period (SMD 0.91; 0.30–1.53). Comparing laser acupuncture to other interventions, no short- (SMD 0.35; ?0.01–0.71) or long-term effects (SMD 0.20; ?0.26–0.66) were found on the pressure pain threshold (see Appendix 4).In the studies measuring pain with a visual analogue scale, subgroup analysis of pain scores was performed for the three most common diagnoses—myofascial pain or musculoskeletal trigger point syndrome, lateral epicondylitis, and temporomandibular joint pain (Fig. 3). The subgroup differences were not significant at the end of intervention and during the follow-up period (p > 0.05). The overall effect on pain in the short term moderately favored laser acupuncture (SMD ?0.49; ?0.79 to ?0.18). Effects calculated from long-term follow-up almost doubled, which suggested that laser acupuncture has a strong beneficial effect on pain (SMD ?0.95; ?1.55 to ?0.35).

Thumbnail image of Figure 3. Opens large image
Figure 3
Forest plot comparison of different diagnoses. CI = confidence interval; SD = standard deviation.

3.4.2. Myofascial pain/musculoskeletal trigger points
Among 13 studies investigating the effectiveness of laser acupuncture for myofascial pain or musculoskeletal trigger points, only six showed favorable effects at the end of intervention [[61], [63], [64], [66], [67], [77]]. During the follow-up period, four out of six studies demonstrated a positive effect in favor of laser acupuncture [[39], [59], [63], [77]]. In most of the studies showing no significant effect of laser acupuncture, laser parameters were reported inadequately [[34], [45], [50], [52], [58], [69]]. The overall effect of laser acupuncture on pain was positive, with a moderate effect at short term (SMD ?0.49; ?0.83 to ?0.16) and a strong effect at long term (SMD ?0.95; ?1.68 to ?0.23).

3.4.3. Lateral epicondylitis
Two studies examined the effect of laser acupuncture on lateral epicondylitis and showed conflicting results [[40], [51]]. The overall effects did not suggest any favorable result of laser acupuncture at any time point. The study by Emanet et al [40] reported a positive conclusion during the follow-up period; yet the effect was not significant (SMD ?0.42; ?1.00–0.16). Again, the laser parameters employed in this study were unclear and incomplete; thus, it is not possible to estimate whether or not the dosage was appropriate.

3.4.4. Temporomandibular joint pain
Two studies [[33], [36]] compared laser acupuncture with placebo in treating temporomandibular joint pain at the end of intervention. Mixed results were obtained: one was positive [33] and the other one was inconclusive [36]. The latter study involved two laser acupuncture groups receiving different dosages. The group that received a higher dosage showed a better effect of laser acupuncture compared with the group receiving a lower dosage; however, neither of them have a significant effect on pain. During the follow-up period, only one study [42] provided data; hence, outcome effect was not estimated.

3.4.5. Functional outcome
Most of the studies assessed functional improvement using a wide range of scales. Each study could involve multiple results from different functional scales; hence, an estimated overall effect size across the studies was not possible. Studies were more likely to report positive effects during the follow-up period rather than at the end of the intervention. Only two out of 11 studies [[51], [63]] reported a positive short-term effect on functional outcomes, while six out of eight studies [[39], [40], [51], [57], [62], [63]] showed positive effects at long term (see Appendix 4).

Two studies [[40], [51]] investigated lateral epicondylitis; the pooled effect sizes of handgrip strength strongly favored laser acupuncture at both time points, but were significant only during the long-term follow-up period (MD5.16; 1.14–9.19). In regard to the small number of studies analyzed, it is important not to overlook this significant pooled effect (see Appendix 4).

Sensitivity analyses were conducted to explore whether or not the above mentioned main findings were affected by any studies with high risk of bias in certain domains. We exclude studies with any of the following: high risk of attrition bias, selection bias, and performance bias. No significant difference was found after excluding high-risk studies.

3.5. Appropriateness of laser acupuncture treatment
All included studies were analyzed for the appropriateness of laser parameters used. They were grouped separately into those reporting positive effects and those reporting inconclusive or no effects, and are displayed, along with the parameters used, in Table 2, Table 3[[62], [57], [41], [54], [56], [63], [77], [47], [43], [51], [48], [66], [67], [33], [36], [44], [39], [40], [35], [34], [61], [69], [65], [70], [60], [78], [71], [81], [72], [68], [53], [46], [74], [50], [64], [59], [45], [80], [38], [58], [52], [42], [37], [75], [73], [76], [49], [79], [55]], respectively. It is notable that four studies [[52], [59], [74], [80]] reported no significant difference between groups; by contrast, their calculated effect sizes from RevMan (The Cochrane Collaboration) analysis favored laser acupuncture.

Table 2
Studies reporting positive effect of laser acupuncture.a
Authors Average output (mW) Power density (mW/cm2) Dose (J) PEDro
Studies included in meta-analysis
Chow et al [62] 300 670 9 10
Chow et al [57] 300 670 9 10
Glazov [41] 10 50 0.2 9
Yurtkuran et al [54] 4 10 0.48 8
Armagan et al [56] 50 75 2 8
Gur et al [63] 11.2 11.2 2 8
Ceccherelli et al [77] 5 ? 0.1 or 1 8
Shen et al [47] 36 and 200 ? ? 7
Öz et al [43]? 300 1071 3 7
Lam and Cheing [51] 25 208 0.275 7
Shirani et al [48] 17.3 or 1.76 17.3 or 1.76 7.2 6
Hakgüder et al [66] 5 25.5 0.98 6
Gür et al [67] 11.2 11.2 2 6
Ferreira et al [33] 50 1250 4.5 6
Sattayut and Bradley [36] 60 or 300 333 or 1666 4 or 20 6
Zhao et al [44] 36 and 200 36 and 100 163.2 6
Rayegani et al [39]? 1100 ? ? 6
Emanet et al [40] ? ? ? 5
Lin et al [35] 40 50 12 4
Kannan [34]? 2.4 2.4 0.074 4
Ceylan et al [61] 8 40 1.44 3
Chen et al [69] 15 or 1.5 ? 18 or 1.8 2
Studies not included in meta-analysis
Al-Shenqiti and Oldham [65] 100 800 4 8
Conti [70] 100 ? 4 7
Tam [60]? 27 135? 3 to 4 6
Snyder-Mackler et al [78] 0.95 0.95 0.02 6
Laaskso et al [71] 10 or 25 278 or 893 1 or 5 5
Snyder-Mackler et al [81] 0.95 0.95 0.014 5
Lögdberg-Andersson et al [72] 8 8 0.5 to 1 5
Wong et al [68] 30 107 5.4 5
Mazzetto et al [53] 70 8750 0.72 4
?Laser acupuncture compared to other interventions.

PEDro = physiotherapy evidence database.

aThe symbol ‘?’ indicates insufficient details for calculating the missing parameters.
Table 3
Studies reporting inconclusive or no effect of laser acupuncture.
Authors Average output (mW) Power density (mW/cm2) Dose (J) PEDro
Studies included in meta-analysis
Glazov et al [46] 10 50 0.2 9
Vecchio et al [74] 30 429 3 9
Dundar et al [50] 58 58 7 9
Ilbuldu et al [64]? ? ? 2 8
Altan et al [59] ? ? ? 7
Carrasco et al [45] 50 or 60 or 70 ? ? 6
Lundeberg et al [80] 1.56 or 0.07 ? 0.09 or 0.004 5
Lee and Han [38] 450 6428 27 or 54 or 135 5
Kiralp et al [58]? ? ? ? 5
Matsutani et al [52] 30 ? ? 4
Katsoulis et al [42] 40 1000 1.6–2.4 2
Studies not included in meta-analysis
Skorupska et al [37]? 0–400 ? ? 8
Haker and Lundeberg [75] 12 ? 0.36 7
Papadopoulos et al [73] 50 400 3 6
Haker and Lundeberg [76] ? ? 0.6 5
Shen et al [49] ? ? ? 5
Waylonis et al [79] 1 ? 0.02 4
Aigner et al [55] 5 5 0.08 4
?Laser acupuncture compared to other interventions.

PEDro = physiotherapy evidence database.

The symbol ‘?’ indicates Insufficient details for calculating the missing parameters.

Almost 70% of studies reporting positive results used the clinically appropriate dosage suggested by Baxter et al [17]. Their systematic review stated that laser acupuncture would be effective when irradiation is applied at a minimum average output power of 10 mW and an energy dose of at least 0.5 J per point.

By contrast, studies reporting inconclusive or no effect of laser acupuncture either failed to describe the parameters comprehensively or applied an inappropriate dosage.

Half of these negative studies are deemed of low methodological quality, with PEDro scores of < 6.

3.6. Application site
The most common sites for the application of laser acupuncture were trigger points (39%). Subgrouping to perform another analysis to examine any difference of the effects on pain with different application sites was performed. No significant difference was observed between the subgroups at the end of intervention and during the follow-up period (p > 0.05). However, only the application at trigger points showed a positive effect in favor of laser acupuncture; this was not seen in case of application at acupuncture points or tender points. (see Appendix 5).

3.7. Risk of bias across studies
Considering the heterogeneity of the studies, funnel plots were drawn according to different outcome measures. Visual assessment of funnel plots did not show any considerable asymmetry, indicating a comprehensive coverage of publications. Hence, publication-related bias was low in this review.

4. Discussion
This systematic review investigated the clinical effectiveness of laser acupuncture, focusing on its effects on pain and functional outcomes while treating musculoskeletal disorders. The current findings strengthen the evidence from a previous systematic review [17]. The key findings in the current review support the continued use of laser acupuncture for treating musculoskeletal pain. Results from the meta-analysis suggest that the effect of laser acupuncture on pain and functional outcomes tended to be more significant during long-term follow-up periods rather than at the end of intervention. These results indicate that laser acupuncture may be effective in treating musculoskeletal pain and improving function if an adequate dosage is used, and that the effects are long lasting, as evidenced by the increase in effect sizes demonstrated in the meta-analysis at 6–26 weeks postrandomization. It is important to stress that results from the included studies were dependent upon the appropriateness of laser parameters used. Studies with higher methodological quality, which also reported dosages properly, showed a more consistent result, with a favorable effect of laser acupuncture on both pain and functional outcomes.

To the best of our knowledge, there has been no further evaluation of the latest literature on laser acupuncture since a previous systematic review [17]. It concluded that laser acupuncture was an effective treatment for myofascial pain, based on a moderate level of evidence from 18 RCTs that were published prior to 2005. A massive growth in publications in recent years has provided further evidence on the effectiveness of laser acupuncture. Not surprisingly, a large number of clinical trials were identified from the current literature, most of which were published during the past decade. The total number of eligible studies included in this systematic review was more than twofold that of the past review [17].

4.1. Primary outcomes
The majority of studies reported positive findings on the effects of laser acupuncture on both pain and functional outcomes; by contrast, one-third of reviewed studies reported no benefit. Given the heterogeneity of included studies, meta-analyses were performed using subgroups of studies according to their study populations and follow-up time point. The three most common diagnoses were analyzed separately in order to have a minimum of two studies for each analysis. Sensitivity analyses excluded studies comparing laser acupuncture with other active treatments, as the primary scope of this review was to evaluate whether or not laser acupuncture is effective, rather than comparing its effectiveness with other active treatments.

4.1.1. Myofascial pain/musculoskeletal trigger points
Ten studies showed positive effects of laser acupuncture on myofascial pain or pain at trigger points: four studies [[34], [50], [52], [58]] had an individual effect size that did not favor the laser group. Coincidently, all these studies did not include follow-up assessments to investigate possible long-term effects. Given the increased effect sizes at follow-up, as highlighted here, it is possible that these researchers might have overlooked a potential effect in the longer term; another study [59] found positive effects only during the follow-up period, but not at the end of intervention.

4.1.2. Lateral epicondylitis
Emanet et al [40] showed more favorable effects in the short term than in the long term. However, the individual effect size (for pain) from the forest plot crossed zero at the long-term time point, indicating a lack of statistical significance. Although the pooled effects from another study [51] did not suggest any favorable outcome for treatment with laser acupuncture to reduce pain in lateral epicondylitis, results for handgrip assessment yielded some interesting findings. Both studies investigated the effectiveness of laser acupuncture by evaluating pain and functional outcomes, and appeared to be more homogeneous, so the mean difference was used as the pooled effect result. Again, the estimated effect size for functional outcome (handgrip) favored laser acupuncture, especially during the follow-up period. However, it should be stressed that this analysis is based on two studies examining laser acupuncture, and the result may not be generalized to other conditions.

4.1.3. Temporomandibular joint pain
The three studies reviewed showed mixed results, and only one of these reported outcomes at long term. At short term, the effect was inconclusive. No further analysis was carried out to compare the effects at different time points.

4.2. Increased long-term follow-up effects
Findings related to the three different diagnoses showed a consistent trend of better pain-relieving effects during the follow-up period. Pooled effect sizes were doubled during the follow-up period compared to those at the end of intervention. This phenomenon may account for the conflicting results from some of the negative studies. Without taking into consideration the possibility of delayed or long-lasting effects, their conclusions of lack of effectiveness may be flawed. Results from our analyses included both short- and long-term follow-up data; these data were separated into similar time points to allow more comparable subgroup analyses.

4.3. Weaknesses of negative studies
The five studies [[38], [42], [46], [50], [74]] that found no significant benefit of laser acupuncture had a number of shortcomings. In one study [74], a mismatch was found between the calculated individual effect and the authors’ conclusion. Although the effect size (expressed in the SMD) for pain favored laser acupuncture, Vecchio et al [74] reported no benefit. This apparent error was also highlighted by another systematic review [83], which suggested a flaw in their analysis. In another study on back pain, Glazov and colleagues [41] performed a post hoc analysis on their data, which challenged the results of their original study [46]. They suggested that the randomization failed to create comparable groups and resulted in an imbalanced baseline characteristic that responded differently to the intervention. The PEDro quality rating of the study by Katsoulis et al [42] was exceptionally low (2 out of a PEDro score of 10), representing a major performance bias. The remaining two studies [[38], [50]] applied laser acupuncture around the neck and upper trapezius muscles area. The parameters selected in both studies were similar to the other two positive studies [[57], [66]] targeting the neck region, but the authors’ conclusions were based on results measured only at short term. Consequences of these apparent methodological flaws may be an underestimation of the true effect of laser acupuncture from these studies.

5. Clinical relevance of the laser parameter
Variation in application of the laser acupuncture intervention can very likely account for a certain degree of difference in outcomes. Such clinical heterogeneity should be considered when evaluating the effectiveness of a therapy. Laser acupuncture has been suggested to be a dosage-dependent modality [[16], [21]]; these sources suggest that the energy delivered to the target point by laser acupuncture has to reach a threshold in order to produce a desired effect. Thus, the dosages reported in the included studies may explain the observed difference in outcomes. Characteristics of the laser beam and the application site of the laser would directly affect the actual energy received by the target point [[10], [14]]. Although detailed discussion of the potential mechanisms of laser acupuncture is beyond the scope of this review, the importance of selecting and reporting parameters accurately is paramount to understand and interpret the results of individual studies.

Unfortunately, the quality of reporting of parameters and dosages varied among the studies included in this review; five studies stated neither the power density nor the irradiated area [[40], [58], [59], [64], [75]]. This brings into question whether or not an appropriate dosage was applied. Reporting of these parameters is essential, as recommended by the World Association for Laser Therapy guidelines [28], to determine the appropriateness of the dosage. In addition, unclear reporting of parameters was more commonly seen among studies with negative or inconclusive results (Table 2, Table 3).

It is challenging to draw meaningful conclusions regarding an effective dosage window from these studies due to the variation in the application of laser acupuncture and the wide dosage range employed. This systematic review covered different musculoskeletal conditions, and each condition may have required a distinct parameter and dosage regime for clinical effectiveness. Site of application is a key factor in the selection of parameters, given that there may be a specific acupuncture point for a particular diagnosis. In this review, the point of application was not limited to acupuncture points only, but included trigger and tender point applications as well, because a wide range of evidence suggests overlapping of acupuncture points [[84], [85], [86]]. It seems unwise to exclude those studies using trigger points or tender points even though the existence of these specific points is still controversial [[85], [87], [88]]. A subgroup analysis based on different application sites was performed; however, no obvious difference could be seen between groups. Application on acupuncture, trigger, and tender points appeared equally effective.

6. Quality of included studies in our review
The number and proportion of trials rated to be of high methodological quality doubled in this review, compared to a previous review [17]. Over two-thirds of the 49 RCTs included in this review were high-quality studies, whereas in the previous review less than one-third of the studies were of high quality. Considering this growth in the number of higher-quality studies in this body of literature, the findings of this systematic review were expected to be more robust.

There was an apparent relationship between levels of methodological quality and reported results. Two-thirds of high-quality (PEDro score ?6) studies reported beneficial effects of laser acupuncture, which is similar to the proportion for all included studies. Lower-quality studies appeared to show more conflicting results, with equal numbers of studies reporting benefits (n = 9) or no benefits (n = 9). This methodological heterogeneity should be considered when assessing the overall pooled effect in the meta-analysis. However, it should be stressed that the sensitivity analyses, excluding studies with high risk of bias in various domains, failed to show any differences in overall findings that conflicted with the effects estimated.

6.1. Limitations
The limitations of this review include potential bias related to heterogeneity and methodological quality of the included studies. These problems were anticipated while designing the methodology of this review, and so different subgroup analyses were initiated to address this limitation. Another limitation of this review is that some of the studies have a high risk of bias in some of the domains; however, the sensitivity analyses suggested no major effects upon the outcomes. Lastly, even though non-English publications were excluded, the funnel plot assessment did not detect any potential publication bias. Although this kind of visual assessment is considered to be prone to error [89], it is one of the most common methods adopted for detecting publication bias owing to its simplicity [31]. Given the large number of studies included in this meta-analysis, funnel plot should be able to detect possible bias.

6.2. Recommendations
Using the Grading of Recommendations Assessment, Development, and Evaluation system [90], the strength of recommendation is based on not only the quality of the evidence, but also other factors that should not outweigh the benefit of the treatment. Using pain and functional outcomes to assess the clinical effectiveness of laser acupuncture, most of the included studies were found to be high-quality RCTs, providing high-quality evidence. Yet the quality of evidence was downgraded (?2) due to inconsistency and imprecision of the results for both pain and functional outcome measures [32]. Owing to the possible dose response for pain-relieving effects, and a large effect from functional outcome, the quality of evidence was upgraded (+1). As a result, there is a moderate quality of evidence supporting the effectiveness of laser acupuncture for treating pain and improving functional outcomes in musculoskeletal disorders. It suggests with moderate confidence that the estimated effect from the meta-analysis is likely to be close to the true effect. Serious adverse events have seldom been reported for laser acupuncture, given its noninvasive nature; this is in keeping with the results of all the included studies. Based upon this systematic review, a strong recommendation can be made that laser acupuncture is effective for improving musculoskeletal pain and functional outcomes at 6–26 weeks.

7. Conclusion
Overall, the evidence is sufficiently robust to determine the effectiveness of laser acupuncture at long term for treating musculoskeletal conditions. In trials reporting negative or inconclusive results, neither enough evaluation was carried out nor were the participants followed up to a sufficient time point. These trials did not allow complete evaluation of pain and functional outcomes, and their conclusions were made based upon results measured at short term only. Hence, this review highlights the importance of providing a sufficient course of treatment to allow laser acupuncture to work effectively in the clinical situation.

Although the evidence does not allow us to determine an effective dosage window for laser acupuncture, the possible range of applications was largely adjusted and designed to fit specific musculoskeletal conditions. To foster the development of clinical guidelines, future research should carefully define the study population and provide rationale for the parameters chosen. This would facilitate not only pooling of data for meta-analysis, but also more precise analysis for a specific condition or application site. With the improvement in quality of evidence over time, more robust recommendations for clinical application of laser acupuncture can be anticipated in the future.

Disclosure statement
The authors declare that they have no conflicts of interest and no financial interests related to the material of this manuscript.

Appendix A. Supplementary data

View File

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Evid Based Complement Alternat Med. 2013; 2013: 934783.
Published online Nov 20, 2013. doi:  10.1155/2013/934783

# Effectiveness of Interstitial Laser Acupuncture Depends upon Dosage: Experimental Results from Electrocardiographic and Electrocorticographic Recordings

Wei He, 1 , 2 Gerhard Litscher, 1 , 2 ,* Xiang-Hong Jing, 1 ,* Hong Shi, 1 Xiao-Yu Wang, 1 Ingrid Gaischek, 2 Yang-Shuai Su, 1 Daniela Litscher, 2 Zhao-Kun Yang, 1 Juan-Juan Xin, 1 and Ling Hu 1
1Department of Meridians, Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, No. 16 Nanxiaojie, Dongzhimen, Beijing 100700, China
2Stronach Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, TCM Research Center Graz, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
*Gerhard Litscher: ta.zarginudem@rehcstil.drahreg and
*Xiang-Hong Jing: ten.362@bjthxj
Received October 4, 2013; Accepted November 6, 2013.

## Abstract

The purpose of this study was to evaluate the influence of the duration of interstitial laser acupuncture therapy effects on neurovegetative and neurobioelectrical parameters like heart rate (HR), heart rate variability (HRV), and electroencephalogram (EEG). We investigated 6 male Sprague-Dawley rats. They underwent 10min, 20min, and 30min interstitial laser acupuncture (in randomized order, with a break of at least 30min between the different measurement conditions) at the acupoint Neiguan. HR changed significantly only during 20min red laser stimulation, whereas 10 and 30min stimulation did not induce significant changes. HRV did not change significantly during any of the different durations; however, an increase was found during 20min irradiation. Neither the LF/HF ratio of HRV nor the integrated EEG showed significant changes. In this study, it could be experimentally proved that some effects of laser acupuncture are time dependent, and therefore the dosage, as well known from theory, also depends on the time factor. We could especially demonstrate that different treatment times lead to different effects on neurovegetative and neurobioelectrical parameters. Further studies are needed to verify or refute these results.

## 1. Introduction

In a previous study, our research team from China and Austria investigated interstitial (i.st.) laser acupuncture in anesthetized Sprague-Dawley rats for the first time [1]. In that preliminary study, we explored i.st. laser acupuncture, intravenous laser blood irradiation, and electroacupuncture under stable conditions and analyzed the effects on physiological neurovegetative parameters and bioelectrical brain activity. We found changes in the rat model; however, the question of the adequate dosage of laser is still an open one in scientific literature [2, 3].

Tunér and Hode, both are very renowned researchers on laser therapy, stated in 2010 [4]: “Anyone who studies the literature carefully can become confused. Some wavelengths achieve the best effects on this and that, while others have poorer effects or none at all. Some doses lead to beneficial effects, but when the dose is increased, the effects wear off. If we treat a condition, some of the parameters we want to influence may be affected, but perhaps not all. If we administer treatment from a distance, we do not get the same effects as if we treat in contact or with pressure. Some frequencies produce effects on pain, others on oedema. What are we to believe? And what do we do to find the best dose, wavelength, and so forth?” [4].

The goal of the present study was to change the dosage of the laser acupuncture treatment via the duration of the i.st. irradiation at the acupoint Neiguan in order to find an optimal treatment time [2]. The data were recorded in Beijing, China, and the analysis was performed in Graz, Austria.

## 2. Animals and Methods

### 2.1. Sprague-Dawley Rats

Six male healthy Sprague-Dawley rats (weight: 190–300g) were kept in an animal house maintained at 24 ± 1°C, with a 12-hour light-dark cycle and free access to food and water for seven days before the experiment. The procedure was the same as in our previous work published recently [1]. The animals were initially anesthetized with an intraperitoneal injection of 10% urethane (1.2g/kg, Sigma-Aldrich, St. Louis, MO, USA). Additional sodium pentobarbital was administered if necessary to prolong the anesthetic state. Animals were sacrificed by an overdose of anesthetics after the study. The study was approved by the Institutional Animal Care and Use Committee of the China Academy of Chinese Medical Sciences and was in accordance with the National Institutes of Health guidelines.

### 2.2. Interstitial Laser Acupuncture

The laser needle for i.st. laser irradiation (length: 35mm; diameter: 0.55mm) was a Modulas needle (type: IN-Light, Schwa-Medico, Ehringshausen, Germany). It emits red laser light in continuous wave mode with a wavelength of 658nm and an output power of 50mW (Figure 1). We stimulated the acupoint Neiguan (PC6) on the left side using i.st. laser acupuncture. The laser needle was inserted about 3mm in the acupoint Neiguan. This acupoint is located proximal to the accessory carpal pad of the forelimb, between the flexor carpi radialis and palmaris longus ligaments [1].

Interstitial laser acupuncture in a rat model.

### 2.3. Procedure

Figure 2 shows the measurement profile. Three measurement periods were compared: one before, one during, and one after stimulation. This scheme was used for all three conditions (10, 20, and 30min i.st. laser acupuncture) in the same rat. The order of the stimulation methods was randomized, and the time between the separate measurement conditions was at least 30min.

Experimental procedure for the different durations of i.st. laser acupuncture stimulation.

### 2.4. Measurement Parameters

As in the previous study [1], we registered electrocardiographic (ECG) and electroencephalographic (EEG) parameters using a biophysical amplifier AVB-10 (Nihon Kohden, Japan). For the ECG, we evaluated heart rate (HR), heart rate variability (HRV), and the LF (low frequency)/HF (high frequency) ratio of HRV. Again, EEG was registered directly on the brain; high cutoff frequency was 100Hz, and the low cutoff frequency was 0.5Hz.

### 2.5. Statistical Analysis

The data were analyzed using Friedman repeated measures analysis of variance (ANOVA) on ranks (SigmaPlot 12.0, Systat Software Inc., Chicago, IL, USA). Post hoc analysis was performed using Holm-Sidak test. The level of significance was defined as P < 0.05.

## 3. Results

The analysis of the HR of all 6 rats is shown in Figure 3. Note the significant (P = 0.042) decrease of HR after 20min i.st. laser acupuncture stimulation at the left Neiguan acupoint. It is also interesting that stimulation durations of 10 and 30min, respectively, did not lead to the same effects in the rat model.

Mean heart rate (HR) of the 6 rats. Note the different stimulation durations (10, 20, and 30min). Significant changes were only found for a duration of 20min (red line). The error bars indicate the standard error (SE).

In contrast to HR, total HRV increased (insignificantly), also during 20min laser stimulation. No increases in total HRV were seen during or after 10min or 30min laser stimulation (Figure 4).

Changes in total heart rate variability (HRV total) before, during, and after the three stimulation procedures. a.u. (norm): normative arbitrary units. For further explanation, compare with Figure 3.

Figure 5 shows the changes of LF/HF HRV ratio. No significant changes were found during any of the stimulation procedures.

LF/HF of the 6 investigated rats. For further explanation, see Figures ?Figures33 and ?and44.

Analysis of the bioelectrical brain activity (EEG, Figure 6) did not reach the level of statistical significance.

Integrated electrical rat brain activity. Note the (insignificant) increase of the integrated EEG after 20min laser stimulation. For further explanation, see Figures ?Figures33 and ?and44.

## 4. Discussion

Interstitial laser acupuncture is a new acupuncture modality that also allows treatment of different body areas like spinal nerves or joints. The application of laser energy can be performed directly in the region of interest.

In our first animal experimental study, we could demonstrate that there are significant changes in neurovegetative parameters like HR and HRV after i.st. laser stimulation of the left Neiguan acupoint in rats [1]. In a human pilot study, it could also be shown that the pain intensity of patients with shoulder pain and spine-associated pain could be significantly reduced [5]. Interstitial laser therapy was also already used as a therapy for liver metastases in Western medicine. First results of a clinical phase I study were published already 10 years ago by a German research team [6]. The authors of that study stated that i.st. laser therapy of liver malignancies is a minimally invasive procedure with little side effects which produces sharply defined, yet small volumes of necrosis [6].

In the last years, there was a continuous increase in publications concerning laser acupuncture (see http://www.pubmed.gov/). However, there are still some important questions concerning dosage and in this context especially treatment duration.

The term treatment dose is identical to energy density, which is measured in watt seconds percm² (= joule (J) percm²). Dosage refers to the amount of energy per unit area brought to bear on tissue or cell culture [4].

As we have shown in many previous studies, some people can feel the laser, others not [7]. Maybe it is appropriate to begin with a low dose for a new patient in the first treatment session to be sure that one does not enter a biosuppressive dose range [4]. In laser acupuncture, the dose is often given in joules per point. It is assumed that a “point” is something small. Tunér and Hode [4] have defined an “acupuncture point” as an area that is 5mm in diameter (~0.2cm²) or less. They stated that “this means if we hit the skin with the light concentrated to this small area and administer 1J “per point,” we have given 1J “per point,” and in this “point” (~0.2cm²) the dose value is 5J/cm²” [4]. The authors of the book [4] further stated that the most common situation in laser therapy is the wish to administer a certain dose (D) to a specified area (A) with a laser, having an (average) output power (P), and therefore it is necessary to calculate the treatment time (t) for the laser probe at hand. If the problem to treat is situated at a depth (d) (where d = 0 to 4cm; this is the maximum penetration depth of the red laser [2, 8]), the following approximate formula can be used to find the treatment time:D×AP×(1+d)?[sec].

(1)

For this formula to work, the correct units to be used are as follows: P must be given in watts (not milliwatts); D must be given in J/cm²; A must be expressed in cm²; and d in cm. The treatment time will then come out in seconds.

If we use this formula for our laser acupuncture experiment in rats, the calculated time for effects seen in laser acupuncture is too small (t = {(5 × 0.2)/0.04}×(1 + 1) = 25sec). Even if we insert d = 4cm (humans), the estimated treatment time (t ? 2min) seems to be too short. Our measurements within this study only showed significant effects on neurovegetative parameters in rats during or after the 20min stimulation duration.

Although the therapeutic use of laser acupuncture in general is gaining popularity, objective evaluation of the dosage-dependent effects is very difficult [9]. Only few studies describe the important parameters like wavelength, irradiance, and the beam profile in detail. For a complete description of the dosage-dependent effects, energy transmission factors have also to be taken into account. These factors are, for example, skin properties such as thickness or pigmentation [9]. The thickness of the skin starts decreasing at the age of 45 years, and the difference in pigmentation between the Caucasian and, for example, African population, which is caused by different concentrations of melanin [10], leads to different penetration depths of the laser beam.

Our present study is the first one comparing different i.st. laser stimulation treatment times (durations) in rats. It is well known that the effectiveness of laser acupuncture depends upon dosage [3, 4]. We used a red laser (658nm) with an output power of about 40 to 50mW, which results in a very high dosage. This dosage is also time dependent. In our study with the experimental rat model, we could demonstrate that different treatment times lead to different effects on neurovegetative and neurobioelectrical parameters. Further studies are needed to verify or refute these results.

## Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

## Authors’ Contribution

Wei He and Gerhard Litscher contributed equally to this study.

## Acknowledgments

This work was supported by the National Key Basic Research Program 973 (nos. 2011CB505201, 2010CB530507), National Natural Science Foundation of China (81173205), and Beijing Natural Science Foundation (7132148). The scientific investigations were supported by the Stronach Medical Group (Chairman Frank Stronach), the Austrian Federal Ministries of Science and Research and Health, the Eurasia-Pacific Uninet (project “Evidence-based high-tech acupuncture and integrative laser medicine for prevention and early intervention of chronic diseases”), and the German Academy of Acupuncture. The laser stimulation was performed with a Schwa-Medico system from the TCM Research Center Graz at Medical University of Graz, Austria.

## References

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2. Litscher G, Opitz G. Technical parameters for laser acupuncture to elicit peripheral and central effects: state-of-the-art and short guidelines based on results from the medical University of Graz, the German Academy of Acupuncture, and the Scientific Literature. Evidence-Based Complementary and Alternative Medicine. 2012;2012:5 pages.697096 [PubMed]
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4. Tunér J, Hode L. The New Laser Therapy Handbook. Grängesberg, Sweden: Prima Books; 2010.
5. Weber M. Interstitial and intraarticular laser therapy as an attractive new therapeutic option for treatment of spinal disorders and progressive joint arthroses. Schmerz & Akupunktur. 2011;2:2–4. (Ger).
6. Engelmann K, Mack MG, Eichler K, Straub R, Zangos S, Vogl TJ. Interstitial photodynamic laser therapy for liver metastases: first results of a clinical phase I-study. RoFo. 2003;175(5):682–687. (Ger). [PubMed]
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Evid Based Complement Alternat Med. 2013; 2013: 984763.
Published online Jun 26, 2013. doi:

# Auricular Acupuncture with Laser

Regina Round, 1 Gerhard Litscher, 1 ,* and Frank Bahr 2
1Frank Bahr Research Group “Auriculomedicine and Pharmacopuncture”, Stronach Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering, Anesthesia and Intensive Care Medicine, and the TCM Research Center Graz, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
2European Academy for TCM, 81245 Munich, Germany
*Gerhard Litscher: ta.zarginudem@rehcstil.drahreg

## Abstract

Auricular acupuncture is a method which has been successfully used in various fields of medicine especially in the treatment of pain relief. The introduction of lasers especially low-level lasers into medicine brought besides the already existing stimulation with needles and electricity an additional technique to auricular acupuncture. This literature research looks at the historical background, the development and the anatomical and neurological aspects of auricular acupuncture in general and auricular laser acupuncture in detail. Preliminary scientific findings on auricular acupuncture with laser have been described in detail and discussed critically in this review article. The results of the studies have shown evidence of the effect of auricular laser acupuncture. However, a comparison of these studies was impossible due to their different study designs. The most important technical as well as study parameters were described in detail in order to give more sufficient evidence and to improve the quality of future studies.

## 1. Introduction

Today, there are many publications on acupuncture but only a few on auricular acupuncture. When you search for the term “acupuncture” in the scientific database PubMed (http://www.pubmed.gov/), more than 18,300 publications are found, while only 836 publications show up when you search for the term “auricular acupuncture.”

The reason for this can be found in history. Acupuncture, being a part of Traditional Chinese Medicine (TCM), has been practiced over thousands of years. From the beginning, Chinese Medicine was passed on from one generation to the next. Therefore, many books have been written—some of them more than 2,100 years ago.

Auricular acupuncture has also been practiced for about 2,500 years, but it was not passed on the same way as TCM was. Only about 60 years ago auricular acupuncture experienced its revival through the French physician named Paul Nogier.

Due to his ongoing research and successful treatments—especially in the field of pain management—auricular acupuncture developed into a distinct treatment system of its own. Currently, auricular acupuncture is used for acute as well as chronic pain associated with sciatica, osteoarthritis, headache, knee arthroscopy, hip fracture, hip arthroplasty, and even cancer [1].

As a result of the technological progress not only the range of treatment has expanded but also have the methods used for stimulating the acupuncture points developed from metal needles over electroacupuncture to laser acupuncture [2].

Research shows that laser acupuncture is still in its early stage of development and up to now only a small amount of different studies have been published.

The results of these studies, however, show that there is high potential in the field of laser acupuncture. Among others there are two main reasons why laser acupuncture should be considered as an alternative treatment to needle acupuncture: first it offers a noninvasive treatment for children or patients who are afraid of needles and second the laser treatment requires less time.

## 2. Classical Acupuncture

Classical acupuncture has its origin in TCM and it is believed to have been practiced for about 2,500 years. It is described as a medical treatment by inserting needles into the skin at specific points on the body.

Acupuncture is based on the principle of Qi. Qi can be described as a vital life force. According to TCM, you inherit Qi when you are born and you obtain Qi by breathing and eating during your lifetime. Qi flows in energetic pathways or channels in the human body—the so-called meridians. They form a meridian system which partially relates to the internal organs and their physiological and pathological conditions. Along these meridians, energy comes to the surface through a series of acupuncture points. They serve as tunnels or access routes to the deeper meridian system. A dysfunction of the Qi can be restored by stimulating these acupuncture points [35].

It should not remain unmentioned that in 1991 a mummy named Iceman or Ötzi was found in the Ötztaler Alps in South Tyrol. Scientists believed that the Iceman was about 5,200 years old. His body showed tattoos on the locations of classical acupuncture points. Due to the strong evidence that was found Dorfer et al. [6] hypothesized that a medical system similar to Chinese acupuncture already existed in Central Europe over 5,200 years ago. This leads to the conclusion that acupuncture originated in the Eurasian continent and is nearly 2,000 years older than it was believed to be.

## 3. Auricular Acupuncture

For a better understanding of auricular acupuncture, we will look at its history and development from two different perspectives:

1. ancient auricular acupuncture referring to the time before the 20th century and up to the 1950s,
2. modern auricular acupuncture referring to the time when Paul Nogier rediscovered auricular acupuncture.

Again this term can be divided into

1. the Chinese system of auricular acupuncture and
2. the Western or European system of auricular acupuncture, which further developed into auriculotherapy and auriculomedicine [7].

### 3.1. Ancient Auricular Acupuncture

#### 3.1.1. Definition

Ancient auricular acupuncture is a treatment based on the stimulation of acupuncture points on the auricle. These points were believed to be connected to the meridians and used empirically for certain treatments mainly for pain relief. They, however, were not part of an acupuncture system limited to the ear but part of a system covering the whole body [8, 9].

#### 3.1.2. History

There is only little evidence from the past to prove which culture ear acupuncture originates from. According to Oleson [7] and Chen [8] a relationship between the ear, the meridians, and the viscera has already been mentioned in the most famous and over 2,100-year old book Huang Di Nei Jing—the Yellow Emperor’s Classic of Internal Medicine. Some of the auricular points which are referred to in this and other books are still used today. They, however, have no connection to the meridians and no logical order.

There has also been historical reference to the use of auricular treatments by Hippocrates, the “father of the western medicine” and paragon of ancient physicians, who lived around 460BC. During his studies in Egypt, Hippocrates learned about the treatment of impotence and how to facilitate ejaculation by practising phlebotomy on the veins of the posterior surface of the ear. He kept on practising and teaching this method at his medical school on the island of Kos. Today, scientists assume that the therapeutic effect was not necessarily caused by phlebotomy itself but simply by stimulating the ear.

Another example is Mediterranean sailors who wore their golden earrings on the central lobule of the ear not only for decoration but also for improving their eyesight [711].

In 1636 Lusitanus Zactaus, a Portuguese doctor, described the treatment of low back pain and sciatica by cauterizing the earlap. About sixty years later, in 1717, the Italian doctor Antonio Maria Valsalva found new areas on the ear to relieve dental pain by cauterization. He described this in his famous book De Aure Humana Tractatus. In 1810 Professor Ignazio Colla of Parma reported a patient who claimed that after being stung by a bee in the antihelix, all the pain in his legs was gone immediately. From around 1850 onwards, there was a big hype about ear cauterization. It was mainly used as relief from dental pain or during dental extraction entirely. Sometimes it was even used to prevent dental extraction. Dysfunctions of the facial nerve were also treated this way. Due to scientific inexplicability, however, the methods began to be forgotten [9, 10].

### 3.2. Modern Auricular Acupuncture

#### 3.2.1. Definition

According to Gori and Firenzuoli [9], modern auricular acupuncture is defined as “a diagnostic and treatment system based on normalizing the body’s dysfunction by stimulating acupuncture points on the external ear.” It is not based on TCM, but on the presumption of Paul Nogier that a somatotopic organization of the body is represented on the human auricle.

#### 3.2.2. History

It was not until 1950 when the French physician and later founder of auriculotherapy Dr. Paul Nogier discovered peculiar scars on the antihelix of his patient, who had been successfully treated for sciatic pain syndrome. These scars were caused by cauterization. Presuming it was something new, he started research and discovered that the pain ceased within a couple of hours or sometimes even minutes after being cauterized.

Following a series of his clinical studies, Paul Nogier replaced cauterizing with needling the acupuncture points. Despite the lack of scientific validation, Paul Nogier kept on investigating this phenomenon. In his research he theorized that a somatotopy, as already known of the sensory and motor cortices of the brain, could also be presented on the ear. This resulted in his discovery of the body’s anatomy displaying itself on the ear as an inverted fetus (see Figure 1).

Inverted fetus. Modified from [10].

In 1956 Dr. Niboyet, France’s most famous acupuncturist at the time, took notice of Paul Nogier’s work and invited him to speak at the Congress of the Société Mediterranéenne in Marseille. The presentation was later published in the German acupuncture journal “Deutsche Zeitschrift für Akupunkteure.” Eventually, Paul Nogier’s discovery found its way to China where a group of Chinese acupuncturists conducted a study on over 2000 patients which allowed them to verify his findings. In 1959 an article about French auricular acupuncture was published in a Chinese journal called “Popular Medicine” in which Paul Nogier was credited for his discovery. At the same year the Chinese acknowledged Paul Nogier as “the Father of Auricular Acupuncture” [7, 10, 12].

### 3.3. The Chinese and the Western System of Auricular Acupuncture

Like his Chinese colleagues, Paul Nogier carried on investigating. While Paul Nogier continued his work by looking at the auricular points from an anatomical point of view, Chinese scientists developed the Chinese system by looking at the functional connection between the auricular acupuncture points and their effects on the body.

In 1966, Paul Nogier discovered that the radial artery pulse showed a reaction to the stimulation of the auricle. Assuming that this response involved the ear and the heart, he called this response “Reflexe Auriculocardiaque.” Later when he realized that this response was caused by the autonomic nervous system, he changed its name to vascular autonomic signal (VAS). This reflex or signal can be explained as a vascular reaction to the stimulation of the skin. With this unique vascular reflex auricular therapy advanced into auricular medicine, a system for advanced diagnosis and treatment.

In the late 1950s Paul Nogier introduced a small number of 42 auricular acupuncture points to Chinese scientists. Only 20 years later, in the late 1970s, Chinese acupuncturists had already increased the number to over 1,000 points most of which were empirically found.

In 1982, the World Health Organization (WHO) launched international working groups with the aim to facilitate teaching, research, and clinical practice of auricular acupuncture all over the world. In 1990, a standardization of auricular acupuncture was established by introducing 3 criteria. An auricular point had to have an international and a common name, its therapeutic value had to be proven, and its location on the auricle had to be generally accepted. Thirty nine auricular points fulfilled all 3 criteria; 36 points failed one or more of the criteria. Finding an agreement on these issues was a very important step in the development of auricular acupuncture. Due to different approaches of French and Chinese auricular acupuncturists, there is still a lot of discrepancy on certain auricular points and their mappings [8, 10, 13, 14].

## 4. Paul Nogier

Paul Nogier was born in Lyon in 1908. He was the son of a tenured professor at the Medical University of Lyon. After 3 years of studying physics, Paul Nogier went on to study medicine.

In 1938, he established his general medicine practice in Lyon where he also practiced homeopathy, manipulative medicine, and body acupuncture. To pursue these methods, Paul Nogier started a monthly study session with his students in 1942, which he kept going until he died in 1996. In 1969, he published his first book called Traité d’Auriculothérapie.

Furthermore, he received some of France’s most honorable awards, and in 1990 the WHO honored him for his great contribution in medicine and recognized him as the founder of auricular therapy and auricular medicine. Only a few months before his death in 1996 the Ècole Internationale Paul Nogier was founded [12, 15].

Raphael Nogier, Paul’s son, pursued his father’s work and described him as “a man of innovative thoughts and productive action who listened to his patients, respected what they had to say and thoroughly investigated their maladies. He tirelessly examined his patients from Monday morning to Saturday evening” [7].

## 5. The Auricle

### 5.1. Microsystem of the Ear

A microsystem is the projection of the whole body in its function and structure on certain parts of the body. In addition to the auricle microsystems can also be found on the scalp, the feet, the hands, and the iris.

Thanks to Paul Nogier’s rediscovery, auricular acupuncture has developed into one of the most commonly used and explored microsystems in the last 60 years [15, 16].

### 5.2. Anatomy of the Auricle

The ear is divided into 3 anatomic parts: the external ear (lat.: auris externa), the middle ear (lat.: auris media), and the internal ear (lat.: auris interna).

The external ear consists of the pinna or auricle (lat.: auricular), the external auditory canal (lat.: meatus acusticus externus), and the tympanic membrane (lat.: membrane tympanica).

In auricular acupuncture the most important anatomic structure is the auricle. The ear cartilage (lat.: cartilage auricularis) provides a supporting framework for the auricle and gives the auricle its funnel shape, while the ear lobe (lat.: lobulus auricularis) has no elastic cartilaginous part at all.

The outer part of the ear cartilage is called the helix. The helix crus divides the concha, the deepest point of the auricle, into the cymbia conchae or hemiconcha superior and the cavity of conchae or hemiconcha inferior.

At the opposite of the helix, one finds the antihelix. In between lies the triangular fossa. The sulcus between the antihelix and helix, is called the scapha or scaphoid fossa. Together with the helix it disembogues in the ear lobe.

The cartilaginous bead that lies in front of the external auditorial canal is called tragus. Opposite of it is the antitragus. Between the tragus and the antitragus lies the incisura intertragica (see Figure 2) [10, 17, 18].

Anatomy of the auricle.

The posterior auricle can be divided into 5 main parts of the back of the ear: the posterior groove behind the antihelix, the posterior lobe, the posterior concha, the posterior triangle behind the triangular fossa, and the posterior periphery behind the scapha and the helix [19].

### 5.3. Innervation of the Auricle (See Figure 3)

Green marks the branch of the vagus nerve, red marks the auriculotemporal nerve, blue marks the lesser occipital nerve, and yellow marks the greater auricular nerve. Modified from [20, 21].

The auricle is innervated by spinal and cranial nerves (CN). The facial nerve is responsible for the motoric innervation of the outer ear muscle.

Responsible for the sensitive innervation are the greater auricle nerve (GAN), the lesser occipital nerve, the auriculotemporal nerve—the third division and mandibular branch of the trigeminal nerve—and the auricular branches of the vagus nerve (CN X), the glossopharyngeal nerve (CN IX), and the facial nerve (CN VII) [18].

The studies of He et al., Ueno et al. [20, 21], and Peuker and Filler [17] do not coincide on the areas of innervation.

According to He et al. and Ueno et al. [20, 21] the greater auricle nerve (GAN) innervates both surfaces of the lower part of the auricle whereas Peuker and Filler [17] find additional innervation of the GAN in the tail of the helix and the scapha.

He et al. and Ueno et al. [20, 21] suggest that the lesser occipital nerve supplies the skin of the upper and back parts of the auricle with fibers. Peuker and Filler [17] do not mention this nerve in their studies.

According to He et al. and Ueno et al. [20, 21] the auriculotemporal nerve innervates the anterosuperior and the anteromedial areas of the auricle (see also Table 1). This involves the crus and the upper part of helix body, the antihelix, the triangular fossa, and the tragus. Peuker and Filler [17] found the auriculotemporal nerve solely in the crus and the upper part of the helix.

Innervation pattern (modified from [17]); auricle branch of the vagus nerve (ABVN), greater auricular nerve (GAN), auriculotemporal nerve (ATN).

The auricle branch of the vagus nerve (ABVN) supplies the concha, mainly the cavity of the conchae, and most of the region around the external auditorial canal according to He et al. and Ueno et al. [20, 21]. Peuker and Filler [17] found the ABVN also in the concha but mainly in the cymbia of the conchae and also in the antihelix.

## 6. Modern Auricular Acupuncture

### 6.1. Somatotopy

Paul Nogier’s discovery of the inverted fetus being projected on the auricle is the basis of modern auricular acupuncture. As it is shown in Figure 4 the head with the brain structures are represented on the ear lobe; the spine runs along the antihelix. The inner organs are represented in the concha. The legs and the arms are represented towards the upper rim of the auricle. This somatotopic representation is often seen as a homunculus like it is known of the sensory cortex in the brain [16, 22].

Somatotopy. Modified from [10].

### 6.2. Embryological Aspects

The somatotopic mapping also reveals an embryological pattern of the organs. As you can see in Figure 5, organs originating from the ectoderm are presented on the ear lobe and the tragus, organs originating from the endoderm on the concha, and mesodermal organs on the remaining part of the auricle [16].

Auricular embryology.

### 6.3. Neurological Aspects

The mechanism of auricular acupuncture is believed to work through the autonomic nervous system. By stimulating the auricle, the information travels through sympathetic and parasympathetic nerve fibers from the ear to the brain and from the brain through the spinal cord to specific areas in the body [16, 19].

Heine [23] stated in his survey that auricular acupuncture points are dot-like structures with a diameter of one-tenth millimetres at the most. These structures consist of a combination of collagen and elastic fibers which are pervaded by nerve endings, arterioles, venules, and capillaries.

According to Soliman and Frank [16], the vagal nerve carries the parasympathetic fibers and the branch of the trigeminal nerve carries the sympathetic fibers to the reticular formation where the information gets distributed to the corresponding brain structures.

So far there is no evidence in the literature that auricular acupuncture has a direct influence on the sympathetic system. However, numerous studies have shown that auricular acupuncture influences the parasympathetic activity, thus, also the autonomic nervous system which can have an impact on the cardiovascular system, the endocrine system, the respiratory and gastrointestinal system, the urinary system, and in the treatment of epilepsy and depression or even an anti-inflammatory effect [19, 20, 2431].

With a 75% share of all parasympathetic fibers, the vagus nerve has the highest influence on the parasympathetic system [32].

The afferent fibers of the vagus nerve synapse in structures of the medulla in particular in the nucleus tractus solitarius (NTS), the nucleus of the spinal tract of the trigeminal nerve, medial reticular formation of the medulla, the area postrema, the dorsal motor nucleus of the vagus, and the nucleus ambiguus. The majority of the vagal fibers lead into the NTS. Most of the information that is received by the NTS is spread to various areas of the brain such as the hypothalamus, the central nucleus of the amygdala, and other nuclei in the brainstem.

The efferent fibers of the vagus nerve lead to the heart, lungs, stomach, intestines, liver, pancreas, and kidneys [20, 33].

Despite the high amount of parasympathetic fibers of the vagus nerve, the auricle branch is the only peripheral branch of the vagus nerve. Thus, He et al. [20] theorized that auricular vagal stimulation can alter the autonomic as well as the central nervous system via the concha to the NTS and further on to the corresponding structures of the brain. They suggested the existence of an “auriculovagal afferent pathway.”

## 7. Detection of the Auricular Acupuncture Points

French and Chinese physicians suggested already in the 1970s that the auricle can not only be used for therapy but also for the diagnosis of dysfunctions in the body [22, 3436].

The survey of Oleson et al. [22] investigated the theory by examining patients with musculoskeletal pain. In 75.2% of the cases there was an accordance between the conventional medical diagnosis and the auricular diagnosis. It is believed that the reaction of the ear is caused again through neurological pathways. In normal conditions, the ear is “electrically silent,” but under pathological conditions the ear turns “electrically active” [16].

The inspection and palpation of the auricle are primary steps for the detection of “reactive points.” Abnormalities like swelling, blushing, desquamation, or tenderness can be signs of pathological conditions in the body.

Mechanical and electrical point finders (Figure 6) are also used for a more precise detection of acupuncture points. Mechanical point finders depend very much on the sensitivity of the patients which can often lead to distorted results, whereas electrical point finders supply more objective results by measuring the electrical skin resistance. Recently, point finders with laser have been applied for the identification of “reactive acupuncture points” as well [15, 22].

Point finder [10].

Besides inspection, palpation, and point detectors, the vascular autonomic signal (VAS) is also used for the finding of auricular points.

## 8. Vascular Autonomic Signal (VAS)

Paul Nogier discovered this signal in 1966 assuming that there was a connection between the ear and the heart. Later, he realized that it was a response of the generalized autonomic nervous system.

The VAS is a vasculocutaneous reflex that can be felt like a stationary wave of the pulse on the arterial wall (compare Figure 7). This pulse is the result of cardiac output and its rebound as the blood piles up against the arterioles and capillaries. It is a response and adjustment of the nervous system. Any stimulation of the skin by light, laser, heat, or touch can provoke the VAS.

Detection of VAS. Modified from [10].

In Europe, the VAS became another method used for finding “reactive” auricular points. Hereby, practitioners use the radial artery pulse for its detection. VAS also allows the identification of treatable points which are not painful but still show a dysfunction of the body.

While in the past practitioners used their thumb to palpate the VAS, nowadays it can also be detected with bidirectional Doppler ultrasonography [11].

## 9. Methods of Stimulating the Ear Points

### 9.1. Acupressure

Auricular acupressure is a noninvasive method that stimulates the acupuncture points by applying pressure using fingers, knuckles, or dull objects like magnet beads or vaccaria seeds.

### 9.2. Needle Acupuncture

There are different methods of stimulating the ear points. The most common method is acupuncture. Hereby needles are used for the stimulation of the auricle. In former days people used fish bones, sharp stones, or bamboo clips as acupuncture material. Later, these materials were replaced with gold or silver. Today, the needles are made of high tensile stainless steel and coated in gold or silver. Gold needles are used for reducing (supplying) and silver needles are used for reinforcing (drainage). On the back of the ear they are applied the other way round. The needles stay in place for about 20–45 minutes.

Sometimes after an acupuncture treatment semipermanent needles are attached to certain acupuncture points to enhance the effect of the treatment. These needles are solely made of high tensile stainless steel and stay in the ear for an average time of one week [10, 37].

### 9.3. Electro Acupuncture

Electroacupuncture is a new modern technique of controlled electrical stimulation on the ear. Hereby, small electrical currents are applied to needles which have been inserted at specific acupuncture points.

The stimulation can either be on low frequency (2Hz) or high frequency (100Hz) depending on the pathological issue.

A new auricular electroacupuncture device called P-Stim was invented in the early 1990s by the Austrian physician Dr. Szeles and has been subject of many studies mainly on the treatment of chronic and acute pain since then [38, 39].

### 9.4. Laser Acupuncture

Laser acupuncture is a noninvasive method that stimulates auricular acupuncture points by applying laser light. It will be further discussed in the following chapters.

## 10. Adverse Reactions of Auricular Acupuncture

Adverse reactions happen very rarely in auricular acupuncture. So far, there have been reports neither on life-threatening reactions nor on irreversible or serious adverse events after acupuncture. Minor events can be local pain, local bleeding, or infections after needle acupuncture. There have been nine documented cases of perichondritis and one case of chondritis since 1980. In the worst case these diseases can lead to chondronecrosis or even deformation of the auricle. Out of these ten cases, eight patients received permanent needle acupuncture. Proper disinfection and regular inspection of permanent needles can help to avoid such side effects [40].

It has been suggested that patients with diabetes mellitus, immunosuppressed patients, or weakened patients suffering from chronic diseases should not receive permanent needle treatment [41].

## 11. Important Points in Auricular Acupuncture

As mentioned earlier, there is a huge amount of auricular points used in the Chinese as well as in the Western system. In the following, the most commonly used and researched points in auricular acupuncture will be introduced.

## 12. Shenmen

Shenmen, meaning “spirit gate,” is located at the apex of the triangular fossa (Figure 8). This point is derived from the Chinese system but is also used in the Western system. Generally, it is used in combination with other auricular points. It is also the most commonly used point in auricular acupuncture mainly for the treatment of pain, stress, anxiety, and depression as well as alcohol or drug abuse, cessation of smoking, and weight loss [1, 19, 20, 25, 30, 4262].

Shenmen [7, 63].:

## 13. Heart Point

There are two different locations of the Heart point in auricular acupuncture. According to the Western system, the Heart point is located in the antihelix whereas in the Chinese system it is situated in the hemiconcha inferior (Figure 9).

Heart point of the Western system (red), Heart point of the Chinese system (green) [7, 63].

In most of the studies, the Chinese Heart point and its considered effect on the cardiovascular system and vagal activity have been investigated [2527, 31, 6466].

In their survey on advanced auricular acupuncture, Frank and Soliman [67] explained the shifting of the location of the Heart point and the Chinese Shenmen according to the three phases which depend on the stage of illness.

Phase 1, representing the original map of the inverted fetus, stands for normal physiology or acute pathology. In phase 2, the inverted fetus is represented in an upright position on the map and stands for degenerative conditions. Phase 3 shows the fetus in a transverse position and stands for subacute and chronic conditions.

With this advanced approach and the Western point of view of the representation of the anatomy and the organs on the auricle, Frank and Soliman [67] showed that Shenmen correlates with the Western auricular points of the spleen in phase 1, the thalamus in phase 2, and the liver in phase 3. They also showed that through the shift the location of the Chinese and the Western Heart point coincide in phase 2.

## 14. Thalamus Point

The Thalamus point is situated on the lower edge of the antitragus (Figure 10). This point is mainly used in combination with Shenmen and the Lung point in pain therapy [1, 53].

Thalamus point [7, 63].

## 15. Point Zero

Point Zero is located on a notch in the crus of the helix (Figure 11). It is one of the most important points of the auricle and was first described by Paul Nogier. He named this point “Point Zero” to express its function as a balancing point responsible for the homeostatic in the body in analogy to the “center of the body” according to the tenets of TCM [10, 19].

Point Zero [7, 63].

This point is used in the treatment of pain relief in combination with other auricular acupuncture points including Shenmen [53].

## 16. Lung Points

There are 2 Lung points (Figure 12). Both are situated in the hemiconcha inferior, representing the right or the left side of the lung. They are also two of the most commonly used auricular acupuncture points. In most studies only one point is stimulated. The Lung points are mainly used for the treatment of alcohol or drug dependency and pain relief especially after surgery. Studies show that auricular acupuncture might have an impact on the autonomic nervous system [1, 25, 28, 31, 4345, 48, 51, 5557].

Lung points [7, 63].

## 17. More Details on the Auricular Acupuncture Points

Studies which investigated the effects of auricular acupuncture on pathological conditions often used a combination of auricular acupuncture points and other auricular or even body acupuncture points.

Studies on pain therapy after surgeries, for example, used Shenmen and one of the Lung points as basic points in combination with the auricular acupuncture point corresponding to the treated area, for example, the point for the knee joint after a knee surgery [55, 57].

Studies on drug and alcohol dependencies used a combination of auricular points suggested by the National Acupuncture Detoxification Association (NADA) including Shenmen, Sympathetic point, Kidney point, Liver point, and Lung point [43, 44, 48].

Studies investigating the effects of auricular acupuncture on the autonomic nervous system tested either the Heart point or the Lung point individually or in comparison to body acupuncture points. Both points have their locations in the concha, the area which is innervated mainly by the vagus nerve [2528, 64, 65, 68]. There are also studies investigating the effect of Shenmen on anxiety compared to other auricular acupuncture points or body acupuncture points [58, 61].

Many studies provide poor information about the names or the exact locations of the treated auricular acupuncture points; mostly they only refer to the anatomical areas that had been treated. This lack of information is one of the problems in comparing the studies and makes it difficult to prove the effectiveness of auricular acupuncture [24, 47, 49, 6973].

## 18. Recent Studies on Auricular Acupuncture

This section covers recent studies of auricular acupuncture which were conducted either by acupressure, needling, or electro acupuncture. Studies on auricular laser acupuncture will be treated later on separately.

In former days, auricular acupuncture was mainly used for the treatment of sciatica and low back pain. After Paul Nogier’s discovery of the microsystem on the ear, numerous clinical and experimental studies on the effects of auricular acupuncture have been carried out mainly in Europe, Asia, and America. Studies show that besides the already known success in treating low back pain many other diseases can be cured by using auricular acupuncture.

A review of Chen [46] showed that auricular acupuncture offers a vast field of applications. Fifty six kinds of illnesses including diseases of the respiratory tract, the circulatory system, the digestive system, the urinary system and the nervous system, diseases in the fields of otolaryngology, ophthalmology, dermatology, paediatrics, and gynaecology as well as acute abdomen, obesity, drinking, and smoking cessation were discussed in these studies. This review included retrospective as well as randomized controlled studies. Auricular acupuncture was effective in most cases especially in the treatment of hypertension, acute pain of the digestive system, dermatological diseases—like psoriasis, urticarial, or acne—and obesity. Due to the small amounts of treated people and randomized controlled (RCT) studies, the quality of this review is poor but still it shows that auricular acupuncture has the potential of being effective in many fields of medicine.

### 18.1. Pain

There are many studies on pain management with auricular acupuncture. It has shown its effectiveness on acute as well as chronic pain. Low back pain, headache, and pain caused by osteoarthritis were treated with auricular acupuncture. It was even used for postoperative pain control [1, 39].

Studies have shown that auricular acupuncture can be effective especially in the treatment of postoperative pain which would further result in a decrease of analgesic requirement. More studies should be conducted for more reliable and conclusive scientific evidence [5557, 72, 74].

### 18.2. Obesity

There is evidence that auricular acupuncture can be used to achieve weight loss. Hsu et al. [49] ran a randomized controlled study with 60 obese women. These women were treated with auricular acupuncture over a period of 3 months. Although there was no change in body weight, body mass index, and waist circumference, there was a significant difference in the levels of obesity-related hormones. Particularly the hormone ghrelin showed an increase and the hormone leptin showed a decrease after 3 months of treatment. Previous studies have shown that obese people have a lower level of ghrelin than people with normal weight and that an increase of this level can be associated with weight loss.

### 18.3. Anxiety

Studies on anxious patients before operations or dental treatments and on older patients with postoperative anxiety have given evidence of the effectiveness of auricular acupuncture in these fields. The mechanism is still inconclusive, but scientists believe that auricular acupuncture might have an impact on the release of neurotransmitters such as serotonin which helps in the regulation of anxiety [42, 58, 61, 75, 76].

However, there is still no evidence on a successful treatment of patients with generalized anxiety disorder or anxiety neurosis [76].

### 18.4. Cardiovascular System

Recent studies on rats showed that auricular acupuncture regulates the cardiovascular function by activating baroreceptor sensitive neurons in the nucleus tractus solitarius (NTS). The arterial pressure and the heart rate were significantly reduced by auricular acupuncture [26, 77].

Another Chinese publication reported a decrease in systolic as well as diastolic pressure in patients with hypertension after electric pulse stimulation. The total effective rate had been 90.7% [68].

### 18.5. Insomnia

There is evidence that auricular acupuncture can also be effective in cases of insomnia. A combination of auricular acupressure with routine care was more efficient than solely auricular acupressure. However, due to methodological limitations and inconclusive results further evidence and research have yet to be considered [47, 52, 78].

### 18.6. Dermatological Conditions

Only a few studies have been implemented on psoriasis vulgaris. So far, there is one survey that shows a therapeutic effect of auricular acupuncture in combination with a decoction of TCM [79].

Auricular acupuncture has also been used for the treatment of verruca plana or flat warts. This randomized work showed a statistically better outcome in the treatment group than in the control group [80].

However, in both cases further investigations need to be considered to have more scientific evidence on the treatment of psoriasis vulgaris as well as verruca plana.

### 18.7. Opiate Addiction and Alcohol Abuse

The euphoric feeling of cocaine is assumed to be triggered by blocking the reuptake of the neurotransmitters noradrenalin, serotonin, and mainly dopamine. Hereby cocaine acts as an indirect dopamine agonist [48].

Auricular acupuncture is believed to have its effect by stimulating the vagus nerve at one of the Lung points on the auricle. This leads to a stimulation of the hypothalamus, which leads to the release of serotonin and further to an activation of methionine encephalin which inhibits the release of ?-aminobutyric acid (GABA). The inhibition of GABA causes an increase in dopamine. Hypothetically this mechanism reduces cravings and hereby supports the patient on his path to self-recovery [48].

Besides a Lung point the NADA determined further auricular points which presumably help not only drug addicts but also patients with alcohol problems during their protracted withdrawal. Research showed that patients described amongst others feelings of wellbeing and relaxation, peacefulness and harmony, reductions of anxiety and drug consumption. However, the craving for drugs and alcohol remained and the effects were only temporary [43].

Further studies also showed a positive effect on combined therapies. For example, auricular acupuncture combined with carbamazepine treatment showed good results for alcohol withdrawals and combined with psychotherapy it was effective for drug patients [81, 82].

Here, too, more randomized controlled studies with higher number of patients need to be performed in order to receive more scientifically significant evidence on the effect of auricular acupuncture.

### 18.8. Epileptic Seizures

In the last 20 years epilepsy, and especially drug-resistant epilepsy, has been successfully treated with vagus nerve stimulation (VNS) [83].

He et al. [29] hypothesize that auricular acupuncture can also be a possible treatment for epileptic seizures just as the VNS therapy. Clinical trials showed that auricular electroacupuncture led to a decrease of frequency and severity of seizures.

It is still unclear how the antiseizure effect works, but it is assumed that auricular acupuncture as well as VNS triggers more than one neuromodulatory mechanism which leads to an effective treatment [33].

He et al. [29] suggest two mechanisms for the success of auricular acupuncture. Firstly, the activation of the NTS leading to a suppression of the affected parts in the brain and secondly on the assumption of Granata et al. [84] that epilepsy might be caused by immune-mediated processes, the activation of the cholinergic anti-inflammatory pathway [84].

Recent studies on trigeminal nerve stimulation (TNS) have also been successful in the treatment of epileptic seizures [8587].

### 18.9. Smoking Cessation

In the last decades auricular as well as body acupuncture had been a very common method to help people to lead a life without tobacco. White et al. [88] published a large review of smoking cessation both in auricular as well as in body acupuncture. Although this study showed that the effects of acupuncture were not better than other methods of smoking cessation, the authors pointed out that there is evidence of the effect of acupuncture and further bias-free studies need to be conducted in order to prove these effects. A new method of auricular electro acupuncture, called “Smokex-Pro,” has been previously developed. A recently conducted study showed that after the treatment 47.9% of the patients stayed abstinent for at least 2 years [89].

18.10. Summary of Recent Studies

These aforementioned studies have shown that auricular acupuncture can be used in many fields of medicine and there is evidence of its effect. However, the lack of information, the small sample size, and the difference in study parameters give most of the studies a poor quality and make them difficult to compare. For more significant evidence, further investigations need to be conducted.

## 19. Laser in Auricular Acupuncture

### 19.1. Definition and History

The word “Laser” is an acronym for “Light Amplification by Stimulated Emission of Radiation.” The properties of laser such as its extreme monochromaticity, its polarisation, and its high coherence make the laser so unique and versatile [90].

### 19.2. History of the Laser

In 1917, Albert Einstein laid the foundation of the laser technology based on the principle of stimulated emission. Also based on this principle Charles H. Townes invented in 1954 the first MASER—short for microwave amplification by the stimulated emission of radiation—for which he received (with Alexander M. Prokhorov and Nikolai G. Basov) the Nobel Prize in 1964. In 1958, Townes and Arthur L. Schawlow published their study “Infrared and optical maser” which was used as a basis for the construction of the first laser in 1960 by the physicist Theodor Maiman. A development of various kinds of lasers ensued [91].

### 19.3. Laser in Medicine

In the early 1960s a Ruby laser was introduced into medicine for the photocoagulation of the retina. Due to severe side effects, the treatment was discontinued. In the late 1960s, an Argon laser was developed for the use of detached retina treatment.

Today, laser therapy is used in many fields of medicine apart from ophthalmology also in dermatology, otolaryngology, dental medicine, general surgery, and vascular surgery. Depending on the aim of the treatment lasers can be of high intensity or low intensity.

High-intensity (level) lasers have the ability to cut, destroy, or cauterize tissues due to their thermal effect whereas the effect of low-intensity (level) lasers (LLL), also called “soft laser” or “cold laser,” is believed to be caused by the interaction of electromagnetic radiation with the tissue. It has been shown to be effective in wound healing, musculoskeletal pain, and rheumatoid arthritis as well as in laser acupuncture [90, 91].

### 19.4. History of Laser Acupuncture

Between 1970 and 1972 reports on successful therapies of hypertension and asthma with laser body acupuncture in the USSR were published [92].

The Canadian Friedrich Plog suggested the use of laser in body acupuncture already in 1973. In 1979, the Chinese surgeon Zhou started using laser acupuncture instead of needle acupuncture and acupressure for anaesthesia successfully. First studies on laser auricular acupuncture have been reported in 1984 conducted by Seitz and Kleinkort [93]. Different laser instruments have been developed over the years.

In 2001, the first “laser needles” (Figure 13) were invented at the University of Paderborn (Germany). The first scientific investigations were performed at the Medical University of Graz. For the first time it was possible to stimulate different acupuncture points at the same time [9497].

Laser needle for acupuncture.

### 19.5. Types of Laser in Auricular Acupuncture

Low-level lasers (LLL) are the most commonly used lasers in body acupuncture as well as auricular acupuncture. They are defined by wavelengths between 300nm and 10,600nm, power densities between 10?2W/cm2 and 100W/cm2, and energy densities between 10?2J/cm2 and 102W/cm2. The wavelength of a laser is defined by its laser medium which can be gaseous, fluid, solid, or semiconducting [98].

In laser acupuncture the most frequently used lasers are gas lasers, mainly the Helium Neon (HeNe) lasers. In recent years, semiconductor lasers such as Aluminium Gallium Arsenide (AlGaAs) lasers or Gallium Arsenide (GaAs) lasers have become more popular in laser acupuncture.

Most recently, ultralow level lasers (ULLL) have also been used in auricular acupuncture.

#### 19.5.1. Helium Neon Laser

The Helium Neon (HeNe) laser, a low-level laser, was one of the first gas lasers. The medium of the laser is a mixture of Helium and Neon. In laser acupuncture, HeNe lasers have a wavelength of 632.8nm [99].

#### 19.5.2. Argon Laser

The Argon laser is also a low-level and gas laser. In laser acupuncture, the wavelength of an Argon laser is usually 514nm [73].

#### 19.5.3. Aluminium Gallium Arsenide Laser

The Aluminium Gallium Arsenide (AlGaAs) laser is a semiconducting low-level laser. In laser acupuncture, the standardized wavelength is 780nm [99].

#### 19.5.4. Gallium Arsenide Laser

The Gallium Arsenide (GaAr) laser is also one of the most commonly used semiconducting low-level lasers. Its standardized wavelength is 940nm in laser acupuncture [99].

#### 19.5.5. Ultralow-Level Laser (ULLL)

Recently, there have been also studies of ultralow-level lasers (ULLL) in auricular as well as body acupuncture. The output power of an ULLL is significantly smaller than of an LLL; consequently, the energy density and the power density are also a lot smaller [65, 100, 101].

### 19.6. “Laser Needles”

In 2001, the first “laser needles” were invented at the University of Paderborn in Germany, with the trade name Laserneedle (Figure 14). Since then, many new developments of these laser needles evolved. This semiconducting laser instrument is equipped with up to 10 laser needles and has the ability to work on different wavelengths, mainly red (685nm), infrared (788nm), and violet (405nm) [95].

Laser needles. Modified from [97].

### 19.7. Classification and Safety of Low-Level Lasers

According to the European Norm (EN 60825-1), low-level lasers are classified as “3R” lasers equivalent to the old classification “3b,” meaning that radiation can be a risk of serious damage to the eye. To avoid this risk, the patient and acupuncturist should wear special glasses during the treatment. Laser as well as the treatment room must be marked specifically [10, 102].

## 20. Technical Parameters

### 20.1. Wavelength

The wavelength is one of the most important technical parameters in laser acupuncture. Its unit is expressed in nanometers (nm). A laser can have a wavelength spectrum between 240nm and 3,000nm. In laser acupuncture the lasers have wavelengths between 405nm and 904nm (Table 2). Lasers with wavelengths over 785nm are infrared lasers in other words invisible light lasers. The wavelength is not only responsible for the coloring of the laser light but also how deep the laser light penetrates through the skin. For example, the red laser light with a wavelength of 685nm has a penetration depth of about 4cm [95, 103, 104].

Wavelengths. Modified from [15].

### 20.2. Output Power

The output power is the power level of the laser light. Its unit is given in milliwatts (mW). In laser acupuncture, the applied dose depends on the output power of the laser. The higher the output power the higher the power density influences the depth of penetration. The designation of average output power is also very important especially when using a pulsed laser [95]

### 20.3. Power Density

The power density is expressed in terms of watt per cm2 (W/cm2) or milliwatt per cm2 (mW/cm2). It states the intensity of the laser beam and is in indirect proportion to the diameter of the laser beam [95].

Schikora [105] calculated that the power density had to be more than 1.3W/cm2 for laser acupuncture to achieve the same effect as needle acupuncture.

Calculation of the power density (mW/cm2) is as follows:

Power??Density??(mW/cm2)=Output??Power?(mW)Beam??Area??(cm2).
(1)

### 20.4. Energy Density

The unit of the energy density is watt-seconds per cm2 (Ws/cm2), which equals Joules per cm2 (J/cm2). The energy density is the treatment dose and states the amount of energy supplied per cm2 for the time of irradiation [95].

Calculation of the energy density (Ws/cm2)

Energy??Density??(Ws/cm2)=Output??Power?(mW)×Time?(s)Beam??Area??(cm2)
(2)

### 20.5. Beam Diameter or Beam Area

Another important parameter is the beam area or the diameter of the beam (cm2). With one of these two parameters the energy density can be calculated if the output power and the time are stated.

Calculation of the Beam area (cm2)

Beam??Area??(cm2)=Diameter??(cm)×0.7854
(3)

### 20.6. Dose Range

According to the study of Litscher and Opitz [95], the dose range can be “from 0.001J/cm2 (=Ws/cm2) to 10J/cm2 (=Ws/cm2) and more.”

### 20.7. Continuous or Pulsed Laser

A laser can have pulsed or continuous waves. There is the assumption that pulsed laser light can “interfere with other pulsing biological phenomena” which would make a continuous waved laser a better option for laser acupuncture treatment. As mentioned previously, it is important to calculate the average output power when using pulsed lasers [95].

The time of radiation is also an important parameter in laser acupuncture. Most of the time it is in seconds (s). It is an important parameter for the calculation of energy density. The radiation time can last from 1s to up to 100s [37].

## 21. Important Study Parameters

According to Birch [106] studies on acupuncture respectively on auricular acupuncture should fulfil additional criteria to the already existing international standards of medical journals in order to achieve sufficient evidence.

Most important parameters that should be considered in studies of auricular laser acupuncture are listed in the following.

### 21.1. Research Question

The question of research needs to be clearly defined. On the basis of this research question, a proper study model shall be designed in order to achieve a meaningful result [106].

### 21.2. Randomized Controlled Studies

The use of randomized controlled studies has often been discussed in the literature. Still they are considered to be necessary for the efficiency of a study and stay as a gold standard [48, 106, 107].

### 21.3. Sample Size

The sample size in a study is also a very important parameter for the evidence of the effectiveness of auricular acupuncture. A smaller amount can be used in pilot studies however, in studies with more reference groups the amount of people has to be larger in order to give sufficient evidence. In most of the studies of auricular acupuncture, the number of treated patients is often too low [106].

### 21.4. Criteria

The inclusion and exclusion criteria need to be accurately defined and strictly executed [106].

### 21.5. Acupuncturist

Acupuncturists need to have very good qualifications which have to be stated in detail in the study. If there is more than one acupuncturist involved in the study then they should receive special training in accordance with the study. Particularly in auricular acupuncture with needles the points have to be needled correctly otherwise the results have a higher chance of being distorted. However, the risk of falsified results decreases by using a laser [106].

### 21.6. Nomenclature and Location

Due to the different nomenclatures in auricular acupuncture, the name and the exact location of the points need to be stated clearly in studies.

### 21.7. Description of the Acupuncture Proceeding

The description of the proceeding has to include detailed information on the treated points, the system (e.g., Chinese or Western), the material used, the number and frequency of treatments, and the methods such as manual needling, electrical stimulation or laser stimulation. Studies on electroacupuncture and laser acupuncture need to provide proper information on technical parameters [106].

### 21.8. Period of Treatment

Another important parameter for the quality of a study is the time period of the treatment and the follow-up. Birch [106] suggested a time period of at least 3 months, preferably one year. The length of periods can vary depending on the pathological conditions; longer durations are also suggested for studies on drugs and alcohol abuse [108].

### 21.9. Number of Treatments

The amount of treatments and the time between treatments are very important parameters for reproducible studies in laser auricular acupuncture [109].

### 21.10. Reference Groups

Birch [106] recommended that the acupuncture treatment should always be compared to 3 different groups. The acupuncture treatment should be compared to sham acupuncture group, a group receiving standard medical therapy as well as a group which does not receive any treatment. Most of the studies compare auricular acupuncture to sham treatment groups or standard medical treatment groups.

### 21.11. Sham Acupuncture versus Placebo Acupuncture

Birch [106] believes in most cases sham acupuncture with needles is used under wrong assumptions. Sham treatment is often mistakenly equated to placebo treatment. The chosen sham acupuncture points are not necessarily used for treatment of the medical condition that is investigated; however, they can still have an impact on the body when they are needled.

In the study of Irnich et al. [110], sham laser acupuncture was conducted by deactivating the laser irradiation but not the red light or acoustic sound. In this case, sham laser acupuncture cannot be counted as a placebo treatment. It can only be treated as a placebo treatment if the laser stays entirely switched off. This must be clearly stated in the studies.

Studies where auricular acupuncture is used as an adjunctive treatment and studies of certain pathological conditions necessitate additional use of medical treatment, for example, withdrawal symptoms, anxiety, pain, anaesthesia, or hypertension. Here, the medication needs to be documented accurately [106].

## 22. Human Skin

### 22.1. Optical Properties of the Skin

The optical properties of the human skin play an important role in laser acupuncture. The multilayered, inhomogeneous, and anisotropic structure of the skin determines the absorption and scattering of the radiation.

Melanin and haemoglobin are the main substances responsible for the absorption of the laser light. Melanin, responsible for the pigmentation of the skin, is mainly situated in the dermis and haemoglobin mainly in the epidermis. Further substances such as bilirubin, carotene, lipids, cell nuclei, and filamentous proteins may also contribute to the absorption of the laser light.

The scattering of the radiation is mainly caused by the filamentous proteins Keratin, which is found in the epidermis and responsible for the thickness of the skin, and collagen in the dermis. Melanosomes in the epidermis, cell nuclei, cell walls, and other structures can also have an influence on the scattering of the radiation.

Due to the dynamic of these substances their influence on the penetration of the laser light varies among human beings. Just to name a couple of examples, the thickness of the skin starts decreasing at the age of 45; the difference in the pigmentation of the Caucasian and the black population is caused by the different concentration of melanin [103, 111, 112].

### 22.2. Penetration of the Laser Light

The optical properties and the wavelength are the two main factors for the penetration of the laser light. It is believed that in body acupuncture the nociceptive structures lie 2-3cm underneath the skin’s surface. To achieve this depth, the wavelength must be between 605nm and 850nm which can be reached by red and infrared lasers [103, 105].

Recent studies with violet lasers have shown an effect on the blood flow velocity in the basilar artery by stimulating body acupuncture points. The penetration depth of the violet laser with a wavelength of 405nm is about 1mm [94].

Esnouf et al. [113] conducted a study evaluating the penetration depth of an Aluminium Gallium Arsenide laser with a wavelength of 850nm. It showed that “most of the laser radiation was absorbed within the first 1mm of the skin.” With this new finding it can be assumed that a violet laser can have the same effect as red or infrared lasers. Due to its low penetration depth the violet laser might even be the laser of first choice in auricular acupuncture since the penetration depth on the auricle does not necessarily require the same depth as in body laser acupuncture.

### 22.3. “Deqi” Sensation

In TCM the “Deqi” sensation is a signal to confirm the correct positioning of the needle in body acupuncture. “Deqi” can be seen as a benchmark of efficient acupuncture. It has been described as a feeling of numbness, prickling, flowing, or heaviness around the acupuncture point. Acupuncturists can make the “Deqi” sensation more perceptible by rotating or moving the needle back and forth during the therapy. In auricular acupuncture patients have described the “Deqi” feeling as a warm sense on the ear during treatment [45, 114].

Recent studies on body acupuncture suggest that “Deqi” sensation can also be achieved through laser acupuncture. In the studies the patients identified the “Deqi” sensation as a heavy sense or an electrical current or a feeling of an ant bite [94, 115].

## 23. Methods of Verification

In the last years, different noninvasive bioengineering methods have been used for verifying laser acupuncture.

Methods for the measurement of the peripheral effect are

1. Laser Doppler Flowmetry (LDF) and
2. Laser Doppler Imaging (LDI).

The cerebral effects can be measured with

1. multidirectional Transcranial Ultrasound Doppler Sonography (TCD),
2. cerebral Near-Infrared Spectroscopy (NIRS), and
3. functional Magnetic Resonance Imaging (fMRI).

### 23.1. Laser Doppler Flowmetry (LDF)

Laser Doppler flowmetry is a method to measure changes in the microcirculation. Flux is the main parameter and is defined as the product of average velocity and concentration of red blood cells in superficial vessels. This technique uses the Doppler effect—also called Doppler shift—which is based on the shifting of the light caused by moving blood cells [104, 116].

### 23.2. Laser Doppler Imaging (LDI)

This method is also based on the principle of the Doppler effect. Hereby, the reflected light acquires data that are transformed into a color-coded picture displaying the distribution of tissue perfusion [104].

### 23.3. Multidirectional Transcranial Ultrasound Doppler Sonography (TCD)

The TCD is a relatively new recording technique in acupuncture which is able to measure the blood flow velocity in the middle cerebral artery, the anterior cerebral artery, the posterior cerebral artery, the supratrochlear artery, and the ophthalmic artery. The TCM Research Center in Graz developed a helmet for transcranial ultrasound investigations where the probe holder construction was situated at the “windows to the brain,” meaning transnuchal, transtemporal, and transorbital (Figure 15) [104].

“Windows of the brain”: transorbital ((a), (c)), transnuchal ((b) right), transtemporal ((b) left, (c) right). Modified from [104].

### 23.4. Functional Magnetic Resonance Imaging (fMRI)

With this technique, it is possible to measure metabolic and circulatory changes of the brain. Hereby the fMRI uses the magnetic properties of oxygenated and deoxygenated haemoglobin to identify changes in their concentration in the blood [104].

### 23.5. Near Infrared Spectroscopy (NIRS)

NIRS is a noninvasive spectroscopic technique that measures the functional activities in the brain by using an optical window in the near-infrared light spectrum. The spectral range must be between 630nm and 1300nm, so the light can get through the cranium to investigate the metabolism in the cerebral cortex [104].

### 23.6. Bispectral Index (BIS) and Electroencephalogram (EEG)

The EEG is a method to measure electrical brain activities. In auricular acupuncture, EEG is mainly used to examine the activities of the cerebral cortex.

The BIS is an important numerical descriptor of the EEG which is mainly used in anaesthesia [30, 104].

Taking into account that acupuncturists handle the laser equipment with care and responsibility, the advantages opposite the disadvantages in laser auricular acupuncture are outbalanced.

Auricular acupuncture is often used as an adjunctive treatment, for example, during withdrawal therapies or for pain relief. It has shown that patients treated additionally with auricular acupuncture required less medication which further leads to a reduction of side effects and secondary diseases and consequently results in a decrease of costs [5457, 72, 74].

Auricular acupuncture therapy does not require an inpatient treatment. Patients can be treated as outpatients which would further lead to a decrease of inpatients following a reduction of costs.

### 24.2. Comparison to Auricular Acupuncture with Needles

The laser treatment being a noninvasive method is one of the biggest benefits. Patients with fear of needles as well as children of all ages can be treated. The low risks of local bleeding and infections such as perichondritis and chondritis disappear entirely [99].

In studies of auricular laser acupuncture a placebo treatment can be simulated easier than in studies of acupuncture with needles.

Auricular acupuncture with laser has also the advantage that it takes less time than with needles [37].

### 24.3. Comparison to Body Acupuncture with Laser

Auricular acupuncture has two main advantages versus body acupuncture in needling as well as in laser treatment; on one side auricular acupuncture is easier to apply because the patients do not need to get undressed and on the other side the stimulation is not as sophisticated as in body acupuncture [59].

Risk of serious damage to the eye can be reduced drastically or even erased by cautious use of the laser instrument and also the wearing of safety glasses during the treatment.

## 26. Recent Studies and Their Quality

Not many studies have been published up to now. This is no surprise considering that auricular acupuncture has only found its way into medicine in the last 60 years and laser therapy only in the last 40 years. By using the keywords “auricular” and “acupuncture” and “laser” on PubMed as few as 28 publications were found. The first paper was published in the year 1982. Out of these 28 publications, 17 studies were published in English, 6 in Russian, 3 in Chinese, and 2 in Italian.

Only 14 publications investigated specifically the effects of auricular acupuncture with laser. In the following 10 of these studies will be discussed in detail; the remaining 4 studies were either in Russian or Chinese and were not taken for further evaluation.

With the exception of 2 studies, different subjects were investigated which made it difficult to compare the results of the publications with each other in order to find sufficient evidence of auricular acupuncture with laser.

### 26.1. Experimental Pain

King et al. [51] investigated on 80 healthy subjects whether laser auricular acupuncture can reduce pain or its threshold. Eighty healthy subjects with regard to the exclusion and inclusion criteria were chosen to take part. The subjects were randomly divided into 2 groups, an experimental group which received laser treatment on Shenmen, Lung point, Wrist point, and Dermis point and a control group which received sham acupuncture on the same points but without the laser being activated. Each point was stimulated for 30s. For the stimulation of the acupuncture points, a continuous waved HeNe laser with a wavelength of 632.8nm, an average power of 1mW and a peak power of 1mW was used. For the simulation of the pain an electric electrode was fixed on the left wrist of the subjects. There was no further information on the technical parameters such as power density, energy density, or the diameter of the laser beam. In 71% (29 subjects) of the experimental group there was an increase in the threshold of the pain whereas in the control group the increase was only 33% (13 subjects).

The outcome shows evidence that laser auricular acupuncture can have an effect on pain. Further studies need to be conducted for more evidence; however, the missing technical parameters make a reproducibility of this study difficult. Studies on patients with real pain instead of experimental pain should also be investigated.

### 26.2. Insomnia

In the Chinese study of Yao [117], 46 patients were treated for insomnia under the aspects of TCM. The treated auricular points were Shenmen, Endocrine point, Subcortex point, Brain point, Heart point, Kidney point, Spleen point, Stomach point, Liver point, and Kidney point. The laser instrument was a PU-1 semiconductor laser with a wavelength of 830nm, an output power of 3mW. The diameter of the laser beam was 2mm. The irradiation time lasted for 1 minute. The treatment was once a day, 12 times with pauses of 5-to 7-day in-between therapy. The results showed that 69.5% of the patients (32 patients) were able to sleep for more than 7 hours, 28.3% of the patients (13 patients) were able to sleep between 5 and 6 hours. Auricular acupuncture had no effect on only one patient (2.2%). The total effectiveness was 97.8%.

This outcome shows that auricular acupuncture can be effective in the treatment of insomnia. However, a description of the exact location of the points was missing and there was no information whether the patients received laser treatment on all of the mentioned points or only on certain points. The technical parameters did not include if it was a pulsed or continuous waved laser. No reference groups were selected. No inclusion or exclusion criteria were defined and the amount of people treated was too low to give sufficient evidence on this subject.

Further studies need to be conducted for more evidence. Due to the lack of information, a reproducibility of this study is very difficult.

### 26.3. Acne Vulgaris

In a Chinese study of Sun [118], 68 patients were treated for acne vulgaris. These patients were randomly divided into a treatment group of 36 people who received laser auricular acupuncture and into a control group of 32 people who received body acupuncture with needles. For auricular acupuncture the points Lung, Spleen, Large Intestine, Sanjiao, Endocrine, Adrenal Gland, and Cheek were stimulated with an HeNe laser. Only 3 or 4 of these points were used for each treatment; however, there was no further information how often or in which combination these points were used and no description of the exact location of the auricular points. The HeNe laser had power density of 25mW/cm2. The points were treated with this laser from a distance of 30–50cm for 3–5 minutes per session. Altogether, the patients received 10 treatments. In the control group the patients were treated 10 times on different body acupuncture points with needles.

After the treatment 28 patients of the treatment group had no lesions left, in 6 cases 70% of the lesions were gone and only 2 patients had a cure rate of 30–70% of the lesions, whereas in the control group only 15 patients had a full cure of the lesions, in 14 cases 70% of the lesions were gone and only 30–70% of the lesions disappeared on 3 patients [118].

The results show evidence of the impact of auricular laser acupuncture. However, the exact location and combination of the auricular points, further technical parameters, for example, beam diameter or energy density, and a definition of exclusion and inclusion criteria were missing. Further studies with higher sample size and a third nontreatment reference group should be conducted for further proof of the effect of auricular laser acupuncture. The lack of information makes it again difficult to reproduce this study.

### 26.4. Alcohol Addiction and Withdrawal

In recent years auricular acupuncture has been subject to many studies on alcohol addiction or alcohol withdrawals. So far two studies on different subjects in this field have been published on auricular acupuncture with laser.

Zalewska-Kaszubska and Obzejta [73] investigated the possibility of auricular acupuncture as an adjunctive treatment of alcohol abuse and of its influence of the ?-endorphin level in the plasma which is believed to have an influence on alcohol withdrawal. Fifty three patients were treated with a combination of auricular laser acupuncture and body laser acupuncture. The patients were chosen by exclusion and inclusion criteria. Out of these 53 patients only 15 patients finished the study. The patients were not divided into reference groups.

The auricular points were stated in numbers 82, 83, 87, 51, and 55. According to Rubach [37], point number 82 is Point Zero, number 83 is the Anxiety point, 87 is the Stomach point, 51 is the Vegetative point I, and 55 is Shenmen. These points were stimulated with a semiconducting Argon laser with a wavelength of 540nm, an output power of 100mW, and a beam area of 0.05cm2. The irradiation time lasted for 10s per point.

A spot on the neck vessel projection was stimulated by an HeNe laser with a wavelength of 632.8nm, an output power of 25mW, and a beam area of 0.2cm2. The irradiation time was 5min. There was no further information about the exact location of this spot.

The whole treatment consisted of 4 sessions. Each session lasted 20 days. The auricle was stimulated every 2nd day and the neck vessel was continuously stimulated over a 20-day period. Inbetween the sessions there was a break of one week. For the valuation of the ?-endorphin level, the patients gave blood before the first laser treatment and one day after each laser session. They also had to undertake the Beck Depression Inventory-Fast Screen (BDI-FS) after each session for evaluating their state of mind.

The results showed an increase in the ?-endorphin level and according to the BDI-FS a positive mood in the patients. The authors believe that an increase in the ?-endorphin levels is linked to an increase in the mood and consequently a reduction of alcohol withdrawal [73].

This study gave sufficient information on the technical parameters of the lasers but insufficient information on the location of the stimulated auricular as well as body points. Although the results showed a positive outcome, the low number of patients which completed the study and the missing of reference groups call for further studies with better quality and information.

Trümpler et al. [119] investigated in their randomized controlled study the duration of alcohol withdrawal by comparing laser acupuncture with needle acupuncture and sham laser acupuncture on the auricle. Forty eight inpatients were chosen under certain criteria and were randomly divided into three reference groups. The points were chosen individually with the help of an electronic point finder. The most frequently stimulated points were—according to the nomenclature of Oleson—the Diaphragm point, the Cheerfulness point, the Insomnia point, the Sympathetic point, the Spleen point, the Laterality point, a Lung point, and Shenmen. A semiconducting laser with a wavelength of 830nm (name: Modulus; product of schwa-medico, Inc., Ehringshausen, Germany) was used for the auricular laser acupuncture. No further technical parameters such as output power, diameter of the beam, or beam area were given. Each auricular point was stimulated for 60s. In the laser sham acupuncture group the laser was inactivated. The needle acupuncture was performed with stainless steel needles to a depth of 1–3mm for about 40min.

The treatment was applied daily until the end of withdrawal symptoms. Besides the acupuncture treatment, patients received Clomethiazole or in case of intoleration benzodiazepines on an individual basis. Other medications were kept unchanged for the time of the study.

The outcome of this study did not show any difference of the withdrawal duration inbetween the reference groups. The needle acupuncture treatment seemed to have more efficiency than laser acupuncture treatment. However, there was no difference between sham and laser acupuncture. There was no information whether the sham acupuncture was applied with an entirely switched off laser or the laser irradiation was just deactivated. The authors see the cause for this insufficient result in the small number of patients, the different degrees of severity of diseases induced by long-term alcohol abuse, the different pharmacological management of withdrawal, and unequal provision of care [119].

For further improvement of this study’s quality a non-treatment group should have been added as another reference group. Also, the combination of the individual auricular points should have been listed more precisely; maintaining to the standard use of the NADA might lead to a more meaningful result and better comparison for further studies.

### 26.5. Chronic Allergic Dermatoses

Hou et al. [50] investigated the effects of auricular laser acupuncture on 35 patients suffering from eczemas, on 46 patients suffering from urticaria, on 41 suffering from fascial cosmetic dermatitis, and on 25 patients suffering from atopic dermatitis. The auricular acupuncture points Shenmen, Urticaria, and Subcortex were stimulated with a semiconducting AlGaAs laser each for 3 minutes. There was no further technical information of the laser. The whole treatment consisted of 2 sessions. Each session had a 5-minute treatment with intervals of 3-4 days inbetween. Medical treatment of antihistamine and corticosteroid was discontinued and a serum IgE level was determined before and after treatment. Only in the cases of eczema and urticarial, the IgE levels decreased after the treatment. The symptoms of all four dermatoses, however, improved significantly.

Even though the results show evidence in the treatment of chronic dermatoses with auricular acupuncture, the deficiency of information, and the small amount of patients give this study a poor quality.

For further evidence, a randomized controlled study with a larger number of patients, exact information of technical parameters, and definition of criteria as well as a longer period of treatment including a follow-up should be conducted.

### 26.6. Laser Acupuncture for Adolescent Smokers

In this double-blind randomized study of Yiming et al. [62], auricular laser acupuncture was investigated for cessation of smoking on adolescent smokers. Three hundred thirty patients between the age of 12 and 18 years were divided into a laser acupuncture group and a sham acupuncture group. 128 adolescents of the laser acupuncture group completed the study and were treated on the auricular acupuncture points Ershénmén (probably Shenmen), Kó (probably Mouth), Fèi (probably Lung), and Wàibi. One hundred fourty adolescents of the sham acupuncture group completed the study and were treated on the same auricular points but without any radiation.

An HeNe laser with a wavelength of 632.8nm, an output power of 2.5 to 3mW, and a diameter of 1mm was used for the laser stimulation. The auricular points were stimulated from a distance of about 1mm for 60s. The distance was chosen so that no pain or sensation could be felt. The treatment consisted of 12 sessions. Three sessions were given per week.

The results showed no significant effect of auricular laser acupuncture compared to sham acupuncture. In both groups around 21% of the patients stopped smoking after the first treatment. A three-month follow-up showed a complete cessation of 25% of 101 patients in the laser acupuncture group and 26% of 107 patients in the sham acupuncture group [62].

The quality of this study was low. For a reproduction of this study, the nomenclature of the points and its localization should have been described according to the nomenclature of the WHO [14]. The details of the technical parameters were imprecise. It is also questionable whether with a distance of about 1mm the laser acupuncture can have the same effect than by placing the laser needle directly on the skin.

### 26.7. Animal Experiment: Microcirculation

Komori et al. [70] investigated in 40 rabbits the changes in microcirculation after auricular stimulation. The rabbits were randomly allocated into 4 reference groups with 10 rabbits each. The first group received needle acupuncture treatment, the second received near-infrared lamp irradiation, the third group received laser acupuncture stimulation, and the fourth group acted as control group and received no treatment. Stainless needles were used for the needle acupuncture treatment and a near-infrared lamp with a wavelength of 1540nm and an energy density of 40mW/mm2 were used for the near-infrared treatment. The irradiation time was 1s. A semiconducting AlGaAs laser with a wavelength of 830nm, an output power of 60mW, an energy density of 39mW/mm2, and a diameter of 1.4mm were used for the laser acupuncture. The rabbit ear chamber method was used for the verification of the microcirculation. This method facilitates the observation of a single blood vessel via intravital microscopy as well as effects of different interventions on peripheral hemodynamics.

The stimulated area on the rabbits’ ears corresponds to the concha of the human auricle. The results showed a significant increase in the arteriolar diameter, the blood flow velocity and the blood flow rate after needle acupuncture, near-infrared lamp irradiation as well as laser acupuncture. Several studies have been conducted examining the relation of laser as well as needle acupuncture to the blood flow. Substance P—a neurotransmitter and calcitonin-related peptide—and Nitric oxide—responsible for vasodilatation—seemed to play an important role in this mechanism [70].

This study was of good quality and it proved that auricular acupuncture has an effect on the microcirculation. It can be considered to have an effect on diseases caused by poor peripheral blood flow. Further studies should be performed on this subject.

### 26.8. Ultralow-Level Laser: Postural Instability

Bergamaschi et al. [100] investigated on 34 elderly patients the effects of auricular as well as body laser acupuncture with an ultralow-lever laser. The patients were divided into 3 reference groups. nine patients received auricular laser acupuncture, 9 patients received body laser acupuncture, and 16 patients received sham auricular acupuncture, hereby the laser stayed switched off. A semiconducting laser (product: BioliteLP020) with an output power of 0.03mW was used. The irradiation was administered in 20 half-second flashes. The single point energy dose was about 0.3mJ. The bioactive body acupuncture points were selected with a point finder. Instead of stimulating auricular acupuncture points auriculotherapy zones according to the Auriculoterapia Posturale secondo Scoppa method were stimulated. For the verification of the results, 4 balance tests were performed before treatment, right after treatment within 15 minutes of the first test, within 1 hour after the first test, and 3 days after the first test. The results showed an average improvement of 15% after the treatment and a long-term improvement of 5–10% 3 days after the treatment in body as well as auricular laser acupuncture.

The results show slight evidence on the effects of body and auricular laser acupuncture. For further evidence, more studies on this subject need to be conducted with a higher amount of treated patients, a definition of exclusion and inclusion criteria plus the medication of the patients should be taken into account.

### 26.9. Ultralow-Level Laser: Violet Laser Stimulation on Rats

Gao et al. [65] conducted a study testing the effects of a violet laser on heart rate, heart rate variability, and mean arterial blood pressure on anaesthetised rats by stimulating two body acupuncture points (Baihui (GV20) and Zusanli (ST36)) and the Heart point situated on the inferior concha of the auricle. The points were stimulated separately with a continuous waved laser (product: Conrad Electronic, SE) with a wavelength of 405nm and an output power of 1mW. The irradiation time lasted 2 minutes. The blood pressure was measured via a polyethylene catheter on the left common carotid artery connected to a blood pressure transducer and amplifier. The mean heart rate and the heart rate variability were monitored with an electrocardiogram (ECG) and measured before, during, and after the stimulation.

The results showed changes in the heart rate on all acupuncture points especially after the stimulation of Baihui. The total heart rate variability changed insignificantly on all acupuncture points. The mean arterial blood pressure decreased slightly after stimulating the Baihui acupoint [65].

This study showed that a violet laser can have an impact on physiological neurovegetative parameters. However, there was no evidence that a violet laser had more effect on auricular acupuncture than on body acupuncture. Quite the contrary, the stimulation on Baihui showed more effect than on the Heart point. Further studies need to be carried out for further evidence.

## 27. Conclusion

Recent studies have shown that auricular laser acupuncture can have an effect on the body.

However, a comparison of the results is not given because of the small amount of studies, different subjects of research, and different study approaches. Studies in the past have often shown low quality due to insufficient and different levels of information.

In order to achieve a higher grade of comparability the different technical and study parameters discussed previously have to be stated accurately. Furthermore, study designs of the same subject need to be reconciled with each other. To achieve meaningful and comparable results, further studies following these proposals need to be conducted.

Recent conclusive studies of auricular acupressure, auricular electroacupuncture and auricular acupuncture, with needles should also be consulted for further studies on auricular laser acupuncture for example studies investigating the mechanism of auricular acupuncture. There is strong evidence that the influence on the autonomic nervous system through the stimulation of the ABVN can be one of its mechanisms [20, 26, 77].

By taking all these basic conditions into consideration, future studies on auricular laser acupuncture will be more significant and will show stronger evidence of its effect.

## Conflict of Interests

The authors declare that they have no conflict of interests.

## Acknowledgments

The authors would like to thank Ms. Ingrid Gaischek, M.S. (Medical University of Graz), for paper preparation and for designing and drawing illustrations, and Ms. Xiaoyu Wang, M.S. Ph.D (Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing) for critically revising the location of the acupoints. The work was supported by the German Academy of Acupuncture (DAA), the Stronach Medical Group, the Austrian Federal Ministries of Science and Research and of Health, and Eurasia-Pacific Uninet. It is part of the research areas Neuroscience and Sustainable Health Research at the Medical University of Graz. The corresponding author is a Guest Professor at different institutions and universities in China. Professor Litscher is also Visiting Professor at China Medical University in the Graduate Institute of Acupuncture Science in Taichung, Taiwan.

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# The effects of multi-mode audio frequency pulse modulating laser together with electrical stimulation on blood pressure and hemorrheology of the spontaneously hypertensive rats.

[Article in Chinese]
Gong W, Huang S, Si G, Zhang K, Chen Z.

Source

Department of Biomedical Engineering, Sun Yat-sen University, Guangzhou 510080, China.

Abstract

In order to explore new ways in restraining the ascending blood pressure, this paper reports a research on the effects of multi-mode audio frequency pulse modulating laser irradiation with electrical stimulation on the hemorrheology and blood pressure of the spontaneously hypertensive rats (SHR). Forty male SHR were randomly divided into four groups: Group A (control), Group B (treated with electrical stimulation on stomach 36 point (ST-36)), Group C (treated with low level pulse laser irradiation on Erjian acupuncture point), Group D (low level laser irradiation together with electrical stimulation on Erjian acupuncture point and ST-36). Laser irradiation lasted for 45 min/ day, while electrical stimulation lasted for 30 min/day. After 10 days’ treatment, we compared the hemorrheology and blood pressure of the rats in the four groups. The results were that values of hemorrheology in group A and group C were obviously improved compared with those in the other two groups. Meanwhile, the blood pressures in the three treated groups (B, C, and D) were lower than in the control group after the treatment, and the value of the rats in group A was the lowest. In conclusion, the treatment the laser irradiation combined with electrodes stimulation on spontaneously hypertensive rats brought better results of hemorrheology and blood pressure in the tested rats.

Photomed Laser Surg.  2012 Jul 10. [Epub ahead of print]

# Electrophysiological Effects of Single Point Transcutaneous 650 and 808 nm Laser Irradiation of Rat Sciatic Nerve: A Study of Relevance for Low-Level Laser Therapy and Laser Acupuncture.

Chow R, Yan W, Armati P.

Source

Nerve Research Foundation, Brain and Mind Research Institute, The University of Sydney , Camperdown NSW, Australia .

Abstract

Abstract Objective: The purpose of this study was to evaluate effects of transcutaneous 650 nm and 808 nm laser irradiation (LI) to a single point overlying rat sciatic nerve; a comparison to four point LI and relevance to the clinical application of low-level laser therapy (LLLT) and laser acupuncture (LA).

Background data: Transcutaneous LI inhibits somatosensory and motor conduction when delivered to four points overlying sciatic nerve; however, effects of the same total energy delivered to a single point over the nerve, equating to laser acupuncture, are undefined.

Methods: Transcutaneous 808 nm, 450 mW, (13.5 or 54 J) continuous wave (cw) mode or 650 nm, 35 mW, (1.1 or 4.4 J), cw LI or sham LI, was applied for 30 or 120 sec to a single point overlying the midpoint of rat sciatic nerve. Somatosensory evoked potentials (SSEPs) and compound muscle action potentials (CMAPs) were then recorded after 10 and 20 min, and after 24 and 48 h.

Results: 120 sec of 808 nm LI increased SSEP amplitudes only at 10 min, with no effect of 30 or 120 sec at other time points on SSEPs or on CMAPs. LI 650 nm for 30 or 120 sec did not alter SSEPs or CMAPs at any time point.

Conclusions: Localized transcutaneous 808 LI to a single point overlying sciatic nerve increases SSEP amplitudes when compared with delivery of the same total energy to four points, which causes decreased SSEP amplitudes and conduction block. Therefore, the area and duration of delivery are important, independent variables with implications for clinical delivery of both LLLT and LA.

Evid Based Complement Alternat Med.  2011;2011:485945. Epub 2011 Mar 10.

# Is sham laser a valid control for acupuncture trials?

Irnich D, Salih N, Offenbächer M, Fleckenstein J.

Source

Multidisciplinary Pain Center, Department of Anaesthesiology, University of Munich, Pettenkoferstraße 8A, 80336 Munich, Germany.

Abstract

Methodological problems of acupuncture trials focus on adequate placebo controls. In this trial we evaluated the use of sham laser acupuncture as a control procedure. Thirty-four healthy volunteers received verum laser (invisible infrared laser emission and red light, 45 s and 1 J per point) and sham laser (red light) treatment at three acupuncture points (LI4, LU7 and LR3) in a randomized, double-blinded, cross-over design. The main outcome measure was the ratio of correct to incorrect ratings of treatment immediately after each session. The secondary outcome measure was the occurrence of deqi-like sensations at the acupuncture points and their intensity on a 10-fold visual analog scale (VAS; 10 being the strongest sensible sensation). We pooled the results of three former trials to evaluate the credibility of sham laser acupuncture when compared to needle acupuncture. Fifteen out of 34 (44%) healthy volunteers (age: 28 ± 10.7 years) identified the used laser device after the first session and 14 (41%) after the second session. Hence, both treatments were undistinguishable (P = .26). Deqi-like sensations occurred in 46% of active laser (2.34 VAS) and in 49.0% of sham laser beams (2.49 VAS). The credibility of sham laser was not different from needle acupuncture. Sham laser acupuncture can serve as a valid placebo control in laser acupuncture studies. Due to similar credibility and the lack of sensory input on the peripheral nervous system, sham laser acupuncture can also serve as a sham control for acupuncture trials, in order to evaluate needling effects per se.

Evid Based Complement Alternat Med.  2011;2011:808203. Epub 2011 Mar 1.

# The Problem of Metal Needles in Acupuncture-fMRI Studies.

Beissner F, Nöth U, Schockert T.

### Source

Brain Imaging Center, Goethe University, 60325 Frankfurt, Germany.

Abstract

Acupuncture is a therapy based on sensory stimulation of the human body by means of metal needles. The exact underlying mechanisms of acupuncture have not been clarified so far. Functional magnetic resonance imaging (fMRI) has become an important tool in acupuncture research. Standard acupuncture needles, which are made of ferromagnetic steel, however, are problematic in acupuncture-fMRI studies for several reasons, such as attraction by the scanner’s magnetic field, significant image distortions and signal-dropouts, when positioned close to the head or even heating due to absorption of radio frequency (RF). The aim of this study was to compare two novel types of acupuncture needles with a standard needle for their effect on MRI image quality. The standard needle severely reduced image quality, when located inside the RF coil. The nonferromagnetic metal needle may pose a risk due to RF heating, while the plastic needle has a significantly larger diameter. In conclusion, our recommendations are: (1) standard needles should not be used in MRI; (2) Nonferromagnetic metal needles seem to be the best choice for acupoints outside of the transmitter coil; and (3) only plastic needles are suited for points inside the coil. Laser acupuncture may be a safe alternative, too.

J Altern Complement Med.  2011 Jan;17(1):67-70. Epub 2011 Jan 5.

# Integrative approach focusing on acupuncture in the treatment of chronic complex regional pain syndrome.

Sprague M, Chang JC.

Source

Coastal Carolina Neuropsychiatric Center, Jacksonville, NC, USA.

Abstract

BACKGROUND:

Chronic complex regional pain syndrome (CRPS) is a chronic pain condition that leads to sympathetic nervous system involvement and trophic changes.

OBJECTIVE:

This study describes the use of acupuncture in a case study of CRPS. DESIGN, SETTING, AND PATIENT: This is a single case report of a 34-year-old patient diagnosed with CRPS.

INTERVENTION:

Acupuncture treatment including acupoints along the Gallbladder, Liver, Spleen, Heart, and Kidney meridians. Self-treatment plan included a laser acupuncture pen device and disposable press needles.

MAIN OUTCOME MEASURES:

Beck Depression Inventory (BDI), McGill Pain Questionnaire, and Sheehan Disability Scale (SDS).

RESULTS:

The Patient reported a decrease in pain levels, depression, and an improved quality of life. Pretreatment SDS score of 17, a 12 on the BDI, and a 67 on the McGill Pain Questionnaire. Post-treatment SDS decreased to 4, her BDI went to 0, and her McGill Pain Questionnaire decreased to a 10.

CONCLUSIONS:

More research is needed and case studies performed to support our findings.

BMJC Complement Altern Med.  2010 Dec 28;10:81.

# Deqi sensations without cutaneous sensory input: results of an RCT.

Salih N, Bäumler PI, Simang M, Irnich D.

Source

Multidisciplinary Pain Center, Department of Anesthesiology, University of Munich, Munich, Germany.

Abstract

BACKGROUND:

Deqi is defined in relation to acupuncture needling as a sensory perception of varying character. In a recently published sham laser validation study, we found that subjects in the verum and the sham laser group experienced deqi sensations. Therefore, we aim to further analyze whether the perceptions reported in the two study arms were distinguishable and whether expectancy effects exhibited considerable impact on our results.

METHODS:

A detailed re-analysis focusing on deqi sensations was performed from data collected in a previously published placebo-controlled, double-blind, clinical cross-over trial for a sham laser evaluation. Thirty-four healthy volunteers (28 ± 10.7 years; 16 women, 18 men) received two laser acupuncture treatments at three acupuncture points LI4 (hégu), LU7 (liéque), and LR3 (táichong); once by verum laser and once using a sham device containing an inactive laser in randomized order. Outcome measures were frequency, intensity (evaluated by visual analogue scale; VAS), and quality of the subjects’ sensations perceived during treatments (assessed with the “acupuncture sensation scale”).

RESULTS:

Both, verum and the sham laser acupuncture result in similar deqi sensations with regard to frequency (p-value = 0.67), intensity (p-value = 0.71) and quality (p-values between 0.15 – 0.98). In both groups the most frequently used adjectives to describe these perceptions were “spreading”, “radiating”, “tingling”, “tugging”, “pulsing”, “warm”, “dull”, and “electric”. Sensations reported were consistent with the perception of deqi as previously defined in literature. Subjects’ conviction regarding the effectiveness of laser acupuncture or the history of having received acupuncture treatments before did not correlate with the frequency or intensity of sensations reported.

CONCLUSIONS:

Since deqi sensations, described as sensory perceptions, were elicited without any cutaneous sensory input, we assume that they are a product of non-specific effects from the overall treatment procedure. Expectancy-effects due to previous acupuncture experience and belief in laser acupuncture do not seem to play a major role in elicitation of deqi sensations. Our results give hints that deqi might be a central phenomenon of awareness and consciousness, and that its relevance should be taken into account, even in clinical trials. However, further research is required to understand mechanisms underlying deqi.

Biomed Eng Online.  2010 Nov 23;9:78.

# Biomedical engineering meets acupuncture–development of a miniaturized 48-channel skin impedance measurement system for needle and laser acupuncture.

Litscher G, Wang L.

Source

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine and TCM Research Center Graz, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria. gerhard.litscher@medunigraz.at

Abstract

BACKGROUND:

Due to controversially discussed results in scientific literature concerning changes of electrical skin impedance before and during acupuncture a new measurement system has been developed.

METHODS:

The prototype measures and analyzes the electrical skin impedance computer-based and simultaneously in 48 channels within a 2.5×3.5 cm matrix. Preliminary measurements in one person were performed using metal needle and violet laser (405 nm) acupuncture at the acupoint Kongzui (LU6). The new system is an improvement on devices previously developed by other researchers for this purpose.

RESULTS:

Skin impedance in the immediate surroundings of the acupoint was lowered reproducibly following needle stimulation and also violet laser stimulation.

CONCLUSIONS:

A new instrumentation for skin impedance measurements is presented. The following hypotheses suggested by our results will have to be tested in further studies: Needle acupuncture causes significant, specific local changes of electrical skin impedance parameters. Optical stimulation (violet laser) at an acupoint causes direct electrical biosignal changes.

Complement Ther Clin Pract. 2010 Aug;16(3):158-60. Epub 2010 Jan 27.

# Emg analysis after laser acupuncture in patients with temporomandibular dysfunction (TMD). Implications for practice.

Hotta PT, Hotta TH, Bataglion C, Bataglion SA, de Souza Coronatto EA, Siéssere S, Regalo SC.

Ribeirão Preto Dental School/ São Paulo University, Ribeirão Preto, SP, Brazil.

### Abstract

The aim of this study was to analyze the effect of low level laser applied to acupuncture points of patients diagnosed with temporomandibular dysfunction (TMD). Ten patients aged between 20 and 50 years were clinically examined with regard to pain and dysfunction of the masticatory system. They received laser applications (GaAlAs diode laser, 780 nm wavelength; 70 mW power output, 35 j/cm(2)) in acupuncture specific points (Ig4, C3, E6, E7) once a week, for ten sessions. The range of jaw movement was registered after each session and visual analogue scale (VAS) was applied. Results were analyzed (SPSS-15.0-Chicago) during the comparison, before and after treatment. Statistical tests showed significant improvements (p < 0.01) in painful symptoms and electromyographic activities of masseter muscles in maximal habitual occlusion after laser applications but no significant improvements (p = 0.05) in measurements of mandibular movements. The laser therapy in specific acupuncture points promoted improvement of symptoms and it may be used as complementary therapy for TMD.

Lik Sprava. 2010 Jan-Mar;(1-2):106-10.

# Infrared laser puncture and manual therapy in the treatment of cervical and thoracic osteochondrosis and neurological manifestations of this disease

[Article in Ukrainian]

Koval’chuk VV, Sereda VH.

### Abstract

The effect of two methods of the treatment (traditional and in combination with lascropuncture infrared radiation and manual therapy) on clinical symptoms of vertebral refractory pain syndroms was studied in 120 patients with neck-pectoral osteochondrosis. The empirical knowledge confirmed the necessity of expediency of these methods in the treatment of this pathology.

Conf Proc IEEE Eng Med Biol Soc.  2010;2010:1262-5.

# Effectiveness of Laser treatment at acupuncture sites compared to traditional acupuncture in the treatment of peripheral artery disease.

Cunha RG, Rodrigues KC, Salvador M, Zangaro RA.

Source

Research and Development Institute, IP&D, Univap, Av. Shishima Hifumi, 2911, São José dos Campos, 12244-000, SP, Brazil. rodrigogcunha@hotmail.com

Abstract

Cardiovascular diseases are the main causes of mortality, not only in Brazil, but around the world. The use of acupuncture as a complementary and alternative treatment for cardiovascular diseases has been suggested for animals as well as human beings. Possible advantages in using acupuncture are the low cost of treatment and low risks of collateral damage from a combination of acupuncture with other medical treatments. The purpose of this study is to assess the effect of traditional acupuncture with needles and laser acupuncture on arterial pressure and peripheral circulation of inferior limbs in patients with circulatory deficiency. Ten acupuncture points were stimulated in 40 individuals, being that 20 were stimulated by Aluminum gallium arsenide (AlGaAs) laser with emission in the red spectral region (650 nm) using an energy density of 2,4 J/cm2, and 20 were stimulated by systemic acupuncture needles. The analysis of peripheral circulation was performed based on the measurement of arterial pressure of the ankle and arms, using sphygmomanometer and Doppler equipment. The variance of the revascularization index of the laser acupuncture group was 0,057, and 0.030 for the needles group with p= 0,006. These results show that only those treated with laser acupuncture exhibit a significant increase in systolic pressure of their lower limbs, with a consequent improvement of the Revascularization Index, suggesting that different stimuli on acupuncture points generate different variations of peripheral resistance of lower limbs. is column.

J Acupunct Meridian Stud. 2009 Sep;2(3):202-9.

# Modernization of traditional acupuncture using multimodal computer-based high-tech methods-recent results of blue laser and teleacupuncture from the Medical University of Graz.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine and TCM Research Center, Medical University of Graz, Austria. gerhard.litscher@medunigraz.at

### Abstract

Basic and clinical research in traditional Chinese and Korean acupuncture has been performed at the Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine and the Traditional Chinese Medicine Research Center at the Medical University of Graz since 1997. This publication focuses on the latest innovative aspects that underline the further enhancement and development of acupuncture. In this context, novel biomedical and neuroscientific methods are of paramount importance for the fast and efficient modernization of the ancient Asian healing method. Traditional and future oriented acupuncture stimulation methods can be divided into manual needle, laser needle (blue, red and infrared laser light) and electrical punctual stimulation at the body, hand and ear. Special emphasis in this research article is given to totally new technical and methodological investigations, e.g. the first data published worldwide in medicine obtained with new blue laser acupuncture equipment. In this regard, critical summary and recent results from peripheral and central measurements during acupuncture stimulation using high-tech bioengineering assessment are given. In addition, we describe the first teleacupuncture performed between Asia and Europe.

Acupunct Med.  2009 Sep;27(3):94-100.

# Laser acupuncture for chronic non-specific low back pain: a controlled clinical trial.

Glazov G, Schattner P, Lopez D, Shandley K.

### Source

Department of General Practice, Faculty of Medicine, University of Western Australia, Perth, Australia. glazog01@student.uwa.edu.au

### Abstract

##### OBJECTIVE:

the primary aim was to determine if laser acupuncture (LA) is more effective than sham laser in reducing pain and disability in adults with chronic non-specific low back pain.

##### METHODS:

the design was a double blind, two-group parallel randomised controlled trial. The active intervention was an 830 nm (infrared), 10 mW, Ga-Al-As laser diode laser for acupuncture and a sham control. The primary outcome measures were changes in pain (visual analogue scale) and disability (Oswestry Disability Index) at the end of 5-10 treatment sessions. Secondary outcomes were patient global assessment, psychological distress (Depression Anxiety Stress Scale) and subjective wellbeing (Personal Wellbeing Index). Follow up was performed at 6 weeks and 6 months after completion of treatment.

##### RESULTS:

100 participants were enrolled and treated in a general practice setting. Per protocol analysis of the primary outcome measures using ANOVA suggested that although there was a significant overall improvement in pain and disability after the course of treatments (p<0.01), there was no significant difference between the intervention and control group in both the primary and most secondary outcome measures.

##### CONCLUSION:

this study did not show a specific effect for LA using infrared laser at 0.2 Joules per point for chronic low back pain. The overall intervention appeared effective because of placebo and other factors. As there was some concern about baseline inequality between the groups further research using tighter inclusion criteria should attempt to replicate the result and examine if a dose response may exist.

Zhongguo Zhen Jiu. 2009 Jun;29(6):478-83.

# Relationship between laser acupuncture analgesia and the function of mast cells

[Article in Chinese]

Cheng K, Shen XY, Ding GH, Wu F.

Shanghai University of TCM, Shanghai 201203, China. cheng_ker@hotmail.com

OBJECTIVE: To observe the analgesic effects of single-and combined-laser irradiation with low-intensity applied at “Zusanli” (ST 36) in rats, and their relation to degranulation of mast cells.

METHODS: Sixty-six SD rats were randomly divided into 6 groups: normal control group (Group NC), model control group (Group MC), sham irradiation group (Group SI), 10.6 microm laser irradiation group (Group 10.6 microm LI), 650 nm laser irradiation group (Group 650 nm LI) and combined (10.6 microm + 650 nm) laser irradiation group (Group CLI). Complete Freund’s Adjuvant (0.05 mL) was injected into the left ankle joints of all the rats except those in Group NC to cause acute adjuvant-induced arthritis. In treatment, laser irradiation was applied at “Zusanli” (ST 36) for 30 minutes in all the rats except those in Group NC and Group MC. The paw withdrawal latency (PWL) to radian heat was used to compare analgesic effects among the groups. By means of toluidine blue, dyed slices of local tissues of “Zusanli” (ST 36) were used to observe changes of mast cell degranulation before and after laser irradiation.

RESULTS: The pain thresholds to irradiation of the rats in Group 650 nm LI and Group CLI were significantly higher than those in Group MC and Group SI (P < 0.01), and the mast cell degranulation rate in Group 650 nm LI and Group CLI were also significantly higher than that in Group MC and Group SI (P < 0.001). The pain threshold and mast cell degranulation rate in Group 10. 6 microm LI were not significantly different from those in Group MC and Group SI. There was a linear correlation between mast cell degranulation rate and PWL with 0. 737 in coefficient (P < 0.001).

CONCLUSION: Single 650 nm laser and combined 650 nm + 10.6 microm laser with low intensity irradiated at “Zusanli” (ST 36) in acute adjuvant rats can provide remarkable analgesic effects, and there was a positive correlation between mast cell degranulation rate and analgesic effects, which plays an important part in laser irradiation-induced analgesia.

Res Vet Sci. 2009 Jun 26. [Epub ahead of print]

# Laser acupuncture for acute inflammatory, visceral and neuropathic pain relief: An experimental study in the laboratory rat.

Lorenzini L, Giuliani A, Giardino L, Calzà L.

DIMORFIPA, University of Bologna, Via Tolara di Sopra 50, 40064 Ozzano Emilia (Bologna), Italy.

Laser acupuncture is defined as the stimulation of traditional acupuncture points with low-intensity, non-thermal laser irradiation. We explored the clinical efficacy of a very low level diode laser wavelength 670nm (Biolite LP020, RGM, Genoa, Italy), used to stimulate acupoints ST36 Zu San Li and TH5 Waiguan, on well-established experimental models of acute and persistent pain in the rat, e.g. acute inflammatory pain, muscle pain, visceral pain and neuropathic pain. We report the anti-edema and anti-hyperalgesia effects of laser acupuncture in models of acute inflammatory pain, e.g. CFA-induced inflammation and myofascial pain. We also indicate that spontaneous pain and thermal hyperalgesia are reduced in a neuropathic pain model, e.g. axotomy. On the contrary, no effects due to laser-acupuncture were observed on disconfort indices in a model of visceral pain, e.g. cystitis due to cyclophosphamide. We thus provide evidences that acupoints stimulation using a very low intensity laser irradiation can control pain and edema in specific experimental conditions.

Evid Based Complement Alternat Med. 2009 Jun;6(2):153-8. Epub 2007 Nov 12.

# Ten Years Evidence-based High-Tech Acupuncture–A Short Review of Peripherally Measured Effects.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz/Austria. gerhard.litscher@meduni-graz.at.

### Abstract

Since 1997, the Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine of Graz Medical University has been dealing with the demystification of acupuncture and examining, using non-invasive methods, how different stimulation modalities (manual needle acupuncture, laserneedle acupuncture and electro acupuncture) affect peripheral and central functions. Laser is also an important instrument for acupuncture. One only needs to mention the treatment of children or of patients with needle phobia. The laserneedle acupuncture, which was examined scientifically for the first time in Graz, represents a new painless acupuncture method for which up to ten laserneedles are glued to the skin, but not stuck into it. This first part of the short review article summarizes some of the peripherally measured effects of acupuncture obtained at the Medical University of Graz within the last 10 years.

JAnesth Analg. 2009 Feb;108(2):635-40.

# Microcirculatory responses to acupuncture stimulation and phototherapy.

Komori M, Takada K, Tomizawa Y, Nishiyama K, Kondo I, Kawamata M, Ozaki M.

Department of Anesthesiology, Medical Center East, Tokyo Women’s Medical University, 2-1-10, Nishiogu, Arakawa-ku, Tokyo 116-8567, Japan. komorim@nifty.com

### Abstract

BACKGROUND: Acupuncture stimulation and phototherapy have been reported to have analgesic effects and improve the microcirculation. However, few studies have directly examined changes in peripheral blood vessels, either quantitatively or objectively. We assessed the responses of arteriolar blood flow to acupuncture stimulation and phototherapy under direct vision to examine the effects of these treatments.

METHODS: We used 40 rabbits with a rabbit ear chamber attached to the auricle. The rabbit ear chamber was fixed to the auricle under a dissecting microscope. Arterioles were selected and observed with the use of a microscope video camera. Pentobarbital was injected IV. The trachea was intubated and spontaneous respiration was maintained. Rabbits were randomly assigned to receive acupuncture stimulation (acupuncture group, n = 10), near-infrared lamp irradiation (lamp group, n = 10), near-infrared low-powered laser irradiation (laser group, n = 10), or no irradiation (control group, n = 10). In the acupuncture group, an acupuncture needle was placed in the auricle for 20 min. The lamp group repeatedly received 1 s of near infrared irradiation (1540 mW) followed by 4 s of treatment cessation. The laser group continuously received 60 mW of laser irradiation. In the lamp and laser groups, the auricle (same site as that of the acupuncture needles in the acupuncture group) was irradiated for 10 min with a contact probe. Arteriolar diameter and blood flow velocity were measured at baseline and for 60 min after acupuncture or irradiation treatment. Blood flow rate was calculated by multiplying the blood flow velocity by the cross-sectional area of the vessels.

RESULTS: Arteriolar diameter significantly increased to 131% +/- 14% in the acupuncture group (P < 0.005), 129% +/- 19% in the lamp group (P < 0.005), and 128% +/- 11% in the laser group (P < 0.005) when compared with the pretreatment value (100%). Maximum values were reached 20 min after the end of the acupuncture stimulation, and 10 min after the end of lamp and laser irradiation. The three groups showed significant increases in arteriolar diameter when compared with the control group (P < 0.005). Blood flow velocity and blood flow rate showed similar trends to arteriolar diameter. Treatment effect persisted for 40-50 min after the end of stimulation and irradiation.

CONCLUSIONS: Acupuncture stimulation and phototherapy were directly confirmed to increase the diameter and blood flow velocity of the peripheral arterioles. Acupuncture stimulation and phototherapy, associated with minimal systemic and local side effects, can enhance the microcirculation and may be a useful supportive treatment for diseases caused by poor peripheral blood flow.

Eur J Obstet Gynecol Reprod Biol. 2009 Jan;142(1):68-72. Epub 2008 Nov 4.

# Patients’ sensation during and after laserneedle versus metal needle treatment.

van Amerongen KS, Kuhn A, Mueller M.

Department of Obstetrics and Gynaecology, Inselspital, Bern University Hospital, and University of Bern, Switzerland. k.staehler@spin.ch

### Abstract

OBJECTIVES: Aim of the study was to evaluate the patients’ sensations during and after laserneedle versus metal needle acupuncture.

STUDY DESIGN: The prospective study was performed at the gynaecological outpatient department of a University Teaching Hospital of Bern, Switzerland. Thirty female patients per group were included in the study and randomized into laserneedle or metal needle group. All women visited the acupuncture out patient department because of gynaecological disorders. Age of the patients in the metal needle group was 38 years in median (range 18-73 years); mean age was 41+/-13.3. Age in the laserneedle group was 36 years in median (range 16-60 years) and mean age was 39.1+/-12.2. Interventions were laserneedle acupuncture and metal needle acupuncture. Patients answered a questionnaire before, after the first treatment and prior to the second treatment. The questionnaires asked about the patients’ knowledge of the various acupuncture methods and their health condition before treatment, their perception of pain, warmth, tiredness and relaxation during or after application of the needles or during or after the treatment. Statistics were performed by Graph Pad InStat 3 for windows.

RESULTS: The common metal needle technique was well known by the patients in comparison to the laserneedle method (p<0.0001***). Laserneedle acupuncture is a method which is painless (p<0.0001***), energy inducing and relaxing (p=0.0257*) which leads to a warming sensation (p=0.0009***) during treatment.

CONCLUSION: Both methods laserneedle and metal needle acupuncture are valuable methods in achieving relaxation and improvement of gynaecological symptoms. Laserneedle acupuncture is painless and easy to apply which is a valuable reason to support this technique in the future.

J Acupunct Meridian Stud. 2008 Dec;1(2):65-82.

# Clinical effectiveness of laser acupuncture: a systematic review.

Baxter GD, Bleakley C, McDonough S.

Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand. david.baxter@otago.ac.nz

### Abstract

The use of laser light as an alternative to needles to stimulate acupuncture points has been promoted for almost three decades. However, there has been no systematic assessment of the evidence to support the effectiveness of this form of acupuncture to date. A systematic review was therefore undertaken of RCTs evaluating laser acupuncture as a primary intervention. Relevant studies (n = 18) were identified using computer-based literature searches and selected hand searches. Evidence was found to support the use of laser acupuncture in the treatment of myofascial pain, postoperative nausea and vomiting and for the relief of chronic tension headache. Laser acupuncture would appear to represent an effective form of acupuncture for the management of these conditions and could be considered as a viable alternative to more traditional forms of acupuncture point stimulation.

Chiropr Med. 2008 Dec;7(4):134-9.

# Effect of laser acupoint treatment on blood pressure and body weight-a pilot study.

Zhang J, Marquina N, Oxinos G, Sau A, Ng D.

Associate Director of Research, Research Department, Logan College of Chiropractic, Chesterfield, MO.

OBJECTIVE: This study reports on the effects of laser acupuncture on blood pressure, body weight, and heart rate variability by stimulating acupuncture points and meridians on college students and faculty members. METHODS: Forty-five students and faculty members from a chiropractic college were recruited in the study. All subjects signed a written informed consent before their participation in the study. This study was a randomized controlled pilot study with subjects divided into control and experimental groups. The control group received a sham low-level laser therapy treatment with no power output to the laser during their “treatment.” The experimental group was treated with an activated laser. The acupuncture points used in this study were LI 4 and LI 11 for body weight and blood pressure. The treatment groups received 16 J of laser energy output for a total treatment time of 8 minutes (4 minutes for each of the 2 points).

RESULTS: After using the laser treatment for 90 days (at least 12 treatments per subject), both the systolic and diastolic blood pressures decreased significantly (P < .01). The mean systolic blood pressure was 129.6 +/- 14.7 mm Hg before the treatment and was reduced to 122.5 +/- 17.2 mm Hg (P < .001). The mean diastolic blood pressure was 85.6 +/- 8.0 mm Hg before treatment and was reduced to 77.2 +/- 8.7 mm Hg (P < .001). Subject’s body weight was reduced in the active acupoint group, but the weight reduction did not reach a significant level. There were no significant changes in the heart rate variability.

CONCLUSION: It was concluded that low-level laser treatment of acupoint resulted in lower blood pressure by stimulating the LI 11 and LI 4. No significant difference was observed in both the body weight and heart rate variability after the laser acupoint treatment.

Evid Based Complement Alternat Med. 2008 Nov 5. [Epub ahead of print]

# Ten Years Evidence-based High-Tech Acupuncture Part 3: A Short Review of Animal Experiments.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine and TCM Research Center Graz, Medical University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria. gerhard.litscher@meduni-graz.at.

### Abstract

High-tech acupuncture research has been performed for 10 years at the Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine at the Medical University of Graz. This article as a part of a series comprises animal experiments in the field of needle and laser acupuncture. The investigations presented in this article were performed in pigs, dogs and sheep. In all studies sedative stimulation effects of the acupoint Yintang are described using different measurement parameters (EEG-bispectral index, EEG spectral edge frequency and metabolic parameters).

Zhongguo Zhen Jiu. 2008 Sep;28(9):662-4.

# Observation on therapeutic effect of low energy He-Ne laser acupoint radiation on infantile cold

[Article in Chinese]

Zhou GY, Zhou GS, Zhang H.

Department of Rehabilitation Medicine, The First Affiliated Hospital of Xinxiang Medical College, Weihui, Henan 453100, China. zhouxiaoguo@yahoo.com.cn

OBJECTIVE: To search for an effective therapy for infantile cold.

METHODS: Two hundred and fifty-five cases were randomly divided into a laser group (n = 130) and a medication group (n = 125). The laser group were treated with lower energy He-Ne laser radiation at Tiantu (CV 22), Renying (ST 9), Dazhui (CV 14), Fengmen (BL 12), etc. and the medication group were treated mainly with oral administration of Amantadine tablets. The therapeutic effect was assessed after treatment of 5 days.

RESULTS: The laser group in alleviation of cough, nasal obstruction, rhinorrhea, sputum sound were significantly better than the medication group (P < 0.001, P < 0.01); the cured rate was 68.5% in the laser group and 42.4% in the medication group, the former being better than the latter (P < 0.001).

CONCLUSION: The low energy He-Ne laser acupoint radiation has a significant therapeutic effect on infantile cold.

Zhongguo Zhen Jiu. 2008 Apr;28(4):265-6.

# Observation on the therapeutic effect of acupuncture combined with He-Ne laser radiation on facial paralysis.

[Article in Chinese]

Hou YL, Li ZC, Ouyang Q, Li X, Li H, Zhao M.

Section of Physiotherapy, General Hospital of Beijing Military Area, Beijing 100700, China.

OBJECTIVE: To compare therapeutic effects of acupuncture combined with He-Ne laser radiation and western medicine on facial paralysis.

METHODS: Ninety-seven cases were randomly divided into an acupuncture with laser group (n=55) and a medication group (n=42). The acupuncture with laser group were treated by acupuncture at main points, Dicang (ST 4), Jiache (ST 6), Sibai (ST 2), Qianzheng, Xiaguan (ST 7), Yingxiang (LI 20), Yangbai (GB 14), Yuyao (EX-HN 4), Yifeng (TE 17), Hegu (LI 4), in combination with He-Ne laser radiation; the medication group were treated with routine western medicine including intravenous dripping of low molecular dextran, compound Danshen and ATP injections, intramuscular injection of VitB1 and VitB12 , and oral administration of oryzanol and prednisone. Seven days constituted one course. After two courses their therapeutic effects were observed.

RESULTS: The cured rate was 81.8% in the acupuncture with laser group and 45.20% in the medication group with a significant difference between the two groups(P<0.01).

CONCLUSION: The therapeutic effect of acupuncture combined with He-Ne laser radiation on facial paralysis is better than that of routine medication.

Med Pregl. 2008 Mar-Apr;61(3-4):123-30.

# Innovative approach to laser acupuncture therapy of acute obstruction in asthmatic children.

[Article in English, Serbian]

Nedeljkovi? M, Ljustina-Pribi? R, Savi? K.

Institut za onkologiju Vojvodine, Sremska Kamenica. nedeljkovic@neobee.net

A prospective randomized study encompassed 100 patients with asthma in the stage of acute bronchial obstruction, 7 to 17 years of age, of both sexes and with the similar rate of attack severity. The patients were spirometrically monitored (FVC, FEV1, PEF and FEF 25-75%) by a pediatrician-pulmonologist for 12 days. Fifty patients were subjected to conservative drug therapy, whereas other 50 patients additionally underwent the Su Jok therapy according to the 6-Ki principles, applying laser ray at the acupuncture points in the hand. After 12 days of treatment the group, in which both therapy methods were applied, reached the range of referent values for all investigated parameters. In the same period of time the group undergoing only conservative drug therapy retained values below the reference ones for the given age for 3 (FEV1, PEFR and FEF 25-75%) out of 5 investigated parameters. The obtained results differed from the group subjected to the combined therapy with the high rate of statistical significance. On the basis of the obtained results the efficacy of the 6-Ki technique of Su Jok therapy was confirmed as the therapeutic method supplementary to the conservative drug therapy in the treatment of acute bronchial obstruction in asthmatic children, provided that therapy is carried out in stationary conditions and under constant spirometric surveillance of the patient.

Photomed Laser Surg. 2008 Sep 11. [Epub ahead of print]

# Study of Autonomic Nervous Activity of Night Shift Workers Treated with Laser Acupuncture.

Wu JH, Chen HY, Chang YJ, Wu HC, Chang WD, Chu YJ, Jiang JA.

Department of Biomedical Engineering, Ming Chuan University, Da Chien General Hospital, Miaoli, Taiwan.

Abstract Objective: The aim of this study was to evaluate the impact of laser acupuncture on the autonomic nervous system (ANS) of the night shift worker.

Background Data: Many articles have demonstrated that levels of affective disorders and stress are high in night shift workers. We applied laser energy to the Neiguan point (PC6) to examine the impact of laser acupuncture on the ANS of 45 healthy young males who were night shift workers and evaluated their heart-rate variability (HRV).

Materials and Methods: The laser group (n = 15) received laser acupuncture (9.7 J/cm(2), 830 nm) for 10 min, and the placebo group (n = 15) received sham laser treatment. The effects before and after this intervention on the HRV of the subjects were assessed, along with those seen after 30 min of lying down. Results: After treatment and after the 30-min rest period, the independent-sample t-test showed that both groups exhibited statistically significant differences in high-frequency (HF) HRV, low-frequency (LF) HRV, and the LF:HF ratio of HRV (p < 0.05). Compared with the placebo group, the paired-samples t-test showed that after laser treatment the treatment group had a statistically significant improvement in HF HRV (p = 0.001), LF HRV (p = 0.001), and the LF:HF HRV ratio (p = 0.02).

Conclusions: Laser acupuncture stimulation applied to the Neiguan point increased vagal activity and suppression of cardiac sympathetic nerves. This effect was positive and could be used to help patients who have circadian rhythm disorders.

Lasers Med Sci. 2008 Sep 9. [Epub ahead of print]

# Effects of acupuncture at the Hoku acupoint on the pulsatile laser Doppler signal at the heartbeat frequency.

Hsiu H, Hsu WC, Hsu CL, Jan MY, Wang-Lin YY.

Department of Electrical Engineering, Yuan Ze University, 135 Yuan-Tung Road, Taoyuan, Taiwan, Republic of China, hhsiu@saturn.yzu.edu.tw.

We aimed to assess the effects of acupuncture by analyzing the alternating current (AC) component of skin blood-flow signals (around the heartbeat frequency) simultaneously recorded at the Hoku acupoint, which is an important acupoint in oriental medicine, and two nearby non-acupoints following acupuncture stimulation (AS). Laser Doppler flowmetry signals were measured in 28 experiments on nine volunteers. Each experiment involved the recording of a 20-min control-data sequence and two sets of effects data recorded 0-20 min and 50-70 min after the AS had been stopped. The direct current (DC) and AC components (DCflux and ACflux, respectively), pulse width (PW), and foot delay time (FDT) of the flux signal were calculated. The DCflux, ACflux, PW, and FDT were all significantly increased only at Hoku following AS. Regression analysis between the DCflux and ACflux revealed that the slope was largest (>1) at Hoku among the measurement sites. Our results indicated that both the DCflux and ACflux in the microcirculatory perfusion were increased by stimulation at the Hoku acupoint, with the change being greatest for the latter. Parameters calculated from the pulsatile flux waveform, such as the PW and FDT, could contribute to noninvasive evaluations of the sympathetic neural activities and of the improvement in perfusion following AS.

Med Pregl. 2008 Mar-Apr;61(3-4):123-30.

# Innovative approach to laser acupuncture therapy of acute obstruction in asthmatic children.

[Article in English, Serbian]

Nedeljkovi? M, Ljustina-Pribi? R, Savi? K.

Institut za onkologiju Vojvodine, Sremska Kamenica. nedeljkovic@neobee.net

A prospective randomized study encompassed 100 patients with asthma in the stage of acute bronchial obstruction, 7 to 17 years of age, of both sexes and with the similar rate of attack severity. The patients were spirometrically monitored (FVC, FEV1, PEF and FEF 25-75%) by a pediatrician-pulmonologist for 12 days. Fifty patients were subjected to conservative drug therapy, whereas other 50 patients additionally underwent the Su Jok therapy according to the 6-Ki principles, applying laser ray at the acupuncture points in the hand. After 12 days of treatment the group, in which both therapy methods were applied, reached the range of referent values for all investigated parameters. In the same period of time the group undergoing only conservative drug therapy retained values below the reference ones for the given age for 3 (FEV1, PEFR and FEF 25-75%) out of 5 investigated parameters. The obtained results differed from the group subjected to the combined therapy with the high rate of statistical significance. On the basis of the obtained results the efficacy of the 6-Ki technique of Su Jok therapy was confirmed as the therapeutic method supplementary to the conservative drug therapy in the treatment of acute bronchial obstruction in asthmatic children, provided that therapy is carried out in stationary conditions and under constant spirometric surveillance of the patient.

Zhongguo Zhen Jiu. 2008 Apr;28(4):265-6.

# Observation on the therapeutic effect of acupuncture combined with He-Ne laser radiation on facial paralysis.

[Article in Chinese]

Hou YL, Li ZC, Ouyang Q, Li X, Li H, Zhao M.

Section of Physiotherapy, General Hospital of Beijing Military Area, Beijing 100700, China.

OBJECTIVE: To compare therapeutic effects of acupuncture combined with He-Ne laser radiation and western medicine on facial paralysis.

METHODS: Ninety-seven cases were randomly divided into an acupuncture with laser group (n=55) and a medication group (n=42). The acupuncture with laser group were treated by acupuncture at main points, Dicang (ST 4), Jiache (ST 6), Sibai (ST 2), Qianzheng, Xiaguan (ST 7), Yingxiang (LI 20), Yangbai (GB 14), Yuyao (EX-HN 4), Yifeng (TE 17), Hegu (LI 4), in combination with He-Ne laser radiation; the medication group were treated with routine western medicine including intravenous dripping of low molecular dextran, compound Danshen and ATP injections, intramuscular injection of VitB1 and VitB12 , and oral administration of oryzanol and prednisone. Seven days constituted one course. After two courses their therapeutic effects were observed.

RESULTS: The cured rate was 81.8% in the acupuncture with laser group and 45.20% in the medication group with a significant difference between the two groups(P<0.01).

CONCLUSION: The therapeutic effect of acupuncture combined with He-Ne laser radiation on facial paralysis is better than that of routine medication.

Schmerz. 2008 Feb;22(1):9-15.

# Evidence for laser acupuncture in cases of orthopedic diseases: a systematic review.

[Article in German]

Schüller BK, Neugebauer EA.

Institut für Forschung in der operativen Medizin (IFOM), Fakultät für Medizin der Universität Witten/Herdecke, Ostmerheimer Str. 200, 51109, Köln, Deutschland.

BACKGROUND AND OBJECTIVES: The aim of this review is to evaluate the evidence for laser acupuncture in selected orthopaedic diseases.

MATERIAL AND METHODS: Randomized controlled studies, meta-analyses and systematic reviews were identified by a systematic search strategy in Medline and the Cochrane library. The studies were evaluated using the quality criteria of the Oxford Centre of Evidence Based Medicine.

RESULTS: For the selected orthopedic diseases (medial and lateral epicondylitis, myofascial pain syndrome of the neck, back and shoulder and osteoarthritis), meta-analyses, systematic reviews and eight randomized controlled studies were found. All other published studies used laser therapy without consideration of classical acupuncture points. All studies had significant drawbacks in methodological quality and the number of patients included. In more recent trials, improvement towards higher methodological quality was obvious. Although current evidence is equivocal, positive effects can be assumed in myofascial pain syndromes of the neck, back and shoulder. Laser acupuncture is advantageous in terms of side effects compared to classical acupuncture techniques.

CONCLUSION: Better, well designed randomized studies with higher power are mandatory in orthopedic diseases.

Pediatr Allergy Immunol. 2007 Mar;18(2):160-6.

# Laser acupuncture and probiotics in school age children with asthma: a randomized, placebo-controlled pilot study of therapy guided by principles of Traditional Chinese Medicine.

Stockert K, Schneider B, Porenta G, Rath R, Nissel H, Eichler I.

Austrian Society for Acupuncture, Huglgasse 1-3, Vienna, Austria. karin.stockert@gmx.at

Traditional Chinese Medicine (TCM) postulates an interaction between the lung as a Yin-organ and the large intestine as a Yang-organ. The aim of this pilot study was to investigate in asthmatic school age children whether treatment with laser acupuncture and probiotics according to TCM portends a clinical benefit to standard medical treatment performed according to pediatric guidelines. Seventeen children aged 6-12 yr with intermittent or mild persistent asthma were enrolled in this randomized, placebo-controlled, double-blind pilot study. Eight patients received laser acupuncture for 10 wk and probiotic treatment in the form of oral drops (living non-pathogenic Enterococcus faecalis) for 7 wk. Nine patients in the control group were treated with a laser pen which did not emit laser light and were given placebo drops. Peak flow variability (PFV) and forced expiratory volume in 1 s (FEV(1)) were measured and Quality of Life was assessed by a standardized questionnaire. Laser acupuncture and probiotics significantly decreased mean (standard deviation) weekly PFV as a measurement of bronchial hyperreactivity by -17.4% (14.2) in the TCM group vs. 2.2% (22.5) in the control group (p = 0.034). No significant effect was detected for FEV(1), Quality of Life criteria and additional medication. As an exploratory result, patients in the TCM group had fewer days of acute febrile infections when compared with the control group [1.14 (1.4) vs. 2.66 (2.5), p = 0.18]. In conclusion, this pilot study generates the hypothesis that the interactive treatment of lung and large intestine according to TCM by laser acupuncture and probiotics has a beneficial clinical effect on bronchial hyperreactivity in school age children with intermittent or mild persistent asthma and might be helpful in the prevention of acute respiratory exacerbations. These results should be confirmed by further studies.

Am J Chin Med. 2007;35(2):231-40.

# Appearance of human meridian-like structure and acupoints and its time correction by infrared thermal imaging.

Yang HQ, Xie SS, Hu XL, Chen L, Li H.

Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Institute of Laser and OptoElectronics Technology, Fujian Normal University, Fuzhou 350007, China.

The meridians and acupoints of human bodies at natural condition are investigated among 30 healthy volunteers by infrared thermal imaging technique. The results give clear evidence of the existence of infrared radiant tracks along human meridian courses. The time dependent evolution of the infrared radiant track is observed for the first time. The time rhythm of acupoints is also studied. Our findings not only support the view that infrared radiant tracks along human meridian courses is a normal vital and physiological phenomenon appearing in human beings, but also offer a potential method for noninvasive diagnostic by studying the physiological function and pathological change of meridians or acupoints by means of thermography.

Pain. 2007 Nov 15; [Epub ahead of print]

# Laser acupuncture in children with headache: A double-blind, randomized, bicenter, placebo-controlled trial.

Gottschling S, Meyer S, Gribova I, Distler L, Berrang J, Gortner L, Graf N, Shamdeen MG.

University Children’s Hospital, Department of Pediatric Hematology and Oncology, Saarland University, Kirrbergerstr., 66421 Homburg, Germany.

Rom J Intern Med. 2007;45(3):281-5.

# Biophysics behavior of acupuncture points irradiated with low energy lasers.

Moldovan C.

National Acupuncture & Homeopathy Centre, Bucharest, Romania. cornelmldvn@pcnet.ro

This work describes the Low Energy Laser (LEL) coherent light interaction with the skin cover on acupuncture loci for the purpose of detecting and measuring the spatial and temporal alteration of the thermal, electric and optical properties of the LI4 (HEGU) acupoint, irradiated with a 685 nm, 30 mW, III.B Laser. Novel electrostatic imaging technique, an original Acupuncture 3-D Thermal and Electric Mapping Technique and an original Method for Laser-Skin Reflectance, were used in the study. The results indicate that the visible laser light, with low frequency and low power, specifically modify the 3-D pattern of the temperature, electric potential and electric impedance outline of an acupuncture point, meanwhile with a significant decrease of the laser reflectance index, all measured on a 27 apparently healthy subject lot (48 years mean age, 54% male), when comparing with a non-active, non-acupunctural skin area, placed on the volar side of the same hand. The biophysical method presented, combines in a complex way and reproducible the electro stasis exploration (bioelectric homeostasis), with cutaneous thermodynamic exploration and photo-optical exploration of the derma and provides information that can be appreciated in dynamics and compared depending on the exploration target.

Am J Chin Med. 2007;35(5):743-52.

# Differences in optical transport properties between human meridian and non-meridian.

Yang HQ, Xie SS, Liu SH, Li H, Guo ZY.

Key Laboratory of Opto Electronic Science and Technology for Medicine of Ministry of Education, Institute of Laser and Optoelectronics Technology, Fujian Normal University, Fuzhou 350007, China.

This study is to present a new scheme for the detection of human meridian system non-invasively. The optical transport properties along the pericardium meridian and a non-meridian path about 1 cm away from the meridian were measured non- invasively on 20 healthy people in vivo. 633 nm, 658 nm and 785 nm red lasers were used for irradiation, and the diffuse light emittances at different points on meridian and non-meridian directions were collected respectively and compared. Our study suggested that the light propagation characteristics along both the meridian and non-meridian directions conformed to the Beer’s exponential attenuation law. Statistical analysis of the results suggested that the optical properties of human meridian differ from those of the surrounding tissue (p < 0.05), and the light attenuation is less when propagating along the pericardium meridian than along the non-meridian direction. These findings not only confirmed the objective existence of acupuncture meridians, but also shed new light on the understanding of meridians.

Photomed Laser Surg. 2007 Feb;25(1):21-5.

# Laser needle acupuncture at Neiguan (PC6) does not mediate heart rate variability in young, healthy men.

Hübscher M, Vogt L, Banzer W.

Department of Sports Medicine, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt/Main, Germany. m.huebscher@sport.uni-frankfurt.de

OBJECTIVE: The aim of this randomized, double-blinded, placebo-controlled trial was to evaluate specific effects of laser needle acupuncture at the Neiguan point (PC6) on sympathetic and parasympathetic nerve activity in healthy subjects using heart rate variability (HRV) analysis.

BACKGROUND DATA: Acupuncture at the Neiguan point (PC6) has been shown to modulate the autonomic nervous system.

METHODS: Forty-five healthy non-smoking males were randomly divided into a placebo group (n = 20) with no laser irradiation and into an intervention group (n = 25) for which laser needle irradiation (36.8 kJ/cm(2)) was performed on the right forearm. Monitoring of HRV was performed before, during, and after intervention.

RESULTS: Repeated-measures MANOVA did not show statistically significant main effects of time (F = 1.29, p = 0.27) or of group (F = 1.67, p = 0.16). The time by group interaction was also not statistically significant (F = 0.95, p = 0.54).

CONCLUSION: Our results suggest that heart rate variability was not influenced by laser needle acupuncture at the Neiguan point (PC6).

EMLA Laser Health J 2007;2:46-67
European Medical Laser Association (EMLA)L

# LaserNeedle in veterinary practice

A. Roesti.

Wimmis, Switzerland

LaserNeedle is a new non invasive optical acupuncture stimulation method. The father of the LaserNeedle technique is Prof. Dr. Dr. med G. Litscher from the biomedical technical Research institute for anaesthesia and intensive care at the University of Graz in Austria.

The utmost important advantage of the LaserNeedle System is, that you can treat 8 selected acupuncture points at the same time. LaserNeedle emits highly concentrated red and infrared coherent laser rays of 680 nm with a very high energetically density onto the acupuncture point (~4.6 kJ/cm 2 ) (Ø 20 min. of stimulation).

LaserNeedles are taped perpendicular to the acupuncture point of the skin. The red and infrared Laser light is transmitted through an optical cable to the acupuncture point. There we have very little reflection of the Laser rays. Each point to be treated is detected and selected with the RAC/VAS.

The effect of the LaserNeedle stimulation is the same as all the other conventional LLLasers. Especially the stimulation of the vegetative nerve system, with neuromodulating effect. They reduce significantly pain, resolves muscular spasms and increase post operative mobility. It stimulates the microcirculation and the immune system By means of the Laser Needle the consumption of drugs and anti-inflammatory medicaments could be reduced significantly. The indication of LaserNeedle is the same as all other LLLT.

Crit Rev Biomed Eng. 2007;35(3-4):183-95.

# Bioengineering assessment of acupuncture, part 7: heart rate variability.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine and Traditional Chinese Medicine (TCM Research Center), Medical University of Graz, Graz, Austria. gerhard.litscher@medunigraz.at

### Abstract

In the seventh part of this review article, preliminary research on the topic of acupuncture and heart rate variability is described. Heart rate variability (HRV) refers to the beat-to-beat alterations in heart rate. Under resting conditions, the electrocardiograms of healthy people exhibit periodic variations in the percentage change in sequential chamber complexes (RR-intervals). The parameter HRV is modulated by the blood-pressure control-system, influences from the hypothalamus, and, in particular, the vagal cardiovascular center in the lower brainstem. This review article contains a short summary of scientific literature on HRV and acupuncture.

Lasers Med Sci. 2007 Mar;22(1):37-41. Epub 2006 Nov 21.

# High-intensity laser for acupuncture-like stimulation.

Zeredo JL, Sasaki KM, Toda K.

Division of Integrative Sensory Physiology, Department of Developmental and Reconstructive Medicine, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki, 852-8588, Japan. jorge@nagasaki-u.ac.jp

The insertion of needles into specific parts of the body was shown to provide analgesic and therapeutic effects. In this study, we tested the analgesic effects of high-intensity infrared laser for acupuncture-like stimulation. Twelve adult Sprague-Dawley rats weighing 230 to 250 g were randomly assigned to laser, needle, or restraint groups. Stimulation was directed to the meridian point Taixi (KI 3) for 10 min. For laser stimulation, a pulsed Er:YAG system was used. The laser settings were adjusted to provide a focal raise in the skin temperature to about 45 degrees C. The anti-nociceptive effect was evaluated by the tail-flick test. Both needling and laser stimulation significantly increased the tail-flick latency. Peak needling effect was observed immediately after treatment, while laser stimulation was effective both immediately and 45 min after treatment. High-intensity laser stimulation may be used alternatively or in combination with conventional acupuncture needling for pain relief.

Photomed Laser Surg. 2006 Oct;24(5):575-80.

# Short-time effects of laser needle stimulation on the peripheral microcirculation assessed by laser Doppler spectroscopy and near-infrared spectroscopy.

Banzer W, Hübscher M, Seib M, Vogt L.

Department of Sports Medicine, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt/Main, Germany. banzer@sport.uni-frankfurt.de

OBJECTIVE: The aim of the present study was to evaluate immediate effects of a standardized laser needle stimulation over a defined acupuncture point on the microvascular blood flow and muscle oxygenation in the human forearm.

BACKGROUND DATA: Recently, it has been shown that laser stimulation improves tissue perfusion. This is relevant since adequate blood supply is an important factor in the treatment of pain syndromes.

METHODS: The study was designed as a randomized, double-blinded, placebo-controlled trial. Thirty-three healthy non-smoking males were randomly assigned to a control group (n = 15) with no laser irradiation and to an intervention group (n = 18) for which laser needle irradiation was performed on the right forearm at acupuncture point Pe6. Non-invasive blood flow measurements (laser Doppler spectroscopy [LDS]) were performed before, during, and after intervention. Additionally, the dynamic changes in muscle oxygenation of the m. flexor carpi ulnaris were investigated using near-infrared spectroscopy (NIRS).

RESULTS: Repeated measures MANOVA demonstrated a statistically significant interaction between time and group (p = 0.034, effect size = 0.39), indicating that peripheral blood flow was influenced by laser needle application. In contrast, tissue oxygenation was not affected by the experimental treatment.

CONCLUSION: It has been demonstrated that laser needle stimulation may improve peripheral microcirculation under standardized conditions, whereas tissue oxygenation remained unchanged. Further research is required to determine the influence of various parameter settings and irradiation treatments on the peripheral microcirculation. Moreover, different acupuncture points should be investigated in order to appraise the clinical effectiveness of laserneedle stimulation.

Crit Rev Biomed Eng. 2007;35(1-2):1-36.

# Bioengineering assessment of acupuncture, Part 6: monitoring–neurophysiology.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Graz, Austria.

### Abstract

Neurophysiological monitoring using spontaneous and evoked bioelectrical brain activities provides functional assessment of the central nervous system. This sixth part of the review article summarizes results from electroencephalographic and evoked potential monitoring in connection with acupuncture. The article reflects the impact of new techniques on acupuncture research (e.g., 600 Hz oscillations). Although numerous questions concerning acupuncture remain still unsolved, the present findings could be a further step to discover the complex mechanisms underlying the effects of acupuncture.

Anesth Analg. 2006 Jun;102(6):1745-51.

# Electroencephalogram–entropy and acupuncture.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Graz, Austria. gerhard.litscher@meduni-graz.at

### Abstract

Computer-based measuring of the level of sedation and hypnosis is difficult and has proven to be challenging. The electroencephalogram (EEG) has been proposed as a potential method. Response entropy (RE) and state entropy (SE) are multifactor, dimensionless parameters of a new technology of EEG monitoring, and we investigated them for the first time in acupuncture research within this study. Both parameters have been alleged to reflect changes in the clinical state of sedation. Two different acupuncture schemes were tested in a randomized crossover trial with nine healthy volunteers (mean age +/- sd, 28.8 +/- 3.6 yr; 25-36 yr). Applying and stimulating acupuncture needles or performing laserneedle acupuncture at special sedation points decreased RE and SE significantly (P < or = 0.01; paired t-test) compared with the reference interval before acupuncture. In contrast, acupuncture of points for increasing “Qi-energy” did not decrease parameters of entropy. Specific acupuncture schemes produce specific, reproducible, and quantifiable effects on entropy parameters in the EEG. Therefore, entropy measurements during acupuncture seem to be worthy of further evaluation with a larger series of subjects.

Crit Rev Biomed Eng. 2006;34(6):439-57.

# Bioengineering assessment of acupuncture, part 5: cerebral near-infrared spectroscopy.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Graz, Austria. gerhard.litscher@meduni-graz.at

### Abstract

The assessment of cortical activation in the brain due to acupuncture is crucial. Thus far functional assessment of cortical responses to certain external stimuli (for examples, manual needle, optical, electrical) are very few due to the lack of suitable techniques to monitor changes of brain activities. Near-infrared spectroscopy has been found to be suitable for functional studies during acupuncture. By this neuromonitoring method, hemodynamic changes coupled to cortical activity can be monitored. Near-infrared spectroscopy is used to measure regional changes in oxyhemoglobin, deoxyhemoglobin, and cytochrome aa3 noninvasively and continuously. The studies in this fifth part of a review article, which have been carried out mainly by the research group of Biomedical Engineering in Anesthesia and Intensive Care Medicine at the Medical University of Graz, demonstrate that near-infrared spectroscopy is a suitable technique for the assessment of cortical changes in response to varying forms of acupuncture. The method is likely to play an important role in providing new insights into the effects of acupuncture on brain function.

Crit Rev Biomed Eng. 2006;34(4):327-45.

# Bioengineering assessment of acupuncture, part 4: functional magnetic resonance imaging.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz, Graz, Austria. gerhard.litscher@meduni-graz.at

### Abstract

In the fourth part of this review article, research on the topic of acupuncture and functional magnetic resonance imaging is described. Needle as well as painless laserneedle stimulation have led to significant changes in different areas of the brain. With the help of modern biomedical engineering equipment and neuroscience, some of acupuncture’s secrets have begun to be revealed. The neuro-modulating effects require further investigation in a larger population sample.

Crit Rev Biomed Eng. 2006;34(4):295-326.

# Bioengineering assessment of acupuncture, part 3: ultrasound.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz, Graz, Austria. gerhard.litscher@meduni-graz.at

### Abstract

Multidirectional transcranial ultrasound monitoring can be used to prove quantifiable effects of acupuncture stimulation in the brain. This third part of the review article gives a short introduction in monitoring cerebral blood flow velocity and summarizes the scientific results in this area of research. New constructions from the Medical University of Graz that can be used for evidence-based computer-controlled acupuncture are described. With these new methods and concepts, reproducible effects of needle and laserneedle acupuncture stimulation in cerebral blood flow velocity can be objectified for the first time.

Crit Rev Biomed Eng. 2006;34(4):273-94.

# Bioengineering assessment of acupuncture, part 2: monitoring of microcirculation.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz, Graz, Austria. gerhard.litscher@meduni-graz.at

### Abstract

In the second part of the review article, monitoring of microcirculation during acupuncture is described. Laser Doppler flowmetry and laser Doppler imaging provide easy-to-use, noninvasive, real-time measurements of local tissue blood flow. Using these types of biomedical equipment, it is possible to quantify and objectify peripheral changes in microcirculation during different methods of acupuncture stimulation (manual needle acupuncture and laserneedle acupuncture).

Crit Rev Biomed Eng. 2006;34(1):1-22.

# Bioengineering assessment of acupuncture, part 1: thermography.

Litscher G.

Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Medical University of Graz, Graz, Austria. gerhard.litscher@meduni-graz.at

### Abstract

In Western society, acupuncture is becoming a popular complementary method to medical treatment. However, a scientific understanding of acupuncture has not been completely developed but will absolutely be necessary for the increased acceptance of acupuncture by the Western medical community. This first part of the review article describes, in a general introduction, milestones of acupuncture research within the last 30 years and in a specific part the possibilities and limitations of infrared thermography, a noninvasive biomedical engineering method, within acupuncture research.

Conf Proc IEEE Eng Med Biol Soc. 2006;1:4107-10.

# Design of the laser acupuncture therapeutic instrument.

Li C, Zhen H.

Sch. of Electr. Eng. & Autom., Harbin Inst. of Technol., China. chengweili@hit.edu.cn

Laser acupuncture is defined as the stimulation of traditional acupuncture points with low-intensity, non-thermal laser irradiation. It has been well applied in clinic since the 1970s; however, some traditional acupuncture manipulating methods still cannot be implemented in the design of this kind of instruments, such as lifting and thrusting manipulating method, and twisting and twirling manipulating method, which are the essential acupuncture method in traditional acupuncture. The objective of this work was to design and build a low cost portable laser acupuncture therapeutic instrument, which can implement the two essential acupuncture manipulating methods. Digital PID control theory is used to control the power of laser diode (LD), and to implement the lifting and thrusting manipulating method. Special optical system is designed to implement twisting and twirling manipulating method. M5P430 microcontroller system is used as the control centre of the instrument. The realization of lifting and thrusting manipulating method and twisting and twirling manipulating method are technological innovations in traditional acupuncture coming true in engineering.

Biomed Eng Online. 2005 Jun 15;4(1):38.

# Infrared thermography fails to visualize stimulation-induced meridian-like structures.

Litscher G.

Biomedical Engineering and Research in Anesthesia and Intensive Care Medicine, Medical University of Graz, Austria. gerhard.litscher@meduni-graz.at

BACKGROUND: According to Traditional Chinese Medicine (TCM) the vital energy flows through a system of channels also called meridians. Generally accepted proof for meridians cannot be considered as being given. Goal of this study was to examine whether possible stimulation-induced meridian-like structures, as recently described by other authors, can be visualized and objectified simultaneously at different infrared wavelength ranges.

METHODS: The study analyses evidence for the existence of acupuncture-specific, meridian-like artifacts in 6 healthy volunteers (mean age +/- SD 28.7 +/- 3.7 years; range 25 – 35 years). Two infrared cameras at different wavelength ranges were used for thermographic control of possible stimulation effects (moxibustion-cigar, infrared warmth stimulation, needle and laserneedle stimulation). In addition to thermography, temperature and microcirculatory parameters were registered at a selected point using laser-Doppler flowmetry.

RESULTS AND CONCLUSION: After moxibustion (or infrared light stimulation) of the body at 2 – 5 microm and 7.5 – 13 microm ranges, different structures appear on thermographic images of the human body which are technical artifacts and which are not identical to what are known as meridians in all textbooks of TCM. Further scientific studies are required regarding the possible visualization of meridians.

Neurol Res. 2005 Jun;27(4):423-8.

# An NIRS matrix for detecting and correcting cerebral oxygen desaturation events during surgery and neuroendovascular procedures.

Schwarz G, Litscher G, Delgado PA, Klein GE.

Department of Anesthesiology and Critical Care, Medical University of Graz, Austria. gerhard.schwarz@meduni-graz.at

BACKGROUND: Transcranial cerebral oximetry was developed for early detection of cerebral hypoxia and to avoid cerebral dysfunctions. However, near infrared spectroscopy (NIRS) data obtained during surgery are subject to intrinsic and extrinsic influences that have to be accounted for when interpreting the recordings.

METHODS: We developed an NIRS matrix to provide brief information for specific intervention to correct changes of cerebral oxygen saturation (COS). Selected vital data and the descriptors of cerebrovascular and neurofunctional status were linked to logistic chains.

RESULTS: The matrix is horizontally and vertically grouped and contains five descriptors: 1. change of COS; 2. key variable (parameter related to the change of COS); 3. associated parameters (vital data that do not cause COS alterations); 4. interpretation of values or preconditions most probably due to COS changes; and 5. the intervention most likely to normalize the COS or return it to baseline. The descriptors are grouped horizontally to a logistics chain.

CONCLUSION: The modular expandable NIRS matrix we describe has promise for clinical use in surgical, neurointerventional, and anaesthesiological contexts.

Lasers Med Sci. 2005 Sep;20(2):68-73. Epub 2005 Jul 1.

# Laser acupuncture induced specific cerebral cortical and subcortical activations in humans.

Siedentopf CM, Koppelstaetter F, Haala IA, Haid V, Rhomberg P, Ischebeck A, Buchberger W, Felber S, Schlager A, Golaszewski SM.

Department of Radiology II, University Hospital of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. christian.siedentopf@fmri-easy.de

As recent studies demonstrated, acupuncture can elicit activity in specific brain areas. This study aims to explore further the central effect using laser acupuncture. We investigated the cerebral effects of laser acupuncture at both acupoints GB43 with functional magnetic resonance imaging (fMRI). As a control condition the laser was mounted at the same acupoints but without application of laser stimulation. The group results showed significant brain activations within the thalamus, nucleus subthalamicus, nucleus ruber, the brainstem, and the Brodmann areas 40 and 22 for the acupuncture condition. No significant brain activations were observed within the placebo condition. The activations we observed were laser acupuncture-specific and predominantly ipsilateral. This supports the assumption that acupuncture is mediated by meridians, since meridians do not cross to the other side. Furthermore, we could show that laser acupuncture allows one to design a pure placebo condition.

Forsch Komplementarmed Klass Naturheilkd. 2005 Aug;12(4):190-5. Epub 2005 Aug 29.

# Increases of intracranial pressure and changes of blood flow velocity due to acupressure, needle and laser needle acupuncture?

[Article in German]

Litscher G, Wang L, Schwarz G, Schikora D.

Biomedizintechnische Forschung in Anästhesie und Intensivmedizin, Medizinische Universität Graz, Osterreich. gerhard.litscher@meduni-graz.at

### Abstract

BACKGROUND: Pressure on the acupoints St.7 and SJ.22 can lead to significant, reversible increases in intracranial pressure (ICP) in patients with elevated ICP.

OBJECTIVE: In this study, we investigated whether changes in cerebral parameters in healthy volunteers can also be registered, when the mentioned acupoints associated with ICP, are stimulated.

SUBJECTS AND METHODS: We investigated a total of 34 volunteers (24 females, 10 males) and a 15-year-old intensive care patient after severe head injury. The mean age of volunteers was 25.2 +/- 3.4 years (range 20-35). Stimulation was performed using acupressure techniques, manual needle and laser needle methods. We evaluated the main parameter of mean blood flow velocity in the middle cerebral artery (left and right) as well as the pulsatility index. In addition, near infrared spectroscopy and blood pressure parameters were registered.

RESULTS: Acupressure, manual needle acupuncture and laser needle acupuncture partially led to significant changes in the main goal values.

CONCLUSION: Acupressure as well as acupuncture (needle and laser needle) can evoke reproducible functional changes in the brain. These accompanying effects are not to be ignored, in particular in patients with increased ICP.

Acupunct Med. 2005 Mar;23(1):31-3.

# The use of laser acupuncture for the treatment of neurogenic pruritus in a child–a case history.

Stellon A.

stellon@btinternet.com

### Abstract

This report describes the successful treatment using laser acupuncture of a six year old girl with neurogenic pruritus of the abdomen. It is the first case report of neurogenic pruritus treated by laser acupuncture. The main advantage of using low energy laser, as opposed to acupuncture needles, to stimulate points, is that low energy laser causes little or no sensation, which is particularly useful when treating children.

Neurol Res. 2004 Sep;26(6):698-701.

# Pseudoparadoxical dissociation of cerebral oxygen saturation and cerebral blood flow velocity after acupuncture in a woman with cerebrovascular dementia: a case report.

Schwarz G, Litscher G, Sandner-Kiesling A.

Department of Anaesthesiology for Neurosurgical and Craniofacial Surgery and Intensive Care, Medical University of Graz, Austria. gerhard.schwartz@uni-graz.at

Acupuncture can increase both cerebral oxygen saturation and cerebral blood flow velocity. We describe a 77-year-old woman with cerebrovascular dementia in whom acupuncture reproducibly induced an increase of blood flow velocity but a decrease of regional oxygen saturation. At four of 11 acupuncture sessions, blood flow velocity was measured in the middle cerebral artery with transcranial Doppler sonography and cerebral regional oxygen saturation (rSO(2)) with transcranial near infrared spectroscopy. Cerebral blood flow velocity increased by an average of 20% (range: 7-27%) at all four study points whereas rSO(2) consistently decreased by an average of 7% (range: 4-13%). Clinical status and cognitive function improved. These findings in a patient with vascular dementia may suggest increased oxygen extraction by activated neuronal structures.

Lik Sprava. 2004 Oct-Nov;(7):88-91.

# Eclecticism in medicine.

[Article in Russian]

Macheret EL, Chervonny? IP, Kovalenko OE, Kireev VV, Chuprina GN.

### Abstract

Last years saw a series of publications published in different medical editions, concerning an application sphere of physiotherapy. These publications cast doubt on reflexotherapy as an independent medical discipline. New term physiopuncture was proposed in such publications, actually it is a try terminologically and in practice to substitute acupuncture and its methods (i.e. reflexotherapy) by an other medical specialty physiotherapy. The article does not call physiotherapy in question as a specialty itself, but conclude, that such forcible attribution of the reflexotherapy’s methods to physiotherapy’s is not acceptable. All physical influences on the acupuncture’s points (laserpuncture, electropuncture, shortwave frequency puncture and others) even that being used barely through metameric principle in accordance with WHO recommendations should be referred to the sphere of reflexotherapy.

Biomed Tech (Berl). 2004 May;49(5):106-10.

# Quantification of gender specific thermal sensory and pain threshold before and after laser needle stimulation.

[Article in German]

Litscher G, Wang L, Huber E, Schikora D, Schwarz G.

Abteilung für Biomedizintechnische Forschung in Anästhesie und Intensivmedizin, Medizinische Universität Graz, Osterreich. gerhard.litscher@meduni-graz.at

### Abstract

Quantitative thermal sensory and pain threshold testing (QST) was performed in 29 adult healthy volunteers (mean age 24.2 +/- 2.7 years; range: 18-29 years; 20 females, 9 males) using the Thermal Sensory Analyser TSA-II (Medoc Advanced Medical Systems, Ramat Yishai, Israel, and Minneapolis, Minnesota, USA) before and after laser needle acupuncture and placebo stimulation, respectively. Significant (p < or = 0,001; t-test) gender-specific differences were seen on cold pain threshold analysis. No significant changes in parameters of thermal sensory and pain thresholds were found before and after laser needle or placebo stimulation at acupuncture points for acute pain. However, a trend towards change in the median value of cold pain sensation after laser needle stimulation (p = 0.479; paired t-test; n.s.) was seen within the group of healthy females. The influence of stimulation of acupuncture points for chronic pain on the various parameters needs to be clarified in future studies.

Lasers Med Sci. 2004;19(2):69-80.

# Laser acupuncture: past, present, and future.

Whittaker P.

Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.

Laser acupuncture is defined as the stimulation of traditional acupuncture points with low-intensity, nonthermal laser irradiation. Although the therapeutic use of laser acupuncture is rapidly gaining in popularity, objective evaluation of its efficacy in published studies is difficult because treatment parameters such as wavelength, irradiance, and beam profile are seldom fully described. The depth of laser energy transmission, likely an important determinant of efficacy, is governed not only by these parameters, but also by skin properties such as thickness, age, and pigmentation-factors which have also received little consideration in laser acupuncture. Despite the frequently equivocal nature of the published laser studies, recent evidence of visual cortex activation by laser acupuncture of foot points, together with the known ability of laser irradiation to induce cellular effects at subthermal thresholds, provides impetus for further research.

Lasers Med Sci. 2004;19(1):6-11. Epub 2004 Mar 31.

# Acupuncture using laser needles modulates brain function: first evidence from functional transcranial Doppler sonography and functional magnetic resonance imaging.

Litscher G, Rachbauer D, Ropele S, Wang L, Schikora D, Fazekas F, Ebner F.

Department of Biomedical Engineering and Research in Anesthesia and Critical Care, Medical University of Graz, Auenbruggerplatz 29, 8036, Austria. gerhard.litscher@meduni-graz.at

### Abstract

Acupuncture using laser needles is a new totally painless stimulation method which has been described for the first time. This paper presents an experimental double-blind study in acupuncture research in healthy volunteers using a new optical stimulation method. We investigated 18 healthy volunteers (mean age +/- SD: 25.4 +/- 4.3 years; range: 21-30 years; 11 female, 7 male) in a randomized controlled cross-over trial using functional multidirectional transcranial ultrasound Doppler sonography (fTCD; n = 17) and performed functional magnetic resonance imaging (fMRI) in one volunteer. Stimulation of vision-related acupoints resulted in an increase of mean blood flow velocity in the posterior cerebral artery measured by fTCD [before stimulation (mean +/- SE): 42.2 +/- 2.5; during stimulation: 44.2 +/- 2.6; after stimulation: 42.3 +/- 2.4 cm/s, n.s.]. Mean blood flow velocity in the middle cerebral artery decreased insignificantly. Significant changes (p < 0.05) of brain activity were demonstrated in the occipital and frontal gyrus by fMRI. Optical stimulation using properly adjusted laser needles has the advantage that the stimulation cannot be felt by the patient (painless and no tactile stimulation) and the operator may also be unaware of whether the stimulation system is active. Therefore true double-blind studies in acupuncture research can be performed.

Urologe A. 2004 Jul;43(7):803-6

# Laser acupuncture as third-line therapy for primary nocturnal enuresis.  First results of a prospective study.

[Article in German]

Heller G, Langen PH, Steffens J.

Klinik für Urologie und Kinderurologie, St.-Antonius-Hospital Eschweiler.iliafide@aol.com

Laser acupuncture is a painless, non-invasive, and cost effective treatment for children with therapy resistant monosymptomatic nocturnal enuresis. This kind of acupuncture is an alternative treatment with positive results. Currently, we are treating 24 children (22 males, 2 females) out of a planned 200 children aged between 5 and 12 years. These patients have had a classic monosymptomatic nocturnal enuresis. Up to now, school medicine therapy has been unsuccessful. Over 3 months, we treated the children once a week with acupuncture, inserting at the following points: medial Ren 3, bilateral Ma 36, bilateral Mi 6, bilateral Bl 33, medial Ren 6, medial Ex B5.A better enuresis frequency was achieved in 21 out of the 24 children (87.5%). Before the end of the 12th treatment, six of the 24 children (25%) were completely dry and 16 (66.6%) had an enuresis frequency reduced by more than half after the 12th treatment.

Eur J Anaesthesiol. 2004 Jan;21(1):13-9.

# Effects of acupressure, manual acupuncture and Laserneedle acupuncture on EEG bispectral index and spectral edge frequency in healthy volunteers.

Litscher G.

University of Graz, Department of Biomedical Engineering and Research in Anesthesia and Intensive Care, Graz, Austria. gerhard.litscher@uni-graz.at

### Abstract

BACKGROUND AND OBJECTIVE: The main purpose of this study was to investigate the effects of sensory (acupressure and acupuncture) and optical stimulation (Laserneedle acupuncture) on electroencephalographic bispectral index, spectral edge frequency and a verbal sedation score.

METHODS: Twenty-five healthy volunteers (mean age +/- SD: 25.5 +/- 4.0yr) were investigated during the awake state. The acupuncture point Yintang and a placebo control point were stimulated. The study was performed as a randomized, controlled and partly blinded cross-over trial.

RESULTS: Bispectral index and spectral edge frequency values both decreased significantly (P < 0.001) during acupressure on Yintang to values of 62.9 (minimum 35) +/- 13.9 bispectral index and to 13.3 (minimum 2.9) +/- 8.1 Hz (spectral edge frequency right) and 13.8 (minimum 2.7) +/- 7.3 Hz (spectral edge frequency left), respectively. Bispectral index was also significantly (P < 0.05) affected by Laserneedle acupuncture and acupressure on the control point but the changes were not clinically relevant, 95.4 +/- 4 and 94.2 +/- 4.8, respectively. All interventions significantly (Yintang: P < 0.001; control point: P < 0.012) reduced verbal sedation score.

CONCLUSIONS: The study highlights the electroencephalographic similarities of acupressure induced sedation and general anaesthesia as assessed by bispectral index and spectral edge frequency.

Lasers Med Sci. 2004;19(1):6-11. Epub 2004 Mar 31.

# Acupuncture using laser needles modulates brain function: first evidence from functional transcranial Doppler sonography and functional magnetic resonance imaging.

Litscher G, Rachbauer D, Ropele S, Wang L, Schikora D, Fazekas F, Ebner F.

Department of Biomedical Engineering and Research in Anesthesia and Critical Care, Medical University of Graz, Auenbruggerplatz 29, 8036, Austria. gerhard.litscher@meduni-graz.at

Acupuncture using laser needles is a new totally painless stimulation method which has been described for the first time. This paper presents an experimental double-blind study in acupuncture research in healthy volunteers using a new optical stimulation method. We investigated 18 healthy volunteers (mean age +/- SD: 25.4 +/- 4.3 years; range: 21-30 years; 11 female, 7 male) in a randomized controlled cross-over trial using functional multidirectional transcranial ultrasound Doppler sonography (fTCD; n = 17) and performed functional magnetic resonance imaging (fMRI) in one volunteer. Stimulation of vision-related acupoints resulted in an increase of mean blood flow velocity in the posterior cerebral artery measured by fTCD [before stimulation (mean +/- SE): 42.2 +/- 2.5; during stimulation: 44.2 +/- 2.6; after stimulation: 42.3 +/- 2.4 cm/s, n.s.]. Mean blood flow velocity in the middle cerebral artery decreased insignificantly. Significant changes (p < 0.05) of brain activity were demonstrated in the occipital and frontal gyrus by fMRI. Optical stimulation using properly adjusted laser needles has the advantage that the stimulation cannot be felt by the patient (painless and no tactile stimulation) and the operator may also be unaware of whether the stimulation system is active. Therefore true double-blind studies in acupuncture research can be performed.

Biomed Tech (Berl). 2004 Jan-Feb;49(1-2):2-5.

# Histological investigation of the micromorphological effects of the application of a laser needle–results of an animal experiment.

[Article in German]

Litscher G, Nemetz W, Smolle J, Schwarz G, Schikora D, Uranüs S.

Abteilung für Biomedizintechnische Forschung in Anästhesie und Intensivmedizin, Medizinische Universität Graz. gerhard.litscher@meduni-graz.at

In an experimental animal study (Sus scrofa domesticus) we investigated the effects of the new technique of laser needle stimulation (wavelength: 685 nm; energy density: 4.6 kJ/cm2 per point; application duration: 20 min). The results revealed changes in microcirculatory parameters of the skin resulting in an increase in blood flow. However, the quality and intensity of the laser light did not induce micromorphological alterations in the skin.

Eur J Anaesthesiol. 2004 Jan;21(1):13-9.

# Effects of acupressure, manual acupuncture and Laserneedle acupuncture on EEG bispectral index and spectral edge frequency in healthy volunteers.

Litscher G.

University of Graz, Department of Biomedical Engineering and Research in Anesthesia and Intensive Care, Graz, Austria. gerhard.litscher@uni-graz.at

BACKGROUND AND OBJECTIVE: The main purpose of this study was to investigate the effects of sensory (acupressure and acupuncture) and optical stimulation (Laserneedle acupuncture) on electroencephalographic bispectral index, spectral edge frequency and a verbal sedation score.

METHODS: Twenty-five healthy volunteers (mean age +/- SD: 25.5 +/- 4.0yr) were investigated during the awake state. The acupuncture point Yintang and a placebo control point were stimulated. The study was performed as a randomized, controlled and partly blinded cross-over trial.

RESULTS: Bispectral index and spectral edge frequency values both decreased significantly (P < 0.001) during acupressure on Yintang to values of 62.9 (minimum 35) +/- 13.9 bispectral index and to 13.3 (minimum 2.9) +/- 8.1 Hz (spectral edge frequency right) and 13.8 (minimum 2.7) +/- 7.3 Hz (spectral edge frequency left), respectively. Bispectral index was also significantly (P < 0.05) affected by Laserneedle acupuncture and acupressure on the control point but the changes were not clinically relevant, 95.4 +/- 4 and 94.2 +/- 4.8, respectively. All interventions significantly (Yintang: P < 0.001; control point: P < 0.012) reduced verbal sedation score.

CONCLUSIONS: The study highlights the electroencephalographic similarities of acupressure induced sedation and general anaesthesia as assessed by bispectral index and spectral edge frequency.

Neurol Res. 2003 Oct;25(7):722-8.

# Cerebral and peripheral effects of laser needle-stimulation.

Litscher G.

Department of Biomedical Engineering and Research in Anesthesia and Critical Care, University of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria. gerhard.litscher@uni-graz.at

This study comprises scientific-theoretic fundamental investigations of laserneedle technology, a new and painless method of acupuncture stimulation. Laserneedles are not inserted in the skin, but are merely placed on the surface of the acupuncture point. The study documents the significant changes in peripheral microcirculation (p = 0.005) and surface temperature of the skin (p = 0.02) induced by laser, in 22 healthy volunteers (mean age 24.4 +/- 2.6 years). In addition, a randomised cross-over study to characterise the specific changes in cerebral blood flow velocity with laserneedle acupuncture (p < 0.001) is presented. These results provide important information for characterising the effects of laserneedle acupuncture.

Med Pregl. 2003 Sep-Oct;56(9-10):413-8.

# Low power laser biostimulation in the treatment of bronchial asthma.

[Article in Serbian]

Milojevi? M, Kuruc V.

Institut za plu?ne bolesti, Sremska Kamenica, Medicinski fakultet, Novi Sad. drmilojevic@yahoo.com

### Abstract

INTRODUCTION: Modern concept of acupuncture is based on the fact there are designated locations on the surface of human body, which are related to integrative systems of an organism by means of sensory nerves, correlating and synchronizing organ functioning, depending on external and internal conditions, by means of nervous and neurohumoral regulation of metabolic and regenerative processes, including also mobilisation of immunological, protective and antistress reactions. Apart from standard needle acupuncture, other methods of stimulating acupuncture points are also applied. Due to invention of low power lasers, irradiation laser acupuncture has been introduced into routine medical practice, characterised by painless and aseptic technique and outstanding clinical results.

MATERIAL AND METHODS: The investigation was aimed at defining therapeutic effects of low power laser irradiation by stimulating acupuncture points or local treatment of asthma. A prospective analysis included 50 patients treated at the Institute of Pulmonary Diseases in Sremska Kamenica during 2000, 2001 and 2002. Together with conservative treatment of present disease, these patients were treated with laser stimulation of acupuncture points in duration of ten days. During treatment changes of functional respiratory parameters were recorded. Results were compared with those in the control group. The control group consisted of the same number of patients and differed from the examination group only by not using laser stimulation.

RESULTS: Patients with bronchial asthma presented with significant improvement (p < 0000,5) of all estimated lung function parameters just 30 minutes after laser stimulation. Improvements achieved on the third and the tenth day of treatment were significantly higher (p < 0.001 to p < 0.00005) in the examination group in comparison with the control group. Further investigation confirmed that improvement of measured lung function parameters was significantly higher in younger patients, in patients whose disease lasted shorter, as well as in women. Patients with asthma, who were treated every three months for a one year period, presented with significantly lower frequency and intensity of attacks.

DISCUSSION: The mechanism of laser stimulation activity in treatment of bronchial asthma is explained in detail, correlating our results to those obtained by other authors.

CONCLUSIONS: A ten-day course of low-power laser stimulation of acupuncture points in patients with bronchial asthma improves both the lung function and gas exchange parameters. Positive effects of laser treatment in patients with bronchial asthma are achieved in a short time and they last long, for several weeks, even months. Successive laser stimulation in asthmatics prolongs periods of remission and decreases the severity of asthmatic attacks. Better positive effects of laser stimulation are achieved in younger asthmatics, in those with shorter disease history and in female patients. There is a negative correlation between effects of laser stimulation and patients’ age and disease history. However, these characteristics do not affect response rate and speed but positive laser stimulation effects are achieved in a shorter period in female asthmatics.

Acta Obstet Gynecol Scand. 2003 Jan;82(1):69-73.

# Laser acupuncture and low-calorie diet during visceral obesity therapy after menopause.

Wozniak P, Stachowiak G, Piêta-Doliñska A, Oszukowski P.

Specialistic Outpatient Clinics of Obstetrics and Female Diseases, Polish Mother’s Memorial Hospital, Research Institute, Lód, Poland. wozniak@mazurek.man.lodz.pl

BACKGROUND: To compare the efficiency of low-calorie diet and low-calorie diet applied together with laser acupuncture in the therapy of visceral obesity in postmenopausal women.

METHODS: The study population consisted of 74 postmenopausal females with visceral obesity who were divided into two groups according to an employed 6-month slimming procedure. In the first group (n = 36) a low-calorie diet was applied, while women in the second group (n = 38) were on the same kind of diet, having additionally one cycle of laser acupuncture procedure at the same time. At baseline and at the end of the study, body weight, body mass index and waist-to-hip ratio were determined in all women.

RESULTS: After 6 trial months both groups exhibited a statistically significant drop in body weight, body mass index and waist-to-hip ratio. The mean reduction of body weight, body mass index and waist-to-hip ratio was significantly higher in the second group of women (laser acupuncture plus low-calorie diet).

CONCLUSIONS: (1) Our results testify that the combination of a low-calorie diet and laser acupuncture is characterized by a higher efficacy than a low-calorie diet alone in lowering body weight, body mass index and waist-to-hip-ratio. (2) Laser acupuncture is an additional useful healing method in the therapy of visceral postmenopausal obesity.

Zhonghua Yi Xue Za Zhi (Taipei). 2002 Nov;65(11):501-12.

# New trends in myofascial pain syndrome.

Hong CZ.

Department of Physical Medicine and Rehabilitation, University of California Irvine, Irvine, California, USA. czhong88@ms49.hinet.net

### Abstract

This review article summarizes recent studies on myofascial trigger point (MTrP) to further clarify the mechanism of MTrP. MTrP is the major cause of muscle pain (myofascial pain) in clinical practice. There are multiple MTrP loci in an MTrP region. An MTrP locus contains a sensory component (sensitive locus) and a motor component (active locus). A sensitive locus is the site from which pain, referred pain (ReP), and local twitch response (LTR) can be elicited by needle stimulation. Sensitive loci are probably sensitized nociceptors based on a histological study. They are widely distributed in the whole muscle, but are concentrated in the endplate zone. An active locus is the site from which spontaneous electrical activity (SEA) can be recorded. Active loci are dysfunctional endplates since SEA is essentially the same as endplate noise (EPN) recorded from an abnormal endplate as reported by neurophysiologists. Both ReP and LTRs are mediated through spinal cord mechanisms, demonstrated in both human and animal studies. The pathogenesis of MTrPs appears to be related to the integration in the spinal cord (formation of MTrP circuits) in response to the disturbance of the nerve endings and abnormal contractile mechanism at multiple dysfunctional endplates. Methods usually applied to treat MTrPs include stretch, massage, thermotherapy, electrotherapy, laser therapy, MTrP injection, dry needling, and acupuncture. The mechanism of acupuncture is similar to dry needling or MTrP injection. The new technique of MTrP injection can also be used to treat neurogenic spasticity.

Lasers Med Sci. 2002;17(4):289-95.

# Cerebral vascular effects of non-invasive laserneedles measured by transorbital and transtemporal Doppler sonography.

Litscher G, Schikora D.

Department of Biomedical Engineering and Research in Anesthesia and Critical Care, University of Graz, Austria. gerhard.litscher@uni-graz.at

Laserneedles represent a new non-invasive optical stimulation method which is described for the first time in this paper. We investigated 27 healthy volunteers (mean age+/-SD: 25.15+/-4.12 years; range: 21-38 years; 14 female, 13 male) in a randomised cross-over trial to study differences between laserneedle acupuncture and manual needle acupuncture in specific cerebral parameters. Mean blood flow velocity ( v(m)) showed specific and significant increases in the ophthalmic artery during laserneedle stimulation ( p=0.01) and during manual needle stimulation ( p<0.001) at vision-related acupoints. At the same time insignificant alterations in v(m) were found in the middle cerebral artery for both acupuncture methods. The eight laserneedles used in this study were arranged at the end of the optical fibres. Each fibre was connected to a semiconductor laser diode emitting at 685 nm with a primary output power of about 55 mW. Optical stimulation using properly adjusted laserneedles has the advantage that the stimulation can hardly be felt by the patient and the operator may also be unaware of whether the laserneedle system is active, and therefore true double blind studies in acupuncture research can be performed.

Thorax. 2002 Mar;57(3):222-5.

# Laser acupuncture in children and adolescents with exercise induced asthma.

Gruber W, Eber E, Malle-Scheid D, Pfleger A, Weinhandl E, Dorfer L, Zach MS.

Respiratory and Allergic Disease Division, Paediatric Department, University of Graz, Auenbruggerplatz 30, A-8036 Graz, Austria.

BACKGROUND: Laser acupuncture, a painless technique, is a widely used alternative treatment method for childhood asthma, although its efficacy has not been proved in controlled clinical studies.

METHODS: A double blind, placebo controlled, crossover study was performed to investigate the possible protective effect of a single laser acupuncture treatment on cold dry air hyperventilation induced bronchoconstriction in 44 children and adolescents of mean age 11.9 years (range 7.5-16.7) with exercise induced asthma. Laser acupuncture was performed on real and placebo points in random order on two consecutive days. Lung function was measured before laser acupuncture, immediately after laser acupuncture (just before cold dry air challenge (CACh)), and 3 and 15 minutes after CACh. CACh consisted of a 4 minute isocapnic hyperventilation of -10 degrees C absolute dry air.

RESULTS: Comparison of real acupuncture with placebo acupuncture showed no significant differences in the mean maximum CACh induced decrease in forced expiratory volume in 1 second (27.2 (18.2)% v 23.8 (16.2)%) and maximal expiratory flow at 25% remaining vital capacity (51.6 (20.8)% v 44.4 (22.3)%).

CONCLUSIONS: A single laser acupuncture treatment offers no protection against exercise induced bronchoconstriction in paediatric and adolescent patients.

Eur Urol. 2001 Aug;40(2):201-5

# Prospective randomized trial using laser acupuncture versus desmopressin in the treatment of nocturnal enuresis.

Radmayr C, Schlager A, Studen M, Bartsch G.

Department of Urology, University of Innsbruck, Austria. Christian.Radmayr@uibk.ac.at

OBJECTIVES: Several treatment modalities for children suffering from monosymptomatic nocturnal enuresis are available, but desmopressin is a well-established option. On the other hand, alternative nonpharmacological therapies such as laser acupuncture are more frequently requested by the parents. To our knowledge, there is no prospective randomized trial which evaluated the efficacy of such an alternative approach in comparison with the widespread use of desmopressin.

METHODS: Forty children aged over 5 years presenting with primary nocturnal enuresis underwent a previous evaluation of their voiding function to assure normal voiding patterns and a high nighttime urine production. Then the children were randomized into two groups: group A children were treated with desmopressin alone, and group B children underwent laser acupuncture. All children were investigated after a minimum follow-up period of 6 month to evaluate the duration of the response.

RESULTS: The children of both groups had an initial mean frequency of 5.5 wet nights per week. After a minimum follow-up period of 6 months reevaluation revealed a complete success rate of 75% in the desmopressin-treated group. Additional 10% of the children had a reduction of their wet nights of more than 50%. On the other hand, 6 months after laser acupuncture, 65% of the randomized children were completely dry. Another 10% had a reduction of the enuresis frequency of more than 50% per week. 20% of the children in the desmopressin-treated group did not respond at all as compared with 15% in the acupuncture-treated group. Statistical evaluation revealed no significant differences among the response rates in both groups.

CONCLUSION: Im comparison with pharmacological therapy using desmopressin, our study shows that laser acupuncture should be taken into account as an alternative, noninvasive, painless, cost-effective, and short-term therapy for children with primary nocturnal enuresis in case of a normal bladder function and high nighttime urine production. Success rates indicated no statistically significant differences between the well-established desmopressin therapy and the alternative laser acupuncture.

Br J Anaesth. 1998 Oct;81(4):529-32.

# Laser stimulation of acupuncture point P6 reduces postoperative vomiting in children undergoing strabismus surgery.

Schlager A, Offer T, Baldissera I.

Department of Anaesthesia and Intensive Care Medicine, Leopold Franzens University of Innsbruck, Austria.

We conducted a double-blind, randomized, placebo-controlled study to investigate the effectiveness of P6 acupuncture on postoperative vomiting in children undergoing strabismus surgery. Acupuncture was performed by laser stimulation with a low-level laser. Laser stimulation of P6 was administered 15 min before induction of anaesthesia and 15 min after arriving in the recovery room. In the laser stimulation group, the incidence of vomiting was significantly lower (25%) than that in the placebo group (85%).

# Response of Biological Active Points to Low Energy Laser Compared to Electro-acupuncture and Needle Acupuncture

#### Joint publication in Laser Partner and Laser World (www.laser.nu/lllt/lllt_editorial.htm)

Dr. V. Volkov, Dr. T. Volkov – Private Clinics for Low Energy Laser Therapy, Wellington, New Zealand

#### Abstract

This study compares the response of Biological Active Points (BAP´s) to Low Energy Laser Therapy (LELT), as compared to needle acupuncture and electroacupuncture. Patients were categorized according to the Skin Electro Conductivity (SEC) Ryodoraku test, as modified by A. T. Neborskii. Results were analyzed with the standard SEC diagrams with regard to sex, age, season and menstrual cycle. SEC in BAP´s was measured 15 – 20 minutes after the treatment, and then one week afterwards. Method of assessment was the same in all three groups. BAP´s respond more readily to LELT. The effect of laser acupuncture is more profound and lasts longer then of either electroacupuncture or classical needle acupuncture. Therefore laser stimulation of BAP´s could prove more suitable for outpatients who prefer a longer time between individual treatments.

#### Introduction

Health Practitioners use different modalities of acupuncture, such as needle acupuncture, electroacupuncture, and laser acupuncture. All of these methods show good responses. This study attempts to compare the response of Biological Active Points to Low Energy Laser, compared with electroacupuncture and needle acupuncture.

#### Review and Theory

Classical acupuncture has existed for centuries. However, with the introduction of new technologies for health care, needles have been often replaced by electroacupuncture and laser acupuncture.

Both of these methods are non-invasive and less painful. They are more acceptable for children and other sensitive patients. All methods of acupuncture follow the same classical acupuncture principles.

We did not find in the existing research literature any response to these three modalities of acupuncture.

Subjects and methods

In this study 126 subjects were divided into three modality groups (the age of subjects ranged 20 – 60 years) – for classical acupuncture, electroacupuncture, and laser acupuncture.

These modalities were introduced in three independent clinics (Petone – Lower Hutt, Courtenay Place – Wellington, and Upper Hutt, New Zealand).

In all three clinics, patients were categorized according to the Skin Electro Conductivity (SEC) test by Ryodoraku, as further modified by A. T. Neborskii. Their results were analyzed with the SEC standard diagrams, also with regard to sex, age, season, and menstrual cycle (in women).

Patients were then divided according to our diagnosis of excess and insufficiency syndromes of acupuncture.

The first group was treated by classical acupuncture.

The second group was treated by electroacupuncture device “Diaton”.

The third group was treated by “Maestro” laser device, GaAlAs diode (830 nm, maximum output power 40 mW).

Skin electro conductivity in BAP´s was measured 15 – 20 minutes after the treatment, and then 1 week afterwards. Assessment was the same in all

hre

Figure:    Location of diagnostic points

#### Results

Insufficiency Syndromes – response of BAP´s

 Type of acupuncture SEC before treatment SEC 15 – 20 min. after treatment SEC 1 week after treatment Classical acupuncture 0 – 25 microampermeters 20 – 25 microampermeters 15 – 20 microampermeters Electroacupuncture 0 – 25 microampermeters 25 – 30 microampermeters 20 – 25 microampermeters Laser acupuncture 0 – 25 microampermeters 35 – 40 microampermeters 35 – 40 microampermeters

Excess Syndromes – response of BAB´s

 Type of acupuncture SEC before treatment SEC 15 – 20 min. after treatment SEC 1 week after treatment Classical acupuncture 70 -100 microampermeters 65 – 80 microampermeters 70 – 85 microampermeters Electroacupuncture 70 -100 microampermeters 60 – 80 microampermeters 65 – 85 microampermeters Laser acupuncture 70 -100 microampermeters 50 – 70 microampermeters 50 – 70 microampermeters

All three modalities of acupuncture showed improvement in SEC of BAB´s.

BAB´s responded more readily to laser acupuncture.

BAB´s retained the effect of laser without change up to a week.

Electroacupuncture also produced a profound effect on BAB´s. However, SEC improved on only half of the SEC to laser acupuncture. The effect of electroacupuncture declined slightly up to 5 microampermetres by the end of the week.

Classical needle acupuncture improved SEC of BAB´s but produced only a third of the positive laser effect.

The effect of classical acupuncture gradually declined over the following week of the trial, this being clearly evident.

Our analysis showed that SEC of BAB´s improved under all three acupuncture modalities. The responses have been obvious in both excess and insufficiency syndromes.

#### Conclusions

1.    Biologically Active Points respond more readily to Low Energy Laser Therapy.

2.    The effect of laser acupuncture is more profoound and lasts longer than those of electroacupuncture and classical needle acupuncture.

3.    Therefore laser stimulation of acupuncture points could be more suitable for out patients who prefer longer time periods between individual sessions of acupuncture.

#### References

1.    Pekka J. Pontinen, “Low Level Laser Therapy as a Medical Treatment Modality”, Art Urpo Ltd., Tampere, 1992.

2    A. T. Neborskij, H. Kondratavi?ius, “AGNIS – Manual”, Vilnius, 1995.

3.    F. G. Portnov, “Reflexotherapy of the Electra Acupuncture”, Riga, 1988, (in Russian).

4.    V. N. Surchuk, “Manual for the Electra Acupuncture Diagnosis and Correction of Energy-Information of the Patients with Different Category”, Almaty, 1992, (in Russian).

5.    David G. Baxter, “Therapeutic Lasers”, London, 1994.

6.    V. E. Illarionov, “Principles of Laser Therapy”, Moskva, 1992, (in Russian).

7.    “Maestro User´s Manual”, MediCom, Praha, 2000.

*****

J Altern Complement Med. 1999 Feb;5(1):5-26.

# Carpal tunnel syndrome: clinical outcome after low-level laser acupuncture, microamps transcutaneous electrical nerve stimulation, and other alternative therapies–an open protocol study.

Branco K, Naeser MA.

Acupuncture Healthcare Services, Westport, Massachusetts, USA.

### Abstract

OBJECTIVE: Outcome for carpal tunnel syndrome (CTS) patients (who previously failed standard medical/surgical treatments) treated primarily with a painless, noninvasive technique utilizing red-beam, low-level laser acupuncture and microamps transcutaneous electrical nerve stimulation (TENS) on the affected hand; secondarily, with other alternative therapies.

DESIGN: Open treatment protocol, patients diagnosed with CTS by their physicians.

SETTING: Treatments performed by licensed acupuncturist in a private practice office.

SUBJECTS: Total of 36 hands (from 22 women, 9 men), ages 24-84 years, median pain duration, 24 months. Fourteen hands failed 1-2 surgical release procedures. INTERVENTION/

TREATMENT: Primary treatment: red-beam, 670 nm, continuous wave, 5 mW, diode laser pointer (1-7 J per point), and microamps TENS (< 900 microA) on affected hands. Secondary treatment: infrared low-level laser (904 nm, pulsed, 10 W) and/or needle acupuncture on deeper acupuncture points; Chinese herbal medicine formulas and supplements, on case-by-case basis. Three treatments per week, 4-5 weeks.

OUTCOME MEASURES: Pre- and posttreatment Melzack pain scores; profession and employment status recorded.

RESULTS: Posttreatment, pain significantly reduced (p < .0001), and 33 of 36 hands (91.6%) no pain, or pain reduced by more than 50%. The 14 hands that failed surgical release, successfully treated. Patients remained employed, if not retired. Follow-up after 1-2 years with cases less than age 60, only 2 of 23 hands (8.3%) pain returned, but successfully re-treated within a few weeks.

CONCLUSIONS: Possible mechanisms for effectiveness include increased adenosine triphosphate (ATP) on cellular level, decreased inflammation, temporary increase in serotonin. There are potential cost-savings with this treatment (current estimated cost per case, $12,000; this treatment,$1,000). Safe when applied by licensed acupuncturist trained in laser acupuncture; supplemental home treatments may be performed by patient under supervision of acupuncturist.

Probl Vet Med. 1992 Mar;4(1):66-87.

# Techniques and instrumentation.

Altman S.

### Abstract

There are many methods used to stimulate acupuncture points to achieve therapeutic objectives. Among the most frequently employed are physical pressure or vacuum (acupressure and cupping), temperature variation (cauterization, moxibustion, electronic heat devices, infrared lamps, ultraviolet lights, ice, dry ice, and surface coolants such as ethyl chloride), ultrasound (sonapuncture), injection therapy (aquapuncture), implantation of various materials into points, laser stimulation (laserpuncture), and electrostimulation of the acupuncture points, with or without needles (electroacupuncture). This chapter describes these techniques, their uses, and place in acupuncture therapy.

Fam Pract. 1991 Jun;8(2):168-70.

# Acupuncture: from needle to laser.

Wong TW, Fung KP.

Department of Community and Family Medicine, Chinese University of Hong Kong.

Acupuncture has been used in the treatment of a variety of illnesses for more than 2000 years. The practice of acupuncture is based on a theoretical system different from our understanding of human anatomy and physiology, and has developed through experience and observation. Stimulation of selective acupoints (situated along ‘meridians’ in the body) by inserting needles is believed to restore bodily functions by promoting the flow of ‘vital energy’, throughout the system. Other forms of stimulation which have been developed are heat, electrical stimulation, magnetism and, recently, laser. Laser acupuncture offers distinct advantages over the traditional method because the procedure is pain-free and non-traumatic. Clinical applications include the control of pain in osteoarthritis, lumbago and migraine, and anaesthesia for certain surgical procedures, as well as other ailments of the cardiovascular, respiratory and nervous systems. The technique is easy to learn and there is no need for sophisticated instruments. Thus it is especially useful in developing countries where health resources are limited.

Pain. 1990 Nov;43(2):181-5.

# Hypalgesic efficacy of acupuncture on experimental pain in man.  Comparison of laser acupuncture and needle acupuncture.

Brockhaus A, Elger CE.

Universitäts-Nervenklinik, Epileptologie, Bonn, F.R.G.

The analgesic effect of acupuncture on cutaneous heat stimuli of 43 degrees C has been evaluated in a controlled experimental study with healthy, informed volunteers. Laser acupuncture was administered to 39 probationers using a helium-neon laser under double-blind conditions. The point Hegu (L.I.4) and Jianqian (Extra.) on both sides were each irradiated for 1 min. Forty probationers were needled with stainless steel needles in the point Hegu (L.I.4) on both sides under single-blind conditions. Pain threshold was measured in terms of the time (in msec) that the probationers needed to perceive the cutaneous heat stimulus of 43 degrees C. The painful stimulus was generated by a computer-controlled standardized procedure. The Wilcoxon test was used for the statistical evaluation. Laser acupuncture did not change the pain threshold. Needle acupuncture did, however, increase the pain threshold compared with the initial value (alpha = 0.1%). The difference compared with the control group, where a placebo point was needled, was also significant (alpha = 5%). This controlled experimental study proves the analgesic effect of needle acupuncture on painful heat stimuli. Laser acupuncture had no effect on pain threshold in this study.

J Am Vet Med Assoc. 1989 Nov 15;195(10):1375-9.

# Methods of stimulating acupuncture points for treatment of chronic back pain in horses.

Klide AM, Martin BB Jr.

Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia 19104-6010.

### Abstract

Horses with chronic back pain of 2 to 108 months’ duration were treated using acupuncture (n = 15), laser acupuncture (n = 15), or injection acupuncture (n = 15). Horses were treated once a week for 8 treatments (mean) with needle acupuncture, 11 treatments with laser acupuncture, or 9 treatments with injection acupuncture. After treatment, 37 horses had alleviation of clinical signs of pain and could train and compete: 13 horses treated with needle acupuncture; 11 horses treated with laser acupuncture; and 13 horses treated with injection acupuncture. Seemingly, the 3 types of acupuncture were equally useful for treating horses with chronic back pain.

Ann Acad Med Singapore. 1987 Apr;16(2):261-3.

# Laser acupuncture anaesthesia and therapy in People’s Republic of China.

Qin JN.

Biomedical Engineering Faculty of Shanghai, Second Medical University, People’s Republic of China.

### Abstract

Laser acupuncture anaesthesia has been utilized for operations on thyroid and stomach, and Caesarean sections since 1978 in China. Recently, satisfactory results were reported in stomatology for the extraction of teeth. Laser beams directed at predetermined acupoints produce insensibility in a few minutes without any side effects such as allergy, intoxication, haemorrhage, or infection. This method has been used successfully on more than 5,000 patients for tooth extractions and minor oral and facial operations. Until now, the mechanism of classical acupuncture anaesthesia has been more or less elucidated by the neural or neuro-humoral hypothesis, which states that deep receptors or minute nerve fibres are stimulated mechanically by the needle. But laser irradiation as a stimulant is something different, since it has only low power and short penetration depth, and arouses almost no sensation compared with the acupuncture needle. The mechanism of anaesthesia due to laser irradiation of acupoints on superficial parts of the body should be investigated in further detail. The methods of laser acupuncture anaesthesia, the selection of laser irradiation acupuncture points, the distance and duration of irradiation, and the results of clinical application will be introduced.

No Shinkei Geka. 1985 Jun;13(6):607-12.

# Laser acupuncture therapy for pain and vague complaints in neurosurgery.

[Article in Japanese]

Shibuya M, Ono R, Fujisawa K, Katada K, Sano H, Kanno T, Oshiro T.

The value of diode laser acupuncture for pain and other vague neurological complaints has been studied in chronic patients of head trauma and of cerebrovascular disease or neuralgia in head and neck regions. Gallium-Aluminium-Arsenide (Ga-Al-As) diode laser pain attenuator PANALAS-4000 manufactured by Japan Medical Laser Laboratory was used in the following specifications; wave length: 830 nm, power: 20-40 mW, frequency: 5-50 c.p.s., pulse duty: 0.9. The laser acupuncture was applied to some of the representative Chinese meridian points, local pain points and related nerves for 1 to 7 times in a week. It was given in 310 patients in our neurosurgical department. 175 of 227 patients who complained of pain and 12 of 39 patients who complained of numbness showed improvement within 24 hours, another 24 patients with pain and 16 patients with numbness showed improvement after 24 hours. No side effect was noticed. The duration of the effectiveness was about 2 or 3 days. It is very useful to apply the laser acupuncture for pain and vague complaints in neurosurgery.

Acupunct Electrother Res. 1983;8(3-4):297-302.

# Laser-acupuncture reduces cigarette smoking: a preliminary report.

Zalesskiy VN, Belousova IA, Frolov GV.

### Abstract

The stop-smoking campaign constitutes a component of the cardiovascular and oncology disease-prevention programme. In the study, laser-acupuncture was used in heavy smoking elderly patients with peripheral vascular diseases, as well as in those with lung cancer, to relieve the nicotine abstinence symptoms at the preoperational management stage. To produce a stable negative response to nicotine there was additionally applied steel needle (Seirlin-Kasei & Co., F.R.G.) insertion at cavity of concha, tragus and antitragus areas. In each of 85 patients there were noted positive trends, vegetative and somatic manifestations of abstinence were eliminated, desire to smoke was reduced. Most of them (71%) stopped smoking completely. The results have proven the high therapeutic value of laser-acupuncture in treating for chronic smoking.

Vestn Khir Im I I Grek. 1983 Oct;131(10):105-7.

# Electroacupuncture and laser puncture in postoperative and post-traumatic contractures in children and adolescents.

[Article in Russian]

Plakse?chuk IuA.

### Abstract

An analysis of clinical observations of 62 children enabled the author to recommend analgesia by electropuncture and laserpuncture to be used in the system of rehabilitative measures.

Schweiz Med Wochenschr. 1981 Sep 12;111(37):1360-6.

# Acupuncture and laser treatment in cervical and lumbar syndrome.

[Article in German]

Gallacchi G, Müller W, Plattner GR, Schnorrenberger CC.

### Abstract

Eight random groups, each of 15 patients with tendomyotic cervical and lumbar syndrome, underwent acupuncture, one group receiving needle acupuncture at the “correct” sites according to Chinese medicine and another receiving placebo needles at the same sites. In a third group, acupuncture needles were applied at sites which were wholly inconsistent with Chinese practice. The remaining 5 groups took part in a single blind trial involving various types of radiation at the correct acupuncture sites, using an apparatus emitting either laser rays, red light, mixed light, infrared or no radiation at all, without interference from the therapist. All the groups showed improvement, but an analysis according to Kruskal and Wallis revealed no significant differences between type and site of treatment.