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Increased
Plasma
Concentrations
after
B-Endorphin
Acupuncture:
Comparison
of Electroacupuncture,
Traditional
Chinese
Acupuncture,
TENSand Placebo
TENS
SeflGtAbenyaLar,FeyzaBoneval
Summary
Seventeenpatients with pain from various causes
werc treated by Electrcacupuncturc (n=5),
Traditional
Chinese
(n=1),
Acupunclure
TtanscutaneousElectrical Nerve Stimulation (n=4)
or Placebo TENS (n=1). Each treatmentlasted 25
minules. PlasmaB endorphin concentrationswere
mea<ured bclorc and dipt
lhe 5eJrlon.
Electroacupunctureancl Traditional acupuncturc
treatments were both associated with a significant
risein plasmaB-endorphinlevels.
EA g.oup 1
Key words
Acupuncture, Endoehi ns,Pain, TENS.
Introduction
Althoughthe mechanismunderlyingthis type of
analgesiastill seemsto be a matter of dispute,
acupuncture
has been usedfor millenniumsin the
treatment ot acute and chronic pain. One
explanation for the pain inhibiting effect of
acupunctureis the releaseof endogenousopioid
peptidesffom the centralnervoussystem(/).
The purposeof this study was to evaluatethe
plasma fendorphin levels be{ore ano arrer
acupunctureand to compare this method of
treatmentwith Transcutaneous
ElectricalNerve
(TENS)
Stimulation
and placeboTENS(P TENS).
Method
Seventeenpatientssuffering{rom pain for at least2
months participatedin the stldy (TablesI ancl2).
Noneot the patientswere receiving
drugsthatmight
interferewith plasma B-endorphinlevels. In the
groups,pointsto needlefor individual
acupuncture
patientswere chosen accordingto the aetiologyof
their pain. A predetermined
formulawas useoror
eachillness,with the additionof triggerpoints.The
stainless
steelneedleswere handmanipulated
every
(TA)
l0 minutes in the TraditionalacLlpuncture
group,and electrically
stimulaled
at a low frequency
(2 sHz) in the electroacupunctore
(EA)group.The
intensity
of stimulation
was increased
to just below
painful level. There were no complicationsof
treatment.TranscutaneousElectrical Nerve Stimulationwas at a frequencyof BoHz. No electrical
wasgivenin the placeboTENSgroup.
stimulation
Eachsessionlasted25 minutes.Bloodsamplesfor
8-endorphinassaywere taken immediately before
May 1994Vol 12 Na.l
2f
ACUPUNCTURE
GROUPSCTINICATDATA
Pati.nr A8e/sexAeriology
2
sZF
Cervic.lspondylosis
3
42lM
Lumbardisc herniation
4
36/M
Lumbardisc herniation
5
5l/M
Lumbardisc herniation
TA group 6
22lF
Cervicaltrauma
s3lM
Cervicalspondylosis
6,YM Lumbardisc herniation
9
42lF
De Quervain's
tenosynovrtis
Table2
TENSAND PLACEBO
TENSGROUPSCLINICATDATA
PatientA8€ls€xActiolo8y
^n
TENS
Duration
oiP.in
10
4llF
Lumbardisc herniarion l year
ll
!,,'V
L u nb J r , p o d \ / ^ j .
12
,10/F Cervicalspoidylosis
I yeaf
13
38/F
Cervicalspondylosis
2 yeau
P.TENS 14
75lF
Old lracrurc
2 months
,4 \4 tunbdr ti , h .nrr on
2 mo th.
)p,.
16
l5/F
L u m b a r d i shc e r n i a t i o n 2 m o n r h s
17
36/M
PerianhrjLisof shoulder l year
and aftertreatment.
PlasmaFendorphinimmunoreactivity was measured by means of a
double-antibody radioimmunoassaytechnique
l"llendorphin l-125 R/A Kll', New EnglandNuclear,
Du PontCompany.
Catalogue
No. NEK003).
Intensityof pain was assessed
before and afler the
session
usinga VisualAnalogueScale(VAS)ran8ing
lrom "no pain" Io "pain as bad as it could be,,.
Sludentc-ite.l and Pp"r'on (orreldtionregte.sion
analysis
wereusedfor statistical
evaluation.
The level
of statisticalsignificancewas acceptedal p<0-05.
Ac upuncture in Mecli ci ne
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f,esurls
A. Plasma
P endorphinlevels
Flectroacupuncture(EA)
ptNDORPHINtEVEtSWtrH
coRRELATtON
OF PTASMA
PAIN
SCORES
Traditional
and
Acupuncture(TA)treatmentswefe associatedwith a
significantrise in plasmafiendorphin concentrations(EAgroup:p<0.01,f=4.08;TA group:p<0.05,
r=3.26).
The increase;n
TENS(p=0.73,t=0.38)and placebo
(p=1,
TENS
f=0.0)groupswas statist;cally
insignifi(Table
3 and Figure | ).
cant
E AS r o u p
TABroup
0.96
6.,13
Aftei trealmeni
r
t
-0.89
1.55
A.O7
0.105
0.16
0.211
T E N Sg r o u p
0.57
0.98
4.756
] 63
P .T E N SB r c u p
0.06
0.088
0.06
0.085
Befoietrealment
r
t
(pg/m|)
PtAsMA FENDORPHIN LEVELS
{virluesreportedindicatemeant SD)
Baseline
After lreatmenl t
p
E Ag r o l p
1 1 . J 8 1 : 1 . 5 71 1 . 0 2 t 4 . 1 1
4.08 0.016
T Ag r o u p
12.14!6.25 15.b5!7.4
t.26b 0.017
T I N Sg r o l p
]3.95a1.38 14.0013.16
0.38 0.Zl
P T E N Sg r o u p 1 7 . 0 a ! ) . 0 2 1 7 . 4 4 + 2 . 7 6
0.00
] 00
E& Belo,er€aheniI
TENS
Atunealmed
FigLne 2. Mean UAS Values
xg Berorereahert d
fter redmd
filu.e t. PIasma
P En.JoehinMeanv.hrcs
B. Pain fttinB by vAS
AlthouSh the pain scores o{ the majority of the
patientswere lower aftertreatment,this decreasewas
insignificantfor all groups(Table4 and FiBurc2).
The degree of pain relief was correlated
= r) with the increaseof
(CorrelationCoefficient
plasmap:endorphinonly in the EAgroup(Iable5).
Discussion
Todayseveralvarietiesof acupuncture
are usedto
obtain analgesiain various pain conditions(2).
There is reasonableevidence that acupuncture
is mediatedvia endogenous
opioidsft 4, 5)
analSesia
and pendorphin is the bestdocumentedof these(6).
MEAN PAIN SCORIS
Before
lreatment
After
ireatment
t
E AS r o u p
5.1!2.57
3.2!1.72
2.56 0.061
TASroup
5.2510.41 l-25i1.92
1.85 0.16
T E N Sg r o u p
3.25!1.Q8 2.75!1.7n
1.00 0.19
P T E N 5S r o u p 3 . 5 a 0 . 8 6
Acupuncture
in Medicine
1.75!1.92
p
2.28 0.069
22
fluid p
The sourceof the increasedcerebrospinal
endorphin after EA is uncertain. lt has been
in loweranimalsthat the endogenous
denronslrated
opiate systemIies adjacentto the third ventricle (7).
Takeshige ei a/. demonstratedthat acupuncture
analgesiacausedby low frequencystimulationof
point was abolishedby hypophy
the acupuncture
sectomyand adrenaleclomy.A role for the pituitary
is supportedby this
in the response
to acupuncture
observation.A reductionof sodium ions may have
beenthe reasonfor abolitionof acupunctureanalgesia
after adrenalectomyaB).Fedoseevaet a/. suggested
that besidesthe basalopioid and serotonergicsystems
reportedby Cheng and Pomeranlz(9), there exists
peptidemechanismmediating
an angiotensinergic
(/0).
acup!nctureanalgesia
Moret ei a/. assessedthe analSesic effect of
and concludedthat they
hypnosisand acupunclure,
were nol primarily m€diated by the opiate
endorphinsystem.Plasmapendorphinlevelshave
remained unchangedregardlessof the type of
a n a t g e s{r/a/ , ,
The chanBes
in pendorphinlevelsafterEAand TA
in our study (p<0.05).
were pafticularlysiBnificant
We ob.ened lhal all .ubje,l. 'hohed dn In(redqein
their plasmalevelsafter 25 minutesof treatment.
Thissuggests
thatthe stimulation
of the acupuncture
poinl ele' lricaly o- manualll.e\oles a rc.ponsein
system.
the endorphinergic
Lianfangsuggested
that the peripheralendogenous
opioid peptidesare unlikely to be analgesically
aclive a7).Contradictoryresultswere also obtained
f72)-The plasmachangesof ftendorphin in our
patientsseemrelatedto the attenuation
of painonly
in the EAgroup.
TENS also is a simple and effectiveanalgesic
May 1994 Val 12 No.I
Downloaded from http://aim.bmj.com/ on June 18, 2017 - Published by group.bmj.com
technique.Erikssonshowed that low frequency 7. RichardsonDE {1990)CentralStjmularion-induced
analgesia
in humans Modulation by endogenousopioid peptides.
stimulation(below1oHz)may producea releaseof
Neurobiology.6lI ): 33 7
endogenousopioids (/-3).Pertovaaraet a/. suggested
8. Takeshige C, Tsuchiya M, Cuo SY Sato T (1991)
that the pain thresholdelevationinducedby low
DopaminerSictransmissionin rhe hypothalamic arcuate
frequency TENS is based on non-opioid
nucleus to produce acupuncrureanalSesiain corretation
mechanisms(14). Salaret a/. found an increased
with the pituitaryslnnd. Arain Research
Bulletin.26: 113-22
9 . C h e n 8 R S S , P o m e r a n t zB ( 1 9 7 9 ) E l e c t r o a c u p u n c l ! r e
t unrenlrdrionol opiord-lile .ub\ldnrp: in .crp
analgesiacould be mediatedby at leasrrwo pain relieving
brospinalfluid in a group o{ patientswithout pain
mechanisms:endorphin and non-endophin systenrs.lif€
who were given high frequencyTENSft5). In our
ki.25:1957-62
study,we used high frequencyTENS,and did not l0.FedoseevaOV Kalyuzhnyi LV Sudakov KV 0990) New
find a significant
peptide mcchanism of auriculo-acupuncrure eiecrrorisein plasmap:endorphinlevels.
analgesia: Role of .n8iotensin ll. Acupuncture and
Although acupuncturepoints to neeote were
Ele.trc-Thetapeutics Research.I 5 : 1 a
chosen accordingto the aetioloSyof pain, Li.4
l l . M o r e iV F o B t e A
r , L a v e t r i a rM
e C , L a m b e rH
t , et r/. (1991)
fHegu) in each patient was needled without
Mechanism of analSesia ind!ced by hypnoris and
exception.Agreeingwith Chapman et al. (16) and
acupuicturc: is ihere. difference?PaD. 45i I35 40
Brockhaus
and ElSer(/7} we are ofthe opinionthat 1 2 .K i s e rR S ,K h a t a mM
i , C a t c h e R J( 1 9 8 3 )A c u p u n c t u rree i i e f
ol .hronic pain syndromecorclares wirh increascdptasma
the point Hegu plays an impo(ant role in
mer'enkephalinconcenrratiansIhe Lancet.Dec 17: 1394-6
acupunclure
anaigesta.
l S . E r i k s o n M B E , S j o l u n dB H , N i e l s e n5 ( 1 9 7 9 )L o n St e r m
We concludedthatthe analgesia
of hiBhffequency
res!ltsor peripheraconditioningnimulatjotras an analSesic
TENSis basedon non-opioidmechanisms
and that
m e a s u r ien c h r o n i cp a i n .P a i n .6 ; l l 5 - 4 7
acupunctufe
analgesia
inducedmanuallyor electri- 14. PeftovaaraA, Kemppainen R lohaisson G, Karonei S
(1982) Dental analgesiaproduced by non painful, lowcally is accompaniedby an increasein plasma
hequency
stim!lation is not influencedby stressor reversed
levelsP:endorphin
Acknowledgements
The authorswish to thank Dr N0zhetZiyal PhD,
Chairman of the Turkish Medical Acupuncture
Society;Prof Dr Cnnay Crilbabafor pendorphin
assays;
and Dr AhmetDiricanfor statistical
advice.
Dr ;efkat Abenyakar
Registrar
b y n a l o x o n eP. a m .1 l : 3 2 9 - 8 4
1 5 . S a l aC
r , J o b l , M i n S r i n oS , e t a / . ( 1 9 8 1 )E l f e cot f r r a n s c l t a neols electrotherapyon CSF betaendorphin conrent in
paticntswirholt pain problens. Pain. lO:169 172
l6.chapman RC, Wilson EM, Cehrins jD (1976) Signal
detection evaluation of effe.ls of acupuncture on the
perceptionof prinful denral srinrulation.Adv paln Res.
l T . B r o c k h a u sA , E S e r C E ( 1 9 9 0 ) H y p a l g e s i ce f f i c a . y o t
acupunctureon experimentalpain in man. comparisonof
r a s ear c u p u n c t u raen d n e e d l ea c ! p ! n c l u f e .P a t n . 4 J : 1 8 1 - 5
Dr Feyza Boneval
Chief of Department
PhysicalMedicine and Rehabilitation
gitli EtfatHospital
Istanbul,Turkey
Correspondence to:
Dr t Abenyakar
p K.413 Sikeci
34434 lstanbul,Turkey
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afrer
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4 . C l e m e n g o n e sV M c l o u s h l i n L , I o m l i n S , e r a / . 0 9 s 0 )
Increasedbeta-endorphinbut not merenk€phalinlelek in
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pain. The Lancet.Nav t:9469
5 . Ho WKK, Wen HL (1989) Opioid like activity in the cere
brosplna fluid
pain
of
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e ectro,ac!puncture.Neurophamacology.28(9):96-16
6 . LyrenasS, Nyberg t Lltsch H, et irl (1987) Cerebrospinal
l l u i d d y n o r p h i nl - l 7 a n d b e t a , e n d o e h i ifn l a r ep r e s n a n c y
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M a y 1 9 9 1 V o l1 2 N o . 1
23
Acjpuncturc in Medicine
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Increased plasma β-endorphin
concentrations after acupuncture:
comparison of electroacupuncture,
traditional Chinese acupuncture, TENS and
placebo TENS
Sefkat Abenyakar and Feyza Boneval
Acupunct Med 1994 12: 21-23
doi: 10.1136/aim.12.1.21
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