Background: The relaxing phenomenon induced by acupuncture on hypertonic muscle has not clearly been demonstrated. We studied whether acupuncture stimulation on the hypertonic muscle model induce relaxation. Methods: A rat model of hypertonia was created by inducing tetanic contraction in the triceps surae muscles of 21 Wistar rats (male, 12 weeks) with four electrical stimulations (80 Hz, 5 mA, 5 min.), with a 2 min. interval between each stimulation. The rats were randomly divided into two test groups: 1. Untreated group (N = 12), 2. Group treated with acupuncture stimulation of the triceps surae muscle (N = 9). Rats in the untreated group received no therapeutic treatment after the model was created. Acupuncture was performed within 5 min. after the model was created. Evaluations were taken before and 5 min., 1, 2 and 3 days after tetanic contraction was induced. The rats were anaesthetized and a tension sensor for measuring static and dynamic muscle tension was used to determine triceps surae muscle stretching tension during passive dorsal flexion of the foot (30°, 40°, 50°). Results: In both groups, at each of the angles of passive dorsal flexion, there was a significant increase in stretching tension 5 min. after inducing tetanic contraction compared to before induction, and statistics showed recovery to pre-induced tetanic contraction values after 1 day and thereafter. Compared to the untreated group, however, values 5 min. after induced tetanic contraction tended to be lower in the group treated with acupuncture stimulation. Conclusions: Compared to the untreated group, stretching tension values 5 min. after inducing tetanic contraction tended to be lower in the acupuncture group. This could be due to acupuncture stimulation causing changes in blood flow in the lower leg, including muscle tissue, resulting in reuptake of calcium by the sarcoplasmic reticulum, and/or the influence acupuncture on reducing lower leg edema. Acupuncture stimulation could also have an action on the γ fibers and Ib fibers associated with continuous muscle tonus and muscle relaxation.

Objective: The purpose of this study was to compare the effects of superficial and deep insertion of acupuncture needles in the treatment of patients with neck-shoulder pain and to search for more effective acupuncture methods. Methods: The subjects were patients seen at the Meiji University of Integrative Medicine’s Department of Orthopedic Surgery Clinic. A randomized controlled clinical trial was conducted in which 20 patients with neck-shoulder pain were randomly allocated to either a superficial acupuncture group (n=10) or a deep acupuncture group (n=10). Treatment was applied to points where patients experienced the most pain. The maximum number of stimulation points for both groups was 10. In the superficial acupuncture group, the needle was only inserted to a depth of 5 millimeter. In the deep acupuncture group, the needle was inserted to a depth of 15 to 20 millimeter. Both groups were manually stimulated using a sparrow pecking method over 20 seconds, after which the needle was removed. Both groups were treated weekly for four weeks. The primary outcome measurement was intensity of pain evaluated using a Visual Analogue Scale (VAS). The secondary outcome measurement was the Neck Disability Index (NDI) for the purpose of evaluating the grade of disability in daily life due to neck-shoulder pain. Results: There were no significant differences in age, male-female ratio, disease duration, or the initial scores of VAS and NDI between the two groups. VAS and NDI scores indicated significant differences between the groups (VAS: <0.0001, NDI: p<0.0001) in change over time, with the deep acupuncture group having more favorable results than the superficial acupuncture group. The degree of change from the baseline at the time of each evaluation was calculated, and results for the two groups were compared. The deep acupuncture group showed significantly better improvement in the sustained effects after completion of treatment (VAS: p<0.05). There were no significant differences directly after the first treatment (VAS: p=0.72) or in cumulative effect after repeated treatment (VAS: p=0.24). Discussion and Conclusion: The results of this study suggested it would be more efficient to insert the needle to deep tissues when performing acupuncture treatment on subjective pain sites. The difference in the effects between the two acupuncture methods may be due to the difference in tissue stimulation received. The difference in effect is thought to be due to the differing influence of treatment on pain threshold, muscle blood flow, and muscle tones.

Objective: We applied acupuncture to the cervical region of patients suffering from upper extremity radicular symptoms due to cervical spondylotic radiculopathy (CSR) and verified clinical efficacy. Methods: 16 extremities of 15 patients were selected as subjects diagnosed with CSR and suffering from upper extremity pain and/or dysaesthesia. All of the patients were treated with acupuncture once a week for four weeks, on up to ten sites where tension/induration was recognized in the cervical paraspinal region centered around the affected area. A stainless steel needle 0.18mm in diameter was inserted 10 to 20mm, manipulated using the sparrow pecking method (1Hz, 20sec) and removed. The severity of symptoms was recorded before each treatment and one month after the completion of the treatments using a Visual Analogue Scale (VAS) and evaluated. In addition, a Quality of Life (QOL) evaluation was conducted before treatment, after four treatments, and one month after the completion of the treatments using the Neck Disability Index (NDI) and CSR treatment effectiveness metrics. Results: VAS plots show a significant change in pattern over time in all cases (Neck-shoulder pain: p<0.0001, upper extremity pain: p<0.0001, upper extremity dysaesthesia: p<0.001). Furthermore, in QOL evaluation, both NDI and CSR treatment effectiveness metrics similarly showed a significant change (NDI: p<0.0001, CSR treatment effectiveness metrics: p<0.0001). Because there was a significant difference (p<0.001) between symptoms before treatment and before the fourth treatment, the efficacy of continued treatments was verified. Meanwhile, there was no significant difference between the symptoms at the completion of the treatments and the symptoms one month after the completion of the treatments; thus, the sustained efficacy of treatments over a certain period was verified (p=0.52). Discussion and Conclusion: These results verified that acupuncture treatment to the cervix has continued and sustained efficacy not only on the symptoms of neck and shoulders due to CSR, but also on upper extremity pain and/or dysaesthesia; therefore, we think this is a promising treatment as the first choice for conservative therapy. The mechanism that alleviates upper extremity pain and/or dysaesthesia through acupuncture treatment to the cervix via the stimulation of the posterior branch of the spinal nerve dominating the cervical paraspinal muscle creates a reflex effect in the anterior branch of the same nerve; as a result, it is beneficial for suppressing upper extremity pain dominated by the anterior branch as well as improving nerve blood flow.

Objective: Snapping finger is the result of gliding disorder of the superficial and deep digital flexor tendon and the flexor pollicis longus muscle tendon at the synovial and ligamentous tendon sheath (A1 pulley). In this study, acupuncture was performed at the A1 pulley of the affected finger to determine its effect on pain during snapping and the degree of the snapping phenomenon. Methods: Acupuncture was performed on 19 fingers of 15 patients. No control group of untreated patients was included in the study, and the same acupuncture treatment was used for all of the patients. The acupuncture needles were inserted in the radial and ulnar sides of the flexor tendon (left inserted for 10 min) at the A1 pulley of the affected finger. Treatment was performed a maximum of 5 times (once every 5 to 7 days). Before and after each treatment, the pain during snapping and the degree of the snapping phenomenon were evaluated using a visual analogue scale (VAS) ranging from 0 mm (no symptoms) to 100 mm (intolerable symptoms). Symptoms before the first treatment and before the fifth treatment were compared to determine the degree of change, taking a 50% improvement as the criterion for judging whether there was an improvement or not, and the relationship between improvement or lack of improvement and the duration of the disorder was examined. Results: VAS evaluation showed a significant improvement in pain during snapping and the degree of the snapping phenomenon with scores before the first treatment and before the fifth treatment of 57.1±22.2 (mm, mean±SD)→26.0±29.8, 61.2±23.1→26.1±27.6 respectively. VAS evaluation directly after the first treatment also showed a significant improvement in pain and the degree of the snapping phenomenon with scores of 40.8±19.6 and 44.3±23.9 respectively. Furthermore, by the fifth treatment, pain and the snapping phenomenon were observed to have completely disappeared in 4 and 6 fingers respectively. In patients showing an improvement in pain and the snapping phenomenon, the duration of the disorder was significantly short. Discussion: It is unlikely that acupuncture had an influence on the degeneration and thickening of the ligament tendon sheath. Improvement in the snapping phenomenon is thought to be the result of acupuncture treatment changing regional blood flow and thereby exerting a favorable influence on inflammatory swelling. The alleviation of pain during snapping is believed to be the result of improved flexor tendon gliding as well as the involvement of acupuncture in activation of the pain inhibitory system. Since no control group of untreated patients or sham treatment group were included in the study, the possibility of a placebo effect influencing the results cannot be completely excluded. However, because a difference was observed in the efficacy of the treatment depending on the duration of the disorder, the view is that acupuncture at the impaired A1 pulley could be effective treatment for snapping finger when the main cause is inflammatory swelling of the synovial membrane of the tendon sheath and when the duration of the disorder is short.

Objective: Histological and dynamic assessment to determine the effect of electroacupuncture on tendon repair in a rat model of Achilles tendon rupture. Methods: Sixty 12-week old male Wistar rats were used to prepare an Achilles tendon rupture model. The rats were randomly divided into an electroacupuncture group (EA group) and a control group. The EA group rats were restrained, and under mild anesthesia two acupuncture needles were inserted with the tip of one touching the ruptured tendon on the outer side, and the tip of the other touching it on the inner side. Using the needle on the inner side as the cathode and the needle on the outer side as the anode, electroacupuncture with intermittent direct current was performed (pulse width: 5 ms, stimulation frequency: 50 Hz, stimulation strength: 20 μA, stimulation time: 20 min). Electroacupuncture was performed every day from the day after model preparation until the days of assessment. Rats in the control group were retrained and mildly anesthetized only. Samples from the region of interest were taken 7 and 10 days after model preparation to assess tendon repair. Tissue imaging was performed, using HE staining to measure total cell count and immunohistochemical staining to measure the number of cells positive for TGF-β1 and b-FGF. Tension tests were also performed 10 days after model preparation to measure the maximum failure load of repaired tendon. Results: HE staining showed a significant difference between the assessment results on different days and between the two groups. A clear increase in the cell count was observed in the EA group (day 7: p<0.05, day 10: p<0.001). Immunostaining showed the strongest expression of both TGF-β1 and b-FGF in the EA group 7 days after model preparation, and other significant difference were observed (TGF-β1: day 7 EA group vs. day 10 EA group: p<0.001, vs. day 7 control group: p<0.0001, vs. day 10 control group: p<0.0001) (b-FGF: day 7 EA group vs. 10 EA group: p<0.001, vs. day 7 control group: p<0.0001, vs. 10 day control group: p<0.0001). Maximum failure load of repaired tendon 10 days after model preparation was significantly higher in the EA group (p<0.01). Discussion: Examination in the early stages after Achilles tendon rupture showed an increased cell count and increased expression of growth factors in the EA group, as well as increased tendon strength. These results indicate the beneficial action direct current electroacupuncture has on cell growth and growth factor expression during tendon repair, and suggest it also increases the dynamic strength of repaired tendon. Direct current electroacupuncture is thought to be possibly useful method for promoting tendon repair.

[Objective]The purpose of this study was to compare the effects of superficial and deep insertion of acupuncture needles in the treatment of patients with low back pain and to search for more effective acupuncture methods.
[Methods]A randomized controlled clinical trial was conducted in which 32 patients with low back pain for more than three months of duration were randomly allocated either to a superficial acupuncture group (n = 16) or a deep acupuncture group (n = 16). Treatment was done for the most painful points of the patients. In the superficial insertion group, the needle was only inserted to a depth of 5 mm, whereas in the deep insertion group, the needle was inserted to a depth of about 20 mm, and was manually stimulated (sparrow pecking method) for 20 seconds. Both groups were treated weekly for four weeks. The visual analog scale (VAS) of pain, Roland-Morris Disability Questionnaire (RDQ), and Pain Disability Assessment Scale (PDAS) were used for outcome measurement.
[Result]VAS, RDQ and PDAS scores showed significant differences between groups (VAS:p < 0.05, RDQ:p <0.001, PDAS:p < 0.05) in change over time with the deep insertion group having more favorable results than the superficial insertion group. The degree of change from the baseline at the time of each evaluation was calculated and results for the two groups were compared. The deep insertion group was significantly better in tendency to improve directly after the first treatment (p < 0.01), in cumulative effect after repeated treatment (VAS:p = 0.13, RDQ:p < 0.05, PDAS:p < 0.01), and in sustained effect after completion of treatment (VAS:p < 0.05, RDQ:p < 0.01, PDAS:p <0.05).
[Discussion and Conclusion]The study showed that deep stimulation is a more effective treatment than superficial stimulation. It is thought that the differences of the effects are due to different influences of the treatments on the pain threshold, muscle blood flow, and muscle tones.

[Objective]To evaluate the efficacy of the different depth of acupuncture on the motor function and the pain with osteoarthritis of the knee.
[Design]Single blind randomized controlled trial.
[Method]Subjects were randomly allocated to one of two groups. Acupuncture needles were inserted about 3mm in the superficial acupuncture group and 10 to 20 mm in the deep acupuncture group. Subjects in both groups received the treatments for ten minutes on ten tender points. Acupuncture sessions were performed once a week for 8 weeks and without treatment 4 weeks.
[Outcome Measures]Pain intensity (visual analogue scale :VAS) , Objective evaluation of the motor function (Timed Up &Go test, 20m walking time, Time of going up and down stairs) and QOL (Western Ontario and MacMaster Universities osteoarthritis index :WOMAC).
All measurements were recorded at baseline, 4th, 8th and 11thweek.
[Result]Motor function improved significantly only in the superficial acupuncture group(P<0.05). The degree of pain decreased significantly in both groups (P<0.05).
[Conclusion]Superficial acupuncture provided the improvements on pain and motor function and contributed to the QOL improvement. Therefore the superficial acupuncture would be suggested to be one of the most effective method for the acupuncture treatment of OA of the knee.

[Objective]To examine the effect of electroacupuncture on the healing process in a rat model of a tibia fracture.
[Methods]Thirty twelve week old male Wister rats underwent unilateral open osteotomies of the tibiae. Then the rats were assigned randomly to three groups:electroacupuncture group (EA group, n = 10), sham group (n = 10), and control group (n = 10). In the EA group, a cathodal electrode was connected to an acupuncture needle percutaneously penetrating directly at the osteotomy site. An acupuncture needle was inserted 15 mm proximal to the osteotomy site and was used as an anodal electrode. Electroacupuncture was performed daily for 3weeks. Using an electrical stimulator, 5ms square pulses at a frequency of 50 Hz were delivered at 20 μA for 20 minutes. In the sham group, no electrical stimulation was given to the acupuncture needle inserted at the same site as the above described group. In the control group, no treatment was given. The response was determined at one, three, four, and six weeks after osteotomy by radiographic examination. Rats were sacrificed on the sixth week for a macroscopic and mechanical examination.
[Results]The EA groups showed acceleration of the bone healing process compared with the sham and control group (three weeks after osteotomy ;p<0.05 ), and accretion of the callus in the EA group was observed compared with that in the other group at six weeks after (radiographic evaluation;p < 0.05, gross maximum longitudinal dimensions of the callus;p < 0.01, gross maximum transverse dimensions of the callus;p < 0.05). Moreover, biomechanically, there was an excellent result in the EA group compared with the other group at six weeks after osteotomy (p < 0.05). There was no difference between the sham and control group in any evaluation.
[Discussion and Conclusion]Callus formation was promoted in the EA group over the sham and control group. The results of this study indicated that the use of electroacupuncture can enhance callus development and bone mineralization of the bone healing process.

Objective
The purpose of this trial was to compare the cumulative and sustained effect of repeated acupuncture treatment and repeated local injection of anesthesia for localized low back pain.
Methods
A computer program was used to randomly allocate 26 patients with low back pain to either an acupuncture group (n=13) or a local injection group (n=13). Patients in both groups received treatment at the most painful points (from 2 to 5 points) once a week for a total of 4 weeks. For the acupuncture treatment, a 0.18mm diameter stainless steel needle was inserted to a depth of 10 to 20mm and then manual stimulation using the sparrow pecking method (1Hz) was given. For the local injection, injection needle (25G, 0.5mm in diameter) was inserted to a depth of 10 to 20mm before injection of the anesthetic (a mixture of local anesthetic and neurotropin). The visual analog scale (VAS: 100mm) was used to measure subjective pain intensity before and directly after the first treatment, before subsequent treatments, and at two and four weeks after completion of the treatment. The Roland-Morris Disability Questionnaire (RDQ) and Pain Disability Assessment Scale (PDAS) were also used to evaluate Quality of Life (QOL) of the subject at before the first treatment, at the time of completion of treatment, and at two and four weeks after the completion of treatment.
Results
There was a significant difference (p=0.0016) in changes in the VAS scores between two groups, with more favorable results in the acupuncture group than in the local injection group. Calculation of the degree of change from the initial scores indicated that acupuncture group showed significantly better results than those in the local injection group at directly after the first treatment (p=0.0348), and there was a significant cumulative effect (at the end of treatment: p=0.0076) and sustained effect (two weeks after treatment: p=0.0096, four weeks after treatment: p=0.0128). Similarly, RDQ and PDAS were also better in the acupuncture group compared to the local injection group.
Discussion
Both local injection and acupuncture reduced low back pain. The superior effect of acupuncture directly after treatment and its superior cumulative and sustained effect, indicate that it could be an effective treatment for low back pain. The reason for the disparity between the effects could be due to differences in the mechanisms of pain suppression.