Comparative Effects of Acupressure at Local and Distal Acupuncture Points on Pain Conditions and Autonomic Function in Females with Chronic Neck Pain

Abstract

Acupressure on local and distal acupuncture points might result in sedation and relaxation, thereby reducing chronic neck pain. The aim was to investigate the effect of acupressure at local (LP) and distal acupuncture points (DP) in females with chronic neck pain. Thirty-three females were assigned to three groups: the control group did not receive any stimuli, the LP group received acupressure at local acupuncture points, GB 21, SI 14 and SI 15, and the DP group received acupressure at distal acupuncture points, LI 4, LI 10 and LI 11. Verbal rating scale (VRS), Neck Disability Index (NDI), State-Trait Anxiety Inventory (STAI), muscle hardness (MH), salivary alpha-amylase (sAA) activity, heart rate (HR), heart rate variability (HRV) values and satisfaction due to acupressure were assessed. VRS, NDI, STAI and MH values decreased after acupressure in the LP and the DP group. HR decreased and the power of high frequency (HF) component of HRV increased after acupressure in only the LP group. Although acupressure on not only the LP but also the DP significantly improved pain conditions, acupressure on only the LP affected the autonomic nervous system while acupuncture points per se have different physical effects according to location.

Full text

Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2011, Article ID 543291, 6pages
doi:10.1155/2011/543291
Research Article
Comparative Effects of Acupressure at Local and
Distal Acupuncture Points on Pain Conditions and
Autonomic Function in Females with Chronic Neck Pain
Takako Matsubara,1, 2 Young-Chang P. Arai,2Yukiko Shiro,3Kazuhiro Shimo,2
Makoto Nishihara,2Jun Sato,4and Takahiro Ushida2
1Department of Rehabilitation, Faculty of Health Sciences, Nihon Fukushi University, 26-2 Higashihaemicho, Handa, Aichi
475-0012, Japan
2Multidisciplinary Pain Centre, School of Medicine, Aichi Medical University, Aichi 480-1195, Japan
3Department of Rehabilitation, Faculty of Health Sciences, Nagoya Gakuin University, Aichi 480-1298, Japan
4Futuristic Environmental Simulation Center, Research Institute of Environmental Medicine, Nagoya University,
Nagoya 464-8601, Japan
Correspondence should be addressed to Takako Matsubara, matsubar@n-fukushi.ac.jp
Received 7 July 2010; Accepted 2 September 2010
Copyright © 2011 Takako Matsubara et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Acupressure on local and distal acupuncture points might result in sedation and relaxation, thereby reducing chronic neck pain.
Theaimwastoinvestigatetheeffect of acupressure at local (LP) and distal acupuncture points (DP) in females with chronic neck
pain. Thirty-three females were assigned to three groups: the control group did not receive any stimuli, the LP group received
acupressure at local acupuncture points, GB 21, SI 14 and SI 15, and the DP group received acupressure at distal acupuncture
points, LI 4, LI 10 and LI 11. Verbal rating scale (VRS), Neck Disability Index (NDI), State-Trait Anxiety Inventory (STAI), muscle
hardness (MH), salivary alpha-amylase (sAA) activity, heart rate (HR), heart rate variability (HRV) values and satisfaction due to
acupressure were assessed. VRS, NDI, STAI and MH values decreased after acupressure in the LP and the DP group. HR decreased
and the power of high frequency (HF) component of HRV increased after acupressure in only the LP group. Although acupressure
on not only the LP but also the DP significantly improved pain conditions, acupressure on only the LP affected the autonomic
nervous system while acupuncture points per se have different physical effects according to location.
1. Introduction
Chronic neck pain is a very common symptom especially in
females. In general, neck pain is felt as a dull pain, stiffness,
or discomfort along the trapezius muscles and the muscles
around the scapulae [1]. Common treatment for chronic
neck pain consists of medication, trigger point injection,
massage, and other physical therapies and patient education
[2]. Massage therapy applied on the tender points is popular
in patients with chronic neck pain and provides the patients
not only with comfort during and immediately after it but
also with various side effects such as discomfort/soreness,
tiredness/fatigue, and headache afterwards [3]. Recently,
alternative therapies such as acupuncture and acupressure
have been increasingly sought. Acupressure is a noninvasive
and safe technique, which is manipulated with the fingers
instead of needles on the traditional acupuncture points,
and has been shown to be effective in pain relief, sedation,
and relaxation [4,5]. Tender points located on the trapezius
muscles are consistent with local acupuncture points such as
“Jianjing” (GB 21), “Jianwaishu” (SI 14), and “Jianzhongshu”
(SI 15) and are applied to massage therapy in patients with
chronic neck pain. On the other hand, distal traditional
acupuncture points, “Hegu”(LI4),“Shousanli” (LI 10),
and “Quchi” (LI 11), are contained in the Large Intestine
Meridian of Hand-Yangming and are suggested to be the
points for improving neck-shoulder-arm disorders in the
Chinese/Japanese traditional medicine.
Chronic pain influences the autonomic nervous system.
For example, sympathetic hyperactivation was shown in

2 Evidence-Based Complementary and Alternative Medicine
SI 15
SI 14
GB 21
Figure 1: Local acupuncture points/tender points. “Jianjing”(GB
21) is located at the highest point on the shoulder and at the
midpoint of the line which connects the prominent vertebra and
the acromion. “Jianwaishu” (SI 14) is located directly above the
superior angle of scapula, at 5-6 cm lateral from the posterior
midline and below the spinous process of the first thoracic vertebra.
“Jianzhongshu” (SI 15) is located on the back, at 3-4 cm lateral from
the posterior midline and below the spinous process of the seventh
cervical vertebra.
fibromyalgia (FM) [6], low back pain [7], whiplash associ-
ated disorders [8], and migraine [9]. Furthermore, a study
showed functional change of the sympathetic nervous system
in workers with chronic neck pain [10]. This abnormality in
the sympathetic nervous system might generate and sustain
chronic pain [11]. Several reports showed that acupuncture
and acupressure on the traditional acupuncture points
influence the autonomic nervous system [4,5,11,12]. That
is, these procedures could modulate the activities of the
sympathetic and parasympathetic nerves.
Autonomic nervous function is known to be reflected
in heart rate variability. Rhythmic components of HRV
can be quantitatively assessed by means of power spectral
analysis. HRV is a reliable and noninvasive tool, used to assess
autonomic nervous system regulation of the heart [4,5].
Frequency fluctuations in low frequency of 0.04
−0.15 Hz (LF)
component of HRV are considered markers of sympathetic
and parasympathetic nerve activities, and high frequencies
of 0.15
−0.4 Hz (HF) component fluctuation of HRV are
considered as a marker of parasympathetic nerve activity.
Thus, the LF/HF ratio is considered to be an index of
sympathetic nerve activity.
We hypothesized that acupressure not only on the
tender points/local acupuncture points, “Jianjing” (GB 21),
“Jianwaishu” (SI 14), and “Jianzhongshu” (SI 15), but also
on the distal acupuncture points, “Hegu”(LI4),“Shousanli”
(LI 10), and “Quchi” (LI 11), could induce sedation, thereby
reducing pain, muscle tone, and disability and changing
autonomic nervous activity in subjects with chronic neck
pain. In the present study, we therefore investigated what
effect pressure applied on the local and distal acupuncture
points had on the pain conditions and HRV in females with
chronic neck pain.
2. Methods
2.1. Subjects. After obtaining approval from the ethics com-
mittee of Nihon Fukushi University and written informed
consent, 33 female subjects who complained of chronic
neck pain participated in the present study. The subjects
were randomly allocated to three groups. The exclusion
criteria were menstruation, cardiovascular or neurological
disease, or administration of sedatives, analgesic, or other
medication.
2.2. Group, Administration, and Measurements. Subjects in
the local acupuncture point (LP) group received acupressure
at three tender points on the neck/shoulder muscles, which
were consistent with local acupuncture points, “Jianjing”
(GB 21), “Jianwaishu” (SI 14), and “Jianzhongshu” (SI
15) (Figure 1), subjects in the distal acupuncture point
(DP) group received acupressure at three distal acupuncture
points, “Hegu”(LI4),“Shousanli” (LI 10), and “Quchi”(LI
11) (Figure 2), and subjects in the control group did not
receive any stimuli.
All measurements were performed during the afternoon
hours. Subjects were assessed regarding pain intensity using
verbal rating scale (VRS), pain-related disability using Neck
Disability Index (NDI), pain-related anxiety using State-
Trait Anxiety Inventory-I (STAI-I), muscle hardness (MH)
on bilateral trapezius muscles, pain-associated stress using
salivary alpha-amylase (sAA) activity, heart rate variability
(HRV), and satisfaction using VRS due to acupressure. For
the VRS, the intensity of neck pain or stiffness was evaluated
on a numerical scale from 0 to 3 (0: no pain, 1: mild pain,
2: moderate pain, and 3: severe pain). NDI, which was
published by Vernon in 1991, is the most commonly used
and validated scale designed to assess self-rated disability in
patients with neck pain and disorder [13]. MH was evaluated
using a tissue hardness meter (PEK-1, Imoto Machinery
Co. Ltd., Kyoto, Japan) bilaterally on the midpoint between
the spinous process of seventh cervical vertebra and the
acromion. This point is located on the trapezius muscles, and
the tender point of neck pain often lies on this point, which is
just the acupuncture point, “Jianjing” (GB 21) [1]. sAA was
evaluated using a hand-held sAA monitor (CM-2.1, Nipro,
Osaka, Japan) [14]. Satisfaction due to acupressure was
evaluated on a numerical scale from 0 to 3 (0: no satisfaction,
1: mild satisfaction, 2: moderate satisfaction, and 3: sufficient
satisfaction). VRS and STAI-I before, immediately following,
and 1 day after receiving the treatment, MH and sAA before
and immediately after the treatment, NDI before and 1 day
after the treatment, satisfaction immediately following and 1
day after the treatment were sampled.
After the initial assessment, the subjects were allowed to
lie comfortably on the bed in a quiet environment for 5 min.
Then, the record of the electrocardiogram (ECG) signals for
HRV analysis started.

Evidence-Based Complementary and Alternative Medicine 3
Tab le 1: Age, weight, VRS, NDI, STAI, MH, sAA, HR, and HRV values at pretreatment for each group.
C group (n=11) LP group (n=11) DP group (n=11) Pvalue
Age (yr) 34.8 (4.0) 35.5 (6.4) 37.2 (7.0) .637
Weight (kg) 50.4 (6.8) 52.3 (10.1) 52.2 (4.8) .643
VRS 1.8 (0.6) 2.1 (0.5) 1.7 (0.8) .413
NDI 7.9 (3.8) 9.4 (4.4) 7.6 (4.6) .430
STAI 39.2 (9.5) 44.5 (8.0) 43.2 (6.8) .772
MH (N) 56.9 (5.0) 57.4 (4.5) 56.2 (5.3) .507
sAA (kU/l) 38.2 (20.1) 20.0 (9.0) 36.8 (27.9) .079
HR (bpm) 65.4 (8.7) 65.8 (6.7) 62.3 (14.1) .941
LF (ms2) 490.7(409.2) 274.2 (253.3) 494.1 (1050.7) .084
HF (ms2) 381.8(338.3) 212.8 (186.7) 764.8 (1045.2) .587
LF/HF 1.7(1.4) 1.4 (0.8) 1.0 (0.6) .399
Values expressed as mean (SD).VRS: verbal rating scale. NDI: Neck Disability Index. STAI: State-Trait Anxiety Inventory-I. MH: muscle hardness. sAA:
salivary alpha-amylase. HR: heart rate. LF: the power of low-frequency (0.04
−0.15 Hz, LF) component of heart rate variability (HRV). HF: the power of high-
frequency (0.15
−0.4 Hz, HF) component of HRV. LF/HF: LF/HF ratio of HRV.
LI 11
LI 10 LI 4
Figure 2: Distal acupuncture point. “Hegu” (LI 4) is the most
important analgesic point in the body and is intensively stimulated
in all painful conditions and is located on the highest point of the
adductor pollicis muscle with the thumb and index finger adducted.
“Shousanli” (LI 10) is located on the radial side of the dorsal surface
of the forearm at about 3 cm below the lateral transverse elbow
crease and between the extensor carpi radialis longus and brevis.
“Quchi” (LI 11) is located on the end of the lateral transverse elbow
crease at the middle of the connection between the biceps tendon
and the lateral epicondylus of the humerus.
0
1
2
3
VRS
PostPre 1 day
∗
∗
∗
†
Figure 3: Changes in pain intensity (VRS: verbal rating scale).
: control group. : local acupuncture point (LP) group. :
distal acupuncture point (DP) group. Values are presented as mean.
SD represented with error bars in the LP and the DP groups. ∗
significantly different from pre-treatment in the DP group (P<
.05). ∗∗ significantly different from pretreatment in the LP group
(P<.01). †significantly different from control group in the DP
group (P<.05).
PostPre 1 day
20
25
30
35
40
45
50
55
STAI
∗∗
∗∗
Figure 4: Changes in pain-associated anxiety (STAI-I: State-Trait
Anxiety Inventory-I). : control group. : local acupuncture point
(LP) group. : distal acupuncture point (DP) group. Values are
presented as mean. SD represented with error bars in the LP and
the DP groups. ∗∗ significantly different from pre-treatment in the
LP and the DP groups (P<.01).
Ten minutes later, three sets of acupressure by the pulp
of the right thumb in a rotary fashion at 20
−25 cycles per
minute for 30 seconds on each point were administered
at the right side of GB 21, SI 14, and SI 15 consecutively
and afterwards at the left side of these three points in the
LP group. On the other hand, three sets of procedures
conducted in the same way as shown in the LP group were
administered at the right side of LI 4, LI 10, and LI 11
consecutively and afterwards on the left side of these three
points in the DP group. These procedures were applied by
the same investigator. Following release of acupressure, the
subjects were observed for another 10 minutes. The ECG
signals were obtained from a portable ECG (AC301A, GMS,
Tokyo, Japan) and transferred to a computer loaded with
HRV analysis software (TARAWA/WIN; Suwa Trust, Tokyo,
Japan). The R-R intervals (RRIs) were obtained every 10
seconds. The two components of power of the RRI (ms.ms),
LF (0.04
−0.15 Hz) and HF (0.15−0.5 Hz), were calculated.

4 Evidence-Based Complementary and Alternative Medicine
45
50
55
60
65
MH (N)
Post
Pre
∗∗
∗
Figure 5: Changes in muscle hardness (MH). : control group. :
local acupuncture point (LP) group. : distal acupuncture point
(DP) group. Values are presented as mean. SD represented with
error bars in the LP and the DP groups. ∗significantly different
from pre-treatment in the DP group (P<.05). ∗∗ significantly
different from pre-treatment in the LP group (P<.01).
Heart rate (HR) and the LF and the HF values and the
LF/HF ratio of HRV were analyzed. The data of HR and
HRV values for 30 seconds at 5 minutes before the beginning
of the pressure (pre-treatment) and for 30 seconds at 5
minutes after pressure release (post-treatment) were sampled
for subsequent analysis.
2.3. Data Analysis. Data was presented as mean (SD). VRS,
STAI-I, MH, NDI, HR, and HRV values were analyzed
with Kruskal-Wallis test for intergroup comparison followed
by Dunn’s Multiple Comparison Test. Satisfaction due to
acupressure was analyzed with Mann-Whitney’s U test for
intergroup comparison on the LP and the DP groups. VRS
and STAI-I were analyzed using Friedman test for intragroup
comparison followed by Dunn’s Multiple Comparison Test.
Wilcoxon signed-rank test was used to analyze MH, NDI,
HR, and HRV values for intragroup comparison. P<.05
was considered as statistically significant.
3. Results
Tab l e 1shows the demographic data of the three groups.
There were no significant differences in age, weight, and pre-
treatment values regarding pain conditions among the three
groups (Table 1).
There were no significant differences in all parameters in
the control group. VRS (Figure 3), STAI-I (Figure 4), and
MH (Figure 5) values significantly decreased immediately
after treatment, and NDI (Figure 6) was lower at 1 day
following treatment compared with pre-treatment in the LP
and the DP groups. HR (Figure 7) significantly decreased
and the HF component of HRV (Figure 9) significantly
increased after treatment in the LP group only. There were
no differences on the sAA and the LF components (Figure 8)
and the LF/HF ratio (Figure 10) of HRV among the three
groups. Satisfaction due to acupressure continued to 1 day
after the treatment in the LP and the DP groups (Figure 11).
0
5
10
15
Pre
1day
∗∗
∗†
NDI
Figure 6: Changes in pain-associated disability (NDI:Neck Dis-
ability Index). : control group. : local acupuncture point
(LP) group. : distal acupuncture point (DP) group. Values are
presented as mean. SD represented with error bars in the LP and
the DP groups. ∗significantly different from pre-treatment in the
DP group (P<.05). ∗∗ significantly different from pre-treatment
in the LP group (p<.01). †significantly different from control
group in the DP group (P<.05).
45
50
55
60
65
70
75
HR (bpm)
PostPre
∗
Figure 7: Changes in heart rate (HR). : control group. :local
acupuncture point (LP) group. : distal acupuncture point (DP)
group. Values are presented as mean. SD represented with error
bars in the LP and the DP groups. ∗significantly different from pre-
treatment in the LP group (P<.05).
4. Discussion
Our results demonstrated that acupressure on the local
and the distal acupuncture points significantly reduced
various parameters of the pain-associated conditions, that
is, VRS, STAI-I, MH, and NDI whereas there were no
significant differences in all parameters in the control group.
Although acupressure did not change the LF and the LF/HF
ratio of HRV, acupressure on the local acupuncture points
significantly reduced HR and increased the HF of HRV.
Satisfaction due to acupressure continued until 1 day after
treatment on the distal points as well as the local points.
These results show that acupressure on not only the local
points but also the distal acupuncture points improved
pain-related condition, and furthermore acupressure could
influence the autonomic nervous system.
Mechanical pressure such as massage and acupressure has
been known to decrease tissue adhesion, promote relaxation,

Evidence-Based Complementary and Alternative Medicine 5
0
200
400
600
800
1000
1200
1400
1600
1800
2000
LF (ms2)
PostPre
Figure 8: Changes in the low-frequency (LF) component of heart
rate variability. : control group. : local acupuncture point
(LP) group. : distal acupuncture point (DP) group. Values are
presented as mean. SD represented with error bars in the LP and
the DP groups.
0
200
400
600
800
1000
1200
1400
1600
1800
2000
PostPre
∗
HF (ms2)
Figure 9: Changes in the high-frequency (HF) component of heart
rate variability. : control group. : local acupuncture point
(LP) group. : distal acupuncture point (DP) group. Values are
presented as mean. SD represented with error bars in the LP and
the DP groups. ∗significantly different from pre-treatment in the
LP group (P<.05).
increase regional blood circulation, increase parasympa-
thetic nervous activity, increase intramuscular temperature,
and decrease neuromuscular excitability [15]. Also, many
researchers have demonstrated the effect of acupressure and
acupuncture for sedation [4,5,16,17].
Acupuncture on the tender points has been commonly
used as a treatment for chronic neck pain and appears
to alleviate pain and stiffness [1,18]. The tender points
are known to be located at traditional acupuncture points,
“ah si” point, and also to conform with trigger points and
criterion sites for fibromyalgia [1,18,19]. Tender points
are supposed to be the site where there are nociceptors and
polymodal receptors, which have been sensitized by various
factors. Thus, stimulation such as acupuncture and acupres-
sure on the tender points may activate sensitized polymodal
receptors more powerfully, resulting in stronger effects on
pain relief [1]. In traditional acupuncture medicine, tender
points eliciting tenderness or pain could be selected when
treating chronic neck pain [1].
0
0.5
1
1.5
2
2.5
3
LF/HF
Pre Post
Figure 10: Changes in the LF/HF ratio (LF/HF) of heart rate vari-
ability. : control group. : local acupuncture point (LP) group.
: distal acupuncture point (DP) group. Values are presented as
mean. SD represented with error bars in the LP and the DP groups.
Acupuncture treatment typically applies to not only
the tender points but also the distal acupuncture points
for the treatment of chronic pain. Acupuncture at the
distal acupuncture points could improve pain conditions
in chronic neck pain patients, indicating that nonseg-
mental antinociceptive systems may play a major role in
acupuncture analgesia [2]. Also, electroacupuncture at the
acupuncture point “Hegu” (LI 4) decreases the activity on
anterior cingulated cortex (ACC) and cingulum, thereby
inhibiting nociceptive processing in the brain. Acupuncture
point stimulation at a rich nerve junction such as “Hegu”
may reduce pain-induced cingulation processing, thereby
resulting in pain relief/analgesia [20]. A study showed that
acupuncture improved pain-related disability assessed by
NDI [21], as observed in the present study. Furthermore,
acupuncture may improve activities at work, the quality of
sleep and consequently tiredness, pain-related quality of life,
and psychological variables for women with chronic neck
pain [22].
Acupuncture has been reported to affect the autonomic
nervous system [11,23]. However, acupuncture/acupressure
might have different physiological effects between local and
distal acupuncture points, since we showed that acupressure
at LI-4, LI-10, and LI-11 did not, but at GB-21, SI-14, and
SI-15 significantly influenced autonomic nervous activity.
There are several limitations to the present study. One
of them is that we did not perform longer term followup
after acupressure. We need further evaluation of the longer
effects of acupressure on chronic neck pain and autonomic
nervous system. Another limitation is that we showed only
the effect of acupressure on either local or distal points. Most
acupuncturists and acupressurists use both local and distal
points together in clinical practice. Therefore, further study
is required in order to assess combinational effects.
In conclusion, acupressure significantly improved pain
conditions on not only the local points but also the distal
acupuncture points in females with chronic neck pain
but affected the autonomic nervous system on only local
acupuncture points, as acupuncture points per se have
different physical effects depending on location.

6 Evidence-Based Complementary and Alternative Medicine
0
1
2
3
Satisfaction
1dayPost
Figure 11: Changes in satisfaction due to treatment (VRS: verbal
rating scale). : local acupuncture point (LP) group. : distal
acupuncture point (DP) group. Values are presented as mean. SD
represented with error bars in the LP and the DP groups.
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