Evaluating Training Programs for Electroacupuncture Techniques with Skin Temperature as a New Index

Training in acupuncture techniques has a long history of thousands of years. It has been individually handed down from person (teacher) to person (student). However, techniques and training have not been scientifically evaluated because individual differences may exist among evaluators. In animal studies, some researchers have reported that acupuncture stimulation dilates blood vessels of the skin and skeletal muscles. These studies also reveal an association between skin temperature (ST) and blood circulation volume on the skin. Our previous studies have reported that acupuncture stimulation, especially that of electroacupuncture (EA), can elevate ST. Therefore, we monitored the instructive effects and level of EA techniques with ST and propose that we can bring monitoring ST into training/education of EA as a new index of technical assessment. Moreover, ratio of changes might be used as new criteria for retraining. Healthy students (n = 14) were given with 10 minutes of EA stimulation on the tibialis anterior: Zusanli (ST36) and Tiaokou (ST38). Their ST was monitored before and during stimulation as well as for 30 minutes after stimulation. All subjects showed a nominal increase in ST. At the time, ratios of changes were also calculated. Two subjects did not reach the average of 1.3%. This suggests that the technical level of the therapist was inadequate. Thus, observation of ST elevation and calculation of the average ratio of ST change (elevation) could be applied to a new scientific index of technical assessment in acupuncture treatment training. However, further research (e.g., larger-scale studies, adjustment for gender differences, or other age subjects) How to cite this paper: Kubota, T., Mori, H., Morisawa, T., Hanyu, K., Kuge, H., Watanabe, M. and Tanaka, T.H. (2017) Evaluating Training Programs for Electroacupuncture Techniques with Skin Temperature as a New Index. Health, 9, 15891596. https://doi.org/10.4236/health.2017.911116 Received: July 18, 2017 Accepted: October 27, 2017 Published: October 30, 2017 Copyright © 2017 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
Acupuncture has a long history and is widely practised worldwide [1].One of the oldest findings was the Tyrolean Iceman, who had tattoos at acupuncture points, which suggests the possible origins of acupuncture [2].
In other words, this wisdom of the ancients was handed down from generation to generation for thousands of years.Sometimes it was passed on in the Classics, such as the Yellow Emperor's Classics of internal medicine, and sometimes it was individually handed down from person (teacher) to person (student).
Nowadays, the knowledge and techniques are taught in colleges and universities so that students may obtain national certification.Schools provide a systematized curriculum and textbooks.They also investigate the effectiveness of instruction and have developed many evaluation sheets or check lists [3] [4].
However, scientific evaluation of effectiveness is not easy because individual differences may exist among evaluators.
In animal studies, some researchers have reported that acupuncture stimulation dilates blood vessels of the skin and skeletal muscles [5] [6] [7].These studies also reveal an association between skin temperature (ST) and blood circulation volume on the skin [8] [9].
Previously, we studied whether the effectiveness of electroacupuncture (EA) could be evaluated by changes in ST.We also investigated whether EA elevated ST by various methods such as thermographic laser Doppler velocimetry, near-infrared spectroscopy, and hydrogen clearance and we reported that EA would definitely elevate ST [5] [10] [11] [12] [13].
In this study, we monitored the effectiveness of instruction and level of EA techniques with ST and we propose that we can bring monitoring of ST into training/education of EA as a new index of technical assessment.Moreover, ratio of changes might be used as new criteria for retraining.

Subjects
Healthy students (n = 14 (male = 12, female = 2), average 23.5 ± 2.7 years old) participated in this study.2nd year students of acupuncture and moxibustion course were recruited.A total of 14 students participated.All of them had sufficient training, knowledge and techniques of EA in the course with experienced acupuncturists (Table 1).Subjects worked in pairs; one subject provided EA stimulation to the other.
Next, the roles were reversed.At the same time, they also monitored changes in ST (Figure 1(a)).
This study adhered strictly to the principles of the Declaration of Helsinki.
One week before the study began, the participants were informed of the purpose and procedures of the study, and all of them signed the consent form.This study was approved by the institutional review board of the Tsukuba University of Technology, Tsukuba, Japan (H28-01).

Methods
The protocol of this study is illustrated in Figure 1(b).

EA Stimulation
Subjects rested in the supine position for 15 minutes before they received EA stimulation (1 Hz) for 10 minutes using two disposable acupuncture needles (40 mm in length, 0.20 mm in diameter, Seirin Corporation, Shizuoka, Japan) at a depth of 10 -15 mm into two acupuncture points on the tibialis anterior: Zusanli (ST36) and Tiaokou (ST38).EA was applied on the right leg.An Ohm Pulser LFP-4000A (Zen Iryoki Corporation, Fukuoka, Japan) was used as the device for generating EA stimulation (H28-01).

ST Monitoring Methods
Changes in ST were observed with a monitor, TH-200 (Suzuki Iryoki, Co., Ltd.), in the middle of the two points as shown in Figure 1(c).This experiment was conducted in a room at a constant temperature (24.3˚C ± 0.3˚C) and humidity (31.5% ± 0.8%).

Ratio of ST Changes
Those ratios were obtained by comparison with ST at the point in time before stimulation (pre) according to the below formula Δ% = [pre − (stim, post 0, post 5, post 10, post 15, post 20, post 25, or post 30)/pre] × 100; the average values of Δ % were also calculated (Δ% = 1.26).

Statistical Analysis
Differences between values were determined by two-way analysis of variance followed by post hoc comparisons, Fisher's LSD multiple comparison test with SPSS Advanced Models Version.The level of significance was set at p < 0.05 and all data were presented as mean ± SEM.

Figure 1 .
Figure 1.(a-i) First, subjects worked in pairs; one subject (on the left = figure in white) provided EA stimulation to the other (on the right = figure in black).(a-ii) Second, these roles were reserved (the black gave EA stimulation to the white).At the same time, they also monitored changes in ST.(b) In this study, ST was recorded at (pre); 5 minutes after the start of EA (stim); immediately after EA (post 0); and at 5 (post 5), 10 (post 10), 15 (post 15), 20 (post 20), 25 (post 25), and 30 (post 30) minutes after stimulation.(c) EA stimulation and ST measurement points: ○ EA stimulation, • skin temperature measurement.

Figure 2 .
Figure 2. ST of the EA group (•) showed a significant increase, however, the control group (•) did not.*p < 0.05 vs pre.

Table 2 .
Ratio of ST changes (elevations) after EA stimulation.