Vol.3, No.7, 437-443 (2011)
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Effect of enpishin (press tack acupunctur e needles) on
autonomic function, WBC count and oxidative stress
Mitsunori Tsumaki1, Yoshitomo Saita1, Hiroshi Ikeda1, Kazuo Kaneko1, Takehiko Yukishita2,
Keiko Lee2, Sungdo Kim2, Shinichi Yokota2, Nobuhiro Suetake2, Hiroyuki Kobayashi2*
1Department of Orthopaedics, Graduate School of Medicine, Juntendo University School of Medicine, Tokyo, Japan;
2Department of Hospital Administration, Graduate School of Medicine, Juntendo University School of Medicine, Tokyo, Japan.
*Corresponding Author: koba@juntendo.ac.jp
Received 27 April 2011; revised 27 June 2011; accepted 13 July 2011.
Acupuncture as a vital component of traditional
medical systems of the Far East has been used
to restore and maintain health for over three
millennia. However, the neurobiological corre-
lates of this therapy remain largely unknown.
The purpose of this study was therefore to de-
termine the effect of enpishin acupuncture (pre-
ss tack needles (PTN)) on autonomic function,
WBC count, and oxidative stress between sub-
jects that received either verum or placebo PTN
treatment. Twenty men (mean(SD) age: 36.7(5.1)
years) who provided oral consent were ran-
domized to receive either verum PTN (n = 9) or
placebo PTN (n = 11). Bi-Digital O-Ring Test
(BDORT) was used to select the acupoints for
each participant. Autonomic function and oxi-
dative stress level were analyzed before and
after the treatment via heart rate v ariability (HRV)
and free radical analysis system (FRAS4), re-
spectively. Pre- and post-treatment WBC count
was also evaluated. Verum PTN group had a
statistically significant increa se ( p = 0. 008) in Ln
TP, an index of overall autonomic activity. Sub-
jects in this group also had a significantly
greater (p = 0.006) variation in Ln TP than the
placebo PTN group in response to the treatment.
Similarly, Ln HF of subjects receiving verum
PTN showed a marked increase (p = 0.0026) af-
ter the treatment. Moreover, a significantly
greater (p < 0.001) variation in mean Ln HF be-
fore and after the treatment was noted in the
verum group than the placebo group, reflecting
a greater parasympathetic activation in the
former. In contrast, sympathetic activity was not
significantly influenced by verum PTN based on
the lack of observed changes in LF/HF ratio. In
addition, both groups failed to demonstrate
significant variations in pre- and post-treatment
mean Ln LF/HF ratio. Further, no significant in-
tergroup difference was found with regard to
mean variation in Ln LF/HF ratio. Ver um PTN did
not induce significant changes in WBC count
and markers of oxidative stress, namely reac-
tive oxygen species (ROM) and biological anti-
oxidant potential (BAP). How ever, a comparison
of variations in pre- and post-treatment mean
WBC count showed a significant difference (p =
0.020) between the two treatment modes: verum
group showed a slight increase (225 ± 384.5),
while placebo group showed a minimal de-
crease (190 ± 272.6). Our findings suggest tha t
PTN increases overall autonomic activity, par-
ticularly the parasympathetic function.
Keywords: Heart Rate Variability; Press Tack
Needles; Acupoints; Bi-Digital O-Ring Test;
Oxidative Stress
Acupuncture as a vital component of traditional med-
ical systems of the Far East has been used to restore and
maintain health for over three millennia. It has become
one of the most popular complementary and alternative
medicine (CAM) modalities in the West, most notably in
England and the United States [1-3].
Acupuncture is an invasive procedure in which a
stainless steel needle of 0.2 - 0.4 mm width is inserted
about 1-3 cm into the tissue at a specific acupuncture or
trigger point in the body [4]. It has been used to treat a
vast array of medical conditions as well as sports-related
injuries and muscle fatigue [5-7]. Some of its putative
effects include analgesia and improvement in cardio-
vascular function and peripheral circulation [8,9]. Ac-
M. Tsumaki et al. / Health 3 (2011) 437-4 43
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
cording to the 1997 statement issued by the National
Institute of Health (NIH) Consensus Panel on Acupunc-
ture, there is “clear evidence” of acupuncture’s efficacy
for postoperative or post-chemotherapy nausea and vom-
iting, and “reasonable evidence” in relieving menstrual
cramps, tennis elbow, fibromyalgia, postoperative dental
pain, lower back pain, myofascial pain, and epicondylitis
[10]. More recently, teleacupuncture using computer-
controlled heart rate variability (HRV) analysis per-
formed trans-continentally has shown that acupuncture
influences the autonomic nervous system (ANS) as re-
flected in changes in the sleep-wake cycle [11]. However,
the efficacy and mechanism of acupuncture have not
been clarified from a Western medical perspective and
there is still a paucity of data from prospective random-
ized controlled trials, resulting in differing opinions
among physicians regarding the efficacy of acupuncture.
Japanese style acupuncture is known to be one of the
gentler forms of needling, nonetheless, it may cause pain
or minor bruising during insertion into the skin and
muscles and thus discourage sensitive patients and ath-
letes from seeking such skin-penetrating treatments, es-
pecially before exercising or a competition. For these
reasons, enpishin (a.k.a. press tack needles (PTN)) was
developed in Japan to provide a less invasive alternative.
These minimally invasive needles are 0.2 mm wide and
0.6 mm long and are virtually risk-free from causing
tissue damage or infection. Previous studies have found
PTN to be efficacious for the treatment of muscle fatigue
and pain [10,12,13] as well as for pain and mood distur-
bances related to low back pain [14]. Despite its wide-
spread use, scientific evidence demonstrating its efficacy
is scarce. The aim of this study was therefore to evaluate
the effects of PTN on autonomic function, WBC count,
and oxidative stress in verum and placebo PTN groups,
and in so doing determine the therapeutic value of PTN.
2.1. Stud y Participants
The protocol of this study was approved by the Insti-
tutional Review Board (IRB) at Juntendo University, and
oral consent was obtained from all participants. Twenty
men (mean(SD) age: 36.7(5.1) years) were randomized
to receive either verum PTN (n = 9) or placebo PTN (n =
11). Participants were blinded to treatment allocation
and were briefed on the purpose and nature of the study,
as well as the physical and mental burden of participat-
ing in the study. All eligible participants were non-
smokers, free from underlying diseases such as hyper-
tension, hyperlipidemia, cardiovascular disease, and dia-
betes, and denied ongoing use of cardiovascular medica-
tions, sedative hypnotics, anxiolytics, or other psycho-
tropic medications. On the test day, participants with a
body temperature below 37˚C, without pronounced fa-
tigue, with more than 6 hours of sleep before the test,
and who had refrained from alcohol consumption were
included in the study. Measurements were performed
between 10:00 and 18:00 hours to account for circadian
variations in ANS. Participants were asked to abstain
from all foods and drinks 3 hours prior to the test, and to
empty their bladder shortly before the test. After a
20-minute rest, measurements were taken in a sitting
position while a respiratory rate of 13 breaths per minute
was maintained. All measurements and tests were car-
ried out under quiet conditions in a temperature and hu-
midity controlled (24˚C, 60%) laboratory.
2.2. Methods
2.2.1. Enpishin (Press Tack Acupuncture
Needles (PTN))
Single-use Pyonex PTN (0.2 mm diameter × 0.6 mm
length, Seirin Co. Ltd, Shizuoka, Japan) and placebo
PTN were used in the study. PTN had an adhesive plas-
ter that affixed them on the skin. Acupoints on the body
were first marked and PTN were embedded in the skin
overlying these points. Verum PTN was indistinguish-
able in physical appearance from placebo PTN unless
the end of the tack was felt with a fingertip. Placebo
PTN had a blunt tip that did not pierce the skin, however,
it created a sensation similar to that of skin puncture and
tissue penetration, making it difficult for the subjects to
discriminate between the two PTNs (Figures 1(a) and
1(b)) [15].
2.2.2. Selection of Acupoints
For this study, acupoints located on the wrist and the
upper abdomen conducive for regulating the autonomic
and immune systems were selected from the list (Table
1). The Bi-Digital O-Ring Test (BDORT) was performed
in all participants to select the acupoints that maximized
the treatment effect of PTN in each participant. BDORT
is a non-invasive, diagnostic test that utilizes changes in
finger strength as an index of electromagnetic resonance.
Participants were asked to place one finger on each acu-
point lightly and sequentially, while simultaneously
touching the tips of the thumb and one finger (e.g. index
finger) of the opposite hand to form an “O” (O-ring or a
fairly perfect circle). The examiner (acupuncturist) then
exerted a pull on the O-ring with both of his index finger
and thumb while the participant resisted. The partici-
pant’s finger strength was compromised and O-ring
pulled apart easily if the opposite hand was touching an
afflicted acupoint [16,17]. Acupoints that corresponded
M. Tsumaki et al. / Health 3 (2011) ***-* **
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Figure 1. (a) Physical appearance of verum PTN vs placebo
PTN. (b). Needle tip of verum PTN.
Table 1. List of acupoints used in treatment (WHO 2000)
Wr ist HT7, PC7, LU9, LI5, TE4, SI5
Upper abdomen LR14, ST19, CV12, CV15
with the most significant drop in finger strength were
selected for the treatment. A total of three points (one
from each body area) were selected and marked with a
red pen. Electrical devices such as cell phones, home
electrical appliances, and medical devices that emit elec-
tromagnetic frequencies and interfere with BDORT were
removed from a 3-meter radius of the testing area.
2.2.3. Autonomic Indexes Based on HRV
ANS consists of sympathetic and parasympathetic
nerves that work antagonistically to modulate the rhythm
of the heartbeat. Sympathetic dominance occurs during
stress response such as nervous tension and agitation,
while parasympathetic predominance slows heart rate.
Thus the extent of autonomic influence and factors that
affect it such anxiety and stress can be estimated by
measuring heart rate and R-R interval variability.
HRV analysis consists of time and frequency domain
analysis. The standard deviation of beat-to-beat intervals
(SDNN) obtained from time domain measures reflects
fluctuations in heart rate due to respiratory sinus ar-
rhythmia and serves as the marker of parasympathetic
activity [19]. Frequency domain analysis is accom-
plished by a power spectral analysis of time domain
measures of HRV. The Total Power (TP) is the total NN
interval spectral power and the measure of overall ANS
activity [20]. The R-R interval is the distance between
the two largest spikes (R wave) in the EKG. The spectral
analysis of R-R interval variations yields High Fre-
quency (HF) (>0.15 Hz) and Low Frequency (LF) (0.04
- 0.15 Hz) components. The major contributor to the HF
component is the parasympathetic portion of cardiac
autonomic modulation. HF typically corresponds to res-
piratory sinus arrhythmia and therefore primarily reflects
respiration-mediated HRV. Conversely, the LF compo-
nent reflects the interplay of both sympathetic and para-
sympathetic modulation of heart rate. A similar consid-
eration applies to the ratio of HF and LF as an index of
sympathovagal balance. The current consensus is that
the LF/HF ratio and HF reflect sympathetic and para-
sympathetic activity, respectively [21]. The frequency
domain parameters are obtained from fast Fourier
Transform (FFT) spectral analysis. In this study, fre-
quency domain measures, including very low frequency
(VLF), HF, LF, LF/HF ratio, and total power (TP) were
used as outcome measures.
2.2.4. White Blood Cell (WBC) Count
Blood (10 cc) from the cubital vein using a blood col-
lection vacuum tube was used to determine the WBC
count. Differential WBC count was not evaluated in this
2.2.5. Oxidative Stress Test
Free radical analytical system (FRAS4) was used to
evaluate the status of the endogenous antioxidant de-
fense system. FRAS4 (Diacron International, Italy) con-
sists of d-ROM test (reactive oxygen metabolites) and
BAP test (biological antioxidant potential) to provide a
global assessment of oxidative stress and antioxidant
capacity. For our experiment, one drop of blood from the
vein of the fingertip (20 μL) was used for both tests. The
rationale behind the d-ROM and BAP tests to determine
the level of oxidative stress and antioxidant capacity is
as follows. When free radicals attack and react with var-
M. Tsumaki et al. / Health 3 (2011) 437-4 43
Copyright © 2011 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
ious substances in the body such as lipids, amino acids,
proteins, and nucleotides, these substances in turn be-
come peroxidized and prompt intracellular formation of
hydroperoxides (ROOH). The d-ROM test measures the
blood concentration of ROMs, primarily ROOH (optical
measurement, 505/546 nm), as the level of free radicals
in the body. These are measured in CARR.U. units, with
one CARR.U. equaling 0.08 mg/dL of hydroperoxide.
Meanwhile, BAP test evaluates the redox effect by mea-
suring the substances in the serum with reduction poten-
tial. Venous blood samples are mixed with Fe(III)-con-
taining reagents, then the amount of discoloration in the
Fe(III)-reduced sample is determined by a photometer.
The amount of redox-active iron ions that reacts with the
blood sample is an estimate of the antioxidant potential,
which is expressed as μM or μEq/L.
2.3. Acupuncture Intervention
Before conducting the PTN treatment, HRV analysis
and blood tests were carried out in all participants. Addi-
tionally, HRV analysis was performed before the blood
draw to prevent the pain of venipuncture from affect-
ing autonomic functions. While participants remained
quietly seated, a probe was attached to the left index
finger to measure their HRV for 3 minutes using the
APG Heart Rater SA-3000P (Tokyo Iken, Japan). Blood
tests included WBC count, ROM test as an index of
oxidative stress, and BAP test as an index of antioxidant
After a 5-minute rest following the blood tests and
upon cessation of bleeding, verum or placebo PTN was
embedded in the acupoints selected individually for each
participant via BDORT by the same licensed acupunc-
turist with over 30 years of clinical experience. Blinding
of the acupuncturist was achieved by having the practi-
tioner place PTN on the skin without viewing the needle
tip. Participants remained quietly seated during the 10-
-minute treatment.
HRV analysis and blood tests were repeated after the
PTN treatment. All assessments were performed by an
observer blinded to treatment allocation.
2.4. Statistical Analysis
Autonomic parameters (TP, LF, HF, and LF/HF ratio)
generated from HRV analysis were logarithmically
transformed to obtain a normal distribution. Pre- and
post-treatment means of Ln TP, Ln LF, Ln HF, Ln
LF/HF ratio of the verum and placebo PTN groups were
calculated, and the changes in mean values in each group
were determined using the Wilcoxon signed-rank test.
Treatment effect was estimated from changes in mean
values, and the difference in these changes between the
two groups was also determined by the Wilcoxon sig-
ned-rank test. Similarly, the difference between pre- and
post-treatment means of WBC count, ROM, and BAP, as
well as the difference in mean values between the two
groups were analyzed. The significance level for all cas-
es was set at 5%. The SPSS Ver.11.5 software was used
for all analyses.
3.1. Autonomic Function
Table 2 lists pre- and post-treatment autonomic pa-
rameters (mean ± SD), and Ta b l e 3 lists the changes in
these means.
Verum treatment resulted in a significant increase in
mean Ln TP (p = 0.008), Ln LF (p = 0.028), and Ln HF
(p = 0.008), whereas placebo treatment resulted in a sta-
tistically significant decrease in mean Ln HF (p = 0.026).
When compared with placebo PTN, verum PTN in-
duced significantly greater changes in mean Ln TP (p =
0.006: Table 2), Ln LF (p = 0.020), and Ln HF (p <
3.2. WBC Count, BAP and ROM
Pre- and post-treatment WBC count, BAP, and ROM
(mean ± SD) are shown in Table 4. The changes in these
means are summarized in Tab le 5. Our data showed that
there were no significant differences in pre- and post-
treatment means of WBC count, ROM and BAP between
the treatment modes (verum vs placebo). However, there
Table 2. Pre- and post-treatment HRV parameters (mean ± SD).
Verum PTN group Placebo PTN group
Before After Before After
Mean SD Mean SD
Mean SD Mean SD
Ln TP 6.52 1.15 7.43 0.82 0.008 7.56 1.30 7.45 0.92 0.424
Ln LF 5.48 1.24 6.48 1.15 0.028 6.78 1.46 6.40 1.26 0.091
Ln HF 5.17 1.64 5.90 1.11 0.008 5.39 0.86 5.02 0.84 0.026
Ln LF/HF 0.30 1.30 0.57 1.33 0.441 1.39 0.95 1.38 1.05 0.722
M. Tsumaki et al. / Health 3 (2011) ***-* **
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Table 3. Changes in HRV parameters (mean ± SD).
Verum PTN group Placebo PTN group
Mean SD Mean SD
Ln TP 0.91 0.62 –0.10 0.81 0.006
Ln LF 1.00 1.11 –0.38 0.64 0.020
Ln HF 0.73 0.68 –0.37 0.46 0.000
Ln LF/HF 0.27 0.90 –0.02 0.65 0.503
Table 4. Pre- and post-treatment WBC count, ROM and BAP (mean ± SD).
Verum PTN group Placebo PTN group
Before After Before After
Mean SD Mean SD
Mean SD Mean SD
WBC 6812.5 2882.2 7037.5 944.9 0.127 5480 3182.1 5290.0 986.0 0.057
ROM 1978.3 179.5 1977.8 124.2 0.889 2133.7 158.4 2169.5 83.3 0.541
BAP 319.5 41.2 326.5 45.6 0.401 343.2 31.7 329.2 53.3 0.110
Table 5. Changes in WBC count, ROM and BAP (mean ± SD).
Verum PTN group Placebo PTN group
Mean SD Mean SD
WBC 225 384.5 –190 272.6 0.020
ROM –0.5 154.2 35.8 93.9 0.722
BAP 7.0 28.8 –14.0 27.3 0.183
was a significant difference (p = 0.002) in changes in
mean WBC count between the two treatments: verum
PTN (225 ± 384.5) and placebo PTN (190 ± 272.6).
The main finding from our study was that verum PTN
increased overall autonomic function, in particular, the
parasympathetic activity. Verum PTN resulted in a sig-
nificant increase in Ln TP as well as in changes in mean
Ln TP than those produced by placebo PTN, suggesting
an enhanced overall ANS activity. Similarly, verum
treatment significantly increased Ln HF and changes in
mean Ln HF than placebo treatment, underscoring its
ability to augment parasympathetic function. By contrast,
a significant change in sympathetic function was not
observed after the verum treatment, as observed from the
lack of statistically significant changes in mean Ln
LF/HF. In addition, there was no statistical intergroup
difference in changes in mean Ln LF/HF ratio to indicate
any PTN effect on sympathetic tone.
Verum PTN did not induce significant changes in
WBC count, ROM, and BAP. However, there was a sig-
nificant difference in changes in mean WBC count be-
tween verum and placebo PTN groups: WBC count of
the former increased slightly while it decreased margin-
ally in the latter. Interestingly, a small increase in WBC
count in the verum PTN group was observed within 10
minutes of the treatment. Rapid changes in blood chem-
istry following a mild, superficial stimulation of 0.6 mm
depth with PTN are intriguing findings that warrant fur-
ther investigation.
Based on our findings, PTN acupuncture augmented
parasympathetic input without affecting the sympathetic
tone. According to Nishijo, the efficacy of acupuncture
can be explained in part by neural reflexes: stimulation
of skin and subcutaneous tissue induces a reflex via a
parasympathetic efferent pathway, while deep needling
into the muscles induces a reflex via a sympathetic
β-receptor efferent pathway [22]. In fact mild, superfi-
cial stimulation with PTN is purported to selectively
activate parasympathetic nerves. From these findings,
we hypothesize that PTN would more efficacious than
deep needling with thicker Chinese needles for the treat-
M. Tsumaki et al. / Health 3 (2011) 437-4 43
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
ment of certain conditions such as tension headaches
produced by sympathetically mediated vasoconstriction.
The pain-relieving effect of acupuncture has garnered
much attention since the release of Chinese reports on
acupuncture anesthesia, however pain relief is not the
only indication for acupuncture as it is a therapeutic in-
tervention designed to improve health in general. In fact,
studies have shown that excitation of the polymodal re-
ceptor by acupuncture may activate or modulate the en-
docrine, immune, and autonomic systems to produce
multifarious therapeutic effects [23]. Unfortunately, there
is still little research on the efficacy of acupuncture tech-
niques that employ shallow insertions such as PTN. Most
studies on PTN have investigated its musculoskeletal
effects such as alleviation of muscle soreness after en-
durance activities like marathon or triathlon. Several
studies on intradermal or shallow acupuncture have fou-
nd that such acupuncture can relieve periarthritic pain in
the shoulder [24], ameliorate post-thoracotomy pain [25],
reduce postoperative pain after abdominal surgery [26],
and beneficially influence lipid metabolism in simple
obesity [27]. To our knowledge our study is the first to
examine the neurobiological correlates of PTN that are
not related to pain modulation.
A few studies have demonstrated that acupuncture
stimulation enhances NK cell activities [28] and modu-
lates the number and ratio of immune cell types [29].
Although differential leukocyte count was not evaluated
in this study, we anticipate that further investigation will
reveal a selective increase in lymphocytes than granulo-
cytes, based on previous reports and our own findings
that showed improved vagal tone after PTN treatment.
Regarding the lack of antioxidative response, we sur-
mised that a minimally invasive procedure like PTN did
not stress the body significantly to warrant a defense
response by the host. It might also be possible that a
short treatment with few PTN compared to protocols
employed in clinical practice (i.e., longer treatment time
and more PTN) failed to achieve a meaningful influence
on oxidative stress.
In summary, our findings suggest that PTN enhances
overall autonomic activity, especially the vagal tone, and
may activate WBCs. However, inter-individual varia-
tions in pre- and post-treatment HRV parameters among
our participants indicate that studies with a larger sample
size are needed to confirm our results. Furthermore, an
exploration of the effects of different acupoint combina-
tion and needle retention time in different population
groups will help clarify the efficacy of PTN acupunc-
Our findings suggest that PTN increases overall auto-
nomic activity, particularly the parasympathetic func-
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