Effects of Acupuncture Stimulation on Recovery Ability

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The American Journal of Chinese Medicine, Vol. 37, No. 3, 471–481 © 2009 World Scientific Publishing Company Institute for Advanced Research in Asian Science and Medicine

Effects of Acupuncture Stimulation on Recovery Ability of Male Elite Basketball Athletes Zen-Pin Lin,∗,‡ Lawrence W. Lan,† Tsung-Ying He,§ Shi-Pin Lin,¶ Jang-Geng Lin,// Tsong-Rong Jang†† and Tsung-Jung Ho¶,∗∗ ∗Department of Holistic Wellness †Department of Global Marketing and Logistics, MingDao University, Taiwan ‡College of Acupuncture, Moxibustion and Tuina

Nanjing University of Chinese Medicine, China §Institute of Medical and Molecular Toxicology, Chung Shan Medical University, Taiwan ¶Chinese Medicine Department, China Medical University Beigang Hospital, Taiwan //Graduate Institute of Acupuncture Science ∗∗School of Chinese Medicine, College of Chinese Medicine

China Medical University, Taichung, Taiwan ††Athletics Department and Graduate School

National Taiwan Sport University, Taichung, Taiwan

Abstract: Developing effective methods for helping athletes recover from muscle fatigue is deemed essential, particularly on the eves’ important competitions. This study aimed to investigate the effects of acupuncture stimulation on athletes’ recovery abilities. Subjects were selected from 30 male elite university basketball players who were randomly assigned to 3 groups: acupuncture group, sham group, and normal (control) group, each containing 10 subjects. Acupuncture was carried out on each athlete in acupuncture group at the Neiguan (PC6) and Zusanli (ST36) acupoints, beginning at 15 min prior to exercise and continuing until exhaustion of the subject. Similar acupuncture was also carried out on each athlete in the sham group but the positions were 1 cm away from the PC6 and ST36 acupoints. No acupuncture was conducted on the athletes in the normal group. During the experiments, each subject performed separate runs on the treadmill. The data of heart rate (HRmax ), oxygen consumption (VO2max ), and blood lactic acid were measured during the rest period and at 3 recovery points of time (5th, 30th and 60th min) post-exercise. The results showed that the acupuncture group (PC6 and ST36) has significantly lower HRmax , VO2max and blood lactic

Correspondence to: Dr. Tsung-Jung Ho, School of Chinese Medicine, College of Chinese Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung 404, Taiwan. Tel: (+886) 4-2205-3366 (ext. 3120), Fax: (+886) 4-2201-3703, E-mail: [email protected] The last three authors contributed equally to this work.

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Z.-P. LIN et al. acid than both the sham and normal groups at the 30th min post-exercise. Blood lactic acid of the acupuncture group was also significantly lower than that of the other two groups in the 60th min post-exercise. Our findings have shed some light on the development of effective acupuncture schemes to enhance the recovery ability for elite basketball athletes. Keywords: Acupuncture; Basketball; Heart Rate; VO2max ; Blood Lactic Acid; Neiguan (PC6); Zusanli (ST36).

Introduction In the athletic world, many nations have long strived for developing competitive advantages in sports by employing various scientific methods to improve the athletes’ peak performance in hope of winning competitions. Developing effective methods to help the athletes quickly recover from muscle fatigue after exercise training or fierce competitions and to help them achieve the best physiological situations is deemed essential, especially prior to international competitions. Acupuncture, one of the traditional Chinese medicine (TCM) techniques, has long been used in clinic to treat illnesses or release pains for thousands of years; it was also known to help in recovering from muscle fatigue after exercise. For instance, the World Health Organization (WTO) has acknowledged that acupuncture can treat more than 50 illnesses (Lin et al., 1996). Liang et al. (2003) found that acupuncture can enhance the rate of recovery in terms of both subjective feeling (rate of perceived exertion and self-report emotional state) and objective evidence (isokinetic muscle power output). Itoh et al. (2008) reported that acupuncture can reduce inflammation and decrease pain in delayed onset muscle soreness (DOMS). Moreover, Knardahl et al. (1998) demonstrated that electroacupuncture (applying electric stimulation on the needles during acupuncture) can increase pain threshold. Ulett et al. (1998) also showed that electroacupuncture appears to be more effective than manual acupuncture in producing analgesic effects. Recently, transcutaneous electrical acupoint stimulation (TEAS) has been used to treat various clinical conditions and the reports indicated that TEAS appears to be effective in reducing postoperative nausea and vomiting (Coloma et al., 2002; White et al., 2002; 2005). On the other hand, Qu et al. (1993) found that acupuncture treatment to a fatigued muscle immediately after 3 hours of continuous contraction can result in a 5% improvement in muscle tension output. Lin et al. (1995) demonstrated that ear acupressure is effective in increasing oxygen uptake and lowering lactic acid following exercise. Wang et al. (1999) also reported that acupuncture can enhance the recovery of muscle force capacity after exercise. From the scientific perspective, athletic ability can be a combination of various elements, including muscular strength, speed, power, muscular and cardiopulmonary endurance, flexibility, agility, and balance and coordination, among others. Cardiopulmonary endurance is perhaps the most essential element for all types of sports. VO2max is a fundamental indicator for measuring the cardiovascular endurance. The level of VO2max is one of the critical elements for succeeding in endurance sports because an upper limit of oxygen consumption does exist for each person. In choosing the athletes, however, each element of the proceeding developments of competitive exercise is closely related and is as equally important as

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any other element. Thus, researchers of physical science tried to find out all kinds of biocharacteristics of athletes in distinct ways to reach the most effective training. During the normal exercise training, it is important to properly adjust the quantity of exercise, according to the regularity of dynamic changes in athletes, to prevent them from excessive exercise training or unbearable load. Prior to competitions, however, designing effective methods to help the athletes achieve the best situation so as to outperform others is immediately necessary. Since muscle fatigue was reported to closely relate to human performance (Bigland-Ritchie and Woods, 1984; So et al., 2007) and acupuncture has been regarded as an effective method to improve the rate of muscle recovery after exercise (Ehrlich and Haber, 1992; Qu et al., 1993; Lin et al., 1995; Wang et al., 1999), this study aimed to conduct scientific experiments on selected athletes to investigate in-depth the effects of acupuncture stimulation on recovery abilities. Methods Participants Thirty elite basketball athletes (all male, aged = 21.1 ± 0.6 years, height = 182.3 ± 2.1 cm, and weight = 82.1 ± 4.0 kg) from the University of Physical Education in Taiwan were selected to participate in this study (Table 1). These athletes were randomly divided into 3 groups: acupuncture group (n = 10), sham group (n = 10), and normal group (n = 10). Procedure In the first phase, all subjects were to conduct the experiment without laboratory control. In the second phase, subjects were randomly divided into 3 groups: acupuncture group (AG), sham group (SG), and normal group (NG), each group containing 10 athletes. Acupuncture was carried out for each athlete in the AG at the PC6 and ST36 acupoints beginning 15 min prior to exercise and continuing until exhaustion, which was determined by the subject. Similar acupuncture was also carried out on each athlete in the SG, but the positions were 1 cm away from the PC6 and ST36 acupoints. No acupuncture was conducted on the NG athletes. The following equipment and instruments were used: (1) SENSOR MEDICS Vmax29 Gas Meter; (2) YSI2300 PLUS Lactate Analyzer; (3) 586 PIII Computer and Laser Printer; (4) POLAR Mobile Heart Rate Recorder; (5) Stopwatch; (6) Hygrometer. Each subject was required to wear a mask and a breathing collector. All participants warmed up their muscles Table 1. The Basic Characteristics of Study Subjects Height (cm) Mean ± SD

Weight (kg) Mean ± SD

Age (Year) Mean ± SD

Training Duration (Year) Mean ± SD

182.3 ± 2.1

82.1 ± 4.0

21.1 ± 0.6

7.5 ± 0.8

(n = 30).

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on the bicycle till the RQ indicator reached 0.7 ∼ 0.8 on the Vmax29c before the experiment took place. There was a time lag of 24 hours between the pre-experiment and post-experiment graded exercise tests so as to wash out time to reduce the cross-over effects. It potentially provided better comparison of the effects of stimulation. During the experiment, each subject rode the bicycle until completely exhausted. Initially, the speed was set 60 RPM with power 120 W and it was increased by 30 W every 2 min. The investigation was mainly on the variations during the rest period and the 3 recovery periods (5th, 30th and 60th min post-exercise). Wireless heart recorder (POLAR), Vmax29 gas analyzer, and YSI2300 lactic acid analyzer were to analyze the heart rate, oxygen consumption, and blood lactic acid, respectively. In addition, we drew their blood and measured their serum biochemistry data in resting state, 5th, 30th, and 60th min post-exercise, and then observed the differences. All the serum biochemical data for each subject, including heart rate, oxygen consumption, and blood lactate acid were measured on each stage. Data Analysis SPSS 12.0 for Windows was used for the data analyses. First, a descriptive analysis on the age, height and weight of the participants was conducted. Then the one-way ANOVA and repeated Schfee’ way methods were used to test the differences of VO2max , HRmax , and blood lactic acid among different groups, prior to and after the exercise at 3 different points of time. The level of statistical significance was set at p < 0.05. Results The one-way ANOVA and repeated Schfee’ way test results showed that the HRmax , VO2max , and blood lactic acid in the AG athletes were significantly lower than those of the SG and NG athletes in the 30th min post-exercise (Table 2). Blood lactic acid in AG was also found significantly lower than those in the other 2 groups in the 60th min post-exercise. However, there is no significant difference of HRmax, VO2max , and blood lactic acid between SG and NG athletes in the 5th, 30th, and 60th min post-exercise. These results indicated that acupuncture at Neiguan (PC6) and Zusanli (ST36) could significantly stimulate the post-exercise recovery of heart rate, oxygen consumption, and blood lactic acid for the elite basketball athletes. Our findings indicate that it is beneficial to carry out acupuncture at PC6 and ST36 acupoints, particularly on the eves of competitions, as to enhance the recovery ability for elite basketball athletes. This study has made an inspiring attempt to understand in-depth of the recovery system and physiological profile of basketball athletes by acupuncture. It would facilitate the coaches to provide more appropriate training schemes and recovery plans for the elite basketball athletes. Discussion The following factors have been considered to influence the effectiveness of acupuncture: acupoint selection, matching compatibility, timing of acupuncture, skill of supplement of the insufficiency of acupuncture, depth of acupuncture needling, and length of time and

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Table 2. A Comparison of Cardiopulmonary Endurance Among Acupuncture Group (AG), Sham Group (SG) and Normal Group (NG) Variables

HR (bpm) Rest P5 P30 P60 VO2max (ml/kg/min) Rest P5 P30 P60 Blood lactic acid (mmol/l) Rest P5 P30 P60

Acupuncture Group (AG) Mean ± SD

Sham Group (SG) Mean ± SD

Normal Group (NG) Mean ± SD

68.3 ± 1.31 118.9 ± 2.84 80.0 ± 1.24a 75.2 ± 2.69

69.4 ± 1.77 119.0 ± 2.40 82.3 ± 1.25 75.6 ± 1.64

68.3 ± 1.05 117.8 ± 1.39 83.4 ± 1.89 75.8 ± 1.68

4.4 ± 0.5 23.4 ± 1.31 7.37 ± 0.35a 4.19 ± 0.01

4.3 ± 0.10 23.7 ± 1.15 7.86 ± 0.45 4.23 ± 0.15

4.3 ± 1.6 22.8 ± 1.31 7.9 ± 0.39 4.29 ± 0.14

0.83 ± 0.01 8.65 ± 0.17 3.89 ± 0.29a 1.20 ± 0.11a

0.82 ± 0.01 8.45 ± 0.10 4.78 ± 0.16 1.62 ± 0.11

0.8 ± 0.01 8.54 ± 0.28 4.74 ± 0.12 1.67 ± 0.14

aStatistically significant (p < 0.05) when compared with SG and NG.

connection between non-acupoints and acupoints, among others (Chen et al., 1990; Ernst et al., 2007). This is the reason acupuncture deserves further exploration today despite that its use in clinical treatment for thousands of years. In our recent work, we have attempted to control a similar experimental condition, yet we were still unable to avoid the influences of some of the factors mentioned above. We found that acupuncture is effective in lowering the resting heart rate and carbon dioxide production and that there is a significant difference between the acupuncture group and the control group (Lin et al., 1996). Following nonparametric testing, Hübscher et al. (2008) observed that there were no significant differences between various groups in outcome measures at baseline and after 72 hours, however pain perception (VAS) was significantly lower in the acupuncture subjects than in the sham acupuncture and control subjects. Although acupuncture seemed to have no effects on the mechanical pain threshold or muscle function, it has been proven to reduce perceived pain raised from exercise-induced muscle soreness. Similarly, Itoh et al. (2008) also found that there were significant differences in visual analog scores for pain between the control group and tender point group immediately after treatment and 3 days after exercise (p < 0.05, Dunnetts multiple test) and that tender point acupuncture relieves muscle pain of DOMS. A few studies have discussed acupuncture for VO2max changes in the national elite basketball athletes. Bentley et al. (2001) found that the determination of physiological variables, such as the anaerobic threshold (AT), maximal oxygen uptake (VO2max ) through incremental exercise testing, and relevance of these variables to endurance performance, is a major requirement for coaches and athletes. Many medical institutions recognized the importance of this traditional method and were devoted to research on acupuncture theory and clinical experimentation (Lin et al., 1996). Niu et al. (2000) investigated that when acupuncture

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was applied on the superficial personal nerve after strenuous running exercise, blood lactate removal rate was significantly faster than that of the control group. Xiang et al. (1998) demonstrated an increase in the rate of lactate removal. Richardson and Vincent (1986) found that there is good evidence from controlled studies on the short-term effectiveness of acupuncture in relieving clinical pain in each of the areas they reviewed. This pain control effect of acupuncture might also contribute to the enhanced recovery rate after strenuous exercise. Koo et al. (2002) demonstrated that an analgesic effect could be induced by electroacupuncture points located at a remote site on the body in a stimulus point-specific manner. The suggestion that pain relief or analgesic effect will mediate the adverse feeling after strenuous exercise is echoed by Craig et al. (1999) who indicated that acupuncture therapy might represent a beneficial treatment for the reduction of the muscle damage and soreness associated with intense exercise. Such phenomenon is also in line with the models proposed by Noakes et al. (2005) and St Clair Gibson et al. (2006). Acupuncture stimulation has also been an internationally recognized alternative therapy proven to have substantial improvement on the cardiopulmonary functions (Samuels, 2000; Asamoto and Takeshige, 1992; Matthees, 2001). In these studies, auricular stimulation enhanced the physical capabilities of athletes. The results showed that aerobic function indicators such as VO2max and VEmax improved significantly with stimulation. Based on these findings, auricular stimulation could be used to improve the performance results for marathons, 400 meter sprints, and 800 meter long distance runs. Furthermore, significant differences were observed between participants’ body temperatures prior to stimulation and following auricular stimulation. Previous research reported that rising body temperature could not only increase the enzyme activities, muscular blood volume, and oxygen intake level but also increase the time between contraction and relaxation of muscles, thus enhancing performance and avoiding injuries (Mohr et al., 1998; McNair and Stanley, 1996). These findings demonstrated that in addition to improved functioning of elements necessary for athletic performance, stimulation on the auricular acupuncture points before exercising can also decrease the warm-up time, which can prevent injuries due to insufficient warm-ups and essentially enhance the athletes’ overall performance. Furthermore, auricular acupuncture is both a diagnostic and treatment system, based on normalizing the body’s dysfunction through stimulation of definite points on the ear and its reflex systems, which does not correlate with modern knowledge of anatomy and physiology. Auricular acupuncture stimulation significantly improved oxygen intake in athletes. The VO2max per min was higher in athletes with auricular acupuncture stimulation than in those without. Similar results were found by Sa and Lin (1990) who gave stimulations to subjects using auricular acupuncture patches on the related points to the lung, kidney, spleen, Senjoug, adrenal cortex and endocrine with an aim of improving the VO2max during aggressive exercise. Their results showed that VO2max was only significantly different between the pre-experiment and post-experiment measurements in the acupuncture group but not in the control group. Moreover, many other researchers have also used VO2max as an important indicator for evaluating aerobic ability and sporting performances (Adams et al., 1975; Atomi et al., 1986; Hill and Rowell, 1996; Helgerud et al., 2001). Based on the discussion above, it was concluded that auricular acupuncture stimulation could potentially enhance the aerobic ability of athletes, thus improving sport performance.

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Muscle fatigue has been defined as any exercise-induced loss of ability to produce force with a muscle or muscle group and it involves processes at all levels of the motor pathway between the brain and the muscle (Taylor et al., 2006). Søgaard et al. (2006) regarded human muscle fatigue as a loss of force-generating capacity in voluntary contractions. According to the Chinese medicine theory, fatigue is caused by deficiency or imbalance in life energy (also known as “Qi”) and recovery is promoted through the mechanism of “tonifcation” of Qi, which focuses on boosting the “lung” and “spleen” functions (Li et al., 2004). Noticeable progress has been made in biochemistry, hematological changes, neurophysiology, and clinical treatment and acupuncture has an adjusting and controlling effect on some body functions, allowing the physiological activity of the human body to reach a constant state (Lin et al., 1996). Research in acupuncture analgesia and anesthesia indicated that acupuncture cannot only modify the heart rate and blood flow of coronary arteries, but also lower fat and cholesterol levels (Lin et al., 1996). Acupuncture can be used to improve gas metabolism and pulmonary respiratory function (Plummer, 1981; Chang, 1982; Wang and Wang, 1989; Liu, 1990; Wang and Jin, 1990). In particular, evidence showed that electroacupuncture at PC6 and ST36 acupoints after vigorous exercise, can increase the clearance rate of sarcolactic acid, thus leaving a perception of improved results (Lin, 1991). Moreover, Lin et al. (1996) also reported that acupuncture at both PC6 and ST36 acupoints can decrease resting heart rate and carbon dioxide production. Generally, performing low-intensity aerobic exercise (active recovery) during the immediate post-exercise period is more effective in accelerating lactate clearance than that in inactive rest (passive recovery). Hagberg (1984) pointed out that blood lactic acid, while still important from the exercise physiologist’s viewpoint, now is known to contribute much less than originally believed to the regulation of human’s physiological responses to exercise. Martin et al. (1998) showed that lactate metabolism and its rate of elimination from blood and muscle are important components of recovery following maximal exercise. It is well known that impairment of performance resulting from muscle fatigue differs according to the types of contraction involved, the muscular groups tested, and the exercise duration/intensity. For instance, Millet and Leoers (2004) focused on the origin of muscle fatigue after a prolonged exercise, lasting 30 min to several hours, and found that strength loss with fatigue can originate from different sites: from the motor cortex to the contractile elements, and this was termed “task dependency of muscle fatigue.” They found that electrically-evoked contractions and associated electromyostimulation (EMS) can help characterize peripheral fatigue. Søgaard et al. (2006) indicated that recovery from fatigue caused by weak contractions differs from that caused by maximal contractions. Many others also found that, after fatiguing maximal efforts, changes in the responses to stimulation of the motor cortex during contraction would recover to control levels and voluntary activation would recover in 1–2 min (Gandevia et al., 1996; Taylor et al., 1996; Todd et al., 2005; Søgaard et al., 2006). More recently, Pallard (2008) indicated that both EMS and voluntary muscle contraction (VC) constitute different modes of muscle activation, which induce different acute physiological effects on the neuromuscular system. Long-term application of each mode of muscle activation can produce different muscle adaptations. There are some potential limitations of this study. First, this experiment was designed for a relatively small group of athletes (only 30) since the experiment required that participants

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exercise on the treadmill training machines till exhausted. It required a high degree of willingness of subjects to volunteer and cooperate. The participants of this research were primarily competitive elite athletes who desired eagerly to improve the competition performance through acupuncture stimulation. Enriching the subjects to draw more robust conclusions is necessary for future studies. Secondly, the lifestyle of participants could potentially impact the athletic performance. Therefore, in future studies, the athletes’ lifestyle may need to be closely monitored to decrease the external variations that could affect the experimental results. Thirdly, this study was conducted in a laboratory environment to eliminate interference variables, and therefore it might yield different results from otherwise observed in an uncontrolled environment under competition circumstances. Design of a future study to test the findings of this research in the context of athletic competition is suggested. Lastly, this study did not intend to provide the validation of the direct relation between acupuncture stimulation and sporting performance. Future studies can explore this issue in more depth. In conclusion, it was believed that if the quality and quantity of training intensity, cardiorespiratory function, energy consumption, and blood lactate system during training as well as the body weight and physical ability can be well controlled, the athletes should be able to elaborate their potential and maintain their peak performance. To recover the physiological characteristics during training and competition periods, acupuncture stimulation could be used for all kinds of sports training and for obtaining desirable competition results. To keep the athletes in the best situations, it is important to design effective schemes to help them achieve their peak performance and to recover quickly in the competition phase. This study demonstrated that the acupuncture group (PC6 and ST36) had significantly lower HRmax , VO2max and blood lactic acid than both the sham group and the normal group in the 30th min post-exercise. Blood lactic acid of the acupuncture group was also significantly lower than that of the other 2 groups in the 60th min post-exercise. Our findings have shed some light on the development of effective acupuncture schemes to enhance the recovery ability for elite basketball athletes. It can be used to improve subjects in future sport performance. Acknowledgments The authors are indebted to anonymous referees for their insightful and constructive comments to level up the quality of the original work. This study has been supported/sponsored by the Chinese Taipei Olympic Committee, MingDao University and China Medical University VS Beigang Hospital. References Adams, W.C., E.M. Bernauer, D.B. Dill and J.B. Bomar. Effects of equivalent sea-level and altitude training on VO2max and running performance. J. Appl. Physiol. 39: 262–266, 1975. Asamoto, S. and C. Takeshige. Activation of the satiety center by auricular acupuncture point stimulation. Brain Res. Bull. 29: 157–164, 1992. Atomi, Y., K. Iwaoka, H. Hatta, M. Miyashita and Y. Yamamoto. Daily physical activity levels in preadolescent boys related to VO2max and lactate threshold. Eur. J. Appl. Physiol. Occup. Physiol. 55: 156–161, 1986.

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