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Using a Healing Robotfor the Scientific Studyof Shirodhara Altered States of Consciousness and DecreasedAnxiety Through Indian Dripping Oil Treatments

BY KAZUO UEBABA, FENG-HAO XU,MIKI TAGAWA, RIKAKO ASAKURA,TOMOTAKE ITOU, TAKASHI TATSUSE, YUKIKOTAGUCHI, HIROKO OGAWA, MIZUHOSHIMABAYASHI, AND TATSUYA HISAJIMA

IMAGE COLLAGE: 1999 ARTVILLE, LLC.,BACKGROUND: IMAGE SOURCE.

0739-5175/05/$20.002005IEEE

Shirodhara is one of the oil treatments originating fromKeraliya Panchakarma [1]. It has long been conductedto combat insomnia, headache, anxiety neurosis,depression, schizophrenia, motor-neuron disease,hypertension, and several kinds of psychosis.

In Sanskrit, shiro means head and dhara means dripping;shirodhara is the process of dripping some medium on theforehead for tens of minutes as shown in Figure 1. There areseveral kinds of dhara techniques, depending on the mediumfor dripping. For example, takra dhara uses takra that is pre-pared with the curd of cows milk. Kshira dhara uses cowsmilk mixed with some medicinal herbs such as Sida cordifo-lia or Asparagus rasemosus. Taila dhara uses medicated oilmixed with cows milk, water, herbs, and sesame oil[1][3].

Shirodhara is one of the characteristic healing techniquesof Ayurveda, however, few reports on the physio-psycho-logical changes during shirodhara have been reported [1],[4], [5,]. Also, the psychological effects of shirodhara havenot yet been referred to as altered states of consciousness.One of the critical problems in the study of physiotherapyof Oriental medicine is not being able to use the samereproducible stimulation, especially in Ayurvedic oil treat-ments. To address this problem, we developed a healingrobot which conducts shirodhara in a computerized repro-ducible manner (Figure 2).

We studied the physio-psychological changes during tailadhara conducted by the healing robot and estimated the psy-chological experiences during taila dhara by psychometricstudies of anxiety and altered states of consciousness (ASC).In order to simplify the study, at first we used plain sesameoil as the dripping medium. Usually in Oriental medicine, theeffects on practioners as well as patients are included asimportant factors for the treatments. Therefore, we have alsochecked the physiological changes of the practitioners them-selves in this study.

Study AssessmentsWe undertook a number of different studies to assess theimpact of shirodhara on the patients state of well beingand to assess factors in the therapy that altered thepatients state.

Experiment 1: Physiological Changes of Both Subjectsand Technicians During Manual Shirodhara Sixteen healthy adult females (ages 2156, 33 9 years)signed informed consent and participated in this study.They had no mental disease nor any neuropsychologicaldisorders. The pretreatment control period and the post-treatment period were set for 15 min; the shirodhara treat-ment session was 20 min long (Figure 3). The samesubjects participated twice in the control and active studiesat four-day intervals in a random order.

During shirodhara the monitoring items for the subjectswere: blood pressure (continuous blood pressure monitoring,ANS508 by Nippon Colin Co., Ltd.) and intermittent bloodpressure (automatic sphygmomanometer, ParamatekGP303S), electrocardiogram (ECG) R-R intervals, expiredgas analysis (MetaMax from Marcotek Co., Ltd.), impedancecardiography (Nicoview from NEC), and EEG (F3, F4, P3,P4, or 16 points electrodes; Neurofax by Nihon Kohden Co.,Ltd.). The single EEG (C3 lead) of the technician was record-ed at the same time (Figure 2), and respiratory movement ofthe chests of both subject and technician were also recorded.In the active studies, shirodhara was performed by a machinewith a pumping and heating system. During the control peri-od, the technician manipulated the oil tube tip in as close tothe same manner as possible. The oil used was plain cold-pressed preheated sesame oil (Kadoya Oil Co., Ltd.). Theflow rate (2.12.6 L/min) and temperature (39 1 C) of thesesame oil were kept as steady as possible.

A power frequency analysis of R-R variability was per-formed to assess the balance of the autonomic nervous sys-tem. LF (low frequency) was considered to include thepower spectral density (PSD) of 0.040.15 Hz, and HF(high frequency) was the PSD of 0.150.40 Hz [6], [7].Coherence or spectral distribution of EEG and respiratorymovements were calculated by computer using the programBIMUTUS II (Kissei Comteck).

Experiment 2: Standarization of Oil Weight Between the Manual and Robotic ShirodharaThe weight of the dripped oil was measured at the forehead bya scale (Tanita Co., Ltd.) using various heights of the drippingnozzle and various flow rates.

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Experiment 3: Physio-Psychological Changes DuringShirodhara by the Healing Robot in Relation toAnxiety and Altered States of Consciousness (ASC)Fifty-seven healthy volunteers (ages 2246, 33 8 years) par-ticipated in this study with the healing robot after signinginformed consent. In this experiment, the treatment was regu-lated automatically by the computerized system using thehealing robot (Figure 4). The temperature (39.0 0.5 C) andflow rate (2.3 0.2 L/min) of the oil were kept constant inboth the manual and robotic systems. However, minute regula-tion was possible in the healing robot; the robotic system cankeep the same reproducible dripping speed and pattern.

The oil used was the same plain cold-pressed preheatedsesame oil (Kadoya Oil Co., Ltd.). The pretreatment controlperiod was set at 10 min and the shirodhara treatment sessionwas fixed for 25 min. The mode of dripping sesame oil was asfollows: oil temperature: 39.0 0.2 C oil flow: 2.3 0.2 L/min dripping pattern: 5 min each for eight knot, horizontal, and

vertical, then another 4 min for each. The nozzle of oil moved at the slowest speed (1.5 cm/s). Theseconditions were decided based on results from Experiment 1.

The subjects skin temperature of the right neck, righthand, and right foot was monitored throughout shirodhara.The psychological changes were assessed by psychometricstudies using the State-Trait-Anxiety Inventory (STAI)before and after shirodhara and ASC questionnaires justafter shirodhara. The validity of the ASC questionnaire wasascertained by Saito [8]. The questionnaire asked aboutASC experiences in ten domains (Table 1). The averagescores of these ten domains were calculated from 60 ques-tions. Time recognition was measured by counting 15 or 30s by a stop watch, without showing the time in the stopwatchs display.

Experiment 4: Anxiolytic Effect of the Robotic TherapyIn this experiment, ten of the 57 subjects with abnormally highSTAI scores from Experiment 3 participated. An STAI scoreof more than 40 was considered the criteria for abnormal scoregroups. These 10 females (ages 2335, 30 6 years) receivedshirodhara for 25 min once each week, four times a month.The conditions to regulate the healing robot were the same asthose in Experiment 3.

POMS (Profile of Mood States) scores were also assessedbefore and after shirodhara. POMS was developed by McNair etal. and its validity was previously ascertained [10], [11]. POMS

has five assessment domains: tension andanxiety, depression, anger and hostility,vitality, exhaustion, and confusion.

Experiment 5: Impact of DifferentDripping Media on theExperiences of ShirodharaVarious mediums for dripping wereprepared, such as warm water, warmcows milk, bath salt, and a specialbath salt with the same viscosity assesame oil. The last, special bath saltwas prepared from hyaluronic acidand collagen. The viscosity was mea-sured by a viscometer (BruckfieldCo., Ltd.). Three healthy female sub-jects (34-, 28-, and 30-years-old) tookpart in this experiment. They had thesame method of shirodhara by thehealing robot system: five differentmedia at the same time of day in arandom sequence every four days.These media were ranked based on thesubjects answers to a like/dislikevisual analog scale (VAS) and theASC as well as their anxiety andchanges in foot temperature.

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Fig. 1. The original method of shirodhara. Various kinds of ves-sels are used for reservoirs of dripping oil or other mediums.The dripping technique cannot be regulated in a repro-ducible manner.

Fig. 2. The set up of the manual shirodhara. The technician stood at the head of thesubjects. The subjects had various instruments attached to their bodies and theireyes were closed by towels.

Original Method of Shirodhara

Hand Moving

No Regulation ofOil Flow or Temperature

Manual Method of Shirodhara

EEG of Subject and Technician Oil Temperature: 39 40C, Height: 20 cm

Oil Flow: 2 .1 ~ 2 . 3 L/minGas Analysis, Circulation

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Statistical AnalysisRegarding physiological examinations, a paired t-test and one- or two-way ANOVA was adopted,while psychological questionnaires such as STAIor POMS were analyzed by Wilcoxons signedrank test. The correlation between nonparametricparameters were calculated using Spearmansmethod. However, the average scores of psycho-logical outcomes were analyzed as consecutivenumbers, and Pearsons correlation coefficientswere calculated. In all studies, a p value of lessthan 0.05 was considered statistically significant.

Results

Standardization of ShirodharaIn the manual shirodhara, the oil weight was 16 gat the forehead from the nozzle at 20 cm high. Inthe shirodhara by the healing robot, the sameweight of oil was obtained at 20 cm high in theflow of 2.3 L/min. The diameter of the nozzlewas 8 8 mm. This program of controlling thehealing robot was adopted as the standardizedmethod for oil application.

Physiological ExaminationsIn Experiment 1, comparing automatic withmanual shirodhara, the heart rate and consump-tion of CO2 were compared with the controlstudies of the same subjects. As shown inFigure 5, the heart rate decreased significantlyjust 5 min after starting shirodhara, while therewere no significant changes in the controlstudy. Similar to the heart rate, CO2 excretionand tidal volume also decreased during shirod-hara; again, there were no significant changesin the control study.

Four of the 16 subjects experienced troubles,such as headache, during shirodahra due to theprolonged bed rest or from maintaining thesame position. Their data were excluded fromthe analysis. Data from 12 of the subjects (ages2246, 33 8 years ) were analyzed.

The autonomic nervous balance of the sub-jects were also measured by means of ECG R-Rvariability (LF/HF and HF power of the R-Rvariability). Six subjects who had respirationrates under 0.1 Hz were excluded from theanalysis because the LF and HF componentsoverlapped when respiration rates were under0.1 Hz. The results from the remaining subjectsshowed the LF/HF ratio, an alternative index ofcardiac sympathetic activity, was suppressedduring and after shirodhara (Figure 6).However, HF power, an index of the parasym-pathetic nervous tone, changed in a similar trendin both the active and control studies (Figure 7).The supine position of the experiment itselfmight activate parasympathetic activity.

Regarding a change of the EEG mapping dueto shirodhara, -wave power dominance shiftedfrom the occipital region to the frontal region

Fig. 3. The time table of the experiments. The 20 min of shirodhara wassandwiched between two 10 min pre- and postperiods.

Fig. 4. Functions of the healing robot. The movement of the oil nozzle is reg-ulated. Oil flow and oil temperature are also kept constant. In the future,monitoring sensors of HR, ECG, and EEG can be equipped, the robot mayrespond to voice commands.

During(Closed Eye)

After (Closed Open Eye)

Continuous BPR-R Variation

Cardiac Output(Imped. Cardiog.)

EEG(F3&4,C3&4)

15 min 20 min 15 min

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Expired Gas

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Nozzle: xy Axis MovementThree Kinds of Patterns

Longitudinal, Horizontal, C Shape Pattern

Oil Temperature:Regulated Constant

Monitoring HR, ECG, EEGto Autoregulate Oil Flow and Temperature

5 Respond to the Voice Command

Oil Flow:Regulated Constant

Table 1. Ten domains of ASC in the psychometrics.

Loss of space perception: feeling like floating Loss of time perception: no notice of time passing Loss of speech sense: no mood for saying words Trance: enraptured Concentration: no notice of any change in surroundings Cosmic consciousness: experience such as to have seen truth Passiveness: feeling like being under someones control Momentariness: feeling like only a short period of experience Loss of difference between subjectivity and objectivity: no separation

between oneself and others

Loss of bodily sense: feeling like only mind existing without bodyToshimasa SAITO, Researches on ASC, Shoukei sha, Kyoto, 1981.

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during the treatment. After shirodhara, wave activity wasagain dominant in the occipital region (Figure 8).Simulatenously, -wave coherence was also increased duringshirodhara (data not shown). These differences in heart rate,CO2 excretion, sympathetic tone, and EEG were quite similarto the findings reported in the study of meditation [12].

We simultaneously measured the EEG findings of two han-dlers of the manual shirodhara method (Figure 9). C3 leadEEG measurements from them showed a relative increase of-wave power and a relative decrease of -wave power dur-ing the active experiments, while there were no significantchanges in the control studies. These results indicated thestressful conditions for the handlers.

Psychological Examinations

Anxiolytic Effects of the ShirodharaAt first, STAI scores of 12 healthy female subjects by shi-rodhara were compared with those of 12 other subjectswho had algae packs applied facially for relaxation. Thesubjects state of anxiety, assessed just before and aftershirodhara, decreased abruptly (p < 0.005, Wilcoxonsigned rank test), while the decrease in anxiety in subjectsreceiving the algae pack was not as large as shirodhara (p< 0.05); see Figure 10. The two groups had significantlydifferent decreases in anxiety state as determined by two-way ANOVA.

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Fig. 5. Changes in heart rate, CO2 output, and tidal volume during robotic shirodhara. The results show the averages for all sub-ject who participated in both active and control studies. Compared to the baseline, statistically significant decreases in allthree variables occurred more frequently during the robotic shirodhara treatment.

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ASC Experiences During ShirodharaASC is usually mistaken to be a peculiar experienceinduced by psychotropic drugs. Traditional healing tech-niques such as meditation and oilmassage often induce ASC [8]. Saitoclassified the ASC into ten kinds ofexperiences (ten domains) as shownin Table 1, and he made up the ASCquestionnaire after ascertaining itsreliability and specificity [8]. Weused the questionnaire developed bySaito and assessed each subject justafter shirodhara. The level of theexperiences was categorized into fivedifferent domains with more than fourindicating an ASC experience. Forty-six of the 57 subjects (81%) who weretreated with shirodhara experiencedsome kind of ASC. Average scores foreach domain are shown in Figure 11.The highest ASC scores wereobtained in the domains of trance,passiveness, timeless sensation, word-less sensation, and concentration.

Change of TimeRecognition by ShirodharaIn order to ascertain the experience ofloss-of-time perception, the timerecognition was measured by a stopwatch. Just before and after shirod-hara, 15 or 30 s was measured. Of 57subjects who had shirodhara treatment,15 showed a significant increase intime recognition of 30 s (3036 sec-onds on average), while ten controlsubjects who had no treatment showedno change during 1 h of routine work.This result indicated that shirodharainduced loss-of-time perception andaltered time recognition of the brain.

Correlation Between ASCor Anxiolysis and SkinTemperature of Foot and HandThe correlation between the meanASC score and anxiolytic effects wasnot very high, but a significantcorrelation was obtained (Figure 12;r = 0.34, p < 0.01, Spearmans cor-relation coefficient).

A similar degree of correlation was obtained between themean ASC score and the mean skin temperature of the footduring the latter half of the shirodhara (Figure 13; r =0.35,

Fig. 6. Change of LF/HF ratio during shirodhara. LF/HF is suppressed after starting shi-rodhara.

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p < 0.01, Spearmans correlation coefficient).The mean skin temperature of the foot in the latterhalf of shirodhara is also correlated with adecrease in the state of anxiety (Figure 14;r = 0.37, p < 0.01, Pearsons correlation coef-ficient). The skin temperature of the right hand orright neck had nothing to do with ASC or anxiety.

Anxiolytic Effects of Shirodhara in theSubjects with High AnxietyOf the 57 subjects, ten with a high state of anxi-ety (>40) had successive shirodhara treatmentsfour times every week. The changes in the POMSscore were assessed after the final shirodhara.The result indicated a significant decrease of ten-sion and anxiety (Wilcoxon signed rank test, p