Scholarly Journal of
Otolaryngology
DOI: 10.32474/SJO.2022.09.000316

Research Article

ISSN: 2641-1709

Effect of Thermo-Electrical Stimulation Therapy
on Exhaled Nitric Oxide Concentration: Potential of
Biotherapy as a Treatment for Long COVID
Hirobumi Ito*, Miyuki Fujimatu and Emi Takahashi
Department of ENT, Ito ENT Clinic, Japan*Corresponding Author: Hirobumi Ito, Department of ENT, Ito ENT Clinic, Japan
Received:

December 14, 2022

Published:

December 21, 2022

Abstract
Thermo-electrical stimulation therapy (hereinafter referred to as biotherapy) is a combination of thermal and electricalstimulation therapies to relieve muscle tension and improve circulation in the head and neck regions. Biotherapy is postulated tohave a similar mechanism of action to epipharyngeal abrasive therapy (EAT). Fractional exhaled nitric oxide (FeNO) levels were
measured as a measure of efficacy. The results showed that FeNO levels significantly decreased following biotherapy treatment,suggesting a similar mechanism of action to that of EAT. The possibility of biotherapy as a treatment for long COVID (LC) is being
discussed.

Keywords: Biotherapy; EAT; FeNO; Long COVID; Electroacupuncture
Abbreviations: EAT: Epipharyngeal Abrasive Therapy; FeNO: Fractional Exhaled Nitric Oxide; LC: Long COVID; rmANOVA:

Repeated Measures Analysis of Variance; TES: Therapeutic Electrical Stimulation; FES: Functional Electrical Stimulation; rTMS:
Repetitive Transcranial Magnetic Stimulation; tDCS: Transcranial Direct Current Stimulation

Introduction
Epipharyngeal abrasive therapy (EAT) is a treatment for chronic epipharyngitis [1]. The following are the mechanisms of EAT:
local mucous membrane astringent, bactericidal, and anti-inflammatory effects of zinc chloride; improvement of local circulationand cerebral lymphatic function by phlebotomy; and autonomic
nerve stimulation [2,3]. However, several aspects remain unknown.
Uebaba highlighted a connection with the venous hub theory regarding the mechanism of action of EAT [4]. As for its mechanism ofaction, he speculated that EAT has a circulatory stimulating effectby promoting venous and cerebrospinal fluid lymphatic return, aparasympathetic stimulating effect by somatic-autonomic reflexcaused by head and neck stimulation, and a stimulating effect on
the autonomic nervous system by triggering the respiratory pump

Copyright © All rights are reserved by Hirobumi Ito.

action (parasympathetic stimulation by expiration due to the Hering-Breuer reflex and sympathetic stimulation by inspiration) bychanges in the chest cavity pressure [5,6]. The author speculates
that the circulation-improving and autonomic nerve stimulating
effects may play a significant role in the mechanism of immediate
effects of EAT. Thermo-electrical stimulation therapy is a combination of thermal [7] and electrical stimulation therapy [8] and iscalled biotherapy. Ito reported that biotherapy has sympathomimetic effects [9]. The author speculated that biotherapy may havea similar mechanism of action to that of EAT. Conventionally, theeffectiveness of EAT is frequently measured by the amount of local
bleeding and the degree of improvement in subjective symptoms[10]. Mogitate reported that the concentration of fractional exhaled1032

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nitric oxide (FeNO) decreased with the effect of EAT treatment[11,12]. Therefore, the measurement of FeNO levels may be a biomarker for determining the therapeutic effect of EAT. In this study,
we evaluated the effect of biotherapy on the airway epithelium bymeasuring the change in FeNO levels before and after biotherapy
treatment. EAT is expected to be a treatment for long COVID (LC),and we hypothesize that biotherapy may have similar therapeutic
effects.

Participants and Methods

The participants were 10 adults (mean age, 38.7 ± 13.5 years),
2 males (mean age,56.0 ± 8.5 years) and 8 females (mean age, 34.4
± 10.8 years), who underwent biotherapy to relieve muscle tension
and improve circulation at this hospital from June to September
2022. Thermotherapy was initially performed for approximately
30 min. The whole body was heated using DREAM UP®, a high-frequency heating device that uses electromagnetic waves in the radiofrequency range. Following this, electrical stimulation therapy
was performed using the BBCP_BIO WAVE® with a weak current of
1 mA transcutaneously along the meridians and myofascial meridians for approximately 30 min. In this study, to examine the effect ofbiotherapy on FeNO, FeNO levels were measured before and after
the treatment using a nitric oxide gas analyzer NO breath (measurement range, approximately 5-300 ppb). The FeNO level wasmeasured on an empty stomach, and smokers and those taking anti-allergy medications were excluded. In this study, the FeNO levelmeasured in the same participants without biotherapy was considered the control group, whereas the FeNO level measured following
biotherapy was compared with that in the biotherapy group.
First, a t-test (paired t-test) was performed between the control
and biotherapy groups, comparing the measured values before thestart of treatment (0-min value) and at the end of treatment (60min value) between the two groups.

Next, to examine changes over time, repeated measures analysis of variance (rmANOVA) was performed on the measurements
available before the start of treatment (0-min value), at the end of
the treatment (60-min value), 1 h after the end of treatment (120min value), and 2 h after the end of treatment (180-min value).
Multiple comparisons were made using the Bonferroni method.
As there is individual variation in the measured values, the rate ofchange was determined based on the pretreatment values for eachcase. rmANOVA was performed by obtaining the rate of change at

Copyrights @ Hirobumi Ito

the end of the treatment (60-min value), 1 h after the end of thetreatment (120-min value), and 2 h after the end of the treatment(180-min value). Multiple comparisons were performed using the
Bonferroni method. Statistical analysis was performed using statistical software EZR version 2.6-2. A risk rate of <5% was considered
statistically significant. Oral and written informed consent was obtained from all participants, and the study was conducted in compliance with the Declaration of Helsinki. When handling the dataand other materials related to the study, great care was observed
to protect the confidentiality of the participants. Furthermore, any
information that could identify the participants was excluded when
we published the study results. This is a retrospective observational study based on existing medical records, and no new samples orinformation were obtained.

Results

The FeNO levels of the participants (n=10) before (0-min value) and after (60-min value) treatment was compared using paired
t-test. The control group had FeNO levels of 11.5 3.6 and 10.0 ±3.2 before and after the treatment, respectively, with no significant
difference noted (P=0.076). The biotherapy group had FeNO levelsof 13.0 ± 5.3 and 8.5 ± 4.0 before and after the treatment, respectively, with no significant difference observed (P=0.001). The biotherapy group showed a significant decrease in FeNO levels before(13.0 ± 5.3) and after (8.5 ± 4.0) the treatment (p=0.001) (Figure 1).
The control (n=5) and biotherapy (n=8) groups were able to takefour measurements at 0, 60, 120, and 180 min. rmANOVA on themeasurements of the two groups showed that the measurements
fluctuated over time, with a significant difference between the 0and 60-min measurements. A significant difference was observed
between the 0- and 60-min values. The control group showed lessfluctuation, whereas the biotherapy group showed greater fluctuation. The biotherapy group showed a greater decrease in 60-min
values than the control group, indicating a tendency for FeNO (Figure 2). To exclude the variation of FeNO due to individual differences, rmANOVA was performed between the three measurements bydetermining the rate of change of the 60-, 120-, and 180-min values
with the 0-min value as the reference. No significant difference wasnoted in the rate of change for both groups. Although no significant
difference was noted, the biotherapy group showed a tendency tosuppress the 60-min FeNO values compared with the control group(Figure 3).

Citation: Hirobumi Ito*, Miyuki Fujimatu and Emi Takahashi. Effect of Thermo-Electrical Stimulation Therapy on Exhaled Nitric Oxide
Concentration: Potential of Biotherapy as a Treatment for Long COVID. Sch J Oto. 9(4)-2022. SJO. MS.ID.000316.
DOI: 10.32474/SJO.2022.09.000316.

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Copyrights @ Hirobumi Ito

Figure 1: Comparison of FeNO values before (0-min value) and after (60-min value) treatment in the control and biotherapy
groups. The biotherapy group shows a significant decrease in the FeNO level after the treatment compared with that before
the treatment.

Figure 2: Repeated measures analysis of variance has been performed on measurements taken before the start of treatment(0-min values), at the end of treatment (60-min values), 1 h after the end of treatment (120-min values), and 2 h after the endof treatment (180-min values). Significant differences have been observed between the 0- and 60-min values, and recovery to
the same level has been observed at the 120-min value.

Citation: Hirobumi Ito*, Miyuki Fujimatu and Emi Takahashi. Effect of Thermo-Electrical Stimulation Therapy on Exhaled Nitric Oxide
Concentration: Potential of Biotherapy as a Treatment for Long COVID. Sch J Oto. 9(4)-2022. SJO. MS.ID.000316.
DOI: 10.32474/SJO.2022.09.000316.

1034

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Copyrights @ Hirobumi Ito

Figure 3: Repeated measures analysis of variance has been performed among the three measurements to determine thepercent change in the 60-, 120-, and 180-min values based on the 0-min value. No significant difference in the rate of change
in both groups has been observed.

Discussion
The results of this study showed that biotherapy suppressed
FeNO levels immediately after the end of the treatment (60-min
value). Since FeNO reflects the degree of type 2 inflammation in thelower airway, biotherapy may suppress type 2 inflammation in the
airway epithelium. First, we would like to discuss the significanceof biotherapy and its mechanism of action. Electrostimulation
therapy, massage therapy, thermotherapy, acupuncture, and otherphysical stimulation therapies are called physical therapy; together with exercise therapy, they form the mainstay of rehabilitation
medicine. Electrostimulation therapy is a therapeutic applicationof biological reactions caused by electrical energy and is applied invarious fields, including analgesia, muscle tension relaxation, joint
range of motion improvement, muscle strengthening, neuromuscular reeducation, atrophy prevention, circulation improvement,
wound healing, and edema improvement [7]. Thermotherapy is oneof the basic types of physical therapy, which involves temperature
stimulation to heat or cool the body. The hyperthermia used in thisstudy is deep hyperthermia, which uses electromagnetic waves in
the radiofrequency range to generate Joule heat in the body’s tissues by vibrating the body’s cells at the molecular level and heatingthem from deep inside the body [8]. It has the effects of analgesia,
circulation improvement, tissue heating, wound healing, immune
activation, and relaxation through symptom relief.
Biotherapy is a combination of thermal and electrical stimulation therapies to achieve a synergistic effect. It has been reported
that biotherapy promotes circulation in the human body throughcomprehensive action via massage and thermal effects, as well as

promotes myofascial release and activates autonomic nervous system activity by energizing the fascia [9]. The subcutaneous tissue,
fascia, and various diaphragms of the whole body are connected bya connective tissue called the fascia, which is mostly composed ofcollagen. Collagen is believed to be a piezoelectric element that generates piezoelectricity and may be involved in information transmission [13]. Based on the theory that the phenomenon of weakelectricity flowing through the fascia is the meridian phenomenon[14], biotherapy was developed as a method for externally regulating the flow of electric current in the body. By monitoring how
the participant feels and the state of muscle contraction and freely
selecting the stimulation conditions and site, biotherapy can be adjusted to the participant’s needs. Furthermore, it is possible to stimulate the scalp and perform a head massage. An increase in theta
waves is observed in the electroencephalogram when scalp stimulation is performed [5], and it is expected to be performed not only
for the benefits of scalp massage but also for neuromodulation [15].

Conventional electrical stimulation therapy (electrical stimulation that stimulates the skin surface) is classified into therapeutic
electrical stimulation (TES) and functional electrical stimulation(FES), depending on the treatment method and purpose. TES aims
to elicit purposeful muscle activity through electrical stimulation,
whereas FES is an electrical stimulation therapy that aims to compensate for lost body functions, including central paralysis. Microcurrent therapy, which uses microcurrent stimulation at the insensitive µA level, is also used. In addition to its pain-relieving effect,
microcurrent therapy has been shown to promote the healing of
damaged tissues [16]. Bioelectric current is believed to be approximately 50 µA and is generated mostly during signal transduction in

Citation: Hirobumi Ito*, Miyuki Fujimatu and Emi Takahashi. Effect of Thermo-Electrical Stimulation Therapy on Exhaled Nitric Oxide
Concentration: Potential of Biotherapy as a Treatment for Long COVID. Sch J Oto. 9(4)-2022. SJO. MS.ID.000316.
DOI: 10.32474/SJO.2022.09.000316.

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nerve cells [17]. Bio currents are generated during cell activity andinjury; however, they are attenuated by aging, stress, and adverse
events. It has been reported that the application of weak currentsof 1 mA or less increases mitochondrial ATP synthesis capacity andactivates cell functions [18,19]. The biotherapy performed in thisstudy is expected to be as effective as TES, FES, and microcurrent
stimulation therapy. Regarding safety, the biotherapy used in thisstudy was designed for a maximum stimulation of 1 mA at level 8.
This is the range from AC-1 to AC-2 according to the International
Electrotechnical Commission; although involuntary muscle contraction occurs, there are typically no harmful electrophysiologicaleffects. It is a safe treatment with no harmful electrophysiologicaleffects on the human body regardless of the duration of energization [20].

A treatment method like biotherapy is electroacupuncture
therapy, which combines electrostimulation therapy and acupuncture. Electroacupuncture therapy, wherein muscles are insertedwith needles and stimulated, can directly stimulate muscles withlow electrical resistance, thereby efficiently improving muscle
blood circulation, efficiently stimulating afferent nerves to activate
the analgesic system, and modulating autonomic nervous system
functions through hormone secretion by reflex responses. Electrical stimulation and electroacupuncture are useful methods; however, they are considered to have the disadvantage of stimulating fixedsites. Biotherapy is a manual method of electrical stimulation, andits advantage is that the stimulation site can be freely selected andmoved. Stimulation conditions can be adjusted in detail according
to the purpose of stimulation while observing how the participant
feels and the state of muscle contraction. Biotherapy does not cause
any pain sensation, and by moving the stimulation along the meridians, polymodal receptors, which are believed to be present in several acupuncture points and deep tissues, can be efficiently stimulated. By providing line and surface stimulation along meridians,
nerve, and muscle lines to improve flow, biotherapy can be used toefficiently stimulate a wide range of afferent nerves. The results ofthis study showed that biotherapy significantly decreased the FeNO
level in the biotherapy group compared with that in the control
group, suggesting that biotherapy suppresses type 2 inflammationin the airway epithelium and that the suppression of type 2 inflammation decreased inflammatory cytokine levels and normalized
systemic cell functions. The comparison of the temporal changes
in FeNO levels showed that the suppression of type 2 inflammation
by biotherapy was maximal immediately after the treatment andreturned to the original level over time.

Type 2 cytokines are produced mainly by type 2 innate lymphocytes in the intestinal tract, lung, skin, adipose tissue, and lymphoidtissue. Type 2 innate lymphocytes express β2-adrenergic receptors,
and the response of type 2 innate lymphocytes is inhibitory, as regulated by β2-adrenergic receptors [21]. Therefore, by stimulating
the β2-adrenergic receptors of type 2 innate lymphocytes, sympathetic nerve stimulation may suppress type 2 inflammation. It has
been reported that sympathetic nerve stimulation induces the de-

Copyrights @ Hirobumi Itopolarization of the cell membrane of the stratum corneum, which isa site of reduced skin current resistance. This site often coincides
with meridian points, and biotherapy stimulates meridian points
along meridians, which is believed to stimulate sympathetic nerves
and produce effects [22] more effectively. Ito H reported that biotherapy induced an overall calming of autonomic nervous activity;
however, the sympathetic reflex tended to be stimulated [9]. This
suppression of type 2 inflammation may result in a decrease in thelevels of inflammatory cytokines and FeNO. Biotherapy may reduce
inflammatory cytokine levels and improve vascular endothelial cellfunctions. To date, COVID-19 infection is prevalent, and symptoms,
including respiratory distress, malaise, olfactory and taste disturbances, hair loss, headache, and poor concentration, may persist forseveral months or longer after COVID-19 infection. Moreover, these
symptoms have been reported as sequelae of a new type of coronavirus infection, which is called LC [10]. Regarding the effect of EAT
on LC, Imai K reported that symptoms, such as fatigue, headache,and attention disorder, were significantly improved [23]. Additionally, Ito H reported that LC often develops chronic epipharyngitis
and that the treatment of chronic epipharyngitis with EAT significantly improved the subjective symptoms of LC. Nishi K reported
that EAT suppressed IL-6 and TNFα production in the nasopharyngeal mucosa, and immunohistochemistry revealed a soothing effectof EAT on inflammation [24].
Mogitate M reported that EAT decreased FeNO levels, considering that the improvement of epipharyngitis by EAT suppressed
FeNO levels [11,12]. COVID- 19 is involved in systemic endotheliitis,that is, endothelial cell inflammation via ACE2 receptors all over the
body, including the heart, brain, lung, kidney, and intestinal tract,and LC is believed to be caused by vascular endothelial cell damage[25]. Inflammation in the brain due to brain microglial activation
has been highlighted as a cause of symptoms, including body malaise, fatigue, weakness, and impaired thinking, in myalgic encephalomyelitis/chronic fatigue syndrome [26]. Noninvasive electricalstimulation, such as repetitive transcranial magnetic stimulation(rTMS) [27] and transcranial direct current stimulation (tDCS)[28], have been reported to be useful as a treatment method. Microglial activation in the brain has also been reported in the sequelae of new-type coronavirus infection (LC); symptoms, including
body malaise and brain fog, have become challenging. Moreover,rTMS and tDCS are used as treatment methods for these symptoms.
These electrical stimulation methods are believed to normalize arteriovenous blood flow and restore sensory neurons and cognitive
functions that have been inactivated by the coronavirus. rTMS has
been used as a treatment for depression [27]and brain fog due to
LC. Furthermore, microcurrent stimulation of the brain’s active
neuronal functions [29] is effective as a treatment for brain fog, andEEG changes were observed with scalp stimulation using biotherapy, suggesting that biotherapy may also be effective as a treatment
for brain fog. Additionally, biotherapy may be effective as a treatment for brain fog. These reports suggest that biotherapy, such as
EAT, has anti-inflammatory effects and that noninvasive electric

Citation: Hirobumi Ito*, Miyuki Fujimatu and Emi Takahashi. Effect of Thermo-Electrical Stimulation Therapy on Exhaled Nitric Oxide
Concentration: Potential of Biotherapy as a Treatment for Long COVID. Sch J Oto. 9(4)-2022. SJO. MS.ID.000316.
DOI: 10.32474/SJO.2022.09.000316.

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stimulation of the scalp may improve LC-induced symptoms. Although this study did not evaluate biotherapy as a treatment for LC,
its mechanism of action suggests that biotherapy may be effective
for the treatment of various symptoms of LC.

Lázaro A reported that electroacupuncture stimulation of thevastus medialis muscle in rats causes arteriolar dilation and increased blood flow because of muscle contraction. The electroacupuncture stimulation-induced passive muscle contraction activates
vascular endothelial cell function, which produces and releases
NO, thereby dilating blood vessels and increasing blood flow [30].
Although the results of animal studies suggest that electrostimulation therapy improves vascular endothelial function, biotherapy
has similar effects to electroacupuncture stimulation and may beeffective for LC by improving vascular endothelial function. However, the long-term effects of biotherapy have not been verified, andfurther studies are needed. However, considering the current lackof established treatment for LC, it is an urgent issue to establish aneffective evaluation and treatment method. This is the reason forthe present study.

Conclusion

The results of this study showed that biotherapy suppressed
FeNO levels immediately after the treatment (60-min value). The
effect was maximal immediately after the treatment and recovered
to the same level as that before the treatment 120 min after thetreatment, suggesting that biotherapy suppresses type 2 inflammation by stimulating sympathetic β2-adrenergic receptors. Biotherapy is expected to have not only anti-inflammatory effects but also
improve head and neck circulation and brain function. It is expectedthat biotherapy, such as EAT, will be effective in the treatment of LC.

Acknowledgments

I would like to thank Dr. Kazuo Uebaba, Professor at Hollywood
Graduate University and Visiting Professor at Teikyo Heisei University Institute of Oriental Medicine, and Dr. Suwan Kim, Total Medical Beauty Institute, for taking time out of their busy schedules toprovide guidance on biotherapy. I would like to express my sincere
gratitude to Dr. Mogitate Manabu, Director, Mogitate Otolaryngology, for his guidance in the FeNO measurement.

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Citation: Hirobumi Ito*, Miyuki Fujimatu and Emi Takahashi. Effect of Thermo-Electrical Stimulation Therapy on Exhaled Nitric Oxide
Concentration: Potential of Biotherapy as a Treatment for Long COVID. Sch J Oto. 9(4)-2022. SJO. MS.ID.000316.
DOI: 10.32474/SJO.2022.09.000316.

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