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Original Article

Journal of Evidence-Based
Complementary & Alternative Medicine
Impact of Electroacupuncture Treatment on 1-7
The Author(s) 2016

Quality of Life and Heart Rate Variability Reprints and permission:

DOI: 10.1177/2156587215626615
in Fibromyalgia Patients cam.sagepub.com

Livia G. Daz-Toral, MD1, Tania R. Banderas-Dorantes, PhD1,

and Jose F. Rivas-Vilchis, MD, PhD1

This study examines the effects of electroacupuncture treatment on health-related quality of life and heart rate variability in
women with fibromyalgia. Twenty women with fibromyalgia received a 10-week treatment with electroacupuncture. Primary
outcome measures were the Fibromyalgia Impact Questionnaire, the Short Form 36 Health Survey Questionnaire, and heart rate
variability. Compared with pretreatment, there was a significant improvement in health-related quality of life; electroacupuncture
significantly increases low frequency, low frequency/high frequency, and decreases high frequency, all indicating rise in sympathetic
tone. Fibromyalgia patients showed a significant (P < .05) improvement in pain, fatigue, morning tiredness, stiffness, anxiety, and
depression on the Fibromyalgia Impact Questionnaire scores; and physical function, physical role, body pain, general health, and
vitality scores on the Short Form 36 Health Survey Questionnaire. These changes mainly in mental status scores could be related
to a new autonomic balance with sympathetic predominance at the horary of the study.

fibromyalgia, electroacupuncture, health-related quality of life, heart rate variability

Received August 25, 2015. Received revised December 14, 2015. Accepted for publication December 18, 2015.

Fibromyalgia affects 2% of the Mexican population, of which improvement of symptoms of fibromyalgia.15 Electroacupunc-
80% to 90% are women.1 Several studies pointed that auto- ture has been reported as an efficacious treatment for fibro-
nomic imbalance could contribute to the fibromyalgia myalgia, both in animal fibromyalgia models 16 and in
symptoms.2,3 humans.17,18
Changes in heart rate variability has been correlated with The purpose of this study was to compare health-related
anxiety tests in patients with fibromyalgia,4 pain intensity,5 and quality of life with autonomic activity in patients with fibro-
seems to be a useful noninvasive tool for the evaluation of myalgia, before and after 10 sessions of electroacupuncture
autonomic nervous system.6 Furthermore, fibromyalgia patients treatment.
show sympathetic hyperactivity and abnormal vagal balance.7
Interestingly, a correlation between symptoms severity or qual-
ity of life and autonomic dysfunction has been described.8 Materials and Methods
Fibromyalgia patients experience a variety of symptoms, Participants
including depression, anxiety, sleep disturbances, fatigue, cog-
nitive deficits, and limitations in daily activities.9-11 This study enrolled fibromyalgia outpatients who attend the Acupunc-
ture Clinic of Universidad Autonoma Metropolitana for treatment.
Fibromyalgia patients experience significantly impairment
Fibromyalgia patients were previously diagnosed by a rheumatologist,
in health-related quality of life.12 Furthermore, a comparison using the criteria of the American College of Rheumatology.19 Twenty
between matched controls and persons with fibromyalgia women with fibromyalgia participated in the study.
showed a statistically significant difference between sleep dif-
ficulty symptoms, such as initiating and maintaining sleep, and
health-related quality of life.13 1
Universidad Autonoma Metropolitana, Iztapalapa, Mexico
Despite the interest that fibromyalgia has generated lately,
there is no effective treatment. Therefore, patients have turned Corresponding Author:
Jose F. Rivas-Vilchis, MD, PhD, Departamento de Ciencias de la Salud,
to nonpharmacological options such as acupuncture.14 Acu- Universidad Autonoma Metropolitana Unidad Iztapalapa, San Rafael Atlixco
puncture reduce pain and inflammation of various pathologies 186, Iztapalapa 09340, Mexico.
by stimulating the release of endorphins, and therefore provides Email: jfrv@xanum.uam.mx

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2 Journal of Evidence-Based Complementary & Alternative Medicine

Inclusion Criteria health-related quality of life.26 This self-reported questionnaire exam-

ines 2 main domains of health, namely, the physical and mental com-
1. Patients with fibromyalgia diagnosed based on American ponents. The questions are summarized into 8 scales: (1) physical
College of Rheumatology criteria19 functionwalking, lifting; (2) role limitations-physicallimitations
2. Patients aged 32 to 65 years to perform usual activities; (3) bodily painlevel of bodily pain or
3. Patients who fully understand the research process and were discomfort; (4) general health perceptionsglobal evaluation of
willing to provide informed consent health; (5) vitalityenergy level or fatigue; (6) social function
impact of health or emotional problems on social activities; (7) role
Exclusion Criteria function-emotional; and (8) mental healthanxiety, depression, sense
1. Patients with general musculoskeletal pain due to nonfibro- of psychological well-being. For each domain, a score ranging from 0
myalgia illness (worst measured health) to 100 (best-measured health) was calculated.
2. Patients with mental disorders or other serious organic dis- Higher scores represent better health for that particular subitem; the
eases, such as organ failure first 4 categories of the scale represent the physical component sum-
3. Patients taking oral pain medication or undergoing other inter- mary of the survey and measure domains related to physical health,
ventions for pain relief during the trial whereas the last 4 categories represent the mental component sum-
4. Pregnant or lactating women mary of the survey and measure domains related to mental health.27,28
5. Patients currently participating in another clinical trial Heart rate variability was assessed in the morning between 9:00
and 11:00 AM in a quiet study room with a 25 C environmental tem-
Ethical Issue perature, with the participant lying in the resting supine position. The
This study was performed in accordance with the ethical principles for procedure was explained in detail to the participants. After a rest
medical research involving human subjects of the Declaration of period of 15 minutes, a 5-minute electrocardiogram was recorded. The
Helsinki.20 The protocol, including the informed consent document, 5-minute electrocardiogram segments were amplified, digitized, and
was submitted to the Institutional Ethics Committee of Universidad stored on a computer, using the SphygmoCor device (AtCor Medical,
Autonoma Metropolitana. All participants agreed to participate in the Model EM3, Sydney, Australia). The device takes into account the
study and received detailed information about the purpose of this normal heart beats, ignoring ectopic beats, to derive the statistical
investigation and signed an informed consent document. parameters of the normal R-R intervals (N-N intervals) of the electro-
cardiogram, and estimates several time- and frequency-domain heart
rate variability indices. The time-domain index of heart rate variability
Acupuncture Treatment used in the present analysis was the root mean square difference of
successive normal R-R interval; this measure estimates high-
We based the acupuncture point selections on traditional Chinese frequency variations in heart rate in short-term N-N recordings that
medicine meridian theory, extraordinary vessels, and individualized reflects an estimate of the parasympathetic regulation of the heart. It is
Western acupuncture techniques by using a list of points previously a measure of parasympathetic autonomic function, and its reduction is
reported as being effective in fibromyalgia.21-23 Acupoints GV-20 a marker of parasympathetic withdrawal. Electrocardiogram recording
(head Baihui), CV-17 (Danzhong), PC-6 (Neiguan), H-7 (Shenmen), was performed before electroacupuncture treatment.29,30
L-3 (Taichong), K-3 (Taixi), and B-62 (Shenmai) were selected for Fibromyalgia Impact Questionnaire, Short Form 36 Health Survey
treatment. Sterile stainless steel needles with a double coil, 0.25  Questionnaire, and heart rate variability data were obtained from each
60 mm, were used. Electrical stimulation consisted of biphasic con- patient pre- and posttreatment.
stant current (2 mA) pulses of 15 Hz for 20 minutes (Acupuncture
Stimulator KWD 808 I, Jiangsu, China). Treatment consisted of 2
sessions per week for 10 weeks. A medical doctor specialized in Statistical Analysis
acupuncture, and with more than 20 years of clinical experience, The data are expressed as the mean + standard deviation. Statistical
conducted the electroacupuncture treatments. software SPSS version 13.0 (SPSS Inc, Chicago, IL) was used for all
statistical analysis. Comparisons of heart rate variability before and
after electroacupuncture treatment were performed using 2-tailed,
Outcomes paired Students t tests. Correlation values of total scores of Fibro-
For functional and psychological outcomes, we used Fibromyalgia myalgia Impact Questionnaire, Short Form 36 Health Survey Ques-
Impact Questionnaire score.24 It is the sum of the 8 Fibromyalgia tionnaire subitems with indicators of heart rate variability were
Impact Questionnaire subscales (each on a 0- to 10-point scale) and performed by Pearson correlation analysis. P values of <.05 were
20 items. The subscales are physical function, days wellness and labor considered statistically significant.
capacity, pain, fatigue, morning tiredness, stiffness, anxiety, and
depression. The first 11 items identify the patients function including
shopping, laundry, meal preparation, dish washing, sweeping, bed Results
preparing, walking 100 meters, working in the house garden, driving,
and going up the stairs. Two items are the number of days that the The demographics of the patients with fibromyalgia are shown
patient missed work due to disease and the number of days he/she had in Table 1.
a good feeling. The final 7 items evaluate psychological status includ-
ing depression, anxiety, tiredness, stiffness, working problem, fatigue, Health-Related Quality of Life Indexes
and pain severity. A higher score indicates a lower health status.25
The validated Mexican version of the Short Form 36 Health Survey The higher score of the Fibromyalgia Impact Questionnaire,
Questionnaire was used to assess physical function, mental health, and 100, represents greater severity of illness. The Fibromyalgia

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Daz-Toral et al 3

Table 1. Characteristics of the Study Population. health (r 0.563, P < .05). These positive correlations suggest
that improvements in social function and mental health could
Characteristic n + SD
be related with an increase in vagal activity.
Age in years, mean (SD) 47.0 + 10.8
Body mass index (kg/m2), mean (SD) 27.7 + 5.8
Employment statusjob/home, n (%) 13 (65)/7 (35) Discussion
Pain duration in years, mean (SD) 3.0 + 1.2 The demographics of the population distribution for age with
Tender points, mean (SD) 5.6 + 3.3
fibromyalgia described were similar to those previously found
Severity of pain points in VAS, mean (SD) 6.6 + 2.3
in Mexico as well as the symptoms associated with fibromyal-
Abbreviations: SD, standard deviation; VAS, visual analog scale for pain. gia described in long-term studies in similar populations.1
At baseline, bodily pain in the Short Form 36 Health Survey
Impact Questionnaire scores before and after electroacupunc- Questionnaire and morning tiredness in Fibromyalgia Impact
ture are shown in Figure 1. The basal Fibromyalgia Impact Questionnaire were the most remarkable symptoms. Fibro-
Questionnaire scores indicate levels of moderate fibromyalgia myalgia significantly impairs the quality of life of the patients
and were significantly improved by electroacupuncture treat- and can be highly disabling.31,32 Fibromyalgia Impact Ques-
ment. It is observed that the greatest and significant (P < .05) tionnaire is a tool developed and published to measure the
impact of electroacupuncture treatment was observed in pain, impact of fibromyalgia symptoms on daily living abilities and
fatigue, morning tiredness, stiffness, anxiety, and depression. general health status.25 Our results demonstrate that electroa-
The higher score of Short Form 36 Health Survey Question- cupuncture decreases both clinical and statistically some of the
naire, 100, represents better quality of life. Figure 2 shows values of the Fibromyalgia Impact Questionnaire, particularly
scores of Short Form 36 Health Survey Questionnaire of fatigue and morning tiredness.
patients before and after electroacupuncture treatment. After In fibromyalgia patients, electroacupuncture treatment
treatment with electroacupuncture, fibromyalgia patients results in a significant increase in Short Form 36 Health Survey
improves significantly (P < .05) in physical function, physical Questionnaire scores and reach values similar to those reported
role, body pain, general health, and vitality scores. for the general Mexican population.26 The Short Form 36
Health Survey Questionnaire is a general health status instru-
ment often used in clinical trials and health services research
Heart Rate Variability Analysis and has been demonstrated to have good reliability and validity
Change in heart rate variability components before and after in chronic pain patients.33,34
electroacupuncture are presented in Table 2. Electroacupunc- Although acupuncture techniques are a treatment system
ture elicited significantly increase in low frequency, 58.3 + pointed on normalizing the bodys dysfunction, experimental
15.0 to 76.6 + 4.1 (P < .001); a decrease in high frequency, and clinical investigations have indicated that specific acupunc-
41.5 + 14.8 to 23.3 + 4.1 (P < .001); and an increase in ture techniques have differentiated effects on the autonomic
low frequency/high frequency ratio, 1.7 + 1.0 to 3.4 + 1.1 nervous system and hormones. Several studies have investigated
(P < .001); all indicating rise in sympathetic tone. the effect of acupuncture on the autonomic nervous system in
health and diseases.35,36 In our study, electroacupuncture elicited
a significant decrease in high frequency and an increase in low
Correlation Between Health-Related Quality of Life
frequency and low frequency/high frequency ratio.
Indices With Heart Rate Variability Several studies have addressed the relationship between
The correlation between heart rate variability parameters with heart rate variability with mental and physical disorders such
Fibromyalgia Impact Questionnaire is shown in Table 3. as depression, morning tiredness, and fatigue. There are few
Before treatment, heart rate variability parameters and Fibro- reports that relate mood alterations such anxiety and depression
myalgia Impact Questionnaire scores were negatively corre- with overactive sympathetic tone and subsequently decreased
lated with low frequency (0.481) and positively correlated vagal tone at rest.35,36 Besides, it has been found that fibro-
for high frequency (0.496), both with a P < .1, namely, better myalgia patients had a basal autonomic state characterized by
Fibromyalgia Impact Questionnaire scores corresponds with increased sympathetic and decreased parasympathetic tones.37
higher parasympathetic drive. Nonetheless, it has been reported that the basal state auton-
The correlation between heart rate variability with the Short omous fibromyalgia patients had low heart rate variability val-
Form 36 Health Survey Questionnaire is shown in Tables 4 and ues associated with an increased high frequency and decreased
5 for physical and mental scores, respectively. low frequency.38 These data are consistent with the increased
For physical components, we observed a significantly pos- vagal and decreased sympathetic morning activity in these
itive correlation (r 0.556, P < .05) between general health patients, which could explain tiredness, fatigue, and sleep dur-
and heart rate variability at baseline. For mental components, ing the day.38 Besides, it has been shown that fibromyalgia
we observed a significantly positive correlations between root patients have signs of autonomic dysfunction, particularly both
mean square of the successive differences with social function signs of relentless sympathetic activity and sympathetic hypo-
(r 0.590, P < .05) and heart rate variability with mental reactivity to stress.39

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4 Journal of Evidence-Based Complementary & Alternative Medicine

Figure 1. Fibromyalgia Impact Questionnaire scores before and after electroacupuncture treatment.
Abbreviations: FIQ, Fibromyalgia Impact Questionnaire; PF, physical function; W/LC, days wellness and labor capacity; PN, pain; FT, fatigue; MT,
morning tiredness; SF, stiffness; AX, anxiety; DP, depression.
*Significantly different: P < .05.

Figure 2. Short Form 36 Health Survey Questionnaire scores before and after electroacupuncture treatment.
Abbreviations: PF, physical function; RP, role limitations-physical; BP, bodily pain; GH, general health perceptions; VT, vitality; SF, social function;
RE, role function-emotional; MH, mental health.
*Significantly different: P < .05.

Table 3. Correlation Between Heart Rate Variability and Physical

Table 2. Heart Rate Variability in Fibromyalgia Patients Before and Function of Fibromyalgia Impact Questionnairea.
After Electroacupuncture Treatment.
Basal EA
Basal EA
(Mean + SD) (Mean + SD) P Value rMSSD 0.079 0.109
LF 0.481* 0.158
rMSSD (ms) 38.5 + 33.0 31.8 + 22.3 .3112 HF 0.496* 0.158
LF (ms2; 0.04-0.15 Hz) 58.3 + 15.0 76.6 + 4.1 <.001 LF/HF 0.372 0.021
HF (ms2; 0.04-0.4 Hz) 41.5 + 14.8 23.3 + 4.1 <.001 HRV 0.267 0.030
LF/HF 1.7 + 1.0 3.4 + 1.1 <.001
HRV 8.2 + 4.3 7.4 + 3.3 .3269 Abbreviations: EA, electroacupuncture; rMSSD, root mean square of the suc-
cessive differences; LF, low frequency; HF, high frequency; LF/HF, low fre-
Abbreviations: SD, standard deviation; EA, electroacupuncture; rMSSD, root quency/high frequency ratio; HRV, heart rate variability.
mean square of the successive differences; LF, low frequency; HF, high fre- Data are Pearson correlation coefficients (r).
quency; LF/HF, low frequency/high frequency ratio; HRV, heart rate variability. *P < .1.

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Daz-Toral et al 5

Table 4. Correlation Between Heart Rate Variability and Physical Components of the Short Form 36 Health Survey Questionnairea.


Basal EA Basal EA Basal EA Basal EA

rMSSD 0.350 0.194 0.117 0.0281 0.099 0.324 0.236 0.230

LF 0.047 0.045 0.176 0.271 0.390 0.281 0.132 0.296
HF 0.043 0.045 0.162 0.271 0.391 0.281 0.1394 0.296
LF/HF 0.047 0.045 0.176 0.271 0.390 0.281 0.132 0.296
HRV 0.477 0.266 0.450 0.120 0.479 0.110 0.556* 0.142
Abbreviations: PF, physical function; RP, role limitations-physical; BP, bodily pain; GH, general health perceptions; EA, electroacupuncture; rMSSD, root mean
square of the successive differences; LF, low frequency; HF, high frequency; LF/HF, low frequency/high frequency ratio; HRV, heart rate variability.
Data are Pearson correlation coefficients (r).
*P < .05.

Table 5. Correlation Between Heart Rate Variability and Mental Components of the Short Form 36 Health Survey Questionnaire.


Basal EA Basal EA Basal EA Basal EA

rMSSD 0.267 0.171 0.381 0.590* 0.194 0.222 0.121 0.155

LF 0.021 0.223 0.017 0.183 0.094 0.100 0.024 0.248
HF 0.027 0.223 0.007 0.183 0.093 0.100 0.018 0.248
LF/HF 0.079 0.274 0.004 0.128 0.028 0.104 0.013 0.092
HRV 0.470 0.086 0.393 0.285 0.339 0.194 0.432 0.563*

Abbreviations: VT, vitality; SF, social function; RE, role function-emotional; MH, mental health; EA, electroacupuncture; rMSSD, root mean square of the
successive differences; LF, low frequency; HF, high frequency; LF/HF, low frequency/high frequency ratio; HRV, heart rate variability.
Data are Pearson correlation coefficients (r).
*P < .05.

In our study, the balance parasympathetic/sympathetic of the autonomic profile in these fibromyalgia patients. Future
the treated patients was displaced to a raised sympathetic tone researchers must conduct large-scale and long-term electroacu-
at the time of the recordings. The morning adrenergic effect puncture interventions to study the effects of this treatment on
seen in the patients could explain the improvements in the fibromyalgia evolution and its pathophysiological components.
physical function in the Fibromyalgia Impact Questionnaire
scores, and physical and mental components of Short Form Acknowledgements
36 Health Survey Questionnaire. Therefore, we speculate that We would like to acknowledge the technical assistance of Miguel J.
the sympathetic effect elicited by electroacupuncture in our Reyes-Campos, MD.
fibromyalgia patients could be related to the positive changes
in health-related quality of life, especially the improvement in Author Contributions
mood, depression, and feelings of being sick. Further studies LGDT: Principal investigator of the project, data analysis and inter-
are needed to determine the mechanisms by which electroacu- pretation, manuscript preparation. TRBD: Coinvestigator of the proj-
puncture improves fibromyalgia and the long-term effects of ect, data analysis, technical support, manuscript preparation. JFRV:
Mentor, data analysis, and manuscript preparation.
electroacupuncture on heart rate variability and its conse-
quences to overall cardiovascular risk. Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
Study Limitations the research, authorship, and publication of this article.

The limitations of the study were that the sample size was Funding
relatively small and the lack of a control group. The authors disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This work was
financially supported by the public funds of Universidad Autonoma
Metropolitana, at Iztapalapa.
Fibromyalgia is a major clinical problem and its management is
of utmost importance. Electroacupuncture was shown to be Ethical Approval
beneficial for fibromyalgia patients. The improvement in Ethics Committee of Biological and Health Sciences Division of our
health-related quality of life could be related with changes in institution granted approval to this project, and the procedures

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6 Journal of Evidence-Based Complementary & Alternative Medicine

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