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:

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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

Abstract
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.

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

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2 Journal of Evidence-Based Complementary & Alternative Medicine
Inclusion Criteria
1. Patients with fibromyalgia diagnosed based on American
College of Rheumatology criteria19
2. Patients aged 32 to 65 years
3. Patients who fully understand the research process and were
willing to provide informed consent
Exclusion Criteria
1. Patients with general musculoskeletal pain due to nonfibro-
myalgia illness
2. Patients with mental disorders or other serious organic dis-
eases, such as organ failure
3. Patients taking oral pain medication or undergoing other inter-
ventions for pain relief during the trial
4. Pregnant or lactating women
5. Patients currently participating in another clinical trial
Ethical Issue
This study was performed in accordance with the ethical principles for
medical research involving human subjects of the Declaration of
Helsinki.20 The protocol, including the informed consent document,
was submitted to the Institutional Ethics Committee of Universidad
Autonoma Metropolitana. All participants agreed to participate in the
study and received detailed information about the purpose of this
investigation and signed an informed consent document.
Acupuncture Treatment
We based the acupuncture point selections on traditional Chinese
medicine meridian theory, extraordinary vessels, and individualized
Western acupuncture techniques by using a list of points previously
reported as being effective in fibromyalgia.21-23 Acupoints GV-20
(head Baihui), CV-17 (Danzhong), PC-6 (Neiguan), H-7 (Shenmen),
L-3 (Taichong), K-3 (Taixi), and B-62 (Shenmai) were selected for
treatment. Sterile stainless steel needles with a double coil, 0.25 
60 mm, were used. Electrical stimulation consisted of biphasic con-
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
acupuncture, and with more than 20 years of clinical experience,
conducted the electroacupuncture treatments.
Outcomes
For functional and psychological outcomes, we used Fibromyalgia
Impact Questionnaire score.24 It is the sum of the 8 Fibromyalgia
Impact Questionnaire subscales (each on a 0- to 10-point scale) and
20 items. The subscales are physical function, days wellness and labor
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
preparing, walking 100 meters, working in the house garden, driving,
and going up the stairs. Two items are the number of days that the
patient missed work due to disease and the number of days he/she had
a good feeling. The final 7 items evaluate psychological status includ-
ing depression, anxiety, tiredness, stiffness, working problem, fatigue,
and pain severity. A higher score indicates a lower health status.25
The validated Mexican version of the Short Form 36 Health Survey
Questionnaire was used to assess physical function, mental health, and
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health-related quality of life.26 This self-reported questionnaire exam-
ines 2 main domains of health, namely, the physical and mental com-
ponents. The questions are summarized into 8 scales: (1) physical
functionwalking, lifting; (2) role limitations-physicallimitations
to perform usual activities; (3) bodily painlevel of bodily pain or
discomfort; (4) general health perceptionsglobal evaluation of
health; (5) vitalityenergy level or fatigue; (6) social function
impact of health or emotional problems on social activities; (7) role
function-emotional; and (8) mental healthanxiety, depression, sense
of psychological well-being. For each domain, a score ranging from 0
(worst measured health) to 100 (best-measured health) was calculated.
Higher scores represent better health for that particular subitem; the
first 4 categories of the scale represent the physical component sum-
mary of the survey and measure domains related to physical health,
whereas the last 4 categories represent the mental component sum-
mary of the survey and measure domains related to mental health.27,28
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-
perature, with the participant lying in the resting supine position. The
procedure was explained in detail to the participants. After a rest
period of 15 minutes, a 5-minute electrocardiogram was recorded. The
5-minute electrocardiogram segments were amplified, digitized, and
stored on a computer, using the SphygmoCor device (AtCor Medical,
Model EM3, Sydney, Australia). The device takes into account the
normal heart beats, ignoring ectopic beats, to derive the statistical
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
used in the present analysis was the root mean square difference of
successive normal R-R interval; this measure estimates high-
frequency variations in heart rate in short-term N-N recordings that
reflects an estimate of the parasympathetic regulation of the heart. It is
a measure of parasympathetic autonomic function, and its reduction is
a marker of parasympathetic withdrawal. Electrocardiogram recording
was performed before electroacupuncture treatment.29,30
Fibromyalgia Impact Questionnaire, Short Form 36 Health Survey
Questionnaire, and heart rate variability data were obtained from each
patient pre- and posttreatment.
Statistical Analysis
The data are expressed as the mean + standard deviation. Statistical
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,
paired Students t tests. Correlation values of total scores of Fibro-
myalgia Impact Questionnaire, Short Form 36 Health Survey Ques-
tionnaire subitems with indicators of heart rate variability were
performed by Pearson correlation analysis. P values of <.05 were
considered statistically significant.
Results
The demographics of the patients with fibromyalgia are shown
in Table 1.
Health-Related Quality of Life Indexes
The higher score of the Fibromyalgia Impact Questionnaire,
100, represents greater severity of illness. The Fibromyalgia
Daz-Toral et al
Table 1. Characteristics of the Study Population.
Characteristic
Age in years, mean (SD)
Body mass index (kg/m2), mean (SD)
Employment statusjob/home, n (%) 13 (65)/7 (35)
Pain duration in years, mean (SD)
Tender points, mean (SD)
Severity of pain points in VAS, mean (SD)
Abbreviations: SD, standard deviation; VAS, visual analog scale for pain.
Impact Questionnaire scores before and after electroacupunc-
ture are shown in Figure 1. The basal Fibromyalgia Impact
Questionnaire scores indicate levels of moderate fibromyalgia
and were significantly improved by electroacupuncture treat-
ment. It is observed that the greatest and significant (P < .05)
impact of electroacupuncture treatment was observed in pain,
fatigue, morning tiredness, stiffness, anxiety, and depression.
The higher score of Short Form 36 Health Survey Question-
naire, 100, represents better quality of life. Figure 2 shows
scores of Short Form 36 Health Survey Questionnaire of
patients before and after electroacupuncture treatment. After
treatment with electroacupuncture, fibromyalgia patients
improves significantly (P < .05) in physical function, physical
role, body pain, general health, and vitality scores.
Heart Rate Variability Analysis
Change in heart rate variability components before and after
electroacupuncture are presented in Table 2. Electroacupunc-
ture elicited significantly increase in low frequency, 58.3 +
15.0 to 76.6 + 4.1 (P < .001); a decrease in high frequency,
41.5 + 14.8 to 23.3 + 4.1 (P < .001); and an increase in
low frequency/high frequency ratio, 1.7 + 1.0 to 3.4 + 1.1
(P < .001); all indicating rise in sympathetic tone.
Correlation Between Health-Related Quality of Life
Indices With Heart Rate Variability
The correlation between heart rate variability parameters with
Fibromyalgia Impact Questionnaire is shown in Table 3.
Before treatment, heart rate variability parameters and Fibro-
myalgia Impact Questionnaire scores were negatively corre-
lated with low frequency (0.481) and positively correlated
for high frequency (0.496), both with a P < .1, namely, better
Fibromyalgia Impact Questionnaire scores corresponds with
higher parasympathetic drive.
The correlation between heart rate variability with the Short
Form 36 Health Survey Questionnaire is shown in Tables 4 and
5 for physical and mental scores, respectively.
For physical components, we observed a significantly pos-
itive correlation (r 0.556, P < .05) between general health
and heart rate variability at baseline. For mental components,
we observed a significantly positive correlations between root
mean square of the successive differences with social function
(r 0.590, P < .05) and heart rate variability with mental
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3
health (r 0.563, P < .05). These positive correlations suggest
that improvements in social function and mental health could
n + SD
be related with an increase in vagal activity.
47.0 + 10.8
27.7 + 5.8
Discussion
3.0 + 1.2 The demographics of the population distribution for age with
5.6 + 3.3
fibromyalgia described were similar to those previously found
6.6 + 2.3
in Mexico as well as the symptoms associated with fibromyal-
gia described in long-term studies in similar populations.1
At baseline, bodily pain in the Short Form 36 Health Survey
Questionnaire and morning tiredness in Fibromyalgia Impact
Questionnaire were the most remarkable symptoms. Fibro-
myalgia significantly impairs the quality of life of the patients
and can be highly disabling.31,32 Fibromyalgia Impact Ques-
tionnaire is a tool developed and published to measure the
impact of fibromyalgia symptoms on daily living abilities and
general health status.25 Our results demonstrate that electroa-
cupuncture decreases both clinical and statistically some of the
values of the Fibromyalgia Impact Questionnaire, particularly
fatigue and morning tiredness.
In fibromyalgia patients, electroacupuncture treatment
results in a significant increase in Short Form 36 Health Survey
Questionnaire scores and reach values similar to those reported
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
and has been demonstrated to have good reliability and validity
in chronic pain patients.33,34
Although acupuncture techniques are a treatment system
pointed on normalizing the bodys dysfunction, experimental
and clinical investigations have indicated that specific acupunc-
ture techniques have differentiated effects on the autonomic
nervous system and hormones. Several studies have investigated
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
frequency and low frequency/high frequency ratio.
Several studies have addressed the relationship between
heart rate variability with mental and physical disorders such
as depression, morning tiredness, and fatigue. There are few
reports that relate mood alterations such anxiety and depression
with overactive sympathetic tone and subsequently decreased
vagal tone at rest.35,36 Besides, it has been found that fibro-
myalgia patients had a basal autonomic state characterized by
increased sympathetic and decreased parasympathetic tones.37
Nonetheless, it has been reported that the basal state auton-
omous fibromyalgia patients had low heart rate variability val-
ues associated with an increased high frequency and decreased
low frequency.38 These data are consistent with the increased
vagal and decreased sympathetic morning activity in these
patients, which could explain tiredness, fatigue, and sleep dur-
ing the day.38 Besides, it has been shown that fibromyalgia
patients have signs of autonomic dysfunction, particularly both
signs of relentless sympathetic activity and sympathetic hypo-
reactivity to stress.39
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.
a
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.

PF RP BP GH

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.
a
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.

VT SF RE MH

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.
a
Data are Pearson correlation coefficients (r).
*P < .05.

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

The limitations of the study were that the sample size was
relatively small and the lack of a control group.
Conclusion
Fibromyalgia is a major clinical problem and its management is
of utmost importance. Electroacupuncture was shown to be
beneficial for fibromyalgia patients. The improvement in
health-related quality of life could be related with changes in
Funding
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.
Ethical Approval
Ethics Committee of Biological and Health Sciences Division of our
institution granted approval to this project, and the procedures

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6 Journal of Evidence-Based Complementary & Alternative Medicine
followed the ethical standards provided by Mexican health laws and
Helsinki Convention. Previous Informed consent was obtained from
all individuals for participation in this study.
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