# Exploring Heart Rate Variability as a Biomedical Diagnostic Tool for the Disympathetic Dimension of Eight-Constitution Medicine

Authors: Hyonna Kang; Sean Walsh; Brian Oliver; Terry Royce; Byung Je Cho
Journal: Evidence-Based Complementary and Alternative Medicine
 (2021)

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## Abstract

Background. Eight-Constitution Medicine (ECM), an extension of Traditional Korean Medicine, divides the population into eight groups based on their physiological characteristics. ECM divides these eight groups into two larger groups based on autonomic reactivity: the Sympathicotonic group and the Vagotonic group (herein referred to as the Disympathetic Dimension). Heart Rate Variability (HRV) is a widely used biomedical tool to assess cardiac autonomic function. This raises the question of the utility of using HRV to correctly diagnose ECM constitutions. Methods. A systematic literature review was conducted to evaluate the correlation between HRV and constitutions in Korean Constitutional Medicine, including Eight-Constitution Medicine (ECM) and Sasang Constitution Medicine (SCM). The articles were obtained from both English (Scopus, PubMed, EMBASE, ProQuest, and Medline) and Korean databases (NDSL and RISS), in addition to Google Scholar, without date restriction. 20 studies met the inclusion criteria, and data were extracted against three aspects: (1) correlation between HRV and constitution, (2) HRV reporting and interpretation, and (3) extraneous factors that were controlled in the studies. Results. 386 articles were initially identified, which was reduced to n = 20 studies which met the inclusion criteria. Of these, 19 were SCM studies and 1 was an ECM study. Sample sizes varied from 10 to 8498 men and women, with an age range of 10–80 years. SCM studies explored HRV differences by constitution, measuring HRV at resting, with controlled breathing, before and after acupuncture stimulation, and by other interventions. SCM studies reported either no significant differences (HRV at resting or with controlled breathing studies) or conflicting data (HRV with acupuncture stimulation studies). The single ECM study measured HRV at resting and after acupuncture stimulation but reported no significant differences between the two groups of Sympathicotonia and Vagotonia. Conclusions. Due to inconsistencies in study design, study population, and measures of HRV, there was no consistency in the data to support the use of HRV as a biomedical determinant of ECM constitutions.


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## Body

## 1. Introduction

Eight-Constitution Medicine (ECM) originates from Korean Constitutional Medicine, a further development of Sasang Constitution Medicine (SCM) [1–3]. A constitution refers to the nature of an individual’s health response based on their psychosocial and physiological traits. While SCM classifies people into one of four constitutions (Tae-Yang, Tae-Eum, So-Yang, and So-Eum) [4], ECM differentiates people as one of the eight constitutions: Pulmotonia (PUL), Colonotonia (COL), Renotonia (REN), Vesicotonia (VES), Pancreotonia (PAN), Gastrotonia (GAS), Hepatonia (HEP), and Cholecystonia (CHO) (Figure 1) [5]. Consequently, ECM employs a personalized approach to treatment, even between people with the same ‘disease’, prescribing individualized neuromodulatory protocols (via acupuncture) and lifestyle regimen (including dietary guidance), aligning with the emerging “personalized and preventive” medicine movement [6–8].Figure 1
Eight constitutions and Disympathetic Dimension [5].However, despite over 50 years of ECM research in Korea [2, 5, 9–11], differentiating a patient’s constitution still primarily relies upon the practitioner’s assessment of the radial arterial pulse. This requires highly developed palpatory skills to detect distinct differences in pulse position and contours that differentiate one constitution from another [12–15]. While there is greater interrater agreement reported between experienced practitioners, agreement levels, unfortunately, reduce among inexperienced practitioners [13, 14, 16, 17].To better support reliability and remove subjectivity, a proposal is to differentiate constitutions based instead on autonomic balance. Eppinger and Hess introduced the constitutional concepts of Vagotonia and Sympathicotonia [18], which have a relationship with Heart Rate Variability (HRV). They defined Sympathicotonia as having increased tone in the sympathetic nervous system and with an abnormal increased response to adrenalin, and Vagotonia as having increased tone in the parasympathetic nervous system and with a relatively increased sensitiveness to pilocarpine [5, 18, 19]. This aligns with ECM, which proposes these hereditary factors as constitutional differences and classifies four (of the eight) constitutions into Sympathicotonic type and Vagotonic type (Figure 1) [5].A set of biomedical diagnostics that differentiates the Sympathicotonic and Vagotonic types of ECM (referred to herein as the ‘Disympathetic Dimension’) would provide objective support for assessing the eight-constitution framework. Furthermore, HRV is a widely used biomedical tool to objectively assess cardiac autonomic function [20]. While it is generally agreed that high-frequency HRV can be used to assess cardiac vagal modulation (parasympathetic) [20–25], the same cannot be said for low-frequency HRV assessing cardiac sympathetic modulation [26–31]. HRV, however, is very sensitive to a range of extraneous factors [32].Consequently, to explore HRV as a biomedical diagnostic for ECM, HRV studies in the Korean Constitutional Medicine (Eight-Constitution Medicine, Sasang Constitution Medicine) were critically reviewed against three considerations: (1) the correlation between HRV and constitutions, (2) HRV reporting and interpretation, and (3) controlled extraneous factors.


## 2. Methods

### 2.1. Databases

A systematic review was conducted on full-text articles obtained from both English (Scopus, PubMed, EMBASE, ProQuest, and Medline) and Korean (NDSL, RISS) electronic databases, in addition to Google Scholar, without date restriction.


### 2.2. Search Terms

Search terms for English databases include (“heart rate variability” OR HRV) AND “eight constitution”, (“heart rate variability” OR HRV) AND “8 constitution∗”, (“heart rate variability” OR HRV) AND “Sasang”, while Korean databases search terms include: “heart rate variability” AND 8체질, HRV AND 8체질, HRV AND 팔체질, 심박∗ AND 팔체질, 심박∗ AND 8체질, “Heart rate variability” AND 사상체질, “HRV” AND 사상체질, 심박∗ AND 사상체질.


## 2.1. Databases

A systematic review was conducted on full-text articles obtained from both English (Scopus, PubMed, EMBASE, ProQuest, and Medline) and Korean (NDSL, RISS) electronic databases, in addition to Google Scholar, without date restriction.


## 2.2. Search Terms

Search terms for English databases include (“heart rate variability” OR HRV) AND “eight constitution”, (“heart rate variability” OR HRV) AND “8 constitution∗”, (“heart rate variability” OR HRV) AND “Sasang”, while Korean databases search terms include: “heart rate variability” AND 8체질, HRV AND 8체질, HRV AND 팔체질, 심박∗ AND 팔체질, 심박∗ AND 8체질, “Heart rate variability” AND 사상체질, “HRV” AND 사상체질, 심박∗ AND 사상체질.


## 3. Results

### 3.1. Review Process

From the 386 total records obtained from database search (n = 384) and manual searches (n = 2), full-text articles of n = 36 were obtained after excluding duplicated papers (n = 60) and nonrelevant papers or unavailable articles (n = 290). The articles (n = 36) were further reviewed against the inclusion criteria (i.e., short-term recordings of HRV) for Korean Constitutional Medicine (Eight Constitution or Sasang Constitution). A further 16 articles were excluded, leaving n = 20 papers for critical review. Of these, one was an ECM article, and the others were SCM studies (n = 19). The review process is presented in Figure 2.Figure 2
Systematic review process.


### 3.2. Study Characteristics (Table1)

#### 3.2.1. Demographic Characteristics

Sample sizes varied from 10 to 8498 men and women, with an age range of 10 to 80 years. 13 out of 20 studies were in healthy subjects, and the rest were either patient populations or medical information not being available.Table 1
Summary of studies investigating the correlation between Heart Rate Variability and Korean Constitution Medicine (ECM or SCM).
ReferenceNo.MedicinePopulation (age range)Autonomic stimulusDuration and HRV measuresOther measures[33]1ECM42 patients (14–73)Eight-constitution acupuncture5 min, frequency domainBMI[34]2SCM32 healthy students (20–30)Paced breathing in specific respiration rate5 min, time and frequency domainRespiration rate[35]3SCM60 healthy students (20–30)Ratio of inhalation and exhalation, posture (sitting, standing)Time and frequency domainSelf-evaluation for physical condition (scale 10 cm)[36]4SCM78 healthy students (20–30)Breath-counting meditation5 min, time and frequency domainSkin conductance, temperature, abdominal amplitude, thoracic amplitude[37]5SCM78 studentsMeditation program (α version)Time and frequency domainBDI (depression), STAXI (anger), STAI (anxiety) questionnaires[38]6SCM16 healthy TE constitution (20–60)Taegeuk acupuncture5 min, frequency domainNone[39]7SCM6 healthy SE constitution men (20–30)Taegeuk acupuncture5 min, frequency domainNone[40]8SCM63 fatigue and nonfatigue subjects (40–60)None5 min, time and frequency domainBMI, biochemistry analysis, pulse wave analysis, nail fold capillary microscopy, questionnaires (FSS, GSRS, SF-MPQ, PSQI, SF-12)[41]9SCM8 healthy SY constitution women (20–30)Taegeuk acupuncture5 min, frequency domainNone[42]10SCM47 healthy subjects (29–66)Forrest healing program (aroma, foods, tea by constitution + trekking)5 min, time and frequency domainBMI, body temperature, vital sign (BP, SpO2), electroencephalography, biochemistry analysis, blood cell count, stress hormone test[43]11SCM665 subjects (39–72)None5 min, time and frequency domainBMI, BP, fasting blood sugar, cholesterol, abdominal obesity[44]12SCM20 healthy subjects (18–30)Bee venom acupuncture5 min, time and frequency domainPulse wave analysis, cerebral blood flow[45]13SCM103 idiopathic facial palsy patients (10–79)None5 min, time and frequency domainFacial electromyography[46]14SCM10 TE constitution patientsHerbal formula for TE constitution (Jowisengcheong-tang)5 min, time and frequency domainNone[47]15SCM30 healthy men (20–26)Acupuncture at LI45 min, time and frequency domainNone[48]16SCM39 patients (20–59)Autogenic training5 min, time and frequency domainMBTI questionnaire (extraversion, introversion)[49]17SCM8498 workersNone5 min, time and frequency domainNone[50]18SCM44 healthy subjects (20–30)Emotional stimulus (horror film)120 sec, 197 sec, 120 sec, time and frequency domainNone[51]19SCM86 subjects (22–25)Electroacupuncture30 sec, time domain (SDNN)None[52]20SCM19 healthy subjectsAcupuncture at LI4 and LR35 min, time and frequency domainBP, BMIECM, Eight-Constitution Medicine; SCM, Sasang Constitution Medicine; CM, Constitution Medicine; HRV, Heart Rate Variability; MHR, mean heart rate; BMI, body mass index; TE, Taeumin constitution; SY, Soyangin constitution; FSS, Fatigue Severity Scale; GSRS, Gastrointestinal Symptom Rating Scale; SF-MPQ, Short-Form McGill Pain Questionnaire; PSQI, Pittsburgh Sleep Quality Index; SF-12, Short-Form Health Survey; BP, blood pressure; SpO2, peripheral capillary oxygen saturation; APG, Accelerated Plethysmogram; MBTI, Myers–Briggs Type Indicator.


#### 3.2.2. Study Intervention

To explore constitutional differences, the studies measured HRV at resting level [40, 43, 45, 53] with paced breathing [34, 36, 54], after acupuncture stimulation [38, 39, 41, 44, 47, 51, 52], or other interventions such as meditation [37], forest healing program [42], autogenic training [48], emotional stimulus [50], and constitutional herbal formula [46].


#### 3.2.3. HRV Analysis and Devices

HRV analysis studies varied: time and frequency domain (n = 15), frequency domain only (n = 4), and time domain only (n = 1). All studies used commercial HRV medical devices of ECG (n = 16), PPG (n = 2), or IBI (n = 2).


### 3.3. Correlation between HRV and Constitution

#### 3.3.1. ECM and HRV at Resting and after Acupuncture Stimulation (p < 0.05) (Table 2)

A single ECM study [33] measured HRV baseline at resting and after constitutional acupuncture (i.e., a predefined acupuncture formula for a specific constitution) stimulation but reported no significant differences between the two groups of Sympathicotonia and Vagotonia. The study had a small sample size (42 patients), wide age range (14–73 yr), uncontrolled gender factors, and a short observation period after acupuncture.Table 2
HRV difference by constitution (p < 0.05), before and after acupuncture stimulation.
Reference1 [33]6 [38]9 [41]7 [39]12 [44]15 [47]19 [51]20 [52]ConstitutionECMSCMSCMSCMSCMSCMSCMSCMPopulation (range)42 patients (14–73)16 healthy TE constitution (20–60)8 healthy SY constitution women (20–30)6 healthy SE constitutionmen (20–30)20 healthy subjects (18–30)30 healthy men (20–26)86 subjects (22–25)19 healthy subjectsSubjects by constitution groupSympathicotonia = 22 (Pul, Col, Ren, Ves) Vagotonia = 20 (Hep, Cho, Pan, Gas)TE = 16SY = 8SE = 6SY = 5, TE = 8, SE = 7, TY = 0SY = 8, TE = 13, SE = 9, TY = 0SY = 34, TE = 27, SE = 25, TY = 0SY = 6, TE = 7, SE = 6, TY = 0Age and gender controlled by constitution groupnanaAge, genderAge, genderAgeAge, genderAge, genderAge, genderAcupunctureEight-constitution acupunctureTaegeuk acupuncture (TE)Taegeuk acupuncture (SY)Taegeuk acupuncture (SE)Bee venom acupunctureAcupuncture at LI4ElectroacupunctureAcupuncture at LI4 and LR3HRV baseline difference by constitutionNo differenceNANANANo differenceLow in TE (LF/HF)naNo differenceHRV by constitution compared to baseline, after acupunctureMHRNo differencenanananaNo differencenaTE > SY, SEmRR (ms)nananananananaSDNN (ms)nanananaNo differenceNo differenceSY > TE (passive)TE > SY (active) SY > SE (general)rMSSD (ms)nanananaNo differencenanaSE > TE∗LF (ms2)nananaNo differenceNo differenceNo differencenaHF (ms2)nananaNo differenceNo differenceNo differencenaLFnunaDecreased in TEDecreased in SYNo differencenaIncreased in SYnaTE > SE∗HFnunaIncreased in TEIncreased in SYNo differencenananaSE, SY > TE∗Ln (LF)No differencenanananananaLn (HF)No differencenanananananaLF/HFNo differencenanaNo differenceNo differenceIncreased in SYSE > SYnaTE > SE∗ECM, Eight-Constitution Medicine; SCM, Sasang Constitution Medicine; Pul, Pulmotonia constitution; Col, Colonotonia constitution; Ren, Renotonia constitution; Ves, Vesicotonia constitution; Hep, Hepatonia constitution; Cho, Cholecystonia constitution; Pan, Pancreotonia constitution; Gas, Gastrotonia constitution; TE, Taeumin constitution; SY, Soyangin constitution; SE, Soeumin constitution; TY, Taeyangin constitution; MHR, Mean Heart Rate; na, not available; NA, not applicable.∗Compared to right after needle insertion vs. 1 hour after needle removal.


#### 3.3.2. SCM and HRV at Resting (p < 0.05) (Table 3)

None of the SCM studies reported significant differences in HF at resting between constitutions. Two relatively well-controlled SCM studies indicated Tae-Eum constitution (with characteristics of increased parasympathetic reactivity) showed a lower LF/HF ratio than the So-Yang constitution (with both parasympathetic and sympathetic reactivity) at resting condition (p < 0.05) [43, 47, 55].Table 3
HRV difference by constitution (p < 0.05), at resting.
Reference8 [40]11 [43]113 [45]17 [53]215 [47]ConstitutionSCMSCMSCMSCMSCMPopulation (age)63 fatigue and nonfatigue subjects (40–60)665 subjects (39–72)103 idiopathic facial palsy patients (10–79)8498 workers30 healthy men (20–26)Subjects by constitution groupFatigue:Total:SY = 25 (M 7, F 18)SY 4270SY = 8, TE = 13,SY = 10, TE = 8,SY = 100, TE = 363,TE = 54 (M 27, F27)TE 2331SE = 9, TY = 0SE = 14, TY = 0SE = 202, TY = 0SE = 24 (M 8, F 16)SE 1897Nonfatigue:Female <60 yrsTY (0)TY (0)SY = 15, TE = 7,SY = 36, TE = 140,SE = 9, TY = 0SE = 68, TY = 0Age and gender controlled by constitution groupAgeAge, gender (female < 60 yrs)naGenderAge, genderType of studyCross-sectional study (2012)Cross-sectional study (Genomic cohort 2006)Medical record retrospective review (2008–2009)Health examination 2005Acupuncture at LI4MHRnaNo differenceNo differenceNo differenceNo differencemRR (ms)nananananaSDNN (ms)No differenceNo differenceNo differenceSE > TENo differencerMSSD (ms)No differencenanananaLF (ms2)No differencenaNo differencenaNo differenceHF (ms2)No differencenaNo differencenaNo differenceLFnuNo differenceSY > TE (all) SY > TE, SE (female, below 60 years)nananaHFnuNo differenceTE > SY (all) TE, SE > SY (female, below 60 years)nananaLn (LF)naNonananaLn (HF)naNonananaLF/HFNo differenceSY > TESY > TE, SE (female, below 60 years)SY, TE > SENo differenceLow in TESY, Soyangin constitution; TE, Taeumin constitution; SE, Soeumin constitution; M, male; F, female; na, not available.1Multivariated adjusted odds ratio HRV analysis. The odds ratio adjusted for age, gender, education period, marital status, drinking status, smoking status, past history (hypertension, diabetes mellitus, and hyperlipidemia), BMI, and metabolic syndrome. 2HRV reporting generated indices (stress index, fatigue index) and TP showed a significant difference between constitution groups.


#### 3.3.3. SCM and HRV with Controlled Breathing (p < 0.05) (Table 4)

Three SCM studies explored the effects of different breathing approaches on constitutions by measuring HRV: breath-counting meditation [36], paced breathing (3, 6, or 12 times per min) [34], and the ratio of inhalation and exhalation (4 : 6 and 6 : 4, respectively) with posture changes [35], but HRV measures from both baseline and controlled breathing showed no difference between constitutions.Table 4
HRV difference by constitution (p < 0.05), controlled breathing.
Reference4 [36]2 [34]3 [35]ConstitutionSCMSCMSCMPopulation (age)78 healthy students (20–30)32 healthy students (20–30)60 healthy students (20–30)Subjects by constitution groupSY = 13, TE = 30, SE = 35, TY = 0SY = 10, TE = 11, SE = 11, TY = 0SY = 18, TE = 18, SE = 24, TY = 0Age and gender controlled by constitution groupAgeAgeAgeHRV baseline difference by constitutionMHR : SY, SE > TENo differenceNo differenceHRV by constitution compared to baseline, with paced breathingBreath-counting on inspiration and expiration (not controlling)Paced breathing: 12, 6, or 3 times per minRatio of inhalation and exhalation (4 : 6, 6 : 4)MHRCIB : SE > TECEB : SE, SY > TENo differenceNo differencemRR (ms)naNo differenceNo differenceSDNN (ms)No differenceNo differenceNo differencerMSSD (ms)naNo differenceNo differenceLF (ms2)No differencenaNo differenceHF (ms2)No differencenaNo differenceLFnunanaNo differenceHFnunanaNo differenceLn (LF)naNo differencenaLn (HF)naNo differencenaLF/HFNo differencenanana, not available; CIB, Counting on Inspiration; CEB, Counting on Expiration.


#### 3.3.4. SCM and HRV after Acupuncture Stimulation (p < 0.05) (Table 2)

5 out of 7 SCM acupuncture studies reported some HRV differences between constitutions. Two within-subject studies [38,41] reported that Taegeuk acupuncture stimulation (i.e., a predefined acupuncture formula for a specific constitution) resulted in a significant increase in HFnu in both the Tae-Eum and So-Yang type compared to a resting or stress condition, indicating a relative increase in cardiac vagal modulation. Three between-subject studies based on different acupuncture stimulation methods reported different HRV measures or conflicting data: (1) So-Yang type showed higher SDNN than So-Eum type and Tae-Eum type during passive coping conditions (i.e., enduring pain passively) and the opposite during active coping condition (i.e., pain stimulation will stop when signaling) when pain is induced by electroacupuncture [51]; (2) So-Eum type showed higher rMSSD compared to Tae-Eum type and Tae-Eum type showed higher LFnu and LF/HF compared to So-Eum type based on changes between right after needle insertion at LR3 and LI4 and 1 hour after needle removal [52]; (3) LFnu and LF/HF were increased in So-Yang type and LF/HF was significantly higher in So-Eum type compared to So-Yang type, while LF/HF of Tae-Eum type was in between, after acupuncture stimulation at LI4 only [47].


#### 3.3.5. SCM and HRV after Other Interventions (p < 0.05) (Table 5)

So-Eum type had significantly enhanced HRV (i.e., SDNN) after either a meditation program [37] or an autogenic training program [48]. SDNN (time domain variable) results recorded on short-term HRV, however, may need further validation of reproducibility.Table 5
HRV difference by constitution (p < 0.05), associated with other interventions.
Reference5 [37]10 [42]14 [46]16 [48]18 [50]ConstitutionSCMSCMSCMSCMSCMPopulation78 students47 healthy subjects (29–66)10 TE patients39 patients (20–59)44 healthy subjects (20–30)Subjects by constitution groupnaM (SY = 10, TE = 17, SE = 20, TY = 0)F (SY = 8, TE = 9, SE = 12, TY = 0)TE = 10SY = 9, TE = 12, SE = 18, TY = 0SY = 10, TE = 20 SE = 14, TY = 0Age and gender controlled by constitution groupnaGender, agenanaAgeInterventionMeditation program (α version)Forrest healing program (aroma, foods, tea, trekking)TE herbal formula (Jowisengcheong-tang)Autogenic trainingEmotional stimulus (horror film)HRV baseline difference by constitutionNo differenceNo differencenaNo differenceNo differenceHRV by constitution compared to baseline, associated with other interventionsMHRDecreased in SEDecreased in SYIncreased in SYnaDecreased in TEnamRR (ms)nanaNo differencenaNo differenceSDNN (ms)Increased in SEDecreased in SYNo differenceIncreased in SEIncreased in TENo differencerMSSD (ms)Increased in SENo differenceNo differencenanaLF (ms2)No differenceNo differenceNo differenceNaTE > SY, SEHF (ms2)No differenceNo differenceNo differencenaNo differenceLFnuNo differenceNo differenceNo differenceNo differenceNo differenceHFnuNo differenceNo differenceNo differenceNo differenceNo differenceLn (LF)nananananaLn (HF)nananananaLF/HFNo differenceNo differencenaNo differenceNo differencena, not available; M, male; F, female; SE, Soeumin constitution; SY, Soyangin constitution; TE, Taeumin constitution.


### 3.4. HRV Reporting and Interpretation

#### 3.4.1. Reporting of HRV Measures (Table6)

The number of reported HRV variables varied from more than five (n = 9) to only one (e.g., SDNN or LF/HF) (n = 2). The most frequently reported variable was SDNN (n = 16), and the least was mRR (n = 4). Frequency domain variables were used to describe sympathovagal modulation: LF/HF (n = 14), LF and HF power (n = 12), LFnu and HFnu (n = 11), and natural logarithm (n = 3). Other HRV influencing parameters reported include mean heart rate (n = 13), respiration rate (n = 1), and blood pressure (n = 3).Table 6
Measures of short-term HRV reporting (20 studies).
HRV measures1234567891011121314151617∗∗, ∗181920TotalTime domainmRR (ms)∗✓✓✓✓4SDNN (ms)∗✓✓✓✓✓✓✓NR✓✓✓✓✓✓✓✓16rMSSD (ms)∗✓✓✓✓✓NR✓✓8Frequency domainLF (ms2)∗✓✓✓✓✓✓NR✓✓✓✓✓12HF (ms2)∗✓✓✓✓✓✓NR✓✓✓✓✓12LFnu∗✓✓✓✓✓✓✓✓✓✓✓11HFnu∗✓✓✓✓✓✓✓✓✓✓✓11LF:HF∗✓✓✓✓✓✓✓NR✓✓✓✓✓✓14ln (LF)✓✓✓3ln (HF)✓✓✓3Other measuresMHR (bpm)✓✓✓✓✓✓✓✓✓✓✓✓✓13MRR (BPM)✓1BP (mmHG)✓✓✓3Single vs. multiple Nu/ratioMMMSMMMMMMMSSMSSSMnaMRaw (Y, N)nnyyynyynyyyyyyynynanNR = not reported; na, not applicable; mRR = mean RR interval; SDNN = standard deviation of normal-to-normal intervals; rMSSD = root mean square of successive differences; LF = low-frequency spectral power; HF = high-frequency spectral power; LF : HF = ratio of low-frequency power to high-frequency power; nu = normalized units; ln = natural logarithm; MHR = mean heart rate; MRR = mean respiration rate; BP = blood pressure.∗The approved task force measures of short-term HRV [56,57]; ∗∗, ∗indices from HRV device (nonstandard measures, e.g., stress index and fatigue index).


#### 3.4.2. Normalized Units and Raw Values (Table7)

13 of the 20 studies reported multiple nu/ratios (i.e., HFnu, LFnu, and LF/HF ratio), and this could present potential problems of redundancy and interpretation, especially when the HRV reporting measures provide inconsistent outcomes, as noted in Heathers’ HRV methodology study [32]: for example, if LFnu was significant and LF/HF not, this might be interpreted as a change in sympathetic activity but there is no sympathovagal balance. Some SCM and HRV studies reported redundant [43] or inconsistent results: for example, LFnu increased in So-Yang type, but there is no change in HFnu [47], or HFnu was higher in So-Yang type than Tae-Eum type but there is no difference in LHnu [52]. While the task force recommended that research should always report both raw values and normalized units [56] because the changes in the individual frequency bands may be inconsistent with the reporting of lone normalized HRV values [32], 6 of 20 studies reported normalized units without raw values.Table 7
Reporting raw vs. adjusted values and single vs. multiple normalized ratio units∗.
Raw valuesNo raw valuesSingle nu/ratio unit516Multiple nu/ratio unit8513136n = 19∗Table format [32].


#### 3.4.3. Interpretation of HF, LF, and LF : HF Ratio (Table8)

ECM and SCM studies (n = 14) interpreted HF as reflecting parasympathetic nervous system (PNS) mediated by RSA (Respiratory Sinus Arrhythmia) (n = 7); n = 6 as PNS, and n = 1 as RSA. This mirrors the debate on LF interpretation as a mix of sympathetic and vagal, and baroreceptor activities [58], and the ECM and SCM studies (n = 14) showed a mixed interpretation: baroreceptor activity (n = 1), more SNS than PNS (n = 5), baroreceptor + PNS (n = 1), baroreceptor + SNS + PNS (n = 3), SNS + balance of PNS and SNS (n = 1), and index of SNS (n = 3). Although all the ECM and SCM studies reported LF : HF as an index of sympathovagal balance, a recent consensus suggested lowering its predictive value [58], due to the loose relationship of LF power with sympathetic outflow [32], and the nonlinear and nonreciprocal relationship between SNS and PNS activity [59]. The discrepancy in HRV interpretation is problematic in deriving a conclusive insight on the correlation between constitutions and HRV.Table 8
Various explanations given as the sources of the short-term HRV measures (20 studies).
HRV measuresExplanations12345678∗9101112∗1314∗15161718∗19+20TotalYear20052016201620152014201320132013201220112009200920092008200720072007200720062004LFSNS✓✓✓314SNS > PNS✓✓✓✓✓5SNS, BAL✓1BAR, SNS, PNS✓✓✓3BAR, PNS✓1BAR✓1HFRSA, PNS✓✓✓✓✓✓✓714PNS✓✓✓✓✓✓6RSA✓1LF : HFBAL✓✓✓✓✓✓✓✓✓✓1010BAR, the activity of Baroreflex; PNS, parasympathetic nervous system; SNS, sympathetic nervous system; RSA, respiratory sinus arrhythmia; BAL, a balance of sympathetic and parasympathetic influences.∗Explanation on HRV measures not reported; +not applicable.


#### 3.4.4. Extraneous Factors Controlled for HRV (Table9)

In general, some population variables (i.e., age, health condition, and medication) of ECM and SCM studies (n = 20) were well controlled (n = 14), but gender (n = 9) was relatively less controlled. Several procedure- and environment-related variables were frequently controlled (i.e., posture, resting, circadian rhythm, caffeinated drinks, alcohol, room lighting, or noise), with others less frequently controlled (i.e., smoking, wakefulness or talk, food, physical exercise, and temperature), and some not at all (i.e., bladder filling and stress level).Table 9
Extraneous factors controlled for HRV (20 studies).
Extraneous factors12345∗678910∗11∗121314151617181920TotalStudy populationAge✓✓✓✓✓✓✓✓✓✓✓✓✓13Gender✓✓✓✓✓✓✓7Health condition✓✓✓✓✓✓✓✓∗∗✓✓✓✓✓✓✓✓16Medication✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓15BMI✓✓✓✓4Sample size423260787816663847665201031030398498448619Study procedurePosture✓1✓1✓2✓3✓1✓1✓1✓1✓3✓1✓1✓1✓1✓3✓1✓16Resting✓a✓bNANA✓b✓b✓b✓b✓b✓b✓c✓a✓d✓a✓b13Circadian rhythm✓✓✓✓✓✓✓✓✓✓10Wakefulness, talk✓✓✓✓✓✓✓7Caffeinated drinks✓✓✓✓✓✓✓✓✓✓10Alcohol✓✓✓✓✓✓✓✓✓✓10Smoking✓✓✓✓✓✓✓7Food✓✓✓✓✓✓6Bladder filling0Physical exercise✓✓✓3Stress level0Study environmentLight✓✓✓✓✓✓✓✓✓9Noise✓✓✓✓✓✓✓✓✓✓✓✓✓13Temperature✓✓2Factors total = 19129101001214714168571381887NA, not applicable;a10 min resting before HRV; b5 min resting before HRV; cresting time not available; d1 min resting before HRV; 1supine; 2sitting and standing; 3sitting; ∗information on HRV control factors not available; ∗∗menstruation factor controlled; +multivariated adjusted odds ratio analysis (age, gender, BMI, alcohol drinking status, smoking status, health condition, metabolic syndrome, marital status, and education level); 9 am to 4 pm (wide range).


### 3.5. Classification of Constitutions

An ECM study [33] used pulse diagnosis with an intrarater reliability test (Kappa index 0.83%). SCM studies used QSCCII (Questionnaire for Sasang Constitution Classification) (n = 9), practitioner diagnosis based on SCAT (i.e., Sasang Constitution Analysis Tool including facial, voice, body, and QSCCII) (n = 6), practitioner diagnosis based on QSCCII (n = 4), and practitioner only diagnosis (n = 2).


## 3.1. Review Process

From the 386 total records obtained from database search (n = 384) and manual searches (n = 2), full-text articles of n = 36 were obtained after excluding duplicated papers (n = 60) and nonrelevant papers or unavailable articles (n = 290). The articles (n = 36) were further reviewed against the inclusion criteria (i.e., short-term recordings of HRV) for Korean Constitutional Medicine (Eight Constitution or Sasang Constitution). A further 16 articles were excluded, leaving n = 20 papers for critical review. Of these, one was an ECM article, and the others were SCM studies (n = 19). The review process is presented in Figure 2.Figure 2
Systematic review process.


## 3.2. Study Characteristics (Table1)

### 3.2.1. Demographic Characteristics

Sample sizes varied from 10 to 8498 men and women, with an age range of 10 to 80 years. 13 out of 20 studies were in healthy subjects, and the rest were either patient populations or medical information not being available.Table 1
Summary of studies investigating the correlation between Heart Rate Variability and Korean Constitution Medicine (ECM or SCM).
ReferenceNo.MedicinePopulation (age range)Autonomic stimulusDuration and HRV measuresOther measures[33]1ECM42 patients (14–73)Eight-constitution acupuncture5 min, frequency domainBMI[34]2SCM32 healthy students (20–30)Paced breathing in specific respiration rate5 min, time and frequency domainRespiration rate[35]3SCM60 healthy students (20–30)Ratio of inhalation and exhalation, posture (sitting, standing)Time and frequency domainSelf-evaluation for physical condition (scale 10 cm)[36]4SCM78 healthy students (20–30)Breath-counting meditation5 min, time and frequency domainSkin conductance, temperature, abdominal amplitude, thoracic amplitude[37]5SCM78 studentsMeditation program (α version)Time and frequency domainBDI (depression), STAXI (anger), STAI (anxiety) questionnaires[38]6SCM16 healthy TE constitution (20–60)Taegeuk acupuncture5 min, frequency domainNone[39]7SCM6 healthy SE constitution men (20–30)Taegeuk acupuncture5 min, frequency domainNone[40]8SCM63 fatigue and nonfatigue subjects (40–60)None5 min, time and frequency domainBMI, biochemistry analysis, pulse wave analysis, nail fold capillary microscopy, questionnaires (FSS, GSRS, SF-MPQ, PSQI, SF-12)[41]9SCM8 healthy SY constitution women (20–30)Taegeuk acupuncture5 min, frequency domainNone[42]10SCM47 healthy subjects (29–66)Forrest healing program (aroma, foods, tea by constitution + trekking)5 min, time and frequency domainBMI, body temperature, vital sign (BP, SpO2), electroencephalography, biochemistry analysis, blood cell count, stress hormone test[43]11SCM665 subjects (39–72)None5 min, time and frequency domainBMI, BP, fasting blood sugar, cholesterol, abdominal obesity[44]12SCM20 healthy subjects (18–30)Bee venom acupuncture5 min, time and frequency domainPulse wave analysis, cerebral blood flow[45]13SCM103 idiopathic facial palsy patients (10–79)None5 min, time and frequency domainFacial electromyography[46]14SCM10 TE constitution patientsHerbal formula for TE constitution (Jowisengcheong-tang)5 min, time and frequency domainNone[47]15SCM30 healthy men (20–26)Acupuncture at LI45 min, time and frequency domainNone[48]16SCM39 patients (20–59)Autogenic training5 min, time and frequency domainMBTI questionnaire (extraversion, introversion)[49]17SCM8498 workersNone5 min, time and frequency domainNone[50]18SCM44 healthy subjects (20–30)Emotional stimulus (horror film)120 sec, 197 sec, 120 sec, time and frequency domainNone[51]19SCM86 subjects (22–25)Electroacupuncture30 sec, time domain (SDNN)None[52]20SCM19 healthy subjectsAcupuncture at LI4 and LR35 min, time and frequency domainBP, BMIECM, Eight-Constitution Medicine; SCM, Sasang Constitution Medicine; CM, Constitution Medicine; HRV, Heart Rate Variability; MHR, mean heart rate; BMI, body mass index; TE, Taeumin constitution; SY, Soyangin constitution; FSS, Fatigue Severity Scale; GSRS, Gastrointestinal Symptom Rating Scale; SF-MPQ, Short-Form McGill Pain Questionnaire; PSQI, Pittsburgh Sleep Quality Index; SF-12, Short-Form Health Survey; BP, blood pressure; SpO2, peripheral capillary oxygen saturation; APG, Accelerated Plethysmogram; MBTI, Myers–Briggs Type Indicator.


### 3.2.2. Study Intervention

To explore constitutional differences, the studies measured HRV at resting level [40, 43, 45, 53] with paced breathing [34, 36, 54], after acupuncture stimulation [38, 39, 41, 44, 47, 51, 52], or other interventions such as meditation [37], forest healing program [42], autogenic training [48], emotional stimulus [50], and constitutional herbal formula [46].


### 3.2.3. HRV Analysis and Devices

HRV analysis studies varied: time and frequency domain (n = 15), frequency domain only (n = 4), and time domain only (n = 1). All studies used commercial HRV medical devices of ECG (n = 16), PPG (n = 2), or IBI (n = 2).


## 3.2.1. Demographic Characteristics

Sample sizes varied from 10 to 8498 men and women, with an age range of 10 to 80 years. 13 out of 20 studies were in healthy subjects, and the rest were either patient populations or medical information not being available.Table 1
Summary of studies investigating the correlation between Heart Rate Variability and Korean Constitution Medicine (ECM or SCM).
ReferenceNo.MedicinePopulation (age range)Autonomic stimulusDuration and HRV measuresOther measures[33]1ECM42 patients (14–73)Eight-constitution acupuncture5 min, frequency domainBMI[34]2SCM32 healthy students (20–30)Paced breathing in specific respiration rate5 min, time and frequency domainRespiration rate[35]3SCM60 healthy students (20–30)Ratio of inhalation and exhalation, posture (sitting, standing)Time and frequency domainSelf-evaluation for physical condition (scale 10 cm)[36]4SCM78 healthy students (20–30)Breath-counting meditation5 min, time and frequency domainSkin conductance, temperature, abdominal amplitude, thoracic amplitude[37]5SCM78 studentsMeditation program (α version)Time and frequency domainBDI (depression), STAXI (anger), STAI (anxiety) questionnaires[38]6SCM16 healthy TE constitution (20–60)Taegeuk acupuncture5 min, frequency domainNone[39]7SCM6 healthy SE constitution men (20–30)Taegeuk acupuncture5 min, frequency domainNone[40]8SCM63 fatigue and nonfatigue subjects (40–60)None5 min, time and frequency domainBMI, biochemistry analysis, pulse wave analysis, nail fold capillary microscopy, questionnaires (FSS, GSRS, SF-MPQ, PSQI, SF-12)[41]9SCM8 healthy SY constitution women (20–30)Taegeuk acupuncture5 min, frequency domainNone[42]10SCM47 healthy subjects (29–66)Forrest healing program (aroma, foods, tea by constitution + trekking)5 min, time and frequency domainBMI, body temperature, vital sign (BP, SpO2), electroencephalography, biochemistry analysis, blood cell count, stress hormone test[43]11SCM665 subjects (39–72)None5 min, time and frequency domainBMI, BP, fasting blood sugar, cholesterol, abdominal obesity[44]12SCM20 healthy subjects (18–30)Bee venom acupuncture5 min, time and frequency domainPulse wave analysis, cerebral blood flow[45]13SCM103 idiopathic facial palsy patients (10–79)None5 min, time and frequency domainFacial electromyography[46]14SCM10 TE constitution patientsHerbal formula for TE constitution (Jowisengcheong-tang)5 min, time and frequency domainNone[47]15SCM30 healthy men (20–26)Acupuncture at LI45 min, time and frequency domainNone[48]16SCM39 patients (20–59)Autogenic training5 min, time and frequency domainMBTI questionnaire (extraversion, introversion)[49]17SCM8498 workersNone5 min, time and frequency domainNone[50]18SCM44 healthy subjects (20–30)Emotional stimulus (horror film)120 sec, 197 sec, 120 sec, time and frequency domainNone[51]19SCM86 subjects (22–25)Electroacupuncture30 sec, time domain (SDNN)None[52]20SCM19 healthy subjectsAcupuncture at LI4 and LR35 min, time and frequency domainBP, BMIECM, Eight-Constitution Medicine; SCM, Sasang Constitution Medicine; CM, Constitution Medicine; HRV, Heart Rate Variability; MHR, mean heart rate; BMI, body mass index; TE, Taeumin constitution; SY, Soyangin constitution; FSS, Fatigue Severity Scale; GSRS, Gastrointestinal Symptom Rating Scale; SF-MPQ, Short-Form McGill Pain Questionnaire; PSQI, Pittsburgh Sleep Quality Index; SF-12, Short-Form Health Survey; BP, blood pressure; SpO2, peripheral capillary oxygen saturation; APG, Accelerated Plethysmogram; MBTI, Myers–Briggs Type Indicator.


## 3.2.2. Study Intervention

To explore constitutional differences, the studies measured HRV at resting level [40, 43, 45, 53] with paced breathing [34, 36, 54], after acupuncture stimulation [38, 39, 41, 44, 47, 51, 52], or other interventions such as meditation [37], forest healing program [42], autogenic training [48], emotional stimulus [50], and constitutional herbal formula [46].


## 3.2.3. HRV Analysis and Devices

HRV analysis studies varied: time and frequency domain (n = 15), frequency domain only (n = 4), and time domain only (n = 1). All studies used commercial HRV medical devices of ECG (n = 16), PPG (n = 2), or IBI (n = 2).


## 3.3. Correlation between HRV and Constitution

### 3.3.1. ECM and HRV at Resting and after Acupuncture Stimulation (p < 0.05) (Table 2)

A single ECM study [33] measured HRV baseline at resting and after constitutional acupuncture (i.e., a predefined acupuncture formula for a specific constitution) stimulation but reported no significant differences between the two groups of Sympathicotonia and Vagotonia. The study had a small sample size (42 patients), wide age range (14–73 yr), uncontrolled gender factors, and a short observation period after acupuncture.Table 2
HRV difference by constitution (p < 0.05), before and after acupuncture stimulation.
Reference1 [33]6 [38]9 [41]7 [39]12 [44]15 [47]19 [51]20 [52]ConstitutionECMSCMSCMSCMSCMSCMSCMSCMPopulation (range)42 patients (14–73)16 healthy TE constitution (20–60)8 healthy SY constitution women (20–30)6 healthy SE constitutionmen (20–30)20 healthy subjects (18–30)30 healthy men (20–26)86 subjects (22–25)19 healthy subjectsSubjects by constitution groupSympathicotonia = 22 (Pul, Col, Ren, Ves) Vagotonia = 20 (Hep, Cho, Pan, Gas)TE = 16SY = 8SE = 6SY = 5, TE = 8, SE = 7, TY = 0SY = 8, TE = 13, SE = 9, TY = 0SY = 34, TE = 27, SE = 25, TY = 0SY = 6, TE = 7, SE = 6, TY = 0Age and gender controlled by constitution groupnanaAge, genderAge, genderAgeAge, genderAge, genderAge, genderAcupunctureEight-constitution acupunctureTaegeuk acupuncture (TE)Taegeuk acupuncture (SY)Taegeuk acupuncture (SE)Bee venom acupunctureAcupuncture at LI4ElectroacupunctureAcupuncture at LI4 and LR3HRV baseline difference by constitutionNo differenceNANANANo differenceLow in TE (LF/HF)naNo differenceHRV by constitution compared to baseline, after acupunctureMHRNo differencenanananaNo differencenaTE > SY, SEmRR (ms)nananananananaSDNN (ms)nanananaNo differenceNo differenceSY > TE (passive)TE > SY (active) SY > SE (general)rMSSD (ms)nanananaNo differencenanaSE > TE∗LF (ms2)nananaNo differenceNo differenceNo differencenaHF (ms2)nananaNo differenceNo differenceNo differencenaLFnunaDecreased in TEDecreased in SYNo differencenaIncreased in SYnaTE > SE∗HFnunaIncreased in TEIncreased in SYNo differencenananaSE, SY > TE∗Ln (LF)No differencenanananananaLn (HF)No differencenanananananaLF/HFNo differencenanaNo differenceNo differenceIncreased in SYSE > SYnaTE > SE∗ECM, Eight-Constitution Medicine; SCM, Sasang Constitution Medicine; Pul, Pulmotonia constitution; Col, Colonotonia constitution; Ren, Renotonia constitution; Ves, Vesicotonia constitution; Hep, Hepatonia constitution; Cho, Cholecystonia constitution; Pan, Pancreotonia constitution; Gas, Gastrotonia constitution; TE, Taeumin constitution; SY, Soyangin constitution; SE, Soeumin constitution; TY, Taeyangin constitution; MHR, Mean Heart Rate; na, not available; NA, not applicable.∗Compared to right after needle insertion vs. 1 hour after needle removal.


### 3.3.2. SCM and HRV at Resting (p < 0.05) (Table 3)

None of the SCM studies reported significant differences in HF at resting between constitutions. Two relatively well-controlled SCM studies indicated Tae-Eum constitution (with characteristics of increased parasympathetic reactivity) showed a lower LF/HF ratio than the So-Yang constitution (with both parasympathetic and sympathetic reactivity) at resting condition (p < 0.05) [43, 47, 55].Table 3
HRV difference by constitution (p < 0.05), at resting.
Reference8 [40]11 [43]113 [45]17 [53]215 [47]ConstitutionSCMSCMSCMSCMSCMPopulation (age)63 fatigue and nonfatigue subjects (40–60)665 subjects (39–72)103 idiopathic facial palsy patients (10–79)8498 workers30 healthy men (20–26)Subjects by constitution groupFatigue:Total:SY = 25 (M 7, F 18)SY 4270SY = 8, TE = 13,SY = 10, TE = 8,SY = 100, TE = 363,TE = 54 (M 27, F27)TE 2331SE = 9, TY = 0SE = 14, TY = 0SE = 202, TY = 0SE = 24 (M 8, F 16)SE 1897Nonfatigue:Female <60 yrsTY (0)TY (0)SY = 15, TE = 7,SY = 36, TE = 140,SE = 9, TY = 0SE = 68, TY = 0Age and gender controlled by constitution groupAgeAge, gender (female < 60 yrs)naGenderAge, genderType of studyCross-sectional study (2012)Cross-sectional study (Genomic cohort 2006)Medical record retrospective review (2008–2009)Health examination 2005Acupuncture at LI4MHRnaNo differenceNo differenceNo differenceNo differencemRR (ms)nananananaSDNN (ms)No differenceNo differenceNo differenceSE > TENo differencerMSSD (ms)No differencenanananaLF (ms2)No differencenaNo differencenaNo differenceHF (ms2)No differencenaNo differencenaNo differenceLFnuNo differenceSY > TE (all) SY > TE, SE (female, below 60 years)nananaHFnuNo differenceTE > SY (all) TE, SE > SY (female, below 60 years)nananaLn (LF)naNonananaLn (HF)naNonananaLF/HFNo differenceSY > TESY > TE, SE (female, below 60 years)SY, TE > SENo differenceLow in TESY, Soyangin constitution; TE, Taeumin constitution; SE, Soeumin constitution; M, male; F, female; na, not available.1Multivariated adjusted odds ratio HRV analysis. The odds ratio adjusted for age, gender, education period, marital status, drinking status, smoking status, past history (hypertension, diabetes mellitus, and hyperlipidemia), BMI, and metabolic syndrome. 2HRV reporting generated indices (stress index, fatigue index) and TP showed a significant difference between constitution groups.


### 3.3.3. SCM and HRV with Controlled Breathing (p < 0.05) (Table 4)

Three SCM studies explored the effects of different breathing approaches on constitutions by measuring HRV: breath-counting meditation [36], paced breathing (3, 6, or 12 times per min) [34], and the ratio of inhalation and exhalation (4 : 6 and 6 : 4, respectively) with posture changes [35], but HRV measures from both baseline and controlled breathing showed no difference between constitutions.Table 4
HRV difference by constitution (p < 0.05), controlled breathing.
Reference4 [36]2 [34]3 [35]ConstitutionSCMSCMSCMPopulation (age)78 healthy students (20–30)32 healthy students (20–30)60 healthy students (20–30)Subjects by constitution groupSY = 13, TE = 30, SE = 35, TY = 0SY = 10, TE = 11, SE = 11, TY = 0SY = 18, TE = 18, SE = 24, TY = 0Age and gender controlled by constitution groupAgeAgeAgeHRV baseline difference by constitutionMHR : SY, SE > TENo differenceNo differenceHRV by constitution compared to baseline, with paced breathingBreath-counting on inspiration and expiration (not controlling)Paced breathing: 12, 6, or 3 times per minRatio of inhalation and exhalation (4 : 6, 6 : 4)MHRCIB : SE > TECEB : SE, SY > TENo differenceNo differencemRR (ms)naNo differenceNo differenceSDNN (ms)No differenceNo differenceNo differencerMSSD (ms)naNo differenceNo differenceLF (ms2)No differencenaNo differenceHF (ms2)No differencenaNo differenceLFnunanaNo differenceHFnunanaNo differenceLn (LF)naNo differencenaLn (HF)naNo differencenaLF/HFNo differencenanana, not available; CIB, Counting on Inspiration; CEB, Counting on Expiration.


### 3.3.4. SCM and HRV after Acupuncture Stimulation (p < 0.05) (Table 2)

5 out of 7 SCM acupuncture studies reported some HRV differences between constitutions. Two within-subject studies [38,41] reported that Taegeuk acupuncture stimulation (i.e., a predefined acupuncture formula for a specific constitution) resulted in a significant increase in HFnu in both the Tae-Eum and So-Yang type compared to a resting or stress condition, indicating a relative increase in cardiac vagal modulation. Three between-subject studies based on different acupuncture stimulation methods reported different HRV measures or conflicting data: (1) So-Yang type showed higher SDNN than So-Eum type and Tae-Eum type during passive coping conditions (i.e., enduring pain passively) and the opposite during active coping condition (i.e., pain stimulation will stop when signaling) when pain is induced by electroacupuncture [51]; (2) So-Eum type showed higher rMSSD compared to Tae-Eum type and Tae-Eum type showed higher LFnu and LF/HF compared to So-Eum type based on changes between right after needle insertion at LR3 and LI4 and 1 hour after needle removal [52]; (3) LFnu and LF/HF were increased in So-Yang type and LF/HF was significantly higher in So-Eum type compared to So-Yang type, while LF/HF of Tae-Eum type was in between, after acupuncture stimulation at LI4 only [47].


### 3.3.5. SCM and HRV after Other Interventions (p < 0.05) (Table 5)

So-Eum type had significantly enhanced HRV (i.e., SDNN) after either a meditation program [37] or an autogenic training program [48]. SDNN (time domain variable) results recorded on short-term HRV, however, may need further validation of reproducibility.Table 5
HRV difference by constitution (p < 0.05), associated with other interventions.
Reference5 [37]10 [42]14 [46]16 [48]18 [50]ConstitutionSCMSCMSCMSCMSCMPopulation78 students47 healthy subjects (29–66)10 TE patients39 patients (20–59)44 healthy subjects (20–30)Subjects by constitution groupnaM (SY = 10, TE = 17, SE = 20, TY = 0)F (SY = 8, TE = 9, SE = 12, TY = 0)TE = 10SY = 9, TE = 12, SE = 18, TY = 0SY = 10, TE = 20 SE = 14, TY = 0Age and gender controlled by constitution groupnaGender, agenanaAgeInterventionMeditation program (α version)Forrest healing program (aroma, foods, tea, trekking)TE herbal formula (Jowisengcheong-tang)Autogenic trainingEmotional stimulus (horror film)HRV baseline difference by constitutionNo differenceNo differencenaNo differenceNo differenceHRV by constitution compared to baseline, associated with other interventionsMHRDecreased in SEDecreased in SYIncreased in SYnaDecreased in TEnamRR (ms)nanaNo differencenaNo differenceSDNN (ms)Increased in SEDecreased in SYNo differenceIncreased in SEIncreased in TENo differencerMSSD (ms)Increased in SENo differenceNo differencenanaLF (ms2)No differenceNo differenceNo differenceNaTE > SY, SEHF (ms2)No differenceNo differenceNo differencenaNo differenceLFnuNo differenceNo differenceNo differenceNo differenceNo differenceHFnuNo differenceNo differenceNo differenceNo differenceNo differenceLn (LF)nananananaLn (HF)nananananaLF/HFNo differenceNo differencenaNo differenceNo differencena, not available; M, male; F, female; SE, Soeumin constitution; SY, Soyangin constitution; TE, Taeumin constitution.


## 3.3.1. ECM and HRV at Resting and after Acupuncture Stimulation (p < 0.05) (Table 2)

A single ECM study [33] measured HRV baseline at resting and after constitutional acupuncture (i.e., a predefined acupuncture formula for a specific constitution) stimulation but reported no significant differences between the two groups of Sympathicotonia and Vagotonia. The study had a small sample size (42 patients), wide age range (14–73 yr), uncontrolled gender factors, and a short observation period after acupuncture.Table 2
HRV difference by constitution (p < 0.05), before and after acupuncture stimulation.
Reference1 [33]6 [38]9 [41]7 [39]12 [44]15 [47]19 [51]20 [52]ConstitutionECMSCMSCMSCMSCMSCMSCMSCMPopulation (range)42 patients (14–73)16 healthy TE constitution (20–60)8 healthy SY constitution women (20–30)6 healthy SE constitutionmen (20–30)20 healthy subjects (18–30)30 healthy men (20–26)86 subjects (22–25)19 healthy subjectsSubjects by constitution groupSympathicotonia = 22 (Pul, Col, Ren, Ves) Vagotonia = 20 (Hep, Cho, Pan, Gas)TE = 16SY = 8SE = 6SY = 5, TE = 8, SE = 7, TY = 0SY = 8, TE = 13, SE = 9, TY = 0SY = 34, TE = 27, SE = 25, TY = 0SY = 6, TE = 7, SE = 6, TY = 0Age and gender controlled by constitution groupnanaAge, genderAge, genderAgeAge, genderAge, genderAge, genderAcupunctureEight-constitution acupunctureTaegeuk acupuncture (TE)Taegeuk acupuncture (SY)Taegeuk acupuncture (SE)Bee venom acupunctureAcupuncture at LI4ElectroacupunctureAcupuncture at LI4 and LR3HRV baseline difference by constitutionNo differenceNANANANo differenceLow in TE (LF/HF)naNo differenceHRV by constitution compared to baseline, after acupunctureMHRNo differencenanananaNo differencenaTE > SY, SEmRR (ms)nananananananaSDNN (ms)nanananaNo differenceNo differenceSY > TE (passive)TE > SY (active) SY > SE (general)rMSSD (ms)nanananaNo differencenanaSE > TE∗LF (ms2)nananaNo differenceNo differenceNo differencenaHF (ms2)nananaNo differenceNo differenceNo differencenaLFnunaDecreased in TEDecreased in SYNo differencenaIncreased in SYnaTE > SE∗HFnunaIncreased in TEIncreased in SYNo differencenananaSE, SY > TE∗Ln (LF)No differencenanananananaLn (HF)No differencenanananananaLF/HFNo differencenanaNo differenceNo differenceIncreased in SYSE > SYnaTE > SE∗ECM, Eight-Constitution Medicine; SCM, Sasang Constitution Medicine; Pul, Pulmotonia constitution; Col, Colonotonia constitution; Ren, Renotonia constitution; Ves, Vesicotonia constitution; Hep, Hepatonia constitution; Cho, Cholecystonia constitution; Pan, Pancreotonia constitution; Gas, Gastrotonia constitution; TE, Taeumin constitution; SY, Soyangin constitution; SE, Soeumin constitution; TY, Taeyangin constitution; MHR, Mean Heart Rate; na, not available; NA, not applicable.∗Compared to right after needle insertion vs. 1 hour after needle removal.


## 3.3.2. SCM and HRV at Resting (p < 0.05) (Table 3)

None of the SCM studies reported significant differences in HF at resting between constitutions. Two relatively well-controlled SCM studies indicated Tae-Eum constitution (with characteristics of increased parasympathetic reactivity) showed a lower LF/HF ratio than the So-Yang constitution (with both parasympathetic and sympathetic reactivity) at resting condition (p < 0.05) [43, 47, 55].Table 3
HRV difference by constitution (p < 0.05), at resting.
Reference8 [40]11 [43]113 [45]17 [53]215 [47]ConstitutionSCMSCMSCMSCMSCMPopulation (age)63 fatigue and nonfatigue subjects (40–60)665 subjects (39–72)103 idiopathic facial palsy patients (10–79)8498 workers30 healthy men (20–26)Subjects by constitution groupFatigue:Total:SY = 25 (M 7, F 18)SY 4270SY = 8, TE = 13,SY = 10, TE = 8,SY = 100, TE = 363,TE = 54 (M 27, F27)TE 2331SE = 9, TY = 0SE = 14, TY = 0SE = 202, TY = 0SE = 24 (M 8, F 16)SE 1897Nonfatigue:Female <60 yrsTY (0)TY (0)SY = 15, TE = 7,SY = 36, TE = 140,SE = 9, TY = 0SE = 68, TY = 0Age and gender controlled by constitution groupAgeAge, gender (female < 60 yrs)naGenderAge, genderType of studyCross-sectional study (2012)Cross-sectional study (Genomic cohort 2006)Medical record retrospective review (2008–2009)Health examination 2005Acupuncture at LI4MHRnaNo differenceNo differenceNo differenceNo differencemRR (ms)nananananaSDNN (ms)No differenceNo differenceNo differenceSE > TENo differencerMSSD (ms)No differencenanananaLF (ms2)No differencenaNo differencenaNo differenceHF (ms2)No differencenaNo differencenaNo differenceLFnuNo differenceSY > TE (all) SY > TE, SE (female, below 60 years)nananaHFnuNo differenceTE > SY (all) TE, SE > SY (female, below 60 years)nananaLn (LF)naNonananaLn (HF)naNonananaLF/HFNo differenceSY > TESY > TE, SE (female, below 60 years)SY, TE > SENo differenceLow in TESY, Soyangin constitution; TE, Taeumin constitution; SE, Soeumin constitution; M, male; F, female; na, not available.1Multivariated adjusted odds ratio HRV analysis. The odds ratio adjusted for age, gender, education period, marital status, drinking status, smoking status, past history (hypertension, diabetes mellitus, and hyperlipidemia), BMI, and metabolic syndrome. 2HRV reporting generated indices (stress index, fatigue index) and TP showed a significant difference between constitution groups.


## 3.3.3. SCM and HRV with Controlled Breathing (p < 0.05) (Table 4)

Three SCM studies explored the effects of different breathing approaches on constitutions by measuring HRV: breath-counting meditation [36], paced breathing (3, 6, or 12 times per min) [34], and the ratio of inhalation and exhalation (4 : 6 and 6 : 4, respectively) with posture changes [35], but HRV measures from both baseline and controlled breathing showed no difference between constitutions.Table 4
HRV difference by constitution (p < 0.05), controlled breathing.
Reference4 [36]2 [34]3 [35]ConstitutionSCMSCMSCMPopulation (age)78 healthy students (20–30)32 healthy students (20–30)60 healthy students (20–30)Subjects by constitution groupSY = 13, TE = 30, SE = 35, TY = 0SY = 10, TE = 11, SE = 11, TY = 0SY = 18, TE = 18, SE = 24, TY = 0Age and gender controlled by constitution groupAgeAgeAgeHRV baseline difference by constitutionMHR : SY, SE > TENo differenceNo differenceHRV by constitution compared to baseline, with paced breathingBreath-counting on inspiration and expiration (not controlling)Paced breathing: 12, 6, or 3 times per minRatio of inhalation and exhalation (4 : 6, 6 : 4)MHRCIB : SE > TECEB : SE, SY > TENo differenceNo differencemRR (ms)naNo differenceNo differenceSDNN (ms)No differenceNo differenceNo differencerMSSD (ms)naNo differenceNo differenceLF (ms2)No differencenaNo differenceHF (ms2)No differencenaNo differenceLFnunanaNo differenceHFnunanaNo differenceLn (LF)naNo differencenaLn (HF)naNo differencenaLF/HFNo differencenanana, not available; CIB, Counting on Inspiration; CEB, Counting on Expiration.


## 3.3.4. SCM and HRV after Acupuncture Stimulation (p < 0.05) (Table 2)

5 out of 7 SCM acupuncture studies reported some HRV differences between constitutions. Two within-subject studies [38,41] reported that Taegeuk acupuncture stimulation (i.e., a predefined acupuncture formula for a specific constitution) resulted in a significant increase in HFnu in both the Tae-Eum and So-Yang type compared to a resting or stress condition, indicating a relative increase in cardiac vagal modulation. Three between-subject studies based on different acupuncture stimulation methods reported different HRV measures or conflicting data: (1) So-Yang type showed higher SDNN than So-Eum type and Tae-Eum type during passive coping conditions (i.e., enduring pain passively) and the opposite during active coping condition (i.e., pain stimulation will stop when signaling) when pain is induced by electroacupuncture [51]; (2) So-Eum type showed higher rMSSD compared to Tae-Eum type and Tae-Eum type showed higher LFnu and LF/HF compared to So-Eum type based on changes between right after needle insertion at LR3 and LI4 and 1 hour after needle removal [52]; (3) LFnu and LF/HF were increased in So-Yang type and LF/HF was significantly higher in So-Eum type compared to So-Yang type, while LF/HF of Tae-Eum type was in between, after acupuncture stimulation at LI4 only [47].


## 3.3.5. SCM and HRV after Other Interventions (p < 0.05) (Table 5)

So-Eum type had significantly enhanced HRV (i.e., SDNN) after either a meditation program [37] or an autogenic training program [48]. SDNN (time domain variable) results recorded on short-term HRV, however, may need further validation of reproducibility.Table 5
HRV difference by constitution (p < 0.05), associated with other interventions.
Reference5 [37]10 [42]14 [46]16 [48]18 [50]ConstitutionSCMSCMSCMSCMSCMPopulation78 students47 healthy subjects (29–66)10 TE patients39 patients (20–59)44 healthy subjects (20–30)Subjects by constitution groupnaM (SY = 10, TE = 17, SE = 20, TY = 0)F (SY = 8, TE = 9, SE = 12, TY = 0)TE = 10SY = 9, TE = 12, SE = 18, TY = 0SY = 10, TE = 20 SE = 14, TY = 0Age and gender controlled by constitution groupnaGender, agenanaAgeInterventionMeditation program (α version)Forrest healing program (aroma, foods, tea, trekking)TE herbal formula (Jowisengcheong-tang)Autogenic trainingEmotional stimulus (horror film)HRV baseline difference by constitutionNo differenceNo differencenaNo differenceNo differenceHRV by constitution compared to baseline, associated with other interventionsMHRDecreased in SEDecreased in SYIncreased in SYnaDecreased in TEnamRR (ms)nanaNo differencenaNo differenceSDNN (ms)Increased in SEDecreased in SYNo differenceIncreased in SEIncreased in TENo differencerMSSD (ms)Increased in SENo differenceNo differencenanaLF (ms2)No differenceNo differenceNo differenceNaTE > SY, SEHF (ms2)No differenceNo differenceNo differencenaNo differenceLFnuNo differenceNo differenceNo differenceNo differenceNo differenceHFnuNo differenceNo differenceNo differenceNo differenceNo differenceLn (LF)nananananaLn (HF)nananananaLF/HFNo differenceNo differencenaNo differenceNo differencena, not available; M, male; F, female; SE, Soeumin constitution; SY, Soyangin constitution; TE, Taeumin constitution.


## 3.4. HRV Reporting and Interpretation

### 3.4.1. Reporting of HRV Measures (Table6)

The number of reported HRV variables varied from more than five (n = 9) to only one (e.g., SDNN or LF/HF) (n = 2). The most frequently reported variable was SDNN (n = 16), and the least was mRR (n = 4). Frequency domain variables were used to describe sympathovagal modulation: LF/HF (n = 14), LF and HF power (n = 12), LFnu and HFnu (n = 11), and natural logarithm (n = 3). Other HRV influencing parameters reported include mean heart rate (n = 13), respiration rate (n = 1), and blood pressure (n = 3).Table 6
Measures of short-term HRV reporting (20 studies).
HRV measures1234567891011121314151617∗∗, ∗181920TotalTime domainmRR (ms)∗✓✓✓✓4SDNN (ms)∗✓✓✓✓✓✓✓NR✓✓✓✓✓✓✓✓16rMSSD (ms)∗✓✓✓✓✓NR✓✓8Frequency domainLF (ms2)∗✓✓✓✓✓✓NR✓✓✓✓✓12HF (ms2)∗✓✓✓✓✓✓NR✓✓✓✓✓12LFnu∗✓✓✓✓✓✓✓✓✓✓✓11HFnu∗✓✓✓✓✓✓✓✓✓✓✓11LF:HF∗✓✓✓✓✓✓✓NR✓✓✓✓✓✓14ln (LF)✓✓✓3ln (HF)✓✓✓3Other measuresMHR (bpm)✓✓✓✓✓✓✓✓✓✓✓✓✓13MRR (BPM)✓1BP (mmHG)✓✓✓3Single vs. multiple Nu/ratioMMMSMMMMMMMSSMSSSMnaMRaw (Y, N)nnyyynyynyyyyyyynynanNR = not reported; na, not applicable; mRR = mean RR interval; SDNN = standard deviation of normal-to-normal intervals; rMSSD = root mean square of successive differences; LF = low-frequency spectral power; HF = high-frequency spectral power; LF : HF = ratio of low-frequency power to high-frequency power; nu = normalized units; ln = natural logarithm; MHR = mean heart rate; MRR = mean respiration rate; BP = blood pressure.∗The approved task force measures of short-term HRV [56,57]; ∗∗, ∗indices from HRV device (nonstandard measures, e.g., stress index and fatigue index).


### 3.4.2. Normalized Units and Raw Values (Table7)

13 of the 20 studies reported multiple nu/ratios (i.e., HFnu, LFnu, and LF/HF ratio), and this could present potential problems of redundancy and interpretation, especially when the HRV reporting measures provide inconsistent outcomes, as noted in Heathers’ HRV methodology study [32]: for example, if LFnu was significant and LF/HF not, this might be interpreted as a change in sympathetic activity but there is no sympathovagal balance. Some SCM and HRV studies reported redundant [43] or inconsistent results: for example, LFnu increased in So-Yang type, but there is no change in HFnu [47], or HFnu was higher in So-Yang type than Tae-Eum type but there is no difference in LHnu [52]. While the task force recommended that research should always report both raw values and normalized units [56] because the changes in the individual frequency bands may be inconsistent with the reporting of lone normalized HRV values [32], 6 of 20 studies reported normalized units without raw values.Table 7
Reporting raw vs. adjusted values and single vs. multiple normalized ratio units∗.
Raw valuesNo raw valuesSingle nu/ratio unit516Multiple nu/ratio unit8513136n = 19∗Table format [32].


### 3.4.3. Interpretation of HF, LF, and LF : HF Ratio (Table8)

ECM and SCM studies (n = 14) interpreted HF as reflecting parasympathetic nervous system (PNS) mediated by RSA (Respiratory Sinus Arrhythmia) (n = 7); n = 6 as PNS, and n = 1 as RSA. This mirrors the debate on LF interpretation as a mix of sympathetic and vagal, and baroreceptor activities [58], and the ECM and SCM studies (n = 14) showed a mixed interpretation: baroreceptor activity (n = 1), more SNS than PNS (n = 5), baroreceptor + PNS (n = 1), baroreceptor + SNS + PNS (n = 3), SNS + balance of PNS and SNS (n = 1), and index of SNS (n = 3). Although all the ECM and SCM studies reported LF : HF as an index of sympathovagal balance, a recent consensus suggested lowering its predictive value [58], due to the loose relationship of LF power with sympathetic outflow [32], and the nonlinear and nonreciprocal relationship between SNS and PNS activity [59]. The discrepancy in HRV interpretation is problematic in deriving a conclusive insight on the correlation between constitutions and HRV.Table 8
Various explanations given as the sources of the short-term HRV measures (20 studies).
HRV measuresExplanations12345678∗9101112∗1314∗15161718∗19+20TotalYear20052016201620152014201320132013201220112009200920092008200720072007200720062004LFSNS✓✓✓314SNS > PNS✓✓✓✓✓5SNS, BAL✓1BAR, SNS, PNS✓✓✓3BAR, PNS✓1BAR✓1HFRSA, PNS✓✓✓✓✓✓✓714PNS✓✓✓✓✓✓6RSA✓1LF : HFBAL✓✓✓✓✓✓✓✓✓✓1010BAR, the activity of Baroreflex; PNS, parasympathetic nervous system; SNS, sympathetic nervous system; RSA, respiratory sinus arrhythmia; BAL, a balance of sympathetic and parasympathetic influences.∗Explanation on HRV measures not reported; +not applicable.


### 3.4.4. Extraneous Factors Controlled for HRV (Table9)

In general, some population variables (i.e., age, health condition, and medication) of ECM and SCM studies (n = 20) were well controlled (n = 14), but gender (n = 9) was relatively less controlled. Several procedure- and environment-related variables were frequently controlled (i.e., posture, resting, circadian rhythm, caffeinated drinks, alcohol, room lighting, or noise), with others less frequently controlled (i.e., smoking, wakefulness or talk, food, physical exercise, and temperature), and some not at all (i.e., bladder filling and stress level).Table 9
Extraneous factors controlled for HRV (20 studies).
Extraneous factors12345∗678910∗11∗121314151617181920TotalStudy populationAge✓✓✓✓✓✓✓✓✓✓✓✓✓13Gender✓✓✓✓✓✓✓7Health condition✓✓✓✓✓✓✓✓∗∗✓✓✓✓✓✓✓✓16Medication✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓15BMI✓✓✓✓4Sample size423260787816663847665201031030398498448619Study procedurePosture✓1✓1✓2✓3✓1✓1✓1✓1✓3✓1✓1✓1✓1✓3✓1✓16Resting✓a✓bNANA✓b✓b✓b✓b✓b✓b✓c✓a✓d✓a✓b13Circadian rhythm✓✓✓✓✓✓✓✓✓✓10Wakefulness, talk✓✓✓✓✓✓✓7Caffeinated drinks✓✓✓✓✓✓✓✓✓✓10Alcohol✓✓✓✓✓✓✓✓✓✓10Smoking✓✓✓✓✓✓✓7Food✓✓✓✓✓✓6Bladder filling0Physical exercise✓✓✓3Stress level0Study environmentLight✓✓✓✓✓✓✓✓✓9Noise✓✓✓✓✓✓✓✓✓✓✓✓✓13Temperature✓✓2Factors total = 19129101001214714168571381887NA, not applicable;a10 min resting before HRV; b5 min resting before HRV; cresting time not available; d1 min resting before HRV; 1supine; 2sitting and standing; 3sitting; ∗information on HRV control factors not available; ∗∗menstruation factor controlled; +multivariated adjusted odds ratio analysis (age, gender, BMI, alcohol drinking status, smoking status, health condition, metabolic syndrome, marital status, and education level); 9 am to 4 pm (wide range).


## 3.4.1. Reporting of HRV Measures (Table6)

The number of reported HRV variables varied from more than five (n = 9) to only one (e.g., SDNN or LF/HF) (n = 2). The most frequently reported variable was SDNN (n = 16), and the least was mRR (n = 4). Frequency domain variables were used to describe sympathovagal modulation: LF/HF (n = 14), LF and HF power (n = 12), LFnu and HFnu (n = 11), and natural logarithm (n = 3). Other HRV influencing parameters reported include mean heart rate (n = 13), respiration rate (n = 1), and blood pressure (n = 3).Table 6
Measures of short-term HRV reporting (20 studies).
HRV measures1234567891011121314151617∗∗, ∗181920TotalTime domainmRR (ms)∗✓✓✓✓4SDNN (ms)∗✓✓✓✓✓✓✓NR✓✓✓✓✓✓✓✓16rMSSD (ms)∗✓✓✓✓✓NR✓✓8Frequency domainLF (ms2)∗✓✓✓✓✓✓NR✓✓✓✓✓12HF (ms2)∗✓✓✓✓✓✓NR✓✓✓✓✓12LFnu∗✓✓✓✓✓✓✓✓✓✓✓11HFnu∗✓✓✓✓✓✓✓✓✓✓✓11LF:HF∗✓✓✓✓✓✓✓NR✓✓✓✓✓✓14ln (LF)✓✓✓3ln (HF)✓✓✓3Other measuresMHR (bpm)✓✓✓✓✓✓✓✓✓✓✓✓✓13MRR (BPM)✓1BP (mmHG)✓✓✓3Single vs. multiple Nu/ratioMMMSMMMMMMMSSMSSSMnaMRaw (Y, N)nnyyynyynyyyyyyynynanNR = not reported; na, not applicable; mRR = mean RR interval; SDNN = standard deviation of normal-to-normal intervals; rMSSD = root mean square of successive differences; LF = low-frequency spectral power; HF = high-frequency spectral power; LF : HF = ratio of low-frequency power to high-frequency power; nu = normalized units; ln = natural logarithm; MHR = mean heart rate; MRR = mean respiration rate; BP = blood pressure.∗The approved task force measures of short-term HRV [56,57]; ∗∗, ∗indices from HRV device (nonstandard measures, e.g., stress index and fatigue index).


## 3.4.2. Normalized Units and Raw Values (Table7)

13 of the 20 studies reported multiple nu/ratios (i.e., HFnu, LFnu, and LF/HF ratio), and this could present potential problems of redundancy and interpretation, especially when the HRV reporting measures provide inconsistent outcomes, as noted in Heathers’ HRV methodology study [32]: for example, if LFnu was significant and LF/HF not, this might be interpreted as a change in sympathetic activity but there is no sympathovagal balance. Some SCM and HRV studies reported redundant [43] or inconsistent results: for example, LFnu increased in So-Yang type, but there is no change in HFnu [47], or HFnu was higher in So-Yang type than Tae-Eum type but there is no difference in LHnu [52]. While the task force recommended that research should always report both raw values and normalized units [56] because the changes in the individual frequency bands may be inconsistent with the reporting of lone normalized HRV values [32], 6 of 20 studies reported normalized units without raw values.Table 7
Reporting raw vs. adjusted values and single vs. multiple normalized ratio units∗.
Raw valuesNo raw valuesSingle nu/ratio unit516Multiple nu/ratio unit8513136n = 19∗Table format [32].


## 3.4.3. Interpretation of HF, LF, and LF : HF Ratio (Table8)

ECM and SCM studies (n = 14) interpreted HF as reflecting parasympathetic nervous system (PNS) mediated by RSA (Respiratory Sinus Arrhythmia) (n = 7); n = 6 as PNS, and n = 1 as RSA. This mirrors the debate on LF interpretation as a mix of sympathetic and vagal, and baroreceptor activities [58], and the ECM and SCM studies (n = 14) showed a mixed interpretation: baroreceptor activity (n = 1), more SNS than PNS (n = 5), baroreceptor + PNS (n = 1), baroreceptor + SNS + PNS (n = 3), SNS + balance of PNS and SNS (n = 1), and index of SNS (n = 3). Although all the ECM and SCM studies reported LF : HF as an index of sympathovagal balance, a recent consensus suggested lowering its predictive value [58], due to the loose relationship of LF power with sympathetic outflow [32], and the nonlinear and nonreciprocal relationship between SNS and PNS activity [59]. The discrepancy in HRV interpretation is problematic in deriving a conclusive insight on the correlation between constitutions and HRV.Table 8
Various explanations given as the sources of the short-term HRV measures (20 studies).
HRV measuresExplanations12345678∗9101112∗1314∗15161718∗19+20TotalYear20052016201620152014201320132013201220112009200920092008200720072007200720062004LFSNS✓✓✓314SNS > PNS✓✓✓✓✓5SNS, BAL✓1BAR, SNS, PNS✓✓✓3BAR, PNS✓1BAR✓1HFRSA, PNS✓✓✓✓✓✓✓714PNS✓✓✓✓✓✓6RSA✓1LF : HFBAL✓✓✓✓✓✓✓✓✓✓1010BAR, the activity of Baroreflex; PNS, parasympathetic nervous system; SNS, sympathetic nervous system; RSA, respiratory sinus arrhythmia; BAL, a balance of sympathetic and parasympathetic influences.∗Explanation on HRV measures not reported; +not applicable.


## 3.4.4. Extraneous Factors Controlled for HRV (Table9)

In general, some population variables (i.e., age, health condition, and medication) of ECM and SCM studies (n = 20) were well controlled (n = 14), but gender (n = 9) was relatively less controlled. Several procedure- and environment-related variables were frequently controlled (i.e., posture, resting, circadian rhythm, caffeinated drinks, alcohol, room lighting, or noise), with others less frequently controlled (i.e., smoking, wakefulness or talk, food, physical exercise, and temperature), and some not at all (i.e., bladder filling and stress level).Table 9
Extraneous factors controlled for HRV (20 studies).
Extraneous factors12345∗678910∗11∗121314151617181920TotalStudy populationAge✓✓✓✓✓✓✓✓✓✓✓✓✓13Gender✓✓✓✓✓✓✓7Health condition✓✓✓✓✓✓✓✓∗∗✓✓✓✓✓✓✓✓16Medication✓✓✓✓✓✓✓✓✓✓✓✓✓✓✓15BMI✓✓✓✓4Sample size423260787816663847665201031030398498448619Study procedurePosture✓1✓1✓2✓3✓1✓1✓1✓1✓3✓1✓1✓1✓1✓3✓1✓16Resting✓a✓bNANA✓b✓b✓b✓b✓b✓b✓c✓a✓d✓a✓b13Circadian rhythm✓✓✓✓✓✓✓✓✓✓10Wakefulness, talk✓✓✓✓✓✓✓7Caffeinated drinks✓✓✓✓✓✓✓✓✓✓10Alcohol✓✓✓✓✓✓✓✓✓✓10Smoking✓✓✓✓✓✓✓7Food✓✓✓✓✓✓6Bladder filling0Physical exercise✓✓✓3Stress level0Study environmentLight✓✓✓✓✓✓✓✓✓9Noise✓✓✓✓✓✓✓✓✓✓✓✓✓13Temperature✓✓2Factors total = 19129101001214714168571381887NA, not applicable;a10 min resting before HRV; b5 min resting before HRV; cresting time not available; d1 min resting before HRV; 1supine; 2sitting and standing; 3sitting; ∗information on HRV control factors not available; ∗∗menstruation factor controlled; +multivariated adjusted odds ratio analysis (age, gender, BMI, alcohol drinking status, smoking status, health condition, metabolic syndrome, marital status, and education level); 9 am to 4 pm (wide range).


## 3.5. Classification of Constitutions

An ECM study [33] used pulse diagnosis with an intrarater reliability test (Kappa index 0.83%). SCM studies used QSCCII (Questionnaire for Sasang Constitution Classification) (n = 9), practitioner diagnosis based on SCAT (i.e., Sasang Constitution Analysis Tool including facial, voice, body, and QSCCII) (n = 6), practitioner diagnosis based on QSCCII (n = 4), and practitioner only diagnosis (n = 2).


## 4. Discussion

This systematic review explored HRV as a biomedical diagnostic for the Disympathetic Dimension of ECM.


### 4.1. Limitations of the Study

There are limitations to this review. The focus was on a qualitative and descriptive analysis of ECM and SCM studies on HRV reporting, interpretation, and control of extraneous factors. A review of statistical analysis including study population and effect size calculation was not within the study scope. Most articles were derived from the Korean research literature; despite the care with translation, misinterpretation or misunderstanding of the study contents is possible.


### 4.2. Correlation between HRV and Constitution

The results of the systematic review showed little consistency in the data to support the use of HRV as an objective determinant of ECM constitutions.(1)
A single ECM study of HRV differences after eight-constitution acupuncture had several limitations: sample size, control of age, and gender factors, and the data was not sufficient to draw meaningful conclusions on the use of HRV for constitutional differentiation along the Disympathetic Dimension(2)
While consensus exists for HF as a proxy to evaluate cardiac vagal modulation when the respiratory frequency is mediated, LF and the LF/HF ratio lack a clear relationship to cardiac sympathetic modulation. None of the ECM and SCM studies reported significant differences between constitutions when measuring HF at resting. Two SCM studies showed some constitutional differences in the LF/HF ratio; however, the ratio lacks consensus as a reliable measure for sympathovagal balance [29, 30, 56]. The results alone, therefore, are not enough to explain the constitutional differences in terms of cardiac autonomic modulation.(3)
While constitutional differences in HRV measures (i.e., SDNN, HFnu, LFnu, and LF/HF) in the SCM acupuncture stimulation studies are notable, there were limitations: HRV time domain values such as SDNN [21] are preferably computed through long-term recording (24 hours); therefore, the study result based on 30 seconds of SDNN requires further validation of reproducibility; LF/HF and LFnu are not sufficient to reflect cardiac autonomic modulation and changes in those measures alone have limited predictive value of constitutional differences.(4)
While 5 out of 7 SCM acupuncture studies reported some HRV differences (HFnu, LFnu, LF/HF, and SDNN), the variety of study methods and procedure design made it difficult to compare, consolidate, and draw a robust conclusion. This variety includes: reporting of HRV measures (e.g., HFnu, LFnu, LF/HF, SDNN, and rMSSD), acupuncture methods and points (e.g., Taegeuk acupuncture, bee venom acupuncture, electroacupuncture at ST36 and ST38, acupuncture at LI4 or LI4 and LR3), frequency and duration (e.g., one session vs. three sessions over two weeks, 5 min vs. 15 min acupuncture), stimulation methods (e.g., only acupuncture vs. mental stress and acupuncture), study population (e.g., age, gender), HRV measurement timing (e.g., right after needle removal, 1 hour after needle removal), and control of extraneous factors (e.g., wakefulness or talk, food).


### 4.3. HRV Reporting and Interpretation

HRV reporting in the studies showed some opportunities to improve: inconsistency in the selection of HRV reporting measures, redundancy or inconsistent outcomes of normalized unit reporting (i.e., HFnu, LFnu, and LF/HF ratio) without raw values, and discrepancy in HRV interpretation (HF, LF, and LF/HF ratio). ECM and SCM studies reported only some of the HRV measures (i.e., mRR, SDNN, rMSSD, LF power, HF power, LFnu, HFnu, and LF : HF) that were recommended by a task force [58, 59] and the selection of measures were also inconsistent among the studies.


### 4.4. Extraneous Factors

Among the HRV extraneous factors, some of the population variables (i.e., age, health condition, and medication) were well controlled, but gender and other procedural variables (e.g., wakefulness or talk, food) were less controlled in the studies.In the studies examined, there was no clear relationship between HRV and Korean Constitutional Medicine, including the Disympathetic Dimension of ECM. Reasons included demographic discrepancies (i.e., age, gender, and health conditions), HRV reporting, methodological inconsistencies between the SCM studies, and insufficient ECM research. The continuing debates on whether HRV measures reflect autonomic function accurately add further complications on top of HRV’s sensitivity to various extraneous factors.


## 4.1. Limitations of the Study

There are limitations to this review. The focus was on a qualitative and descriptive analysis of ECM and SCM studies on HRV reporting, interpretation, and control of extraneous factors. A review of statistical analysis including study population and effect size calculation was not within the study scope. Most articles were derived from the Korean research literature; despite the care with translation, misinterpretation or misunderstanding of the study contents is possible.


## 4.2. Correlation between HRV and Constitution

The results of the systematic review showed little consistency in the data to support the use of HRV as an objective determinant of ECM constitutions.(1)
A single ECM study of HRV differences after eight-constitution acupuncture had several limitations: sample size, control of age, and gender factors, and the data was not sufficient to draw meaningful conclusions on the use of HRV for constitutional differentiation along the Disympathetic Dimension(2)
While consensus exists for HF as a proxy to evaluate cardiac vagal modulation when the respiratory frequency is mediated, LF and the LF/HF ratio lack a clear relationship to cardiac sympathetic modulation. None of the ECM and SCM studies reported significant differences between constitutions when measuring HF at resting. Two SCM studies showed some constitutional differences in the LF/HF ratio; however, the ratio lacks consensus as a reliable measure for sympathovagal balance [29, 30, 56]. The results alone, therefore, are not enough to explain the constitutional differences in terms of cardiac autonomic modulation.(3)
While constitutional differences in HRV measures (i.e., SDNN, HFnu, LFnu, and LF/HF) in the SCM acupuncture stimulation studies are notable, there were limitations: HRV time domain values such as SDNN [21] are preferably computed through long-term recording (24 hours); therefore, the study result based on 30 seconds of SDNN requires further validation of reproducibility; LF/HF and LFnu are not sufficient to reflect cardiac autonomic modulation and changes in those measures alone have limited predictive value of constitutional differences.(4)
While 5 out of 7 SCM acupuncture studies reported some HRV differences (HFnu, LFnu, LF/HF, and SDNN), the variety of study methods and procedure design made it difficult to compare, consolidate, and draw a robust conclusion. This variety includes: reporting of HRV measures (e.g., HFnu, LFnu, LF/HF, SDNN, and rMSSD), acupuncture methods and points (e.g., Taegeuk acupuncture, bee venom acupuncture, electroacupuncture at ST36 and ST38, acupuncture at LI4 or LI4 and LR3), frequency and duration (e.g., one session vs. three sessions over two weeks, 5 min vs. 15 min acupuncture), stimulation methods (e.g., only acupuncture vs. mental stress and acupuncture), study population (e.g., age, gender), HRV measurement timing (e.g., right after needle removal, 1 hour after needle removal), and control of extraneous factors (e.g., wakefulness or talk, food).


## 4.3. HRV Reporting and Interpretation

HRV reporting in the studies showed some opportunities to improve: inconsistency in the selection of HRV reporting measures, redundancy or inconsistent outcomes of normalized unit reporting (i.e., HFnu, LFnu, and LF/HF ratio) without raw values, and discrepancy in HRV interpretation (HF, LF, and LF/HF ratio). ECM and SCM studies reported only some of the HRV measures (i.e., mRR, SDNN, rMSSD, LF power, HF power, LFnu, HFnu, and LF : HF) that were recommended by a task force [58, 59] and the selection of measures were also inconsistent among the studies.


## 4.4. Extraneous Factors

Among the HRV extraneous factors, some of the population variables (i.e., age, health condition, and medication) were well controlled, but gender and other procedural variables (e.g., wakefulness or talk, food) were less controlled in the studies.In the studies examined, there was no clear relationship between HRV and Korean Constitutional Medicine, including the Disympathetic Dimension of ECM. Reasons included demographic discrepancies (i.e., age, gender, and health conditions), HRV reporting, methodological inconsistencies between the SCM studies, and insufficient ECM research. The continuing debates on whether HRV measures reflect autonomic function accurately add further complications on top of HRV’s sensitivity to various extraneous factors.


## 5. Conclusions

This review examined HRV in the hope that it would be a useful objective diagnostic tool to bridge the information gap for acupuncture and traditional medicine researchers and, specifically, for determining a patient’s position on the Disympathetic Dimension of Eight-Constitution Medicine. HRV does not seem to be suitable for this purpose alone.



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*Source: 6613798-2021-06-16.xml*