Electrical Acupoint Stimulation Changes Body Composition and the Meridian Systems in Postmenopausal Women with Obesity

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1 The American Journal of Chinese Medicine, Vol. 38, No. 4, World Scientific Publishing Company Institute for Advanced Research in Asian Science and Medicine DOI: /S X Electrical Acupoint Stimulation Changes Body Composition and the Meridian Systems in Postmenopausal Women with Obesity Chia-Hsien Lin Department of Nursing Ching Kuo Institute of Management and Health Keelung, Taiwan Yu-Min Lin and Chi-Feng Liu Graduate Institute of Integration of Traditional Chinese Medicine with Western Nursing National Taipei College of Nursing Taipei, Taiwan Abstract: This study evaluates the effects of electrical stimulation on body composition and the meridian system in postmenopausal women with obesity. Forty-one postmenopausal women were recruited in Taiwan. The body composition was used as a screening test for obesity (percentage of body fat: > 30%, waist circumference: > 80 cm). The experimental group (EG, n ¼ 20) received modulated middle-frequency electrical stimulation treatment for 20 min twice a week for 12 consecutive weeks at the Zusanli (ST36) and Sanyinjiao (SP6) acupoints. The control group (CG, n ¼ 21) did not receive any intervention. The measurements of body composition and the meridian system were recorded for both groups in the pre- and post-study. The results showed that the data of body composition (weight, waist and hip circumference, percentage of body fat, and percentage of lean muscle mass) changed considerably in the EG (p < 0:05); however, no significant difference was observed in the CG. The left triple burner meridian changed notably in both EG and CG throughout the study (p < 0:05), however there was no difference between the two groups in the overall mean value, up-down ratio, qi and blood ratio, and yin-yang ratio. Our findings suggest that modulated middle-frequency electrical stimulation could help to improve body composition in postmenopausal women with obesity, potentially providing them with better care and health by integrating Western medicine and traditional Chinese medicine. Correspondence to: Dr. Chi-Feng Liu, Graduate Institute of Integration of Traditional Chinese Medicine with Western Nursing, National Taipei College of Nursing, No. 365, Ming De Road, Beitou District, Taipei 112, Taiwan. Tel: (þ886) (ext. 3232), Fax: (þ886) , chifeng@ntcn.edu.tw 683

2 684 C.-H. LIN et al. Keywords: Body Composition; Meridian System; Obesity; Postmenopausal Women; Electrical Stimulation. Introduction The prevalence of being overweight generally arises between the age of 20 and 60 years, and overall it seems that while men gain more body weight earlier in life, women tend to accumulate more body weight during the transition through menopause (Poehlman et al., 1995; Ferrara et al., 2002; Sowers et al., 2007). The increase in adiposity during menopause seems to be a consequence of the decline in the endogenous estrogen and reduced energy expenditure (Ferrara et al., 2002; Augoulea et al., 2005). Redistribution of body fat with increased visceral fat is believed to correlate with increased prevalence of metabolic syndrome, and consequently, cardiovascular disease in postmenopausal women (Park et al., 2003; Carr, 2003). The thoroughfare vessel (chong mai) originates in the pelvic cavity and runs alongside the kidney meridian up to the thorax. It is regarded as the sea of blood, where the 12 regular meridians converge. It also helps to regulate the qi and blood inside them. This vessel influences the supply and proper movement of blood in the uterus, and is closely related to the menses. The main difference between the thoroughfare vessel and the conception vessel in relation to menstruation is that the conception vessel controls qi and can be used to tone and nourish, whereas the thoroughfare vessel controls blood and is used to move qi and blood. The conception vessel (ren mai) originates from the perineum, runs along the anterior midline of the abdomen, passes through the cheek, and finally enters the eye socket. It meets all the yin meridians and thus is called the sea of the yin meridians. It is responsible for receiving and bearing the qi of the yin meridians. In traditional Chinese medicine (TCM), the renal qi declines, which leads to a deficiency of the thoroughfare vessel and the conception vessel, tiangui, in turn causing failure in postmenopausal woman (Yu, 2004). In TCM, the meridians and the collaterals are pathways along which qi and blood circulate throughout the body, reach the internal organs and limbs, link the body from head to foot, and regulate the thoroughfare vessels (Xie et al., 2007). Ryodoraku utilized noninvasive electricity at specific acupuncture skin points: Hz of low-frequency electrical currents for regulation and Hz middle-frequency currents for control. Modulated middle-frequency electrical stimulation has been found to reduce pain, improve blood circulation, promote lymph flow, and forge tendon strength, among other things (Zytkowski, 1999; Szecsi et al., 2007). Point electric stimulation utilizes the qi conduct characteristics of acupuncture and the meridian system, converting the qi of the meridians into electricity, and then applying electrical current stimulation to attain the same therapeutic effects that the Chinese achieve by acupuncture (Omura et al., 1989). In TCM, postmenopausal obese women usually have splenic and renal asthenia and hepatic stagnation. The internal organs of a human body can be classified into five visceral organs (wu zang) and six bowel organs (liu fu). The five zang organs are the heart, liver, spleen, lungs, and kidneys. The six fu organs are the stomach,

3 ELECTRICAL STIMULATION ON BODY COMPOSITION AND MERIDIAN SYSTEMS 685 small intestine, large intestine, gallbladder, urinary bladder, and triple energizer (San Jiao). The meridians are intimately connected to the presence or absence of pathological changes in the related five zang viscera and six fu viscera (Omura, 1987; Omura et al., 1989). We used modulated middle-frequency electrical stimulation to generate acupuncture-like stimulation effects at specific acupuncture points and investigated its therapeutic effect on body composition and the meridian system in postmenopausal obese women. The Zusanli (ST 36) and the Sanyinjiao (SP 6) were selected as the main acupoints in the treatment group. Materials and Methods Subjects The prospective study was conducted from April to August All the study procedures were approved by the committee review board at the National Taipei College of Nursing. A total of 50 female volunteers were recruited from various communities in Taipei. Written consent was obtained before their participation in the study. Initial evaluation included measurements of the body composition (i.e., body weight, waist circumference, hip circumference, waist hip ratio, percentage of body fat, and percentage of lean body mass). The weight was measured to the nearest 0.1 kg using an electronic scale. The waist circumference was measured at the level midway between the lateral lower rib margin and the iliac crest, and the hip circumference was measured at the levels of the trochanters in the standing position. A bioelectrical impedance analyzer system (BT-905 Body Composition Analyzer, Skylark Co. Ltd., Taiwan) was used to measure body fat and lean mass. All the participants met the following criteria: (i) had experienced menopause naturally at least one year earlier, (ii) were < 64 years of age, (iii) had > 30% body fat, and (iv) had waist circumference of > 80 cm. Furthermore, individuals with the following conditions were excluded: (i) gynecological disease including hysterectomy and/or oophorectomy, (ii) history of cancer, (iii) cardiac arrhythmia or an implanted cardiac pacemaker, (iv) paralysis of lower limbs or decreased sensation, and (v) inflammation of skin defects exhibited in the skin of lower limbs. Groups and Intervention The patients were screened for the aforementioned criteria. The researchers explained to the patients the purpose of the study, method, procedure, rights and interests of the participants, and the protective measures available for the research subjects. The 41 women participants were randomized into the experimental group (EG, n ¼ 20) and the control group (CG, n ¼ 21). A modulated middle-frequency electrical stimulation device using interferential current (Skylark 730IF, Skylark Device & Systems Co. Ltd., Taiwan) was used. Its specifications are as follows: maximum output current: 50 ma, output voltage: 0 25 V, and wave width: 125 A; two different frequency modulations (FM) were mixed, and the frequency of channel one was set at 4000 Hz and channel two was set at 61 Hz. The measurements of the body composition and the meridian system were recorded for both the groups pre- and post-study. The EG received modulated middle-frequency electrical

4 686 C.-H. LIN et al. Screening case Study explanation 1. Written and verbal consent 2. Fills in the basic document Non-randomized Experimental group Control group (n = 26) (n = 24) Pre-test Experimental group Control group (n = 20) (n = 21) Modulated No intervention middle-frequency electrical stimulation Post-test Data analysis 1. Body composition measured 2. Meridian system measured 1. Body composition measured 2. Meridian system measured Figure 1. Flow diagram of the progress of all data-collection procedures. stimulation treatment for 20 min twice a week for 12 consecutive weeks at the Zusanli (ST36) and the Sanyinjiao (SP6) acupoints. We used a close-by point to complete an electric circuit, rather than using the point in the opposite extremity, thereby letting the current pass through the cardiac region. However, the CG did not receive any intervention. The study design is outlined in Fig. 1. Meridian System We used Ryodoraku instrument (Model No. SD-802P. Skylark Device & Systems Co. Ltd., Taiwan) to measure the meridian system non-invasively. The TCM doctors, who had

5 ELECTRICAL STIMULATION ON BODY COMPOSITION AND MERIDIAN SYSTEMS 687 a Chinese medical license to identify the acupoint locations with accuracy, collected the cases. They pasted two pieces of electrode on the single-sided Zusanli and Sanyinjiao acupoints: Zusanli (ST36) is located 3 inches below the knee, while Sanyinjiao (SP6) is located 3 inches directly above the tip of the medial malleolus on the posterior border of the tibia. Statistical Analysis SPSS version 15.0 for Windows software was used. Descriptive statistics were used to summarize the sample characteristics. The Mann-Whitney U-test for continuous variables and the chi-square test for categorical variables were used to test for the differences between the two groups at the baseline. The Wilcoxon signed rank test was utilized to compare the pre- and post-test body composition data, while ANCOVA was used to analyze and compare the pre- and post-test data for the meridian system. The level of significance for all analyses was set at p < 0:05. Results Description of Sample The basic characteristics of the participants in each group are presented in Table 1. The mean age was 55:1 3:4 years old (range: years old). The average age of menopause was 51:1 2:2 years old (range: years old). More than half of the participants (58.5%, n ¼ 24) gained their excess weight after menopause, gaining 2:81 3:35 kg on an average. There were no statistically significant differences in most of the monographic variables between the EG and CG, except being employed in the study (p < 0:01). Body Composition There were no noteworthy differences in the pre-test of anthropometric characteristics of the EG and CG (p > 0:05) (Table 2). However, the EG showed significant decrease in the waist-to-hip ratio and percentage of body fat with a concomitant increase in the percentage of lean body mass (LBM) after modulated middle-frequency electrical stimulation (p < 0:05). There were no statistically significant differences in the body composition at pre- and post-tests for the CG. Furthermore, the overall body composition in the EG significantly improved more than that in the CG (Table 2). Meridian System Before the test, the left triple burner meridian was 37:20 18:84 and 38:10 21:14 for the EG and CG, respectively (Table 4). In the CG, the left triple burner meridian increased significantly from pre-test (38:10 21:14 ) to post-test (47:19 2:99 ) (p < 0:05). On the other hand, no statistically significant difference was found from pre-test

6 688 C.-H. LIN et al. Table 1. Comparison of the Basic Characteristics of the Sample Overall Subjects EG CG (n ¼41) (n ¼20) (n ¼ 21) Mean SD, Mean SD, Mean SD, Characteristics n (%) n (%) n (%) x Value z Value Age (Years) 55:07 3:39 54:05 3:44 56:05 3: Education Junior High School 12 (29.3) 6 (30) 6 (30) and Below Normal and 19 (46.3) 11 (55) 8 (38.1) Professional Senior High School College/University 10 (24.4) 3 (15) 7 (33.3) Marital Status Married 35 (85.4) 15 (75) 20 (95.2) Others 6 (14.6) 5 (25) 1 (4.8) Working * No 20 (48.8) 5 (25) 15 (71.4) Yes 21 (51.2) 15 (75) 6 (28.6) Years since Menopause 3:98 2:76 3:4 2:89 4:52 2: Age of Menopause 51:12 2:16 50:70 2:16 51:52 2: Weight Gain after Menopause No 17 (41.5) 9 (45) 8 (38.1) Yes 24 (58.5) 11 (55) 13 (61.9) Weight Gain after Menopause (kg) 2:81 3:35 2:78 3:89 2:83 2: History of Disease No 23 (56.1) 12 (60) 11 (52.4) Yes 18 (43.9) 8 (40) 10 (47.6) Eating Three Meals Regularly 31 (75.6) 15 (75) 16 (76.2) Irregularly 10 (24.4) 5 (25) 5 (23.8) Healthy Food No 18 (43.9) 10 (50) 8 (38.1) Yes 23 (56.1) 10 (50) 13 (61.9) Regular Sport No 15 (36.6) 8 (40) 7 (33.3) Yes 26 (63.4) 12 (60) 14 (66.7) (n ¼ 41) * p < 0:01, comparing to the EG (experimental group) and CG (control group).

7 ELECTRICAL STIMULATION ON BODY COMPOSITION AND MERIDIAN SYSTEMS 689 Table 2. Comparison of the Differences between the Pre- and Post-Test Anthropometric Characteristics of the EG (n ¼ 20) and CG (n ¼ 21) Variances Groups Pre-Test Post-Test P-Value Body Weight (kg) EG 64:31 10:43 63:14 10: ** CG 67:08 7:06 67:02 7: Waist Circumference (cm) EG 86:45 7:47 84:85 7: ** CG 86:29 5:71 86:26 5: Hip Circumference (cm) EG 100:90 5:61 99:00 5: ** CG 102:07 5:35 101:71 5: (37:20 18:84 ) to post-test (38:26 3:06 ) in the EG (p > 0:05, Table 3). In the pre-test, the left bladder meridian (44:76 16:00 ) and the right bladder meridian (42:48 16:62 ) in CG were increased significantly more than the left bladder meridian (28:95 15:57, p< 0:05) and the right bladder meridian of EG (33:10 13:78, p < 0:05). However, there were no statistically significant differences between the EG and CG in the overall mean value, up-down ratio, qi and blood ratio, and yin-yang ratio (p > 0:05) (Table 4). Discussion Body Fat (%) EG 35:45 5:14 32:91 3: * CG 37:88 5:34 37:66 4: Lean Body Mass (%) EG 64:56 5:14 67:09 3: * CG 62:12 5:34 62:34 4: Mean SD; * p < 0:01; ** p < 0:001; EG¼ experimental group; CG ¼ control group. Zamboni et al. (1992) found no significant differences in the body weight, body mass index (BMI), waist-to-hip ratio, and total abdominal adipose tissue areas between the premenopausal and postmenopausal women. We, however, found that the BMI, waist circumference, and percentage of body fat in postmenopausal women were higher than those of premenopausal women. This is consistent with the findings of Garaulet et al. (2002), who measured the body fat distribution using abdominal circumference and computerized tomography, and found that body fat distribution did change with menopausal status, with central obesity more pronounced in postmenopausal women. Morita et al. (2006) reported that an initial event during the menopausal process is bone mineral density (BMD) loss, followed by a body fat distribution shift, LBM loss, and a reciprocal increase in the body fat mass. They found that subcutaneous abdominal adipose tissue areas were significantly larger in the premenopausal women, whereas visceral abdominal adipose tissue areas and the subcutaneous-to-visceral abdominal adipose tissue area ratios were significantly higher in the postmenopausal subjects. In a study by Zamboni et al. (1992), after adjusting for BMI, the subcutaneous abdominal adipose tissue areas were significantly lower, and both the visceral abdominal adipose tissue areas and viscera-to-subcutaneous abdominal adipose tissue area ratios were

8 690 C.-H. LIN et al. Table 3. One-Way Analysis of Covariance (ANCOVA) of the Meridian System between the EG and CG Type III Sum of Degree of Mean Sources of Variances Squares () Freedom Squares () F-Test Significance Left Lung Meridian Right Lung Meridian Left Pericardium Meridian Right Pericardium Meridian Left Heart Meridian Right Heart Meridian Left Small Intestine Meridian Right Small Intestine Meridian Left Triple Burner Meridian * Right Triple Burner Meridian Left Large Intestine Meridian Right Large Intestine Meridian Left Spleen Meridian Right Spleen Meridian Left Liver Meridian Right Liver Meridian Left Kidney Meridian Right Kidney Meridian Left Bladder Meridian Right Bladder Meridian Left Gallbladder Meridian Right Gallbladder Meridian Left Stomach Meridian Right Stomach Meridian Overall mean value Up-down ratio Qi and blood ratio Yin-yang ratio One-way Analysis of Covariance (ANCOVA); ** p < 0:05. significantly higher in the postmenopausal women (p < 0:01). They also found a positive correlation between age and waist-to-hip ratio (p < 0:05). Furthermore, Sowers et al. (2007) reported that both chronological aging and ovarian aging contributed to substantial changes in the body composition (fat and skeletal muscle mass) and waist circumference. These changes have important ramifications for establishing a metabolic environment that can be healthy or unhealthy. The average age at natural menopause in our study was 51:12 2:16 years (Table 1), which agrees with the TCM description of women who are 49 cloudy years old, when the kidney yin is insufficient and the menses gradually decrease, finally becoming blocked and ultimately ceasing. On average, our subjects gained 2:81 3:35 kg after menopause. There were no statistically significant differences in most of the monographic variables of the basic characteristics of EG and CG, except being employed in the study (p < 0:01, Table 1): in the EG, there were 15 women (75%) who were employed, whereas in the CG, there were 15 women (71.4%) who were not employed.

9 ELECTRICAL STIMULATION ON BODY COMPOSITION AND MERIDIAN SYSTEMS 691 Table 4. Comparison of the Average Pre- and Post-Test Data of Meridian Performance between the EG (n ¼ 20) and CG (n ¼ 21) Post-Test () Variances Groups Pre-Test () (After Regulation) Left Lung Meridian EG CG Right Lung Meridian EG CG Left Pericardium Meridian EG CG Right Pericardium Meridian EG CG Left Heart Meridian EG CG Right Heart Meridian EG CG Left Small Intestine Meridian EG CG Right Small Intestine Meridian EG CG Left Triple Burner Meridian EG CG Right Triple Burner Meridian EG CG Left Large Intestine Meridian EG CG Right Large Intestine Meridian EG CG Left Spleen Meridian EG CG Right Spleen Meridian EG CG Left Liver Meridian EG CG Right Liver Meridian EG CG Left Kidney Meridian EG CG Right Kidney Meridian EG CG

10 692 C.-H. LIN et al. Table 4. (Continued) Post-Test () Variances Groups Pre-Test () (After Regulation) Left Bladder Meridian EG CG Right Bladder Meridian EG CG Left Gallbladder Meridian EG CG Right Gallbladder Meridian EG CG Left Stomach Meridian EG CG Right Stomach Meridian EG CG Overall mean value EG CG Up-down ratio EG CG Qi and blood ratio EG CG Yin-yang ratio EG CG Mean SD; EG ¼ experimental group; CG ¼ control group. Splenic asthenia, renal asthenia, and hepatic stagnation are common constitutional peculiarities in obese postmenopausal women (Omura, 1987; Omura et al., 1989). Zusanli (ST36) and Sanyinjiao (SP6) are often utilized in reducing the body weight of these patients (Zhang et al., 2005). Zusanli belongs to the leg yang ming stomach meridians and may improve splenic and gastric function. Sanyinjiao (SP6) is the meeting point of the three yin channels of the foot (spleen, liver, and kidney), which include the leg tai yin spleen meridian, leg jue yin liver meridian, and leg shao yin kidney meridian, which can regulate the channel qi of the liver, spleen, and kidney to cure enuresis. In addition, Sanyinjiao s collateral channels all pass through the abdomen, and thus, it can conduct energy through the abdomen by point electric stimulation and then exert an influence on the abdomen. Previous researchers have shown that acupuncture has a weight-reducing effect (Shiraishi et al., 2003). Point electric stimulation uses the characteristics of the collateral channel system of the acupuncture to conduct qi and transform it from the collateral channel system to electricity, which can be augmented to attain the same curative effect of traditional point acupuncture.

11 ELECTRICAL STIMULATION ON BODY COMPOSITION AND MERIDIAN SYSTEMS 693 TCM describes the human collateral channels and functional condition of five zang organs and six fu organs of the human body, and the locations where these are reflected on the body surface. It is believed that if there is a balance of yin and yang, the person will be healthy. TCM studies the human body as a whole and considers that the yin and yang imbalance caused by almost all the diseases can be reflected in the main and collateral channel system; the channels can then be adjusted to control the physiological function and pathological expression of the viscera (Tengxiang et al., 1995). The changes we found in the left arm shao yang triple burner (san jiao) meridians may therefore be related to the relative function changes in the internal organs. Phlegm is a sticky fluid secreted by the mucus membranes of the humans and other animals. Obese postmenopausal women lose the vital energy and do not transport energy in the lower body quite well. Consequently, the phlegm is hindered wetly and the spleen is hindered diffidently and wetly, causing abnormal functioning of the intestinal absorption. The triple burner is the passage through which water, food, and fluid are transported. Adjusting the water and fluid metabolism of the triple burner could improve abnormal interstitial fluid metabolism in the lipoid cells. The present results showed that there were no statistically significant differences between the two groups in the overall mean value, up-down ratio, qi and blood ratio, and yin-yang ratio (Table 4). The TCM point acupuncture combined with modulated intermediate-frequency electrical stimulation may slightly increase the corresponding channels and collaterals, elevating the yang levels in obese postmenopausal women; however, further research is needed. Our findings suggest that modulated middle-frequency electrical stimulation helps to improve the body composition in obese postmenopausal women, and integrating Western medicine and TCM may provide them with better care and better health. References Augoulea, A., G. Mastorakos, I. Lambrinoudaki, G. Christodoulakos and G. Creatsas. Role of postmenopausal hormone replacement therapy on body fat gain and leptin levels. Gynecol. Endocrinol. 20: , Carr, M.C. The emergence of the metabolic syndrome with menopause. J. Clin. Endocrinol. Metab. 88: , Ferrara, M.C., N.A. Lynch, B.J. Nicklas, A.S. Ryan and D.M. Berman. Differences in adipose tissue metabolism between postmenopausal and perimenopausal women. J. Clin. Endocrinol. Metab. 87: , Garaulet, M., F. Pérez-Llamas, J.C. Baraza, M.D. Garcia-Prieto, P.S. Fardy, F.J. Tébar and S. Zamora. Body fat distribution in pre-and post-menopausal women: metabolic and anthropometric variables. J. Nutr. Health. Aging 6: , Morita, Y., I. Iwamoto, N. Mizuma, T. Kuwahata, T. Matsuo, M. Yoshinaga and T. Douchi. Precedence of the shift of body-fat distribution over the change in body composition after menopause. J. Obstet. Gynaecol. Res. 32: , Omura, Y. Meridian-like networks of internal organs, corresponding to traditional Chinese 12 main meridians and their acupuncture points as detected by the Bi-Digital O-Ring Test imaging method : search for the corresponding internal organ of Western medicine for each meridian Part I. Acupunct. Electrother. Res. 12: 53 70, 1987.

12 694 C.-H. LIN et al. Omura, Y., T.L. Lin, L. Debreceni, B.M. Losco, S. Freed, T. Muteki and C.H. Lin. Unique changes found on the Qi Gong (Chi Gong) Master s and patient s body during Qi Gong treatment; their relationships to certain meridians and acupuncture points and the re-creation of therapeutic Qi Gong states by children and adults. Acupunct. Electrother. Res. 14: 61 89, Park, Y.W., S. Zhu, L. Palaniappan, S. Heshka, M.R. Carnethon and S.B. Heymsfield. The metabolic syndrome: prevalence and associated risk factor findings in the U.S. population from the Third National Health and Nutrition Examination Survey, Arch. Intern. Med. 163: , Poehlman, E.T., M.J. Toth and A.W. Gardner. Changes in energy balance and body composition at menopause: a controlled longitudinal study. Ann. Intern. Med. 123: , Shiraishi, T., M. Onoe, T.A. Kojima, T. Kageyama, S. Sawatsugawa, K. Sakurai, H. Yoshimatsu and T. Sakata. Effects of bilateral auricular acupuncture stimulation on body weight in healthy volunteers and mildly obese patients. Exp. Biol. Med. 228: , Sowers, M., H. Zheng, K. Tomey, C. Karvonen-Gutierrez, M. Jannausch, X. Li, M. Yosef and J. Symons. Changes in body composition in women over six years at midlife: ovarian and chronological aging. J. Clin. Endocrinol. Metab. 92: , Szecsi, J., C. Fornusek, P. Krause and A. Straube. Low-frequency rectangular pulse is superior to middle frequency alternating current stimulation in cycling of people with spinal cord injury. Arch. Phys. Med. Rehabil. 88: , Tengxiang, Y., Z. Zequn and D. Yilin. The design and application of microcomputer human body information balance diagnosis and treatment instrument. Medinfo. 8: 913, Xie, H.R., F.C. Li and X.S. Ma. Discussion on the essence of meridian-collateral system. Zhen Ci Yan Jiu 32: , Yu, J. Integrated traditional Chinese and western medicine should make new contribution to the reproductive health of women. Zhong Xi Yi Jie He Xue Bao 2: 83 85, Zamboni, M., F. Armellini, M.P. Milani, M. De Marchi, T. Todesco, R. Robbi, I.A. Bergamo- Andreis and O. Bosello. Body fat distribution in pre- and post-menopausal women: metabolic and anthropometric variables and their inter-relationships. Int. J. Obes. Relat. Metab. Disord. 16: , Zhang, W.P., M. Kanehara, Y.J. Zhang, Z.F. Yu, G.X. Zhang, Y.X. Yang, Y.M. Sun, J.M. Zhang and T. Ishida. The more efficacious acupoints of Zusanli and Sanyinjiao than that of non-acupoints on bone mass in osteopenic ovariectomized rats. Chin. J. Integr. Med. 11: , Zytkowski, A. Ectodermal method of Ryodorak an attempt at clinical measurement for evaluation of physiotherapy effects in patients with low back pain. Neurol. Neurochir. Pol. 32: , 1999.

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