Comprehensive and Systematic Auricular Diagnosis Protocol

A randomized controlled study of auricular point acupressure to manage chemotherapy-induced neuropathy: Study protocol

OBJECTIVE

Chemotherapy-induced neuropathy (CIN) significantly impacts cancer patients, leading to functional disability, diminished quality of life, and increased healthcare costs amid the ongoing opioid crisis. Auricular point acupressure (APA), a non-invasive and non-pharmacological alternative, has shown potential for alleviating the pain, numbness, and tingling associated with CIN. This study aims to assess the efficacy of APA for CIN symptoms and physical function and to examine the mechanisms underlying APA's effects on CIN.

METHODS

This is a three-arm randomized controlled clinical trial protocol. Patients aged 18 and older who are experiencing CIN are randomly assigned to one of the three groups: an APA group (in-person APA; mAPA), a sham control group (virtual APA; vAPA), and a wait-list usual care control group (UC). During the four-week program, participants in the mAPA receive an in-person APA treatment and training; the sham control participants (vAPA) receive a self-guided smartphone APA application with APA demonstration videos; and the UC participants will continue with the usual care and be re-randomized into one of the APA groups. The primary outcomes are changes in CIN symptoms and physical function. Secondary outcomes include evaluating pain sensory thresholds, motor and cognitive functioning, inflammatory signaling, brain connectivity, opioid use, and quality of life. The outcomes are measured at baseline, program completion (4 weeks), and at monthly follow-up for 3 months post-intervention.

DISCUSSION

This study will provide evidence supporting the potential viability of APA as an intervention for CIN.

TRIAL REGISTRATION

ClinicalTrials.gov, ID NCT04920097 registered on 3 June 2021.

Adapting and Evaluating a Theory-Driven, Non-Pharmacological Intervention to Self-Manage Pain

BACKGROUND

The existing literature has limited detail on theory-driven interventions, particularly in pain studies. We adapted Bandura's self-efficacy framework toward a theory-driven, non-pharmacological intervention using auricular point acupressure (APA) and evaluated participants' perceptions of this intervention on their pain self-management. APA is a non-invasive modality based on auricular acupuncture principles.

METHODS

We mapped our study intervention components according to Bandura's key sources of self-efficacy (performance accomplishments, vicarious experience, verbal persuasion, and emotional arousal) to facilitate the self-management of pain. Through a qualitative study design, we conducted virtual interviews at one and three months after a 4-week APA intervention among 23 participants using purposive sampling to describe their experiences in managing their pain based on our theory-driven APA intervention.

RESULTS

Using thematic analyses, we found four themes: the enhanced self-management of pain, improved pain outcomes, the feasibility of technology, and the sustainability of APA.

CONCLUSIONS

Describing how interventions are mapped according to the elements of theoretical frameworks can help to guide intervention development, advance science and knowledge development, and promote the implementation of interventions. As such, using Bandura's self-efficacy theory as a foundation for the APA intervention, APA was found to be feasible and sustainable, improving self-management, pain intensity, and pain-related outcomes. Participants provided recommendations for the further improvement of this theory-driven intervention.

Retention, adherence, and acceptability testing of a digital health intervention in a 3-group randomized controlled trial for chronic musculoskeletal pain

OBJECTIVES

Evaluate a digital health intervention using Auricular Point Acupressure (APA) for chronic musculoskeletal pain in terms of participant retention, adherence, acceptability, and satisfaction. Chronic musculoskeletal pain is a global concern and there are persistent challenges in pain management. Despite the value of digital health interventions, these interventions need to be fully evaluated for feasibility.

METHODS

We conducted a 3-group, longitudinal, randomized controlled trial (RCT). After Institutional Review Board approval, we posted recruitment flyers in a university, healthcare clinics, and community settings. Participants were randomized into an in-person + app group (n = 8), virtual + app group (n = 7), and a wait-list, education-enhanced control group (n = 8), evaluating our outcomes using standard feasibility measures. The 4-week intervention consisted of virtual sessions, telecommunications, and our APA app, followed by a 3-month follow-up.

RESULTS

Data from 22 participants were subsequently analyzed (95.7%). All app participants adhered to the study protocol and used APA at the minimum recommended frequency and duration. The virtual + app group used APA more during the intervention and follow-up periods. All app participants found the intervention to be acceptable and at least 80% overall were satisfied with APA at the 3-month follow-up. There were no adverse events reported.

CONCLUSIONS

Our digital health intervention was found to be acceptable and sustainable; participants adhered to and were satisfied with the intervention providing support for a larger RCT.

CLINICAL TRIAL

#: NCT05020470.

Biological Correlates of the Effects of Auricular Point Acupressure on Pain

BACKGROUND

To identify candidate inflammatory biomarkers for the underlying mechanism of auricular point acupressure (APA) on pain relief and examine the correlations among pain intensity, interference, and inflammatory biomarkers.

DESIGN

This is a secondary data analysis.

METHODS

Data on inflammatory biomarkers collected via blood samples and patient self-reported pain intensity and interference from three pilot studies (chronic low back pain, n = 61; arthralgia related to aromatase inhibitors, n = 20; and chemotherapy-induced neuropathy, n = 15) were integrated and analyzed. This paper reports the results based on within-subject treatment effects (change in scores from pre- to post-APA intervention) for each study group (chronic low back pain, cancer pain), between-group differences (changes in scores from pre- to post-intervention between targeted-point APA [T-APA] and non-targeted-point APA [NT-APA]), and correlations among pain intensity, interference, and biomarkers.

RESULTS

Within-group analysis (the change score from pre- to post-APA) revealed statistically significant changes in three biomarkers: TNF-α (cancer pain in the APA group, p = .03), β-endorphin (back pain in the APA group, p = .04), and IL-2 (back pain in the NT-APA group, p = .002). Based on between-group analysis in patients with chronic low back pain (T-APA vs NT-APA), IL-4 had the largest effect size (0.35), followed by TNF-α (0.29). A strong positive monotonic relationship between IL-1β and IL-2 was detected.

CONCLUSIONS

The current findings further support the potential role of inflammatory biomarkers in the analgesic effects of APA. More work is needed to gain a comprehensive understanding of the underlying mechanisms of APA on chronic pain. Because it is simple, inexpensive, and has no negative side effects, APA can be widely disseminated as an alternative to opioids.

Nurse-Administered Auricular Point Acupressure for Cancer-Related Pain

PURPOSE

The study aimed to (1) examine the feasibility of providing a training course on auricular point acupressure (APA) for clinical oncology nurses to integrate APA into real-world nursing care settings, and (2) examine the effectiveness of APA on cancer-related pain (CRP) under usual inpatient oncology ward conditions.

METHODS

This was a 2-phase feasibility study. Phase 1, an in-person, 8 hour training program was provided to oncology nurses. Phase 2, a prospective and feasibility study was conducted to evaluate the integration of APA into nursing care activities to manage CRP. Oncology patients were included if their pain was rated at ≥4 on a 0 to 10 numeric rating scale in the past 24 hours. Patients received 1 APA treatment administered by the nurses and were instructed to stimulate the points for 3 days. Study outcomes (pain intensity, fatigue, and sleep disturbance), pain medication use, and APA practice were measured by a phone survey daily.

RESULTS

Ten oncology nurses received APA training in phase 1. APA had been added to the hospital's electronic health records (EHRs) as a pain treatment. In phase 2, 33 oncology patients received APA treatment with a 100% adherence rate (pressing the seeds 3 times per day, 3 minutes per time based on the suggestion). The side effects of APA were minimal (~8%-12% felt tenderness on the ear). After 3 days of APA, patients reported 38% pain relief, 39% less fatigue, and 45% improvement in sleep disturbance; 24% reduced any type of pain medication use and 19% reduced opioid use (10 mg opioids using milligram morphine equivalent). The major barrier to integrating APA into routine nursing practice was time management (how to include APA in a daily workflow).

CONCLUSION

It is feasible to provide 8-hour training to oncology nurses for mastering APA skill and then integrating APA into their daily nursing care for patients with CRP. Based on the promising findings (decreased pain, improved fatigue and sleep disturbance, and less opioid use), the next step is to conduct a randomized clinical trial with a larger sample to confirm the efficacy of APA for oncology nurses to treat CRP in real-world practice.ClinicalTrial.gov identifier number: NCT04040140.

Self-Guided Smartphone Application to Manage Chronic Musculoskeletal Pain: A Randomized, Controlled Pilot Trial

OBJECTIVE

The goal of this study is to evaluate the feasibility and efficacy of an auricular point acupressure smartphone app (mAPA) to self-manage chronic musculoskeletal pain.

METHODS

A prospective, longitudinal, randomized, controlled pilot trial was conducted using a three-group design (self-guided mAPA (n = 14); in-person mAPA (n = 12); and control (n = 11)). The primary outcomes included physical function and pain intensity.

RESULTS

After a 4-week APA intervention, participants in the in-person mAPA group had improved physical function of 32% immediately post-intervention and 29% at the 1M follow-up. Participants in the self-guided mAPA group had higher improvement (42% at post-intervention and 48% at the 1M follow-up). Both mAPA groups had similar degrees of pain intensity relief at post-intervention (45% for in-person and 48% for the self-guided group) and the 1M follow-up (42% for in-person and 45% for the self-guided group). Over 50% of the participants in each group reached at least 30% reduced pain intensity at post-intervention, and this was sustained in the mAPA groups at the 1M follow-up. Approximately 80% of the participants in both mAPA groups were satisfied with the treatment outcomes and adhered to the suggested APA practice; however, participants in the self-guided group had higher duration and more frequency in APA use. The attrition rate was 16% at the 1M follow-up. No adverse effects of APA were reported, and participants found APA to be beneficial and the app to be valuable.

CONCLUSIONS

The study findings indicate that participants effectively learned APA using a smartphone app, whether they were self-guided or received in-person training. They were able to self-administer APA to successfully manage their pain. Participants found APA to be valuable in their pain self-management and expressed satisfaction with the intervention using the app.

Exploring the Feasibility of Virtually Delivered Auricular Point Acupressure in Self-Managing Chronic Pain: Qualitative Study

Background

Chronic pain remains highly prevalent. Current pharmacological and non-pharmacological strategies have not adequately managed chronic pain which has contributed to disability and high healthcare costs. With existing challenges in providing adequate pain care and access, we tested vAPA, a virtually delivered, self-management intervention using Auricular Point Acupressure (APA) by mobile app and virtual consultations (telehealth). Our key purpose was to evaluate the feasibility of the vAPA in self-managing chronic pain in preparation for a future randomized controlled trial.

Methods

We conducted a descriptive, qualitative study evaluating our 4-week vAPA intervention among 18 participants. We used directed qualitative content analysis. Results and Conclusion. Participants perceived that vAPA was feasible (acceptable, useable, practical, and beneficial). In addition, the following themes were gathered: better control of pain, less use of pain medications, self-management and motivation in pain, and expectations for pain relief. Refinements were recommended for the app, content, and delivery to improve study interventions. Findings are relevant in moving forward to a future randomized controlled trial and for wider implementation in a pragmatic clinical trial.

Evaluating Auricular Point Acupressure for Chronic Low Back Pain Self-Management Using Technology: A Feasibility Study

BACKGROUND

Chronic low back pain, one of the most common reasons for seeking healthcare services, causes significant negative impacts on individuals and society. Nonpharmacologic therapies and self-management are included in practice guidelines, but their implementation is challenging.

AIM

To assess the feasibility of using an auricular point acupressure (APA) mobile app as a self-guided tool to learn and self-administer APA to manage chronic low back pain (cLBP) and to compare cLBP outcomes between 2 groups (app vs app + telehealth).

DESIGN

A 2-phase study design was used. In phase 1, participants (app group, n = 18) had in-person study visits and installed the app to learn and self-administer APA to manage cLBP. In phase 2, all research activities occurred remotely due to the COVID-19 pandemic, so a second group was recruited (app + telehealth, n = 19). The app + telehealth group underwent a virtual session, installed the app, and were provided the opportunity for questions and verification on the accuracy of the self-administered APA.

SETTING

The participants were recruited by distributing study flyers at outpatient clinics and referrals.

PARTICIPANTS

Participants with chronic low back pain were eliglbe for the study.

METHODS

Using a quasi-experimental design with a mixed methods approach, all participants were instructed to download the APA app, provided an APA kit (includes seeds embedded within pre-cut squares of adhesive tape), and advised to self-administer APA with guidance from the app for 4 weeks to manage their cLBP. Study outcomes were collected at the preintervention time point as well as postintervention and 1-month follow-up. Interviews were also conducted at the postintervention time point.

RESULTS

Of the 37 participants enrolled, six dropped out, and the attrition rate was 16%. Adherence to APA practice was high (85%-94%). After 4 weeks of APA treatment, participants in the app + telehealth group experienced a 29% decrease in pain intensity during the postintervention time point and a 35% reduction during the 1-month follow-up. Similar improvements were noted in pain interference (28%) and physical function (39%) for participants in the app + telehealth group at the 1-month follow-up. These changes are slightly higher compared with those in the app group (21% pain intensity reduction, 23% improved pain interferences, and 26% improved physical function) during the 1-month follow-up. Overall, APA was found to be feasible using the app and the qualitative findings showed acceptability of the intervention in both groups.

CONCLUSIONS

It is feasible to learn and self-administer APA with an app, supplemented with either in-person or telehealth sessions, presenting a promising intervention toward cLBP self-management. Telehealth was found to boost this intervention effectively.

Auricular Therapy for Treating Phantom Limb Pain Accompanied by Jumping Residual Limb: A Short Review and Case Study

Phantom limb pain (PLP) is a common complaint among patients after amputation, while jumping residual limb is a rare post-amputation complication, they rarely happen at the same time and both remain difficult to manage. At present, there is a paucity of literature on this topic, and no treatment has been proven effective for treating both of them. In the present brief report, we described a patient who developed severe PLP accompanied by jumping residual limb after below-the-knee amputation and she was treated by auricular therapy (AT) with satisfactory effect.

Auricular Point Acupressure Smartphone Application to Manage Chronic Musculoskeletal Pain: A Longitudinal, One-Group, Open Pilot Trial

BACKGROUND

Chronic musculoskeletal pain (CMP) is the most common self-reported chronic pain condition. Current treatment for CMP is limited.

METHODS

This was a two-phase study. In Phase 1, three auricular point acupressure (APA)-naïve participants were recruited to explore their experiences of APA and a smartphone app was developed based on their feedback. In Phase 2, a prospective longitudinal study was used to examine the effectiveness of the smartphone app to self-manage CMP.

RESULTS

Phase 1 resulted in the successful development of the APA smartphone app. In Phase 2, after four weeks of APA, participants reported reduced pain intensity (30%), pain interference (35%), and disability (40%), as well as improved physical function (47%). The mean score for the participants' perception of treatment efficacy was 4.94 (SD = 2.08, scale of 0-7) indicating that approximately 70% of participants rated global improvements with noticeable changes. The majority (88%, n = 22) of the participants were satisfied with the treatment: 32% [8] were very satisfied and 56% [n = 14] were somewhat satisfied. The average frequency of pressing APA seeds per day was 2.93 times (SD = 2.27, range 0-10) and 1.60 minutes per time (SD = 2.64, range 0-10); the participants were able to adhere to the suggested pressing time per day, although they only pressed the ear points about 53% of the suggested time.

CONCLUSION

It is feasible for individuals to learn APA from the smartphone app and successfully self-administer APA to manage their pain. Participants found the app useful and were satisfied with the information provided through the app.

Preliminary Effectiveness of Auricular Point Acupressure on Chemotherapy-Induced Neuropathy: Part 1 Self-Reported Outcomes

PURPOSE

To reduce chemotherapy-induced neuropathy (CIN)-a significant challenge among cancer patients following chemotherapy-we explored the effects of auricular point acupressure (APA), which involves needleless, acupuncture-like stimulation on specific ear points.

DESIGN/METHOD

This pilot study examined the effects of a 4-week APA intervention in the management of CIN. Descriptive analysis was used to examine the changes in study outcomes.

RESULTS

Fifteen participants were enrolled. Two participants dropped out because they developed new medical conditions. Thirteen participants completed the study (87% retention rate). Study participants had more severe symptoms in their lower extremities (i.e., toes, feet, soles) than in their upper extremities (i.e., fingers, wrists, elbows). After the 4-week APA intervention, the mean percentage change scores ranged from 38% (tingling) to 49% (numbness); compared to pre-intervention, the therapeutic effects of APA were sustained at the 1-month follow-up. Function in both upper and lower extremities improved after the APA intervention (≥28%) and continued to improve at the 1-month follow-up (≥36%).

CONCLUSIONS

Preliminary results from this small sample provide initial evidence of the effectiveness of APA on CIN. Future studies should confirm these results using a larger sample, a comparative sham control, and an examination of the underlying physiological mechanisms of the anti-CIN effects of APA.

CLINICAL IMPLICATIONS

APA may provide an inexpensive and effective complementary approach for the self-management of CIN. Once the seeds have been taped to the patient's ear by the provider, patients are empowered to self-manage their CIN in their own environment.

Auricular Point Acupressure to Manage Aromatase Inhibitor-Induced Arthralgia in Postmenopausal Breast Cancer Survivors: A Pilot Study

PURPOSE/OBJECTIVES

To assess the feasibility of auricular point acupressure to manage aromatase inhibitor-induced arthralgia.
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DESIGN

Wait list control design.
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SETTING

Outpatient clinics and oncology center.
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SAMPLE

20 women with aromatase inhibitor-induced arthralgia.
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METHODS

After baseline data were collected, participants waited one month before they received acupressure once per week for four weeks at a convenient time. The baseline data served as the control comparison. Self-reported measures and blood samples were obtained at baseline, at preintervention, weekly during the intervention, and at post-intervention.
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MAIN RESEARCH VARIABLES

The primary outcomes included pain intensity, pain interference, stiffness, and physical function. Inflammatory cytokines and chemokines were tested.
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FINDINGS

After the four-week intervention, participants reported decreases in worst pain and pain interference, and improvements in physical function, cancer-related symptom severity, and interference. The proinflammatory cytokines and chemokines displayed a trend of a mean percentage reduction. The anti-inflammatory cytokine interleukin-13 increased from pre- to postintervention.
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CONCLUSIONS

Auricular point acupressure is feasible and may be effective in managing arthralgia in breast cancer survivors.
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IMPLICATIONS FOR NURSING

Nurses can administer acupressure in clinical settings, which could enhance the management of aromatase inhibitor-induced arthralgia and contribute to a shift from traditional disease-based biomedical models to a broader, integrative, medical paradigm for managing aromatase inhibitor-induced arthralgia.

Pilot Randomized Controlled Trial of Auricular Point Acupressure to Manage Symptom Clusters of Pain, Fatigue, and Disturbed Sleep in Breast Cancer Patients

BACKGROUND

Current management for a symptom cluster of pain, fatigue, and disturbed sleep in breast cancer patients has limited effects.

OBJECTIVE

The purposes of this prospective, randomized controlled pilot study were to (1) assess the feasibility and tolerability of auricular point acupressure (APA) intervention to manage pain, fatigue, and sleep disturbance in breast cancer patients and (2) provide an initial appraisal of effect size as compared with a control intervention.

METHODS

Thirty-one participants were randomized into either an active APA group (n = 16) or a control APA group (n = 15), which included the sham APA treatment not related to the symptoms. All participants received the APA once a week for 4 weeks. Self-report measures were obtained at baseline, weekly during intervention, at end of intervention, and at a 1-month follow-up.

RESULTS

For the 4-week of APA treatment, the retention rate was 88% for the active APA group and 73% for the control APA group. After 4 weeks of APA, participants in the active APA treatment had reported a reduction of 71% in pain, 44% in fatigue, 31% in sleep disturbance, and 61% in interference with daily activities. The control APA group experienced some moderate reduction in these symptoms.

CONCLUSION

Given that this was a pilot study with a small sample size, results must be interpreted with caution.

IMPLICATIONS FOR PRACTICE

Our results suggest that APA may provide an inexpensive and effective complementary approach for the management of symptom clusters for breast cancer patients, and further study is warranted.

Association of Auricular Reflective Points and Status of Type 2 Diabetes Mellitus: A Matched Case-Control Study

The reflexive property of the ear can cause various physical attributes to appear on the auricle in the presence of bodily disorders. The association of auricular signals (presence or absence of discoloration, marks after pressing, tenderness, and electrical resistance) and diabetes mellitus (DM) should be further investigated because auricular diagnosis is an objective, painless, and noninvasive method that provides rapid access to information. A matched case-control study on 282 subjects was conducted. Cases (n = 141) were defined as those diagnosed with type 2 DM (T2DM). Every subject in the case group was matched with the control by age and gender. Ear diagnosis was conducted in three aspects: inspection, electrical detection, and tenderness testing. Results suggest that the tenderness and electrical conductivity of some auricular points, including “pancreas and gallbladder,” “endocrine,” “kidney,” “lower tragus,” “heart,” and “eyes,” were associated with T2DM status in Chinese population. In the subgroup analyses, certain auricular signals were also associated with glycemic control, disease duration, and related complications. Auricular diagnosis could be considered as a screening method for vulnerable populations with T2DM risk. Thus, appropriate interventions can be implemented to prevent or delay the progression of T2DM.

Day-to-Day Changes of Auricular Point Acupressure to Manage Chronic Low Back Pain: A 29-day Randomized Controlled Study

OBJECTIVE

The purpose of this study was to determine the effects of a 4-week auricular point acupressure (APA) treatment on chronic low back pain (CLBP) outcomes and examine the day-to-day variability of CLBP in individuals receiving APA for CLBP over 29 days.

DESIGN

This was a prospective, randomized controlled trial (RCT). Data were collected at baseline, during each of the four office visits for APA treatment, after the completion of the 4-week intervention, and 1 month after the last treatment. A daily diary was given to each participant to record his or her APA practices, analgesic use, and pain intensity.

INTERVENTIONS

APA was used to manage CLBP. The participants received one APA treatment per week for 4 weeks.

PATIENTS AND SETTING

Sixty-one participants with CLBP were randomized into either a real APA or sham APA treatment group. Participants were recruited from primary care offices and clinics or through the Research Participant Registry at the University of Pittsburgh.

RESULTS

Among participants in the real APA group, a 30% reduction of worst pain was exhibited after the first day of APA treatment, and continuous reduction in pain (44%) was reported by the completion of the 4-week APA. This magnitude of pain reduction reached the clinically significant level of improvement reported in other clinical trials of chronic pain therapies. Analgesic use by participants in the real APA group also was reduced compared with use by participants in the sham group.

CONCLUSION

This study shows that APA is a promising pain management strategy that is not invasive and can be self-managed by participants for CLBP. Given the day-to-day fluctuation in ratings, the tighter ecologic assessment of pain scores and other treatment parameters are an important pragmatic aspect of the design of chronic pain studies.

Association of auricular reflective points and the status of lower urinary tract symptoms in aging males

OBJECTIVE

This study aimed to investigate the association between auricular reflective points and the status of lower urinary tract symptoms (LUTS) among Chinese aging males.

METHODS

A total of 113 male participants, with 69 having LUTS (LUTS+ve) and 44 having no LUTS (LUTS-ve), were recruited for this case-control study. Ear diagnosis was conducted in three ways: inspection, electrical skin resistance measurement, and tenderness testing.

RESULTS

Quality of life was lower among the LUTS+ve cases than among the LUTS-ve cases. The tenderness and electrical conductivity of a number of auricular points, including the "angle of superior concha", the "urinary bladder", the "ureter", the "kidney", the "urethra", and the "internal genitals" were associated with LUTS in the Chinese aging males. In terms of electrical conductivity, the "angle of superior concha" on both ears exhibited the highest sensitivity among the other auricular points under testing. This auricular point also demonstrated considerable sensitivity, specificity, and positive/negative predictive values for both ears during the tenderness testing.

CONCLUSIONS

Auricular diagnosis has a pre-diagnostic value and could be considered as a screening method for the aging population with relatively high LUTS risk.

Efficacy of auricular therapy for pain management: a systematic review and meta-analysis

Objective. The objective of this systematic review and meta-analysis was to assess the efficacy of auricular therapy by including a sham therapy control group. Methods. Relevant, randomized clinical trials (RCTs) were identified by searching medical related databases from, depending on journal, 1900 (at the earliest) to 1994 (at the latest) through May 2013. The outcome measure was a pain intensity score. Results. Twenty-two RCTs were identified and 13 RCTs were included for meta-analysis. In these studies, auricular therapy provided significant pain relief when compared to a sham or control group. The overall standardized mean differences (SMD) was 1.59 (95% CI [-2.36, -0.82]) (13 trials, total subject numbers = 806), indicating that, on average, the mean decrease in pain score for auricular therapy group was 1.59 standard deviations greater than the mean decrease for the sham control. In terms of the efficacy of the different treatment methods, auricular acupressure boasts the largest strength of evidence for pain relief, followed by auricular acupuncture. Electroacupuncture stimulation did not show significant evidence for efficacy, which may be due to the small sample size (i.e., only 19 subjects were included). Conclusion. Further large-scale RCTs are needed to determine the efficacy of auricular therapy for pain.