Ear Acupuncture for Immediate Pain Relief-A Systematic Review and Meta-Analysis of Randomized Controlled Trials

A scoping review of mechanisms of auricular acupuncture for treatment of pain

OBJECTIVES

Auricular acupuncture (AA) is becoming increasingly common in primary care clinics, emergency departments and peri-operatively for pain relief. Over the last decade, since the last comprehensive reviews were published, the literature has expanded. In this scoping review, we seek to document the efficacy of AA in treating both acute and chronic pain, describe the mechanism of action of AA in treating pain, and discuss how AA has been integrated into Western medicine to date.

METHODS

The authors performed a MEDLINE search inclusive of articles from 1966 to June 2023 including articles written in English identifying literature. We included human studies when more than 3 patients were included. Three hundred and fourteen unique articles were identified and 152 were selected by title screen. After abstract review, 117 were chosen for full-text review. Following full-text review, 33 articles were excluded and 21 added from references, totaling 105 articles included in our scoping review.

RESULTS

AA reduces pain severity in patients with both acute and chronic pain. The best studies in the acute settings have occurred in the peri-operative setting where sham AA is employed, multiple sessions of AA are given, and medication dosing is carefully monitored. In these cases, AA reduced pain and post-operative medications. In patients with chronic pain, multiple sessions of AA resulted not only in pain relief but also in improvements in function and disability. Literature suggests that AA works through multiple mechanisms with the most compelling data coupled to the autonomic nervous system and neuroendocrine system. Curriculums designed to teach AA and aid in implementation have been published.

CONCLUSION

AA is an accessible, effective means of pain relief. AA is relatively straightforward to learn, and protocols and curriculums exist to teach healthcare professionals this valuable skill. Overcoming implementation barriers, including patient education, are essential next steps.

Battlefield Acupuncture as a Treatment Option for Chronic Tinnitus: A Pilot Study

INTRODUCTION

There is no cure for tinnitus, which is a highly prevalent condition in service members and veterans. Battlefield acupuncture (BFA) can be used to manage pain and stress-related symptoms. We investigated BFA as a safe, low-cost treatment for tinnitus perception and coping in eight chronic tinnitus patients who were followed for 6 months after two BFA treatments to identify changes in tinnitus severity or impact.

MATERIALS AND METHODS

Patients completed case history, Tinnitus Screener, Tinnitus Functional Index (TFI), Tinnitus Reaction Questionnaire (TRQ), and Hospital Anxiety and Depression Scale (HADS) questionnaires at baseline, at two BFA treatment sessions (2 weeks apart), and at four follow-up sessions (at 1, 2, 4 and 6 months after treatment). Questionnaire score changes were evaluated over time by using restricted maximum likelihood hierarchical regression modeling from baseline to 1-, 2-, 4-, and 6-month post-treatment follow-ups.

RESULTS

TFI and TRQ group means were both significantly reduced at 1 month after treatment, and these reductions persisted through the 2- and 4-month follow-ups. The TRQ group mean remained significantly reduced after 6 months.

CONCLUSIONS

Findings from eight chronic tinnitus sufferers who received two BFA treatment sessions are reported here, suggesting at least short-term treatment benefits observed as reductions in tinnitus-related psychological distress and impact. Although these findings are constrained by the study's small sample size and limited treatment period, its findings underscore the need for further research to determine the potential benefits of BFA for individuals who suffer from chronic tinnitus. Future research should consider the possibility of more lasting benefits through extended BFA treatment, with a comparison of BFA treatment against other treatment methods.

Efficacy and safety of acupuncture-point stimulation combined with opioids for the treatment of moderate to severe cancer pain: a network meta-analysis of randomized controlled trials

Background

Pain is one of the most common and troublesome symptoms of cancer. Although potential positive effects of acupuncture-point stimulation (APS) on cancer pain have been observed, knowledge regarding the selection of the optimal APS remains unclear because of a lack of evidence from head-to-head randomized controlled trials (RCTs).

Objective

This study aimed to carry out a network meta-analysis to compare the efficacy and safety of different APS combined with opioids in treating moderate to severe cancer pain and rank these methods for practical consideration.

Methods

A comprehensive search of eight electronic databases was conducted to obtain RCTs involving different APS combined with opioids for moderate to severe cancer pain. Data were screened and extracted independently using predesigned forms. The quality of RCTs was appraised with the Cochrane Collaboration risk-of-bias tool. The primary outcome was the total pain relief rate. Secondary outcomes were the total incidence of adverse reactions, the incidence of nausea and vomiting, and the incidence of constipation. We applied a frequentist, fixed-effect network meta-analysis model to pool effect sizes across trials using rate ratios (RR) with their 95% confidence intervals (CI). Network meta-analysis was performed using Stata/SE 16.0.

Results

We included 48 RCTs, which consisted of 4,026 patients, and investigated nine interventions. A network meta-analysis showed that a combination of APS and opioids was superior in relieving moderate to severe cancer pain and reducing the incidence of adverse reactions such as nausea, vomiting, and constipation compared to opioids alone. The ranking of total pain relief rates was as follows: fire needle (surface under the cumulative ranking curve (SUCRA) = 91.1%), body acupuncture (SUCRA = 85.0%), point embedding (SUCRA = 67.7%), auricular acupuncture (SUCRA = 53.8%), moxibustion (SUCRA = 41.9%), transcutaneous electrical acupoint stimulation (TEAS) (SUCRA = 39.0%), electroacupuncture (SUCRA = 37.4%), and wrist-ankle acupuncture (SUCRA = 34.1%). The ranking of total incidence of adverse reactions was as follows: auricular acupuncture (SUCRA = 23.3%), electroacupuncture (SUCRA = 25.1%), fire needle (SUCRA = 27.2%), point embedding (SUCRA = 42.6%), moxibustion (SUCRA = 48.2%), body acupuncture (SUCRA = 49.8%), wrist-ankle acupuncture (SUCRA = 57.8%), TEAS (SUCRA = 76.3%), and opioids alone (SUCRA = 99.7%).

Conclusions

APS seemed to be effective in relieving cancer pain and reducing opioid-related adverse reactions. Fire needle combined with opioids may be a promising intervention to reduce moderate to severe cancer pain as well as reduce opioid-related adverse reactions. However, the evidence was not conclusive. More high-quality trials investigating the stability of evidence levels of different interventions on cancer pain must be conducted.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier CRD42022362054.

The effectiveness of auricular acupressure on pain management during labor: A systematic review and meta-analysis of randomized controlled trials

AIM

This meta-analysis aimed to systematically evaluate the effectiveness of auricular acupressure on pain management during labor.

METHODS

Six English and three Chinese electronic databases were comprehensively searched from inception to 6 November 2021. The PRISMA checklist was followed. The methodological quality of the included studies was assessed with the Cochrane Collaboration Bias Risk Assessment Tool. The meta-analysis was performed using Review Manager 5.3 software. Heterogeneity between studies was calculated using I² .

RESULTS

Five studies comprising 312 participants were included. The labor pain scores of the auricular acupressure group were significantly lower than those of the usual care group at cervix dilations of 6, 8, and 10 cm, with mean differences (95% confidence intervals) of -1.05 (-1.41, -0.69), -1.44 (-2.07, -0.82), and -1.96 (-3.30, -0.61), respectively. Auricular acupressure can thus effectively improve the labor pain perception at cervix dilations of 6, 8, and 10 cm. Moreover, auricular acupressure shortened the active phase, and had the trend of shortening the second and third stages of labor. There was no evidence that auricular acupressure had an effect on the rate of cesarean section or the 1 and 5 min Apgar scores.

CONCLUSION

Effective labor pain relief, better labor pain perception, and the lack of adverse effects support the use of auricular acupressure. More high-quality and rigorous trials are needed to verify our findings before we can make strong recommendations.

Kinesio Taping vs. Auricular Acupressure for the Personalised Treatment of Primary Dysmenorrhoea: A Pilot Randomized Controlled Trial

BACKGROUND

Dysmenorrhoea is the medical term for menstrual pain. The World Health Organization estimates that up to 81% of women of childbearing age are affected by this condition, and it is one of the leading causes of absenteeism from work and school among women. Although there are pharmacological treatments available for menstrual-pain relief, they do not respond to all women's needs. Therefore, there is a need to study and develop non-pharmacological alternatives to broaden the individualised treatment options for dysmenorrhea. There are scarce studies published on non-pharmacological treatments, such as kinesio tape and auricular acupressure for the relief of menstrual pain, but the scientific evidence available suggest that these techniques may be beneficial in addressing this problem. The objective of this pilot study was to assess and compare the effectiveness of kinesio tape and auricular acupressure to decrease pain and drug intake in women with primary dysmenorrhoea.

METHODS

This was a double-blind randomized clinical controlled trial. The period of study was from September 2017 to August 2018. Women enrolled in the University of Extremadura and who had primary dysmenorrhoea were randomized to five groups: control (n = 23), kinesio tape (n = 23), placebo kinesio tape (n = 23), auricular acupressure (n = 23) and placebo auricular acupressure (n = 22). Measures were taken during the pretreatment phase (at four menstrual cycles), during the post-intervention phase (at four menstrual cycles) and during the follow-up phase (at the first and third menstrual cycles after the treatment was completed). The primary outcome measures were mean pain intensity, maximum pain intensity, number of painful days and dose of drug intake during menstruation, measured with the Visual Analogue Scale. The secondary outcome measures were the length of the cycle, the length of menstruation, the drug intake and the type of drug.

RESULTS

In all, 108 participants completed the study. The statistical analysis (MANOVA, ANOVA, t-paired and McNemar tests) showed that kinesio tape and auricular acupressure have a beneficial effect on pain relief (mean pain intensity, p < 0.001; maximum pain intensity, p < 0.001; number of painful days, p = 0.021; dose of drug intake, p < 0.001). In addition, once the treatments were withdrawn, the auricular-acupressure group maintained lower scores during the first follow-up cycle (p < 0.001).

CONCLUSIONS

Kinesio tape and auricular acupressure decrease pain and drug intake in women with primary dysmenorrhoea. The changes in the auricular-acupressure group seemed to last longer. The results suggest that these techniques could be used as complementary personalised therapies to the pharmacological treatment and not as a substitution.

The Frequency and Perceived Effectiveness of Pain Self-Management Strategies Used by Individuals With Migraine

BACKGROUND

Migraine is ranked among the most important causes of disability worldwide. Some effective migraine treatments have been identified. However, little is known regarding the treatment strategies used by patients with migraine to manage pain or their efficacy.

PURPOSE

This study was designed to (a) investigate the pain management strategies used by migraineurs and their perceived effectiveness and (b) evaluate the association between the number of strategies used and their overall perceived effectiveness.

METHODS

A cross-sectional design with consecutive sampling was used in a medical center in Taiwan. Individuals with migraine (N = 174) completed self-administered questionnaires and in-depth interviews to assess the frequency and perceived effectiveness of a variety of pain management strategies.

RESULTS

Most participants reported using prescription medications (56%) and over-the-counter medications (51%), which were rated as having good efficacy rates of 78% and 81%, respectively. Traditional Chinese medicine (17%) and folk remedies (13%) were used less frequently and rated as relatively less effective at 65% and 48%, respectively. About half (47%) reported using more than one pain management strategy. Significantly more of those who reported using multiple pain management strategies reported at least "some effect" than those who reported using one strategy only (73% vs. 27%, p = .001).

CONCLUSIONS

Prescription medications showed good usage rate and good perceived efficacy. However, about half of the participants used multiple pain management strategies, supporting the need for further research to evaluate the efficacy of combination treatments and to identify those combinations that may have the most additive and/or synergistic effects. Furthermore, the findings indicate that continued use of medications for migraine management is appropriate for many individuals because of the relatively high rates of perceived efficacy for this strategy found in this study.

Acupuncture for palliative cancer pain management: systematic review

BACKGROUND

Pain is one of the most common and problematic symptoms encountered by patients with cancer. Due to the multifactorial aetiology, pain management of these patients frequently requires multidisciplinary interventions including conventional support and specialty palliative care. Acupuncture has been identified as a possible adjunctive therapy for symptom management in cancer pain, and there is currently no systematic review focused solely on the evidence of acupuncture on cancer pain in palliative care.

OBJECTIVE

To critically analyse currently available publications regarding the use of acupuncture for pain management among patients with cancer in palliative care settings.

METHODS

Multiple academic databases were searched from inception to 29 October 2020. Randomised controlled trials involving acupuncture in palliative care for treatment of cancer-related pain were synthesised. Data were extracted by two independent reviewers, and methodological quality of each included study was assessed using the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence.

RESULTS

Five studies (n=189) were included in this systematic review. Results indicated a favourable effect of acupuncture on pain relief in palliative care for patients with cancer. According to OCEBM 2011 Levels of Evidence, they were level 2 in one case (20%), level 3 in two cases (40%) and level 4 in the remaining (40%). Low-level evidence adversely affects the reliability of findings.

CONCLUSIONS

Acupuncture may be an effective and safe treatment associated with pain reduction in the palliative care of patients with cancer. Further high-quality, adequately powered studies are needed in the future.

Lessons Learned in Teaching Battlefield (Ear) Acupuncture to Emergency Medicine Clinicians

Background: Acupuncture, in general, is being proclaimed as an alternative analgesic amid the opioid crisis, and along with this, within emergency departments (EDs) there is a specific interest in a form of ear acupuncture called Battlefield Acupuncture (BFA). It is expected that BFA will be used more widely in emergency medicine as it is easy to learn and can be applied both promptly and easily. Teaching programs will be required to sustain this increased demand and upskill emergency clinicians in this skill. Objectives: This article provides experiences and recommendations, based on faculty experiences from teaching BFA in Australia to ED clinicians combined with formal participant feedback. Main Points: BFA courses were adjusted to suit ED doctors and nurses, along with their unique case mix and associated challenging environment. The content of the BFA courses included evidence, pain indications, contraindications, application, safety, mechanism of action, and how to negotiate barriers of credentialing. Workshops used the latest and most effective teaching methods that encompassed problem-based learning, infotainment, simulation, "four stage skills teaching," and "teaching on the run." Conclusion: It is hoped that the experiences gained, and lessons learned in educating this new frontier of BFA to emergency clinicians will assist others in teaching BFA and its related techniques as a viable analgesic alternative in emergency medicine.

Perceptions Regarding Daith Piercing in Migraine, A Survey of Pediatric Patients

The treatment of migraine is evolving to include non-traditional approaches, as pharmacologic therapy alone is unsuccessful in many patients. Daith piercing, a cartilaginous ear piercing, has become popular as a potential nonpharmacological treatment option for migraine. However, there are no systematic data on the utilization and efficacy of these piercings. Therefore, we investigated the perceptions of pediatric patients regarding Daith piercing and gathered initial retrospective data for patients who had already received it. Patients presenting to a pediatric neurology clinic were invited to complete a questionnaire to assess knowledge about and attitudes towards Daith piercing and their willingness to undergo such a treatment. For those with a Daith piercing, the effects on headaches, function, and mood were evaluated. Of the 171 respondents, 61% had prior knowledge of Daith piercings, 27% knew someone with a Daith piercing, and 60% of patients presenting with headache were willing to undergo piercing. Of the eight patients (5% of respondents) who had already undergone piercing, six (75%) reported improvement in headaches, five (62%) had missed fewer days of school or work, and seven (87%) reported mood improvement. The high proportion of pediatric patients willing to undergo this form of treatment speaks to the desire for and acceptance of nonpharmacologic treatments. Although based on a small sample, the data from children who have already undergone Daith piercing is promising and supports a need for further systematic investigation into this treatment approach.

The Roles of Battlefield Acupuncture and Electroacupuncture in a Patient with Cancer-Related Pain

Background: Pain is one of the most-frightening complications of cancer and disrupts quality of life. Cancer-related pain can be caused by primary cancer itself, metastases that occur, and interventions to treat cancer. Almost all cancer-related pain is pain with moderate-to-severe intensity. Thus, cancer-related pain management often involves administration of opioid analgesics. However, administration of opioid analgesics can cause side-effects that cause new problems for these patients. Several studies have shown that acupuncture can reduce cancer-related pain and data show that acupuncture therapy is safe and can provide clinically meaningful improvements when used in conjunction with standard therapy. Case: A 72-year-old female patient had pain throughout her body since 1 month prior to before being admitted to the hospital. She was unable to sleep at night often cried because she was unable to stand the pain. This was reduced by morphine 3 × /day. Because of the drug's side-effects, she slept more often during the day, could not sleep at night, and was constipated. She also had breakthrough pain, on an average of 2-3 × /day. She had a history of malignancy in the pleura, liver, lungs, and cervix. There was an increase in some tumor markers. Her baseline numeric rating scale (NRS) assessment was 4 with an oral morphine slow-release tablet 3 × 15 mg/day. Acupuncture therapy was performed at Battlefield Acupuncture points of the right ear and body acupuncture points (LI 4, LI 11, ST 36, SP 6, and LR 3) was treated with 3-Hz continuous-wave electroacupuncture for 30 minutes at each session. During this therapy, there were reductions in pain (baseline NRS 4 became 2), need for morphine, morphine side-effects, and frequency of breakthrough pain. There were no significant side-effects due to acupuncture. Conclusions: Acupuncture is an effective and safe therapeutic option for reducing cancer pain with minimal side-effects. Acupuncture can enable a reduced need for narcotic analgesics.

Effect of auricular electroacupuncture combined with body acupuncture in improving the consciousness of patients after traumatic brain injury: Study protocol for a randomized controlled trial

BACKGROUND

Traumatic brain injury (TBI) has become a major cause of morbidity and mortality both in China and abroad. Disorders of consciousness following severe TBI is a common refractory complication, resulting in difficult rehabilitation and poor life quality. However, effective therapeutic approaches remain limited. Although acupuncture has been widely applied in the treatment of neurological disorders in China, its efficacy and safety for consciousness recovery remain to be elucidated.

METHODS

Here, we conduct a study design and protocol of a randomized, blinded, controlled study to evaluate the efficacy and safety of electroacupuncture at auricular acupoints "heart" and "brainstem" combined with body acupuncture in the consciousness recovery of patients with TBI. A total of 80 patients with initial Glasgow coma scale score between 3 and 8 points will be recruited in the trial and randomized into intervention (combined application of auricular electroacupuncture and body acupuncture) group or control (conventional treatment) group. Patients in the intervention group will receive electroacupuncture at bilateral auricular acupoints "heart" and "brainstem" (4 points in total) combined with body acupuncture in addition to conventional treatment while patients in the control group will receive conventional treatment alone for 8 weeks. The primary outcomes are changes of Glasgow coma scale score and mismatch negativity of event-related brain potentials at baseline after 4 weeks after the final treatment and 4 weeks after the final treatment. The secondary outcome measures will be changes of Barthel and FuglMeyer scores at baseline after 4 weeks after the final treatment and 4 weeks after the final treatment. The safety will also be assessed by monitoring the incidence of adverse events and changes in vital signs during the study.

DISCUSSION

Results from this trial will significantly support the application of auricular acupuncture and body acupuncture in the consciousness recovery of patients with severe TBI. If found to be effective and safe, auricular acupuncture combined with body acupuncture will be a valuable complementary option for comatose patients with TBI.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1800020245. Registered on 21 December 2018.

Challenges and Strategies for Implementing Battlefield Acupuncture in the Veterans Administration: A Qualitative Study of Provider Perspectives

Objective: Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges. Materials and Methods: Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide. Results: Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues. Conclusions: System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention.

Efficacy and Safety of Auricular Acupuncture for Cognitive Impairment and Dementia: A Systematic Review

OBJECTIVES

To analyze the efficacy and safety of auricular acupuncture (AA) in patients with cognitive impairment and dementia.

METHODS

Twelve electronic databases were searched for randomized controlled trials evaluating effects of AA in patients with cognitive impairment and/or dementia, from their inception to August 2017. The primary outcome was cognitive function, and secondary outcomes were self-care ability, quality of life, clinical efficacy rate, and incidences of adverse events.

RESULTS

Nine studies were included, and five involving 677 participants were analyzed quantitatively. Compared with Western medications (WM), AA had mixed effects on cognitive functions (Mini-Mental State Examination [MMSE], mean difference [MD] 0.73, 95% confidence interval [CI] -0.02 to 1.48; Hierarchic Dementia Scale [HDS], MD 2.21, 95% CI 1.09 to 3.33); there was no significant improvement in the activities of daily living (ADL) score (MD 0.20, 95% CI -3.51 to 3.91) in patients with vascular dementia (VD). Compared to WM, AA combined with WM showed better clinical efficacy rate (risk ratio [RR] 1.42, 95% CI 1.06 to 1.91) in patients with VD; there was no significant improvement in cognitive functions (MMSE, MD 0.97, 95% CI -0.44 to 2.38; Montreal Cognitive Assessment [MoCA], MD 0.22, 95% CI -1.83 to 2.27) in patients with mild cognitive impairment (MCI). Compared to herbal medicine (HM), AA plus HM showed significant improvements in cognitive function (MMSE, MD 1.31, 95% CI 0.13 to 2.49) in patients with MCI and patients with vascular cognitive impairment, no dementia (VCIND) and in ADL score (MD -6.70, 95% CI -8.78 to -4.62) in patients with MCI. No adverse event associated with AA was reported.

CONCLUSION

The evidence reveals mixed efficacy of AA in patients with cognitive impairment and/or dementia. However, the results were inconclusive because of the small number and poor methodological quality of the included studies.

Does Ear Acupuncture Have a Role for Pain Relief in the Emergency Setting? A Systematic Review and Meta-Analysis

Objective: Ear acupuncture might be the form of acupuncture best suited to improving acute pain management in the emergency department (ED). The primary aim of this review was to assess the analgesic efficacy of ear acupuncture in the ED. Secondary outcomes included measures of patient satisfaction, adverse effects, cost, administration techniques, and reduction of medication usage. Methods: Seven databases and Google Scholar were searched up to April 27, 2017, using MeSH descriptors for three overarching themes (ear acupuncture, pain management, and emergency medicine). Meta-analyses were performed in 3 comparator groups: (1) ear acupuncture versus sham; (2) ear acupuncture-as-adjunct to standard care; and (3) ear acupuncture (both as sole therapy and adjuvant) versus control to calculate the standardized mean difference (SMD) and weighted mean difference (WMD) for pain scores out of 10. Results: Six randomized controlled trials and 2 observational studies, totaling 458 patients, were retrieved after exclusions. The meta-analysis used data from 4 randomized studies representing 286 patients. The above 3 comparator groups resulted in SMDs of 1.69, 1.68, and 1.66, and WMDs of 2.47, 2.84, and 2.61 respectively, all favoring acupuncture. Battlefield (ear) acupuncture was the most commonly used technique. There were no significant adverse effects and patient satisfaction improved. Results regarding if acupuncture reduced medication use were equivocal. Significant study bias and heterogeneity were found. Conclusions: While study numbers are limited, ear acupuncture, either as stand-alone or as-an-adjunct technique, significantly reduced pain scores and has potential benefits for use in the ED. Further studies will define acupuncture's role and if it reduces use of analgesic medications.