By: Weizhe, Liu
The author reports on the effectiveness of ear acupuncture in the treatment of 40 cases of insomnia. The age range was 18-51 years and the duration of disease was from 2 weeks--30 years. Those with organic brain disease or mental illness were excluded from the study. The main points used were Ear Shenmen, Heart, Mouth (experience point to promote sleep), Occiput, Anterior Lobe (Neurasthenia) and Subcortex. Additional points were given according to the differential diagnosis as follows: for deficiency of the Heart and Spleen, Ear Spleen; for disharmony between the Heart and Kidney, Ear Kidney; for Liver fire, Ear Liver; for deficiency of the Heart and Gallbladder, Ear Gallbladder; and for dysfunction of the Stomach, Ear Stomach. Electrodes from a self-made multi-electrode device were placed on the points and stimulated with a continuous wave to the patient's maximum tolerance for 20 minutes. Ear seeds were then applied on both ears and patients asked to press on alternate ears for 20 seconds 3x daily. Ten treatments constituted one course. Cure was defined as sleeping for more than six hours, remarkable effectiveness as more than four hours and effectiveness as intermittent sleep with a slight alleviation of symptoms (undefined). The cure rate was 50%, remarkable effectiveness was 27.5%, effectiveness was 12.5% and 10% had no result. A typical case history was given in which the patient required two courses of treatment (60 days) to be able to sleep 6-8 hours a night without medication. On follow-up a year later she was still sleeping well.
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Tampilkan postingan dengan label Ear acupuncture. Tampilkan semua postingan
Rabu, 28 Januari 2009
Treating different diseases with the point Ear Apex
By: Wang, Xiaoyan
Abstract
The function of the auricular point Ear Apex (Erjian M-HN-10) is discussed in this paper and case histories showing the effective treatment of herpes zoster, acute conjunctivitis, high fever, pharyngitis and aphonia by bleeding Ear Apex with a three-edged needle are discussed.
In each case the patients' suffering was alleviated within a few minutes.
Keywords: Ear apex, bloodletting, bleeding, herpes zoster, acute conjunctivitis, high fever, pharyngitis, aphonia, acupuncture
Introduction
The auricle is a microcosm of the human body and the area of confluence of the twelve primary channels. The point Ear Apex is located at the tip of the helix. With the posterior half of the ear folded forward, the point is located at the highest point of the superior crease. Its action is to promote qi and blood circulation, clear damp-heat and toxic pathogens, remove stagnant qi and blood, resolve swelling and alleviate pain. It is very effective for diseases of head and neck, especially those characterised by excess of yang, heat and pain.
In this article we recount a number of case histories of patients whose disorders were treated by bleeding the point Ear Apex with a traditional three-edged needle using the "pinching method". With this technique, the point to be treated is pinched between the thumb and index finger. This action isolates the points and promotes venous pooling, which facilitates bleeding. The point to be bled is swabbed with 70% isopropyl alcohol and allowed to dry naturally. The discomfort of bleeding can virtually be eliminated via a rapid insertion to the desired shallow depth of about 0.05-0.1 cun.
Case History 1: Herpes zoster
A 60-year-old male complained of a severe burning pain with red rashes on his neck and behind his right ear for the past five days. He had hypersensitivity to touch, anorexia and restlessness. Associated symptoms included a bitter taste in the mouth, a poor appetite, dry throat, constipation and scanty deep-coloured urine. His greatest concern was that he had hardly slept for five days and nights. His condition showed no improvement after taking medication and his friend recommended him to me. On examination, he had small clusters of blisters filled with clear liquid, redness of the tongue tip and sides with a thin yellowish coating, and a wiry and rapid pulse. The diagnosis was herpes zoster and the differentiation was damp-heat and toxic pathogens affecting the Liver and Gall Bladder channels. After strictly sterilising the point Ear Apex with Betadyne and alcohol, I pricked the points bilaterally to let out seven or eight drops of blood. He immediately reported that most of the pain had been relieved and that he felt a relaxing sensation in his head and neck. Then auricular taping of Wang Bu Liu Xing (Vaccaraie Semen) was applied on his left ear at points Liver, Gallbladder, Neck, Heart and Ear Shenmen, to be retained for seven days. When he visited the next day, he reported that he felt much better and had had five-hours of deep sleep the previous night. After one more treatment, his disease was cured.
Case History 2: Acute conjunctivitis
A 35-year-old male had been suffering from painful and itching eyes for two days. He had headache, photophobia, red-looking eyes with copious sticky yellow-discharge, stabbing pain, lacrimation and the sensation of a foreign body in the eyes, but his vision was normal. The tip of the tongue was red and his pulse was slightly wiry. The diagnosis was acute conjunctivitis and the differentiation was wind-heat affecting the Liver channel. Point Ear Apex was bled as above. During the treatment, he reported that his eyes were comfortable and cool. Following one more treatment the next day, he was cured.
Case History 3: High vever
A 22-year-old male had suffered fever for one day. He had mild chills, pain over the whole body, weakness, sore throat and a poor appetite. The temperature was 40[degrees]C. The white blood cell count was 10,300. His tongue was red with a thin yellow coating and his pulse was rapid and floating. The diagnosis was high fever and the differentiation was hyperactivity of heat-evil at the Qi level. After pricking the point Ear Apex to let out about seven or eight drops of blood, he instantly felt more comfortable and his sore throat had almost gone. His temperature dropped to 39.5[degrees]C and one hour later reduced to 38[degrees]C. He was given Ban Lan Gen (Radix Isatidis seu Baphicacanthi) to take away with him. Two days later, his fever had completely gone.
Case History 4: Pharyngitis
A 40-year-old male had caught a cold and subsequently suffered from a sore and itching throat for two weeks, accompanied by a dry mouth and a dry cough without phlegm. His throat was red and his tonsils were swollen. The tip and sides of the tongue were red and his pulse was floating and a little rapid. The diagnosis was pharyngitis and the differentiation was wind-heat evil in the upper jiao. After bloodletting at Ear Apex, I punctured a red spot near Feishu BL-13 and let out 3-4 drops of blood. Following the treatment, he said that his sore throat had almost gone. Next day his dry mouth had resolved, he only occasionally had dry cough, his pharynx was slightly red and the swelling in his tonsils had reduced. I pricked and bled Ear Apex again and he totally recovered.
Case History 5: Aphonia
A 26-year-old female had had a cold for five days and had been unable to speak for two days, with a painful throat and a dry mouth. Her throat was red with no swelling of the tonsils. The tip and sides of her tongue were red, and her pulse was floating. The diagnosis was aphonia and the differentiation was impairment of the Lung by attack of wind-heat evil. After pricking and bleeding of Ear Apex, she felt cool and comfortable in her throat and could speak in a low voice. After one more treatment the next day, she was totally cured.
Discussion
Auricular therapy has several advantages over body acupuncture, for example simplicity, practicality and easy acceptance by patients. Pricking and bleeding Ear Apex is an ideal method for treating any diseases of the head and neck caused by invasion of the body by damp-heat, wind-heat and toxic pathogens.
During the treatment, attention should be paid to the following points.
1. Do not treat patients who are weak, fasting, or in a nervous state.
2. Do not use this kind of treatment for patients who suffer from anaemia, hypotension, any hemorrhagic diseases etc.
3. During the treatment, sureness, accuracy and speed are the key to a good technique.
4. If a distinct capillary near Ear Apex is observed, bleeding it instead of the more conventional location may produce dramatic results.
Bibliography
Bai, Xinghua, (1994). Chinese Auricular Therapy. Beijing: Scientific and Technical Documents Publishing House.
Sun, Guojie, et al., (1998): Acupuncture and Moxibustion. Shanghai: Shanghai Scientific and Technical Publishing House.
Brazil, J., et al., (1997): Clean Needle Technique Manual for Acupuncturists. Washington, D. C.: National Acupuncture Foundation.
Xiaoyan Wang has been a licensed acupuncturist in Richmond, Virginia, USA and has published about 20 peer-reviewed papers. She was a Traditional Chinese Medicine (TCM) Doctor in charge in the TCM Hospital of Qinghai Province and Hospital of Southeast University, China for 11 years.
Abstract
The function of the auricular point Ear Apex (Erjian M-HN-10) is discussed in this paper and case histories showing the effective treatment of herpes zoster, acute conjunctivitis, high fever, pharyngitis and aphonia by bleeding Ear Apex with a three-edged needle are discussed.
In each case the patients' suffering was alleviated within a few minutes.
Keywords: Ear apex, bloodletting, bleeding, herpes zoster, acute conjunctivitis, high fever, pharyngitis, aphonia, acupuncture
Introduction
The auricle is a microcosm of the human body and the area of confluence of the twelve primary channels. The point Ear Apex is located at the tip of the helix. With the posterior half of the ear folded forward, the point is located at the highest point of the superior crease. Its action is to promote qi and blood circulation, clear damp-heat and toxic pathogens, remove stagnant qi and blood, resolve swelling and alleviate pain. It is very effective for diseases of head and neck, especially those characterised by excess of yang, heat and pain.
In this article we recount a number of case histories of patients whose disorders were treated by bleeding the point Ear Apex with a traditional three-edged needle using the "pinching method". With this technique, the point to be treated is pinched between the thumb and index finger. This action isolates the points and promotes venous pooling, which facilitates bleeding. The point to be bled is swabbed with 70% isopropyl alcohol and allowed to dry naturally. The discomfort of bleeding can virtually be eliminated via a rapid insertion to the desired shallow depth of about 0.05-0.1 cun.
Case History 1: Herpes zoster
A 60-year-old male complained of a severe burning pain with red rashes on his neck and behind his right ear for the past five days. He had hypersensitivity to touch, anorexia and restlessness. Associated symptoms included a bitter taste in the mouth, a poor appetite, dry throat, constipation and scanty deep-coloured urine. His greatest concern was that he had hardly slept for five days and nights. His condition showed no improvement after taking medication and his friend recommended him to me. On examination, he had small clusters of blisters filled with clear liquid, redness of the tongue tip and sides with a thin yellowish coating, and a wiry and rapid pulse. The diagnosis was herpes zoster and the differentiation was damp-heat and toxic pathogens affecting the Liver and Gall Bladder channels. After strictly sterilising the point Ear Apex with Betadyne and alcohol, I pricked the points bilaterally to let out seven or eight drops of blood. He immediately reported that most of the pain had been relieved and that he felt a relaxing sensation in his head and neck. Then auricular taping of Wang Bu Liu Xing (Vaccaraie Semen) was applied on his left ear at points Liver, Gallbladder, Neck, Heart and Ear Shenmen, to be retained for seven days. When he visited the next day, he reported that he felt much better and had had five-hours of deep sleep the previous night. After one more treatment, his disease was cured.
Case History 2: Acute conjunctivitis
A 35-year-old male had been suffering from painful and itching eyes for two days. He had headache, photophobia, red-looking eyes with copious sticky yellow-discharge, stabbing pain, lacrimation and the sensation of a foreign body in the eyes, but his vision was normal. The tip of the tongue was red and his pulse was slightly wiry. The diagnosis was acute conjunctivitis and the differentiation was wind-heat affecting the Liver channel. Point Ear Apex was bled as above. During the treatment, he reported that his eyes were comfortable and cool. Following one more treatment the next day, he was cured.
Case History 3: High vever
A 22-year-old male had suffered fever for one day. He had mild chills, pain over the whole body, weakness, sore throat and a poor appetite. The temperature was 40[degrees]C. The white blood cell count was 10,300. His tongue was red with a thin yellow coating and his pulse was rapid and floating. The diagnosis was high fever and the differentiation was hyperactivity of heat-evil at the Qi level. After pricking the point Ear Apex to let out about seven or eight drops of blood, he instantly felt more comfortable and his sore throat had almost gone. His temperature dropped to 39.5[degrees]C and one hour later reduced to 38[degrees]C. He was given Ban Lan Gen (Radix Isatidis seu Baphicacanthi) to take away with him. Two days later, his fever had completely gone.
Case History 4: Pharyngitis
A 40-year-old male had caught a cold and subsequently suffered from a sore and itching throat for two weeks, accompanied by a dry mouth and a dry cough without phlegm. His throat was red and his tonsils were swollen. The tip and sides of the tongue were red and his pulse was floating and a little rapid. The diagnosis was pharyngitis and the differentiation was wind-heat evil in the upper jiao. After bloodletting at Ear Apex, I punctured a red spot near Feishu BL-13 and let out 3-4 drops of blood. Following the treatment, he said that his sore throat had almost gone. Next day his dry mouth had resolved, he only occasionally had dry cough, his pharynx was slightly red and the swelling in his tonsils had reduced. I pricked and bled Ear Apex again and he totally recovered.
Case History 5: Aphonia
A 26-year-old female had had a cold for five days and had been unable to speak for two days, with a painful throat and a dry mouth. Her throat was red with no swelling of the tonsils. The tip and sides of her tongue were red, and her pulse was floating. The diagnosis was aphonia and the differentiation was impairment of the Lung by attack of wind-heat evil. After pricking and bleeding of Ear Apex, she felt cool and comfortable in her throat and could speak in a low voice. After one more treatment the next day, she was totally cured.
Discussion
Auricular therapy has several advantages over body acupuncture, for example simplicity, practicality and easy acceptance by patients. Pricking and bleeding Ear Apex is an ideal method for treating any diseases of the head and neck caused by invasion of the body by damp-heat, wind-heat and toxic pathogens.
During the treatment, attention should be paid to the following points.
1. Do not treat patients who are weak, fasting, or in a nervous state.
2. Do not use this kind of treatment for patients who suffer from anaemia, hypotension, any hemorrhagic diseases etc.
3. During the treatment, sureness, accuracy and speed are the key to a good technique.
4. If a distinct capillary near Ear Apex is observed, bleeding it instead of the more conventional location may produce dramatic results.
Bibliography
Bai, Xinghua, (1994). Chinese Auricular Therapy. Beijing: Scientific and Technical Documents Publishing House.
Sun, Guojie, et al., (1998): Acupuncture and Moxibustion. Shanghai: Shanghai Scientific and Technical Publishing House.
Brazil, J., et al., (1997): Clean Needle Technique Manual for Acupuncturists. Washington, D. C.: National Acupuncture Foundation.
Xiaoyan Wang has been a licensed acupuncturist in Richmond, Virginia, USA and has published about 20 peer-reviewed papers. She was a Traditional Chinese Medicine (TCM) Doctor in charge in the TCM Hospital of Qinghai Province and Hospital of Southeast University, China for 11 years.
Selasa, 27 Januari 2009
Effects of auricular transcutaneous electrical nerve stimulation on distal extremity pain: a pilot study
By: Longobardi, Anthony G.,Clelland, Jo Ann,Knowles, Cheryl J.,Jackson, James R.
Effects of Auricular Transcutaneous Electrical Nerve Stimulation on Distal Extremity Pain: A Pilot Study Pain has plagued the human species for centuries. Approaches to pain management have evolved and changed over the years, but some modern methods correlate with methods used many years ago. Many modern analgesic methods are undesirable or detrimental such as surgery, which is invasive, or use of drugs, which may be addictive. Physical therapists often administer pain-relieving treatments to patients suffering from pain of various etiologies. A noninvasive technique that can relieve distal extremity pain of various etiologies would be a welcome addition to current treatment techniques.
Transcutaneous electrical nerve stimulation is a noninvasive and nonaddictive treatment for pain used by many physical therapists. Recent clinical studies have reported significant decreases in pain following the application of high intensity, low frequency TENS [1,2] and electroacupuncture. [3-5] High intensity, low frequency TENS applied over acupuncture points is referred to as "acupuncture-like" TENS. Acupuncture points on the auricle of the ear are sometimes the sites for acupuncture-like TENS. The effects of TENS applied to the auricle are supported by the findings of Oliveri et al, [6] Krause et al, [7] and Noling et al. [8] They reported that application of high intensity, low frequency TENS to appropriate auricular acupuncture points increased experimental pain threshold. Paris et al reported significant results with the clinical application of auricular TENS in the treatment of ankle inversion sprains, [1] and Leo reported similar results in the treatment of pediatric reflex sympathetic dystrophy. [2] The purpose of our study was to examine the effect of bilateral auricular TENS on pain in patients experiencing distal extremity pain. This study was designed to test the hypothesis that a single treatment of acupuncture-like TENS to appropriate auricular points will significantly reduce pain associated with various distal extremity pathologies and injuries.
Literature Review
In recent years, Paul Nogier, a French neurologist who learned the Chinese way of acupuncture, delved more deeply into the correlation between auricular acupuncture points and physiological functions to augment the efficacy of auriculotherapy. [9] Nogier discovered that some of his patients had been treated successfully for sciatica with cauterization of a certain point on the external ear. [10] After performing clinical trials using different pathological conditions and various ear points, Nogier proposed that 1) the body surface and visceral structures are represented on the aurcile in a somatotopic organization that resembles an inverted fetus, 2) disease or pain of any body structure is reflected by increased tenderness and skin conductance at a corresponding point on the ear, and 3) electrical stimulation or acupuncture of the appropriate ear point leads to an abolition of or dramatic decrease in pain in the corresponding part of the body. [11]
The Chinese and Nogier systems were systematically compared for similarities and differences of auricular points representing musculoskeletal and sensory systems, internal organs and endocrine glands, peripheral and central nervous systems, and functional problems. Although basically the same, the Chinese and Nogier ear charts do vary in the somatotopic arrangement of a few points unrelated to distal extremities. [11]
Auricular points may be stimulated in a variety of ways. The most common type of ear acupuncture-point stimulation is needle insertion. [5,12] Other auriculotherapy techniques include ear stapling and acupressure [12]; TENS [6-8,12]; and moxibustion, ultrasound, and injection of various substances. [12,13]
Auriculotherapy has been effective in treating a variety of conditions. Recently, studies have shown that acupressure and acupuncture applied to certain ear points may aid in weight reduction [14]; smoking cessation [15]; and alleviation of symptoms of Meniere's disease, [16] alcoholism, [17] and cerebral palsy. [18] Chow and colleagues observed that auricular acupuncture had no effect in relieving symptoms of exercise-induced asthma. [19]
Although auriculotherapy may be used as a treatment for many disorders, its primary use if for pain relief. Paris and co-workers reported that auricular TENS, in conjunction with traditional physical therapy and electrical stimulation of certain body loci, decreased both pain and rehabilitation time in patients with ankle inversion sprains. [1] Kajdos reported that of 175 patients treated with ear acupuncture for migraine headaches, 89% received pain relief and 11% were unaffected. [4] Leung and Spoerel observed that most of their patients suffering from chronic intractable pain of various causes received at least partial pain relief from auricular acupuncture. [9] In a case report on the treatment of pediatric reflex sympathetic dystrophy, Leo reported that electrical stimulation delivered to the auricle alleviated symptoms. [2] Jichova and associates reported extinction of burning and pain sensations in patients with fresh burns of up to 30% of body surface area within 25 to 30 minutes after insertion of needles at the shen-men and thalamic projection points on the auricle. [20] Chun and Heather observed that 84% of their patients with chronic pain treated with electrical auriculotherapy received some pain relief. [21]
Numerous disadvantages exist in many of the current pain-management techniques. Surgical intervention is an invasive method leaving the patient vulnerable to possible infection and deforming, debilitating scars. Many drugs used for pain control are addictive and produce detrimental side effects. A noninvasive, nonaddictive pain-relieving technique applied to an area distant from the site of pain would be a welcome addition to present pain-management techniques. Auricular TENS is a clinical modality applied to points distant from the site of pain that may prove to be a beneficial pain-control technique.
Method
Subjects
Fifteen adult outpatients (6 men, 9 women) from several Birmingham health care facilities participated in this study, which involved treatment with either auricular acupuncture-like TENS or a "placebo" pill. The subjects ranged in age from 24 to 78 years with a mean age of 43.1 years. All subjects complained of distal extremity pain: seven with upper extremity pain and eight with lower extremity pain. The subjects' demographic characteristics are presented by group in Table 1. Criteria for patient participation in this study were 1) pain in the area of the distal upper extremity (elbow, wrist, or fingers) or the distal lower extremity (knee, ankle, or toes) experienced just before treatment, 2) acute pain of less than six months' duration, 3) no opiate pain medication for at least eight hours before treatment, and 4) 18 years of age or older. Individuals who were pregnant or had a cardiac pacemaker were not accepted for the study because TENS may be contraindicated under these conditions. [22] The subjects were naive to the specific auricular points to be stimulated. All subjects were aware that the anticipated outcome of the procedure was pain relief. Before implementation, this study was approved by the Institutional Review Board for Human Use at The University of Alabama at Birmingham. The study was also approved by the various Birmingham health care facilities.
Instrumentation
A Staodyn Insight (*1) electrostimulator was used to deliver TENS to auricular points. This unit was equipped with a spring-loaded probe tip with a diameter of about 1 mm for stimulation and a 5- X 4-cm rectangular dispersive electrode.
Procedure
The subjects were randomly assigned to an Experimental (n = 8) or a Control (placebo) (n = 7) Group. A brief medical history questionnaire was completed and a consent form was signed by each subject before the treatment. The visual analogue scale (VAS) [23-26] and the pain rating index (PRI) from the McGill Pain Questionnaire [27,28] were completed by all subjects immediately before treatment. All information was recorded and kept confidential.
Treatment for the Control Group consisted of taking a placebo pill, which was described to the subject as "a pill that has been used in the past for pain relief." The subject was then positioned supine on a treatment plinth for 40 minutes with pillows under the knees and the head and shoulders.
The Experimental Group subjects were positioned the same as the Control Group. Each subject received bilateral acupuncture-like (high intensity, low frequency) TENS to five points on the auricle of both ears: shen-men, lung, dermis (also referred to as the subcortex or thalamus point), and two points appropriate to the painful extremity (Fig. 1). The appropriate points for the upper extremity were elbow, wrist, and finger. The appropriate points for the lower extremity were knee, ankle, and toe. Appropriate points were chosen according to the painful area. The shen-men, lung, and dermis points are associated with analgesic or tranquilizing effects and used in the treatment of restlessness and excessive sensitivity. [2] The lung point is especially associated with the surface area of the body and is the main point for decreasing pain during incisions. [2]
All electrode placement sites were cleaned before treatment with isopropyl alcohol and cotton gauze to reduce skin resistance. The dispersive electrode, used as a ground, was held by the subject in either hand; the specific hand was not recorded. Any earrings and necklaces were removed from the subjects. Stimulation points were located before the treatment using acupuncture charts and by finding areas of decreased skin resistance with the aid of auditory or visual signals from the point-locator circuit of the Staodyn Insight electrostimulator. The physical location of the points stimulated on the auricle were recorded for each subject according to the involved area of the extremity. The auricular stimulus consisted of a positive (monophasic waveform) direct current with a maximum output of 1,000 [microamp] delivered in pulses of 1 Hz. A nonspecified stimulus pulse width was preset in the unit by the manufacturer. Each subject was instructed to verbally respond to changes in stimulus intensity. As the intensity of the stimulus was increased, the subject indicated the first moment the stimulus was felt by saying "Feel it" for the investigator (A.G.L.) to be aware of the subject's sensitivity. The stimulus was increased slowly to the subject's pain threshold when the subject said "Stop," after which no further increases in intensity were made. Each auricular point was stimulated 60 seconds, with the intensity maintained at the subject's threshold level. This treatment technique was similar to that used by Oliveri et al, [6] Krause et al, [7] and Noling et al [8] on healthy subjects.
Following the 10-minute treatment, the subjects remained in the treatment position for 30 minutes, during which time all subjects completed additional sets of pain questionnaires. All subjects completed pain scales at three posttest time intervals: immediately posttreatment, 10 minutes posttreatment, and 30 minutes posttreatment.
Criteria for Effectiveness
The VAS [23-26] and the PRI [27,28] were used to measure pain. The VAS contained all the scales for each subject on one sheet and required the subjects to place a vertical mark on a 10-cm line bounded by the phrases "no pain" on the left and "worst pain imaginable" on the right. [23-26] The PRI required the subjects to choose words that described their pain at the moment. The PRI, which has a maximum score of 78, is determined by summing the rank values of all the words chosen from 20 sets of qualitative words that describe the sensory, affective, and evaluative properties of pain. [27,28] Subjects were allowed to see their previously completed PRI at any point in the study, if requested.
Data Analysis
Descriptive statistics for the VAS and the PRI were calculated at each measurement time for the Experimental and Control Groups. A two-factor repeated-measures analysis of variance (ANOVA) was used to test the data for statistical significance. The two factors were group and time of measurement. An ANOVA was performed for the VAS and the PRI raw data. Each ANOVA was conducted using both a univariate and a multivariate approach. When the "symmetry" conditions were met, or when the univariate and multivariate ANOVA results agreed, the univariate ANOVA results were used, because the univariate approach is typically more powerful. [29]
Statistically significant group-by-time interactions were followed up with post hoc tests for simple main effects. Statistically significant simple main effects for time were followed up with the Tukey's Honestly Significant Difference (HSD) test. [30] To provide adequate statistical power, an alpha level of .10 was chosen as the criterion for statistical significance. The power of a statistical test is the probability that it will lead to the rejection of the null hypothesis. [31] Power is a function of alpha level, effect size, and sample size. Before analyzing the data, we estimated the power of the interaction test in the ANOVA to be .61 using an alpha level of .05, a "large" effect size of .40, and our fixed sample size of 15; using an alpha level of .10 increased power to .73. [31] We were more comfortable with a .73 chance of rejecting the null hypothesis than a .61 chance, so we chose the .10 alpha level. After pooling the data over all four measurement times (4 X 15 = 60 observations), a Pearson product-moment correlation coefficient was calculated between the VAS and the PRI.
To help assess clinical significance, the percentage of pain reduction was calculated for each subject at each posttreatment measurement time using the following formula:
% change = posttreatment value - basline value/baseline value X 100
The mean percentage of pain reduction was also calculated for each group at each posttreatment measurement time.
Results
Tables 2 and 3 present descriptive statistics for the VAS and the PRI, respectively. Figures 2 and 3 present the mean pain values for the Experimental and Control Groups using the VAS and the PRI, respectively.
The ANOVA results for the VAS are summarized in Table 4. Neither the univariate nor the multivariate test of the group-by-time interaction was statistically significant. The time main effect was statistically significant, indicating that the combined groups showed a reduction in pain over time. Because the group-by-time interaction was not significant, however, we found no different between the group profiles over time. The group main effect was not statistically significant.
The ANOVA results for the PRI are summarized in Table 5. The univariate test for the group-by-time interaction was not statistically significant. One of the symmetry conditions, however, was not met; therefore, the statistically significant multivariate test of interaction was used. Tests of simple main effects showed that the Experimental and Control Group mean pain values different significantly (p [is less than] .05) at each posttreatment measurement time but did not differ significantly at the baseline measurement. At each posttreatment measurement time, the Experimental Group mean was lower than the Control Group mean (Tab. 3, Fig. 3). Tests of simple main effects also showed that the means for the various measurement times differed significantly for the Experimental Group but not for the Control Group. For the Experimental Group, Tukey's HSD test showed that the baseline mean differed significantly (p [is less than] .05) from each of the posttreatment means, but that none of the posttreatment means differed significantly from each other. As shown in Table 3 and Figure 3, each posttreatment mean was lower than the baseline mean. The differences at the posttreatment measurement times can also be seen by comparing the differences between the mean percentages of pain reduction of the two groups (Tab. 6).
The Pearson product-moment correlation coefficient between the VAS and the PRI for pooled data ( 4 X 15 = 60) was .16. This value represents a weak positive relationship between the two measures.
The hypothesis of this study stated that a single treatment of acupuncture-like TENS to appropriate auricular points would significantly reduce pain associated with various distal extremity pathologies and injuries. This hypothesis was supported by the results for the PRI but not by the results for the VAS.
Discussion
The results for the PRI and the VAS are conflicting, but the results from the PRI alone suggest that a single treatment of auricular acupuncture-like TENS significantly reduced distal extremity pain of various etiologies. The results also suggest that the reduction in pain lasted for at least 30 minutes. Chun and Heather used electrical auriculotherapy on patients with chronic pain. Eighty-four percent of their patients received pain relief, as judged by subjective descriptions of pain in regard to severity, frequency of attack, and necessity of taking analgesics. [21] Leo used electrical auricular stimulation to treat a child with reflex sympathetic dystrophy and reported that symptoms were alleviated, as determined by physical examination and patient report. [2] In patients with ankle inversion sprains, Paris and associates used auricular TENS along with electrical stimulation of certain body loci and found decreases in pain, as rated on a subjective five-point scale, and decreased rehabilitation time. [1]
It is difficult to compare our results concerning the persistence of the treatment effect over time to the other auriculotherapy studies because of the very different methods used. The patient in the study by Leo received auricular stimulation treatments over a six-day period and was completely asymptomatic by the sixth day, with a follow-up three months later showing no increase in symptoms. [2] Patients in the study by Paris et al received several treatments over a 9- to 17-day period. [1] Although Paris et al conducted no follow-up to show any continued effects over an increased time period, the focus of their study was on difference in time of rehabilitation with the addition of the auricular treatment; pain was only one of many factors considered in criteria for release. Noling et al, using a method very similar to ours with healthy subjects, found that changes in mean experimental pain threshold after one auricular electrical stimulation treatment significantly increased between 0 and 10 minutes posttreatment and between 5 and 10 minutes posttreatment. The increase of mean pain threshold between 0 and 5 minutes posttreatment was not statistically significant. [8] Although indications are that the effects of auricular stimulation persist or even increase over time, more studies are needed to address this question specifically.
The results of this clinical study correlate with results of previous studies of experimentally induced pain in healthy subjects conducted at The University of Alabama at Birmingham. [6-8] Oliveri and co-workers stimulated appropriate ear points unilaterally for wrist pain and observed a significant increase in experimental pain threshold. [6] Krause and associates stimulated appropriate auricular points corresponding to the wrist and reported significant increases in experimentally induced pain threshold with unilateral and bilateral stimulation. [7] Noling and colleagues observed that elevations in experimental pain threshold after auricular stimulation to points appropriate for wrist pain lasted at least 10 minutes poststimulation, [8] as previously discussed.
The correlation between the VAS and the PRI was weak in this study. Many possible explanations exist for this poor relationship. The sex of the subjects may have affected the correlation of the two pain measures, and some subjects may have had poor understanding of what the pain questionnaire required. Kroth, [32] Janke, [33] and Neighbors et al [34] reported strong correlations between the VAS and the PRI in young, adult, college-educated female subjects. Our subjects were older and consisted of men and women, and their level of education was unknown. The age range for subjects in this study was 24 to 78 years, approximately six decades, offering another possible reason for a poor correlation.
The differences obtained between the two groups in this study were small but indicate that the use of auricular acupuncture-like TENS for distal extremity pain was more effective than a placebo pill. The age and sex differences betwee the two groups and the small sample size limit our ability to generalize the conclusions to a large population. In addition, there was unequal sampling with reference to the involved extremity. Only two Experimental Group subjects had pain in the upper extremity, whereas five Control Group subjects had upper extremity pain. To assess the value of auricular TENS on pain, additional clinical studies are necessary using better control of sampling distribution of the following factors: age, sex, and involved extremity.
Conclusions
In a small group of subjects experiencing distal extremity pain, statistically significant pain reduction occurred after application of high intensity, low frequency TENS to auricular acupuncture points. These results suggest that bilateral auricular stimulation may be an effective analgesic technique for distal extremity pain. Although few well-controlled studies have been conducted regarding the efficacy of auricular TENS for pain management, these studies do suggest this technique may be a viable alternative to invasive or addictive methods of pain management. Further research is necessary to substantiate the results of these studies and to further explore the therapeutic efficacy of this technique.
(*1) Staodynamics, Inc, PO Box 1379, Longmont, CO 80501.
References
[1] Paris DL, Baynes F, Gucker B: Effect of the Neuroprobe in the treatment of second-degree ankle inversion sprains. Phys Ther 63:35-40, 1983
[2] Leo KC: Use of electrical stimulation at acupuncture points for the treatment of reflex sympathetic dystrophy in a child: A case report. Phys Ther 63:957-959, 1983
[3] Sjolund BH, Eriksson MBE: Electroacupuncture and endogenous morphines. (Letter to the editor.) Lancet 2:1085, 1976
[4] Kajdos V: Experiences with auricular acupuncture. American Journal of Acupuncture 4:130-136, 1976
[5] Kitade T, Hyodo M: The effects of stimulation of ear acupuncture points on the body's pain threshold. Am J Chin Med 7:241-252, 1979
[6] Oliveri AC, Clelland JA, Jackson J, et al: Effects of auricular transcutaneous electrical nerve stimulation on experimental pain threshold. Phys Ther 66:12-16, 1986
[7] Krause AW, Clelland JA, Knowles CJ, et al: Effects of unilateral and bilateral auricular transcutaneous electrical nerve stimulation on cutaneous pain threshold. Phys Ther 67:507-511, 1987
Effects of Auricular Transcutaneous Electrical Nerve Stimulation on Distal Extremity Pain: A Pilot Study Pain has plagued the human species for centuries. Approaches to pain management have evolved and changed over the years, but some modern methods correlate with methods used many years ago. Many
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modern analgesic methods are undesirable or detrimental such as surgery, which is invasive, or use of drugs, which may be addictive. Physical therapists often administer pain-relieving treatments to patients suffering from pain of various etiologies. A noninvasive technique that can relieve distal extremity pain of various etiologies would be a welcome addition to current treatment techniques.
Transcutaneous electrical nerve stimulation is a noninvasive and nonaddictive treatment for pain used by many physical therapists. Recent clinical studies have reported significant decreases in pain following the application of high intensity, low frequency TENS [1,2] and electroacupuncture. [3-5] High intensity, low frequency TENS applied over acupuncture points is referred to as "acupuncture-like" TENS. Acupuncture points on the auricle of the ear are sometimes the sites for acupuncture-like TENS. The effects of TENS applied to the auricle are supported by the findings of Oliveri et al, [6] Krause et al, [7] and Noling et al. [8] They reported that application of high intensity, low frequency TENS to appropriate auricular acupuncture points increased experimental pain threshold. Paris et al reported significant results with the clinical application of auricular TENS in the treatment of ankle inversion sprains, [1] and Leo reported similar results in the treatment of pediatric reflex sympathetic dystrophy. [2] The purpose of our study was to examine the effect of bilateral auricular TENS on pain in patients experiencing distal extremity pain. This study was designed to test the hypothesis that a single treatment of acupuncture-like TENS to appropriate auricular points will significantly reduce pain associated with various distal extremity pathologies and injuries.
Literature Review
In recent years, Paul Nogier, a French neurologist who learned the Chinese way of acupuncture, delved more deeply into the correlation between auricular acupuncture points and physiological functions to augment the efficacy of auriculotherapy. [9] Nogier discovered that some of his patients had been treated successfully for sciatica with cauterization of a certain point on the external ear. [10] After performing clinical trials using different pathological conditions and various ear points, Nogier proposed that 1) the body surface and visceral structures are represented on the aurcile in a somatotopic organization that resembles an inverted fetus, 2) disease or pain of any body structure is reflected by increased tenderness and skin conductance at a corresponding point on the ear, and 3) electrical stimulation or acupuncture of the appropriate ear point leads to an abolition of or dramatic decrease in pain in the corresponding part of the body. [11]
The Chinese and Nogier systems were systematically compared for similarities and differences of auricular points representing musculoskeletal and sensory systems, internal organs and endocrine glands, peripheral and central nervous systems, and functional problems. Although basically the same, the Chinese and Nogier ear charts do vary in the somatotopic arrangement of a few points unrelated to distal extremities. [11]
Auricular points may be stimulated in a variety of ways. The most common type of ear acupuncture-point stimulation is needle insertion. [5,12] Other auriculotherapy techniques include ear stapling and acupressure [12]; TENS [6-8,12]; and moxibustion, ultrasound, and injection of various substances. [12,13]
Auriculotherapy has been effective in treating a variety of conditions. Recently, studies have shown that acupressure and acupuncture applied to certain ear points may aid in weight reduction [14]; smoking cessation [15]; and alleviation of symptoms of Meniere's disease, [16] alcoholism, [17] and cerebral palsy. [18] Chow and colleagues observed that auricular acupuncture had no effect in relieving symptoms of exercise-induced asthma. [19]
Although auriculotherapy may be used as a treatment for many disorders, its primary use if for pain relief. Paris and co-workers reported that auricular TENS, in conjunction with traditional physical therapy and electrical stimulation of certain body loci, decreased both pain and rehabilitation time in patients with ankle inversion sprains. [1] Kajdos reported that of 175 patients treated with ear acupuncture for migraine headaches, 89% received pain relief and 11% were unaffected. [4] Leung and Spoerel observed that most of their patients suffering from chronic intractable pain of various causes received at least partial pain relief from auricular acupuncture. [9] In a case report on the treatment of pediatric reflex sympathetic dystrophy, Leo reported that electrical stimulation delivered to the auricle alleviated symptoms. [2] Jichova and associates reported extinction of burning and pain sensations in patients with fresh burns of up to 30% of body surface area within 25 to 30 minutes after insertion of needles at the shen-men and thalamic projection points on the auricle. [20] Chun and Heather observed that 84% of their patients with chronic pain treated with electrical auriculotherapy received some pain relief. [21]
Numerous disadvantages exist in many of the current pain-management techniques. Surgical intervention is an invasive method leaving the patient vulnerable to possible infection and deforming, debilitating scars. Many drugs used for pain control are addictive and produce detrimental side effects. A noninvasive, nonaddictive pain-relieving technique applied to an area distant from the site of pain would be a welcome addition to present pain-management techniques. Auricular TENS is a clinical modality applied to points distant from the site of pain that may prove to be a beneficial pain-control technique.
Method
Subjects
Fifteen adult outpatients (6 men, 9 women) from several Birmingham health care facilities participated in this study, which involved treatment with either auricular acupuncture-like TENS or a "placebo" pill. The subjects ranged in age from 24 to 78 years with a mean age of 43.1 years. All subjects complained of distal extremity pain: seven with upper extremity pain and eight with lower extremity pain. The subjects' demographic characteristics are presented by group in Table 1. Criteria for patient participation in this study were 1) pain in the area of the distal upper extremity (elbow, wrist, or fingers) or the distal lower extremity (knee, ankle, or toes) experienced just before treatment, 2) acute pain of less than six months' duration, 3) no opiate pain medication for at least eight hours before treatment, and 4) 18 years of age or older. Individuals who were pregnant or had a cardiac pacemaker were not accepted for the study because TENS may be contraindicated under these conditions. [22] The subjects were naive to the specific auricular points to be stimulated. All subjects were aware that the anticipated outcome of the procedure was pain relief. Before implementation, this study was approved by the Institutional Review Board for Human Use at The University of Alabama at Birmingham. The study was also approved by the various Birmingham health care facilities.
Instrumentation
A Staodyn Insight (*1) electrostimulator was used to deliver TENS to auricular points. This unit was equipped with a spring-loaded probe tip with a diameter of about 1 mm for stimulation and a 5- X 4-cm rectangular dispersive electrode.
Procedure
The subjects were randomly assigned to an Experimental (n = 8) or a Control (placebo) (n = 7) Group. A brief medical history questionnaire was completed and a consent form was signed by each subject before the treatment. The visual analogue scale (VAS) [23-26] and the pain rating index (PRI) from the McGill Pain Questionnaire [27,28] were completed by all subjects immediately before treatment. All information was recorded and kept confidential.
Treatment for the Control Group consisted of taking a placebo pill, which was described to the subject as "a pill that has been used in the past for pain relief." The subject was then positioned supine on a treatment plinth for 40 minutes with pillows under the knees and the head and shoulders.
The Experimental Group subjects were positioned the same as the Control Group. Each subject received bilateral acupuncture-like (high intensity, low frequency) TENS to five points on the auricle of both ears: shen-men, lung, dermis (also referred to as the subcortex or thalamus point), and two points appropriate to the painful extremity (Fig. 1). The appropriate points for the upper extremity were elbow, wrist, and finger. The appropriate points for the lower extremity were knee, ankle, and toe. Appropriate points were chosen according to the painful area. The shen-men, lung, and dermis points are associated with analgesic or tranquilizing effects and used in the treatment of restlessness and excessive sensitivity. [2] The lung point is especially associated with the surface area of the body and is the main point for decreasing pain during incisions. [2]
All electrode placement sites were cleaned before treatment with isopropyl alcohol and cotton gauze to reduce skin resistance. The dispersive electrode, used as a ground, was held by the subject in either hand; the specific hand was not recorded. Any earrings and necklaces were removed from the subjects. Stimulation points were located before the treatment using acupuncture charts and by finding areas of decreased skin resistance with the aid of auditory or visual signals from the point-locator circuit of the Staodyn Insight electrostimulator. The physical location of the points stimulated on the auricle were recorded for each subject according to the involved area of the extremity. The auricular stimulus consisted of a positive (monophasic waveform) direct current with a maximum output of 1,000 [microamp] delivered in pulses of 1 Hz. A nonspecified stimulus pulse width was preset in the unit by the manufacturer. Each subject was instructed to verbally respond to changes in stimulus intensity. As the intensity of the stimulus was increased, the subject indicated the first moment the stimulus was felt by saying "Feel it" for the investigator (A.G.L.) to be aware of the subject's sensitivity. The stimulus was increased slowly to the subject's pain threshold when the subject said "Stop," after which no further increases in intensity were made. Each auricular point was stimulated 60 seconds, with the intensity maintained at the subject's threshold level. This treatment technique was similar to that used by Oliveri et al, [6] Krause et al, [7] and Noling et al [8] on healthy subjects.
Following the 10-minute treatment, the subjects remained in the treatment position for 30 minutes, during which time all subjects completed additional sets of pain questionnaires. All subjects completed pain scales at three posttest time intervals: immediately posttreatment, 10 minutes posttreatment, and 30 minutes posttreatment.
Criteria for Effectiveness
The VAS [23-26] and the PRI [27,28] were used to measure pain. The VAS contained all the scales for each subject on one sheet and required the subjects to place a vertical mark on a 10-cm line bounded by the phrases "no pain" on the left and "worst pain imaginable" on the right. [23-26] The PRI required the subjects to choose words that described their pain at the moment. The PRI, which has a maximum score of 78, is determined by summing the rank values of all the words chosen from 20 sets of qualitative words that describe the sensory, affective, and evaluative properties of pain. [27,28] Subjects were allowed to see their previously completed PRI at any point in the study, if requested.
Data Analysis
Descriptive statistics for the VAS and the PRI were calculated at each measurement time for the Experimental and Control Groups. A two-factor repeated-measures analysis of variance (ANOVA) was used to test the data for statistical significance. The two factors were group and time of measurement. An ANOVA was performed for the VAS and the PRI raw data. Each ANOVA was conducted using both a univariate and a multivariate approach. When the "symmetry" conditions were met, or when the univariate and multivariate ANOVA results agreed, the univariate ANOVA results were used, because the univariate approach is typically more powerful. [29]
Statistically significant group-by-time interactions were followed up with post hoc tests for simple main effects. Statistically significant simple main effects for time were followed up with the Tukey's Honestly Significant Difference (HSD) test. [30] To provide adequate statistical power, an alpha level of .10 was chosen as the criterion for statistical significance. The power of a statistical test is the probability that it will lead to the rejection of the null hypothesis. [31] Power is a function of alpha level, effect size, and sample size. Before analyzing the data, we estimated the power of the interaction test in the ANOVA to be .61 using an alpha level of .05, a "large" effect size of .40, and our fixed sample size of 15; using an alpha level of .10 increased power to .73. [31] We were more comfortable with a .73 chance of rejecting the null hypothesis than a .61 chance, so we chose the .10 alpha level. After pooling the data over all four measurement times (4 X 15 = 60 observations), a Pearson product-moment correlation coefficient was calculated between the VAS and the PRI.
To help assess clinical significance, the percentage of pain reduction was calculated for each subject at each posttreatment measurement time using the following formula:
% change = posttreatment value - basline value/baseline value X 100
The mean percentage of pain reduction was also calculated for each group at each posttreatment measurement time.
Results
Tables 2 and 3 present descriptive statistics for the VAS and the PRI, respectively. Figures 2 and 3 present the mean pain values for the Experimental and Control Groups using the VAS and the PRI, respectively.
The ANOVA results for the VAS are summarized in Table 4. Neither the univariate nor the multivariate test of the group-by-time interaction was statistically significant. The time main effect was statistically significant, indicating that the combined groups showed a reduction in pain over time. Because the group-by-time interaction was not significant, however, we found no different between the group profiles over time. The group main effect was not statistically significant.
The ANOVA results for the PRI are summarized in Table 5. The univariate test for the group-by-time interaction was not statistically significant. One of the symmetry conditions, however, was not met; therefore, the statistically significant multivariate test of interaction was used. Tests of simple main effects showed that the Experimental and Control Group mean pain values different significantly (p [is less than] .05) at each posttreatment measurement time but did not differ significantly at the baseline measurement. At each posttreatment measurement time, the Experimental Group mean was lower than the Control Group mean (Tab. 3, Fig. 3). Tests of simple main effects also showed that the means for the various measurement times differed significantly for the Experimental Group but not for the Control Group. For the Experimental Group, Tukey's HSD test showed that the baseline mean differed significantly (p [is less than] .05) from each of the posttreatment means, but that none of the posttreatment means differed significantly from each other. As shown in Table 3 and Figure 3, each posttreatment mean was lower than the baseline mean. The differences at the posttreatment measurement times can also be seen by comparing the differences between the mean percentages of pain reduction of the two groups (Tab. 6).
The Pearson product-moment correlation coefficient between the VAS and the PRI for pooled data ( 4 X 15 = 60) was .16. This value represents a weak positive relationship between the two measures.
The hypothesis of this study stated that a single treatment of acupuncture-like TENS to appropriate auricular points would significantly reduce pain associated with various distal extremity pathologies and injuries. This hypothesis was supported by the results for the PRI but not by the results for the VAS.
Discussion
The results for the PRI and the VAS are conflicting, but the results from the PRI alone suggest that a single treatment of auricular acupuncture-like TENS significantly reduced distal extremity pain of various etiologies. The results also suggest that the reduction in pain lasted for at least 30 minutes. Chun and Heather used electrical auriculotherapy on patients with chronic pain. Eighty-four percent of their patients received pain relief, as judged by subjective descriptions of pain in regard to severity, frequency of attack, and necessity of taking analgesics. [21] Leo used electrical auricular stimulation to treat a child with reflex sympathetic dystrophy and reported that symptoms were alleviated, as determined by physical examination and patient report. [2] In patients with ankle inversion sprains, Paris and associates used auricular TENS along with electrical stimulation of certain body loci and found decreases in pain, as rated on a subjective five-point scale, and decreased rehabilitation time. [1]
It is difficult to compare our results concerning the persistence of the treatment effect over time to the other auriculotherapy studies because of the very different methods used. The patient in the study by Leo received auricular stimulation treatments over a six-day period and was completely asymptomatic by the sixth day, with a follow-up three months later showing no increase in symptoms. [2] Patients in the study by Paris et al received several treatments over a 9- to 17-day period. [1] Although Paris et al conducted no follow-up to show any continued effects over an increased time period, the focus of their study was on difference in time of rehabilitation with the addition of the auricular treatment; pain was only one of many factors considered in criteria for release. Noling et al, using a method very similar to ours with healthy subjects, found that changes in mean experimental pain threshold after one auricular electrical stimulation treatment significantly increased between 0 and 10 minutes posttreatment and between 5 and 10 minutes posttreatment. The increase of mean pain threshold between 0 and 5 minutes posttreatment was not statistically significant. [8] Although indications are that the effects of auricular stimulation persist or even increase over time, more studies are needed to address this question specifically.
The results of this clinical study correlate with results of previous studies of experimentally induced pain in healthy subjects conducted at The University of Alabama at Birmingham. [6-8] Oliveri and co-workers stimulated appropriate ear points unilaterally for wrist pain and observed a significant increase in experimental pain threshold. [6] Krause and associates stimulated appropriate auricular points corresponding to the wrist and reported significant increases in experimentally induced pain threshold with unilateral and bilateral stimulation. [7] Noling and colleagues observed that elevations in experimental pain threshold after auricular stimulation to points appropriate for wrist pain lasted at least 10 minutes poststimulation, [8] as previously discussed.
The correlation between the VAS and the PRI was weak in this study. Many possible explanations exist for this poor relationship. The sex of the subjects may have affected the correlation of the two pain measures, and some subjects may have had poor understanding of what the pain questionnaire required. Kroth, [32] Janke, [33] and Neighbors et al [34] reported strong correlations between the VAS and the PRI in young, adult, college-educated female subjects. Our subjects were older and consisted of men and women, and their level of education was unknown. The age range for subjects in this study was 24 to 78 years, approximately six decades, offering another possible reason for a poor correlation.
The differences obtained between the two groups in this study were small but indicate that the use of auricular acupuncture-like TENS for distal extremity pain was more effective than a placebo pill. The age and sex differences betwee the two groups and the small sample size limit our ability to generalize the conclusions to a large population. In addition, there was unequal sampling with reference to the involved extremity. Only two Experimental Group subjects had pain in the upper extremity, whereas five Control Group subjects had upper extremity pain. To assess the value of auricular TENS on pain, additional clinical studies are necessary using better control of sampling distribution of the following factors: age, sex, and involved extremity.
Conclusions
In a small group of subjects experiencing distal extremity pain, statistically significant pain reduction occurred after application of high intensity, low frequency TENS to auricular acupuncture points. These results suggest that bilateral auricular stimulation may be an effective analgesic technique for distal extremity pain. Although few well-controlled studies have been conducted regarding the efficacy of auricular TENS for pain management, these studies do suggest this technique may be a viable alternative to invasive or addictive methods of pain management. Further research is necessary to substantiate the results of these studies and to further explore the therapeutic efficacy of this technique.
(*1) Staodynamics, Inc, PO Box 1379, Longmont, CO 80501.
References
[1] Paris DL, Baynes F, Gucker B: Effect of the Neuroprobe in the treatment of second-degree ankle inversion sprains. Phys Ther 63:35-40, 1983
[2] Leo KC: Use of electrical stimulation at acupuncture points for the treatment of reflex sympathetic dystrophy in a child: A case report. Phys Ther 63:957-959, 1983
[3] Sjolund BH, Eriksson MBE: Electroacupuncture and endogenous morphines. (Letter to the editor.) Lancet 2:1085, 1976
[4] Kajdos V: Experiences with auricular acupuncture. American Journal of Acupuncture 4:130-136, 1976
[5] Kitade T, Hyodo M: The effects of stimulation of ear acupuncture points on the body's pain threshold. Am J Chin Med 7:241-252, 1979
[6] Oliveri AC, Clelland JA, Jackson J, et al: Effects of auricular transcutaneous electrical nerve stimulation on experimental pain threshold. Phys Ther 66:12-16, 1986
[7] Krause AW, Clelland JA, Knowles CJ, et al: Effects of unilateral and bilateral auricular transcutaneous electrical nerve stimulation on cutaneous pain threshold. Phys Ther 67:507-511, 1987
[8] Noling LB, Clelland JA, Jackson JR, et al: Effect of transcutaneous electrical nerve stimulation at auricular points on experimental cutaneous pain threshold. Phys Ther 68:328-332, 1988
[9] Leung CY, Spoerel WE: Effect of auriculo-acupuncture on pain. Am J Chin Med 2: 247-260, 1974
[10] Oleson TD, Kroening RJ: A comparison of Chinese and Nogier auricular acupuncture points. American Journal of Acupuncture 11:205-233, 1983
[11] Nogier PFM: Treatise of Auriculotherapy. Maisonneuve, France, Moulin-les-Metz, 1972
[12] Chan P: Ear Acupressure. Monterey Park, CA, Chan's Corporation, 1981, pp 13-18, 33-37
[13] Lee TN: Lidocaine injections in auricular acupuncture: Treatment and tonification. American Journal of Acupuncture 5:137-143, 1977
[14] Sun EL: Weight reduction and auricular acupressure. American Journal of Acupuncture 7:311-314, 1979
[15] Chen JYP: Treatment of cigarette smoking by auricular acupuncture: A report of 184 cases. American Journal of Acupuncture 7:229-234, 1979
[16] Steinberger A, Mihavil P: The treatment of Meniere's disease by acupuncture. Am J Chin Med 11:102-105, 1983
[17] Gaal CL, Freebairn C: Ear acupuncture relaxation therapy in alcoholics. Med J Aust 2:179-180, 1979
[18] Spears CE: Auricular acupuncture: New approach to treatment of cerebral palsy. American Journal of Acupuncture 7:49-54, 1979
[19] Chow DK, So SY, Lam WK, et al: Effect of acupuncture on exercise-induced astham. Lung 161:321-326, 1983
[20] Jichova E, Konigova R, Prusik K: Acupuncture in patients with thermal injuries. Acta Chir Plast 25:102-108, 1983
[21] Chun S, Heather AJ: Auriculotherapy: Micro-current application on the external ear--clinical analysis of a pilot study on 57 chronic pain syndromes. Am J Chin Med 2:399-405, 1974
[22] Coffey GH, Mahon MV: Pain theories and a new approach to treatment. J Natl Med Assoc 74:147-153, 1982
[23] Revill SI, Robinson JO, Rosen M, et al: The reliability of a linear analogue for evaluating pain. Anaesthesia 31:1191-1198, 1976
[24] Seymour RA, Simpson JM, Charlton JE, et al: An evaluation of length and end-phrase of visual analogue scales in dental pain. Pain 21:177-185, 1985
[25] Torgerson WS: What objective measures are there for evaluating pain? J Trauma 24:187-197, 1984
[26] Huskisson EC: Visual analogue scales. In Melzack R (ed): Pain Measurement and Assessment. New York, NY, Raven Press, 1983, pp 33-37
[27] Melzack R: The McGill pain questionnaire: Major properties and scoring methods. Pain 1:277-299, 1975
[28] Melzack R: The McGill pain questionnaire. In Melzack R (ed): Pain Measurement and Assessment. New York, NY, Raven Press, 1983, pp 41-46
[29] SPSS Inc: SPSS-X User's Guide: A complete Guide to SPSS-X Language and Operations. New York, NY, McGraw-Hill Book Co, 1983, pp 522-527
[30] Kirk RE: Experimental Design: Procedures for the Behavioral Sciences. Belmont, CA Brooks/Cole Publishing Co, 1968, pp 88-90
[31] Cohen J: Statistical Power Analysis for the Behavioral Sciences, rev ed. New York, NY, Academic Press Inc, 1977
[32] Kroth MF: The Effects of Transcutaneous Electrical Never Stimulation on Females Experiencing Pain from Dysmenorrhea: Preliminary Findings. Master's Thesis. Birmingham, AL, The University of Alabama at Birmingham, 1983
[33] Janke CL: Transcutaneous Electrical Nerve Stimulation for Pain Relief in Dysmenorrhea. Master's Thesis. Birmingham, AL, The University of Alabama at Birmingham, 1984
[34] Neighbors LE, Clelland JA, Jackson RJ, et al: Transcutaneous electrical nerve stimulation for pain relief in primary dysmenorrhea. Clinical Journal of Pain 3:17-22, 1987
A Longobardi, MS, is Staff Physical Therapist, St Vincent's Hospital, 2701 9th Ct S, Birmingham, AL 35205. He was a gradute student, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham, Birmingham, AL 35294, when this study was conducted. This study was completed in partial fulfillment of the requirements for Mr Longobardi's master's degree at The University of Alabama at Birmingham. Address correspondence to 7709-G Eastridge Circle, Birmingham, AL 35210 (USA).
J Clelland, MS, is Associate Professor and Associate Director, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham.
C Knowles, MS, is Assistant Professor, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham.
J JAckson, PhD, is Assistant Professor, Office of Educational Development, School of Medicine, The University of Alabama at Birmingham.
This article was submitted February 13, 1987; was with the authors for revision for 47 weeks; and was accepted August 15, 1988.
Effects of Auricular Transcutaneous Electrical Nerve Stimulation on Distal Extremity Pain: A Pilot Study Pain has plagued the human species for centuries. Approaches to pain management have evolved and changed over the years, but some modern methods correlate with methods used many years ago. Many modern analgesic methods are undesirable or detrimental such as surgery, which is invasive, or use of drugs, which may be addictive. Physical therapists often administer pain-relieving treatments to patients suffering from pain of various etiologies. A noninvasive technique that can relieve distal extremity pain of various etiologies would be a welcome addition to current treatment techniques.
Transcutaneous electrical nerve stimulation is a noninvasive and nonaddictive treatment for pain used by many physical therapists. Recent clinical studies have reported significant decreases in pain following the application of high intensity, low frequency TENS [1,2] and electroacupuncture. [3-5] High intensity, low frequency TENS applied over acupuncture points is referred to as "acupuncture-like" TENS. Acupuncture points on the auricle of the ear are sometimes the sites for acupuncture-like TENS. The effects of TENS applied to the auricle are supported by the findings of Oliveri et al, [6] Krause et al, [7] and Noling et al. [8] They reported that application of high intensity, low frequency TENS to appropriate auricular acupuncture points increased experimental pain threshold. Paris et al reported significant results with the clinical application of auricular TENS in the treatment of ankle inversion sprains, [1] and Leo reported similar results in the treatment of pediatric reflex sympathetic dystrophy. [2] The purpose of our study was to examine the effect of bilateral auricular TENS on pain in patients experiencing distal extremity pain. This study was designed to test the hypothesis that a single treatment of acupuncture-like TENS to appropriate auricular points will significantly reduce pain associated with various distal extremity pathologies and injuries.
Literature Review
In recent years, Paul Nogier, a French neurologist who learned the Chinese way of acupuncture, delved more deeply into the correlation between auricular acupuncture points and physiological functions to augment the efficacy of auriculotherapy. [9] Nogier discovered that some of his patients had been treated successfully for sciatica with cauterization of a certain point on the external ear. [10] After performing clinical trials using different pathological conditions and various ear points, Nogier proposed that 1) the body surface and visceral structures are represented on the aurcile in a somatotopic organization that resembles an inverted fetus, 2) disease or pain of any body structure is reflected by increased tenderness and skin conductance at a corresponding point on the ear, and 3) electrical stimulation or acupuncture of the appropriate ear point leads to an abolition of or dramatic decrease in pain in the corresponding part of the body. [11]
The Chinese and Nogier systems were systematically compared for similarities and differences of auricular points representing musculoskeletal and sensory systems, internal organs and endocrine glands, peripheral and central nervous systems, and functional problems. Although basically the same, the Chinese and Nogier ear charts do vary in the somatotopic arrangement of a few points unrelated to distal extremities. [11]
Auricular points may be stimulated in a variety of ways. The most common type of ear acupuncture-point stimulation is needle insertion. [5,12] Other auriculotherapy techniques include ear stapling and acupressure [12]; TENS [6-8,12]; and moxibustion, ultrasound, and injection of various substances. [12,13]
Auriculotherapy has been effective in treating a variety of conditions. Recently, studies have shown that acupressure and acupuncture applied to certain ear points may aid in weight reduction [14]; smoking cessation [15]; and alleviation of symptoms of Meniere's disease, [16] alcoholism, [17] and cerebral palsy. [18] Chow and colleagues observed that auricular acupuncture had no effect in relieving symptoms of exercise-induced asthma. [19]
Although auriculotherapy may be used as a treatment for many disorders, its primary use if for pain relief. Paris and co-workers reported that auricular TENS, in conjunction with traditional physical therapy and electrical stimulation of certain body loci, decreased both pain and rehabilitation time in patients with ankle inversion sprains. [1] Kajdos reported that of 175 patients treated with ear acupuncture for migraine headaches, 89% received pain relief and 11% were unaffected. [4] Leung and Spoerel observed that most of their patients suffering from chronic intractable pain of various causes received at least partial pain relief from auricular acupuncture. [9] In a case report on the treatment of pediatric reflex sympathetic dystrophy, Leo reported that electrical stimulation delivered to the auricle alleviated symptoms. [2] Jichova and associates reported extinction of burning and pain sensations in patients with fresh burns of up to 30% of body surface area within 25 to 30 minutes after insertion of needles at the shen-men and thalamic projection points on the auricle. [20] Chun and Heather observed that 84% of their patients with chronic pain treated with electrical auriculotherapy received some pain relief. [21]
Numerous disadvantages exist in many of the current pain-management techniques. Surgical intervention is an invasive method leaving the patient vulnerable to possible infection and deforming, debilitating scars. Many drugs used for pain control are addictive and produce detrimental side effects. A noninvasive, nonaddictive pain-relieving technique applied to an area distant from the site of pain would be a welcome addition to present pain-management techniques. Auricular TENS is a clinical modality applied to points distant from the site of pain that may prove to be a beneficial pain-control technique.
Method
Subjects
Fifteen adult outpatients (6 men, 9 women) from several Birmingham health care facilities participated in this study, which involved treatment with either auricular acupuncture-like TENS or a "placebo" pill. The subjects ranged in age from 24 to 78 years with a mean age of 43.1 years. All subjects complained of distal extremity pain: seven with upper extremity pain and eight with lower extremity pain. The subjects' demographic characteristics are presented by group in Table 1. Criteria for patient participation in this study were 1) pain in the area of the distal upper extremity (elbow, wrist, or fingers) or the distal lower extremity (knee, ankle, or toes) experienced just before treatment, 2) acute pain of less than six months' duration, 3) no opiate pain medication for at least eight hours before treatment, and 4) 18 years of age or older. Individuals who were pregnant or had a cardiac pacemaker were not accepted for the study because TENS may be contraindicated under these conditions. [22] The subjects were naive to the specific auricular points to be stimulated. All subjects were aware that the anticipated outcome of the procedure was pain relief. Before implementation, this study was approved by the Institutional Review Board for Human Use at The University of Alabama at Birmingham. The study was also approved by the various Birmingham health care facilities.
Instrumentation
A Staodyn Insight (*1) electrostimulator was used to deliver TENS to auricular points. This unit was equipped with a spring-loaded probe tip with a diameter of about 1 mm for stimulation and a 5- X 4-cm rectangular dispersive electrode.
Procedure
The subjects were randomly assigned to an Experimental (n = 8) or a Control (placebo) (n = 7) Group. A brief medical history questionnaire was completed and a consent form was signed by each subject before the treatment. The visual analogue scale (VAS) [23-26] and the pain rating index (PRI) from the McGill Pain Questionnaire [27,28] were completed by all subjects immediately before treatment. All information was recorded and kept confidential.
Treatment for the Control Group consisted of taking a placebo pill, which was described to the subject as "a pill that has been used in the past for pain relief." The subject was then positioned supine on a treatment plinth for 40 minutes with pillows under the knees and the head and shoulders.
The Experimental Group subjects were positioned the same as the Control Group. Each subject received bilateral acupuncture-like (high intensity, low frequency) TENS to five points on the auricle of both ears: shen-men, lung, dermis (also referred to as the subcortex or thalamus point), and two points appropriate to the painful extremity (Fig. 1). The appropriate points for the upper extremity were elbow, wrist, and finger. The appropriate points for the lower extremity were knee, ankle, and toe. Appropriate points were chosen according to the painful area. The shen-men, lung, and dermis points are associated with analgesic or tranquilizing effects and used in the treatment of restlessness and excessive sensitivity. [2] The lung point is especially associated with the surface area of the body and is the main point for decreasing pain during incisions. [2]
All electrode placement sites were cleaned before treatment with isopropyl alcohol and cotton gauze to reduce skin resistance. The dispersive electrode, used as a ground, was held by the subject in either hand; the specific hand was not recorded. Any earrings and necklaces were removed from the subjects. Stimulation points were located before the treatment using acupuncture charts and by finding areas of decreased skin resistance with the aid of auditory or visual signals from the point-locator circuit of the Staodyn Insight electrostimulator. The physical location of the points stimulated on the auricle were recorded for each subject according to the involved area of the extremity. The auricular stimulus consisted of a positive (monophasic waveform) direct current with a maximum output of 1,000 [microamp] delivered in pulses of 1 Hz. A nonspecified stimulus pulse width was preset in the unit by the manufacturer. Each subject was instructed to verbally respond to changes in stimulus intensity. As the intensity of the stimulus was increased, the subject indicated the first moment the stimulus was felt by saying "Feel it" for the investigator (A.G.L.) to be aware of the subject's sensitivity. The stimulus was increased slowly to the subject's pain threshold when the subject said "Stop," after which no further increases in intensity were made. Each auricular point was stimulated 60 seconds, with the intensity maintained at the subject's threshold level. This treatment technique was similar to that used by Oliveri et al, [6] Krause et al, [7] and Noling et al [8] on healthy subjects.
Following the 10-minute treatment, the subjects remained in the treatment position for 30 minutes, during which time all subjects completed additional sets of pain questionnaires. All subjects completed pain scales at three posttest time intervals: immediately posttreatment, 10 minutes posttreatment, and 30 minutes posttreatment.
Criteria for Effectiveness
The VAS [23-26] and the PRI [27,28] were used to measure pain. The VAS contained all the scales for each subject on one sheet and required the subjects to place a vertical mark on a 10-cm line bounded by the phrases "no pain" on the left and "worst pain imaginable" on the right. [23-26] The PRI required the subjects to choose words that described their pain at the moment. The PRI, which has a maximum score of 78, is determined by summing the rank values of all the words chosen from 20 sets of qualitative words that describe the sensory, affective, and evaluative properties of pain. [27,28] Subjects were allowed to see their previously completed PRI at any point in the study, if requested.
Data Analysis
Descriptive statistics for the VAS and the PRI were calculated at each measurement time for the Experimental and Control Groups. A two-factor repeated-measures analysis of variance (ANOVA) was used to test the data for statistical significance. The two factors were group and time of measurement. An ANOVA was performed for the VAS and the PRI raw data. Each ANOVA was conducted using both a univariate and a multivariate approach. When the "symmetry" conditions were met, or when the univariate and multivariate ANOVA results agreed, the univariate ANOVA results were used, because the univariate approach is typically more powerful. [29]
Statistically significant group-by-time interactions were followed up with post hoc tests for simple main effects. Statistically significant simple main effects for time were followed up with the Tukey's Honestly Significant Difference (HSD) test. [30] To provide adequate statistical power, an alpha level of .10 was chosen as the criterion for statistical significance. The power of a statistical test is the probability that it will lead to the rejection of the null hypothesis. [31] Power is a function of alpha level, effect size, and sample size. Before analyzing the data, we estimated the power of the interaction test in the ANOVA to be .61 using an alpha level of .05, a "large" effect size of .40, and our fixed sample size of 15; using an alpha level of .10 increased power to .73. [31] We were more comfortable with a .73 chance of rejecting the null hypothesis than a .61 chance, so we chose the .10 alpha level. After pooling the data over all four measurement times (4 X 15 = 60 observations), a Pearson product-moment correlation coefficient was calculated between the VAS and the PRI.
To help assess clinical significance, the percentage of pain reduction was calculated for each subject at each posttreatment measurement time using the following formula:
% change = posttreatment value - basline value/baseline value X 100
The mean percentage of pain reduction was also calculated for each group at each posttreatment measurement time.
Results
Tables 2 and 3 present descriptive statistics for the VAS and the PRI, respectively. Figures 2 and 3 present the mean pain values for the Experimental and Control Groups using the VAS and the PRI, respectively.
The ANOVA results for the VAS are summarized in Table 4. Neither the univariate nor the multivariate test of the group-by-time interaction was statistically significant. The time main effect was statistically significant, indicating that the combined groups showed a reduction in pain over time. Because the group-by-time interaction was not significant, however, we found no different between the group profiles over time. The group main effect was not statistically significant.
The ANOVA results for the PRI are summarized in Table 5. The univariate test for the group-by-time interaction was not statistically significant. One of the symmetry conditions, however, was not met; therefore, the statistically significant multivariate test of interaction was used. Tests of simple main effects showed that the Experimental and Control Group mean pain values different significantly (p [is less than] .05) at each posttreatment measurement time but did not differ significantly at the baseline measurement. At each posttreatment measurement time, the Experimental Group mean was lower than the Control Group mean (Tab. 3, Fig. 3). Tests of simple main effects also showed that the means for the various measurement times differed significantly for the Experimental Group but not for the Control Group. For the Experimental Group, Tukey's HSD test showed that the baseline mean differed significantly (p [is less than] .05) from each of the posttreatment means, but that none of the posttreatment means differed significantly from each other. As shown in Table 3 and Figure 3, each posttreatment mean was lower than the baseline mean. The differences at the posttreatment measurement times can also be seen by comparing the differences between the mean percentages of pain reduction of the two groups (Tab. 6).
The Pearson product-moment correlation coefficient between the VAS and the PRI for pooled data ( 4 X 15 = 60) was .16. This value represents a weak positive relationship between the two measures.
The hypothesis of this study stated that a single treatment of acupuncture-like TENS to appropriate auricular points would significantly reduce pain associated with various distal extremity pathologies and injuries. This hypothesis was supported by the results for the PRI but not by the results for the VAS.
Discussion
The results for the PRI and the VAS are conflicting, but the results from the PRI alone suggest that a single treatment of auricular acupuncture-like TENS significantly reduced distal extremity pain of various etiologies. The results also suggest that the reduction in pain lasted for at least 30 minutes. Chun and Heather used electrical auriculotherapy on patients with chronic pain. Eighty-four percent of their patients received pain relief, as judged by subjective descriptions of pain in regard to severity, frequency of attack, and necessity of taking analgesics. [21] Leo used electrical auricular stimulation to treat a child with reflex sympathetic dystrophy and reported that symptoms were alleviated, as determined by physical examination and patient report. [2] In patients with ankle inversion sprains, Paris and associates used auricular TENS along with electrical stimulation of certain body loci and found decreases in pain, as rated on a subjective five-point scale, and decreased rehabilitation time. [1]
It is difficult to compare our results concerning the persistence of the treatment effect over time to the other auriculotherapy studies because of the very different methods used. The patient in the study by Leo received auricular stimulation treatments over a six-day period and was completely asymptomatic by the sixth day, with a follow-up three months later showing no increase in symptoms. [2] Patients in the study by Paris et al received several treatments over a 9- to 17-day period. [1] Although Paris et al conducted no follow-up to show any continued effects over an increased time period, the focus of their study was on difference in time of rehabilitation with the addition of the auricular treatment; pain was only one of many factors considered in criteria for release. Noling et al, using a method very similar to ours with healthy subjects, found that changes in mean experimental pain threshold after one auricular electrical stimulation treatment significantly increased between 0 and 10 minutes posttreatment and between 5 and 10 minutes posttreatment. The increase of mean pain threshold between 0 and 5 minutes posttreatment was not statistically significant. [8] Although indications are that the effects of auricular stimulation persist or even increase over time, more studies are needed to address this question specifically.
The results of this clinical study correlate with results of previous studies of experimentally induced pain in healthy subjects conducted at The University of Alabama at Birmingham. [6-8] Oliveri and co-workers stimulated appropriate ear points unilaterally for wrist pain and observed a significant increase in experimental pain threshold. [6] Krause and associates stimulated appropriate auricular points corresponding to the wrist and reported significant increases in experimentally induced pain threshold with unilateral and bilateral stimulation. [7] Noling and colleagues observed that elevations in experimental pain threshold after auricular stimulation to points appropriate for wrist pain lasted at least 10 minutes poststimulation, [8] as previously discussed.
The correlation between the VAS and the PRI was weak in this study. Many possible explanations exist for this poor relationship. The sex of the subjects may have affected the correlation of the two pain measures, and some subjects may have had poor understanding of what the pain questionnaire required. Kroth, [32] Janke, [33] and Neighbors et al [34] reported strong correlations between the VAS and the PRI in young, adult, college-educated female subjects. Our subjects were older and consisted of men and women, and their level of education was unknown. The age range for subjects in this study was 24 to 78 years, approximately six decades, offering another possible reason for a poor correlation.
The differences obtained between the two groups in this study were small but indicate that the use of auricular acupuncture-like TENS for distal extremity pain was more effective than a placebo pill. The age and sex differences betwee the two groups and the small sample size limit our ability to generalize the conclusions to a large population. In addition, there was unequal sampling with reference to the involved extremity. Only two Experimental Group subjects had pain in the upper extremity, whereas five Control Group subjects had upper extremity pain. To assess the value of auricular TENS on pain, additional clinical studies are necessary using better control of sampling distribution of the following factors: age, sex, and involved extremity.
Conclusions
In a small group of subjects experiencing distal extremity pain, statistically significant pain reduction occurred after application of high intensity, low frequency TENS to auricular acupuncture points. These results suggest that bilateral auricular stimulation may be an effective analgesic technique for distal extremity pain. Although few well-controlled studies have been conducted regarding the efficacy of auricular TENS for pain management, these studies do suggest this technique may be a viable alternative to invasive or addictive methods of pain management. Further research is necessary to substantiate the results of these studies and to further explore the therapeutic efficacy of this technique.
(*1) Staodynamics, Inc, PO Box 1379, Longmont, CO 80501.
References
[1] Paris DL, Baynes F, Gucker B: Effect of the Neuroprobe in the treatment of second-degree ankle inversion sprains. Phys Ther 63:35-40, 1983
[2] Leo KC: Use of electrical stimulation at acupuncture points for the treatment of reflex sympathetic dystrophy in a child: A case report. Phys Ther 63:957-959, 1983
[3] Sjolund BH, Eriksson MBE: Electroacupuncture and endogenous morphines. (Letter to the editor.) Lancet 2:1085, 1976
[4] Kajdos V: Experiences with auricular acupuncture. American Journal of Acupuncture 4:130-136, 1976
[5] Kitade T, Hyodo M: The effects of stimulation of ear acupuncture points on the body's pain threshold. Am J Chin Med 7:241-252, 1979
[6] Oliveri AC, Clelland JA, Jackson J, et al: Effects of auricular transcutaneous electrical nerve stimulation on experimental pain threshold. Phys Ther 66:12-16, 1986
[7] Krause AW, Clelland JA, Knowles CJ, et al: Effects of unilateral and bilateral auricular transcutaneous electrical nerve stimulation on cutaneous pain threshold. Phys Ther 67:507-511, 1987
Effects of Auricular Transcutaneous Electrical Nerve Stimulation on Distal Extremity Pain: A Pilot Study Pain has plagued the human species for centuries. Approaches to pain management have evolved and changed over the years, but some modern methods correlate with methods used many years ago. Many
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modern analgesic methods are undesirable or detrimental such as surgery, which is invasive, or use of drugs, which may be addictive. Physical therapists often administer pain-relieving treatments to patients suffering from pain of various etiologies. A noninvasive technique that can relieve distal extremity pain of various etiologies would be a welcome addition to current treatment techniques.
Transcutaneous electrical nerve stimulation is a noninvasive and nonaddictive treatment for pain used by many physical therapists. Recent clinical studies have reported significant decreases in pain following the application of high intensity, low frequency TENS [1,2] and electroacupuncture. [3-5] High intensity, low frequency TENS applied over acupuncture points is referred to as "acupuncture-like" TENS. Acupuncture points on the auricle of the ear are sometimes the sites for acupuncture-like TENS. The effects of TENS applied to the auricle are supported by the findings of Oliveri et al, [6] Krause et al, [7] and Noling et al. [8] They reported that application of high intensity, low frequency TENS to appropriate auricular acupuncture points increased experimental pain threshold. Paris et al reported significant results with the clinical application of auricular TENS in the treatment of ankle inversion sprains, [1] and Leo reported similar results in the treatment of pediatric reflex sympathetic dystrophy. [2] The purpose of our study was to examine the effect of bilateral auricular TENS on pain in patients experiencing distal extremity pain. This study was designed to test the hypothesis that a single treatment of acupuncture-like TENS to appropriate auricular points will significantly reduce pain associated with various distal extremity pathologies and injuries.
Literature Review
In recent years, Paul Nogier, a French neurologist who learned the Chinese way of acupuncture, delved more deeply into the correlation between auricular acupuncture points and physiological functions to augment the efficacy of auriculotherapy. [9] Nogier discovered that some of his patients had been treated successfully for sciatica with cauterization of a certain point on the external ear. [10] After performing clinical trials using different pathological conditions and various ear points, Nogier proposed that 1) the body surface and visceral structures are represented on the aurcile in a somatotopic organization that resembles an inverted fetus, 2) disease or pain of any body structure is reflected by increased tenderness and skin conductance at a corresponding point on the ear, and 3) electrical stimulation or acupuncture of the appropriate ear point leads to an abolition of or dramatic decrease in pain in the corresponding part of the body. [11]
The Chinese and Nogier systems were systematically compared for similarities and differences of auricular points representing musculoskeletal and sensory systems, internal organs and endocrine glands, peripheral and central nervous systems, and functional problems. Although basically the same, the Chinese and Nogier ear charts do vary in the somatotopic arrangement of a few points unrelated to distal extremities. [11]
Auricular points may be stimulated in a variety of ways. The most common type of ear acupuncture-point stimulation is needle insertion. [5,12] Other auriculotherapy techniques include ear stapling and acupressure [12]; TENS [6-8,12]; and moxibustion, ultrasound, and injection of various substances. [12,13]
Auriculotherapy has been effective in treating a variety of conditions. Recently, studies have shown that acupressure and acupuncture applied to certain ear points may aid in weight reduction [14]; smoking cessation [15]; and alleviation of symptoms of Meniere's disease, [16] alcoholism, [17] and cerebral palsy. [18] Chow and colleagues observed that auricular acupuncture had no effect in relieving symptoms of exercise-induced asthma. [19]
Although auriculotherapy may be used as a treatment for many disorders, its primary use if for pain relief. Paris and co-workers reported that auricular TENS, in conjunction with traditional physical therapy and electrical stimulation of certain body loci, decreased both pain and rehabilitation time in patients with ankle inversion sprains. [1] Kajdos reported that of 175 patients treated with ear acupuncture for migraine headaches, 89% received pain relief and 11% were unaffected. [4] Leung and Spoerel observed that most of their patients suffering from chronic intractable pain of various causes received at least partial pain relief from auricular acupuncture. [9] In a case report on the treatment of pediatric reflex sympathetic dystrophy, Leo reported that electrical stimulation delivered to the auricle alleviated symptoms. [2] Jichova and associates reported extinction of burning and pain sensations in patients with fresh burns of up to 30% of body surface area within 25 to 30 minutes after insertion of needles at the shen-men and thalamic projection points on the auricle. [20] Chun and Heather observed that 84% of their patients with chronic pain treated with electrical auriculotherapy received some pain relief. [21]
Numerous disadvantages exist in many of the current pain-management techniques. Surgical intervention is an invasive method leaving the patient vulnerable to possible infection and deforming, debilitating scars. Many drugs used for pain control are addictive and produce detrimental side effects. A noninvasive, nonaddictive pain-relieving technique applied to an area distant from the site of pain would be a welcome addition to present pain-management techniques. Auricular TENS is a clinical modality applied to points distant from the site of pain that may prove to be a beneficial pain-control technique.
Method
Subjects
Fifteen adult outpatients (6 men, 9 women) from several Birmingham health care facilities participated in this study, which involved treatment with either auricular acupuncture-like TENS or a "placebo" pill. The subjects ranged in age from 24 to 78 years with a mean age of 43.1 years. All subjects complained of distal extremity pain: seven with upper extremity pain and eight with lower extremity pain. The subjects' demographic characteristics are presented by group in Table 1. Criteria for patient participation in this study were 1) pain in the area of the distal upper extremity (elbow, wrist, or fingers) or the distal lower extremity (knee, ankle, or toes) experienced just before treatment, 2) acute pain of less than six months' duration, 3) no opiate pain medication for at least eight hours before treatment, and 4) 18 years of age or older. Individuals who were pregnant or had a cardiac pacemaker were not accepted for the study because TENS may be contraindicated under these conditions. [22] The subjects were naive to the specific auricular points to be stimulated. All subjects were aware that the anticipated outcome of the procedure was pain relief. Before implementation, this study was approved by the Institutional Review Board for Human Use at The University of Alabama at Birmingham. The study was also approved by the various Birmingham health care facilities.
Instrumentation
A Staodyn Insight (*1) electrostimulator was used to deliver TENS to auricular points. This unit was equipped with a spring-loaded probe tip with a diameter of about 1 mm for stimulation and a 5- X 4-cm rectangular dispersive electrode.
Procedure
The subjects were randomly assigned to an Experimental (n = 8) or a Control (placebo) (n = 7) Group. A brief medical history questionnaire was completed and a consent form was signed by each subject before the treatment. The visual analogue scale (VAS) [23-26] and the pain rating index (PRI) from the McGill Pain Questionnaire [27,28] were completed by all subjects immediately before treatment. All information was recorded and kept confidential.
Treatment for the Control Group consisted of taking a placebo pill, which was described to the subject as "a pill that has been used in the past for pain relief." The subject was then positioned supine on a treatment plinth for 40 minutes with pillows under the knees and the head and shoulders.
The Experimental Group subjects were positioned the same as the Control Group. Each subject received bilateral acupuncture-like (high intensity, low frequency) TENS to five points on the auricle of both ears: shen-men, lung, dermis (also referred to as the subcortex or thalamus point), and two points appropriate to the painful extremity (Fig. 1). The appropriate points for the upper extremity were elbow, wrist, and finger. The appropriate points for the lower extremity were knee, ankle, and toe. Appropriate points were chosen according to the painful area. The shen-men, lung, and dermis points are associated with analgesic or tranquilizing effects and used in the treatment of restlessness and excessive sensitivity. [2] The lung point is especially associated with the surface area of the body and is the main point for decreasing pain during incisions. [2]
All electrode placement sites were cleaned before treatment with isopropyl alcohol and cotton gauze to reduce skin resistance. The dispersive electrode, used as a ground, was held by the subject in either hand; the specific hand was not recorded. Any earrings and necklaces were removed from the subjects. Stimulation points were located before the treatment using acupuncture charts and by finding areas of decreased skin resistance with the aid of auditory or visual signals from the point-locator circuit of the Staodyn Insight electrostimulator. The physical location of the points stimulated on the auricle were recorded for each subject according to the involved area of the extremity. The auricular stimulus consisted of a positive (monophasic waveform) direct current with a maximum output of 1,000 [microamp] delivered in pulses of 1 Hz. A nonspecified stimulus pulse width was preset in the unit by the manufacturer. Each subject was instructed to verbally respond to changes in stimulus intensity. As the intensity of the stimulus was increased, the subject indicated the first moment the stimulus was felt by saying "Feel it" for the investigator (A.G.L.) to be aware of the subject's sensitivity. The stimulus was increased slowly to the subject's pain threshold when the subject said "Stop," after which no further increases in intensity were made. Each auricular point was stimulated 60 seconds, with the intensity maintained at the subject's threshold level. This treatment technique was similar to that used by Oliveri et al, [6] Krause et al, [7] and Noling et al [8] on healthy subjects.
Following the 10-minute treatment, the subjects remained in the treatment position for 30 minutes, during which time all subjects completed additional sets of pain questionnaires. All subjects completed pain scales at three posttest time intervals: immediately posttreatment, 10 minutes posttreatment, and 30 minutes posttreatment.
Criteria for Effectiveness
The VAS [23-26] and the PRI [27,28] were used to measure pain. The VAS contained all the scales for each subject on one sheet and required the subjects to place a vertical mark on a 10-cm line bounded by the phrases "no pain" on the left and "worst pain imaginable" on the right. [23-26] The PRI required the subjects to choose words that described their pain at the moment. The PRI, which has a maximum score of 78, is determined by summing the rank values of all the words chosen from 20 sets of qualitative words that describe the sensory, affective, and evaluative properties of pain. [27,28] Subjects were allowed to see their previously completed PRI at any point in the study, if requested.
Data Analysis
Descriptive statistics for the VAS and the PRI were calculated at each measurement time for the Experimental and Control Groups. A two-factor repeated-measures analysis of variance (ANOVA) was used to test the data for statistical significance. The two factors were group and time of measurement. An ANOVA was performed for the VAS and the PRI raw data. Each ANOVA was conducted using both a univariate and a multivariate approach. When the "symmetry" conditions were met, or when the univariate and multivariate ANOVA results agreed, the univariate ANOVA results were used, because the univariate approach is typically more powerful. [29]
Statistically significant group-by-time interactions were followed up with post hoc tests for simple main effects. Statistically significant simple main effects for time were followed up with the Tukey's Honestly Significant Difference (HSD) test. [30] To provide adequate statistical power, an alpha level of .10 was chosen as the criterion for statistical significance. The power of a statistical test is the probability that it will lead to the rejection of the null hypothesis. [31] Power is a function of alpha level, effect size, and sample size. Before analyzing the data, we estimated the power of the interaction test in the ANOVA to be .61 using an alpha level of .05, a "large" effect size of .40, and our fixed sample size of 15; using an alpha level of .10 increased power to .73. [31] We were more comfortable with a .73 chance of rejecting the null hypothesis than a .61 chance, so we chose the .10 alpha level. After pooling the data over all four measurement times (4 X 15 = 60 observations), a Pearson product-moment correlation coefficient was calculated between the VAS and the PRI.
To help assess clinical significance, the percentage of pain reduction was calculated for each subject at each posttreatment measurement time using the following formula:
% change = posttreatment value - basline value/baseline value X 100
The mean percentage of pain reduction was also calculated for each group at each posttreatment measurement time.
Results
Tables 2 and 3 present descriptive statistics for the VAS and the PRI, respectively. Figures 2 and 3 present the mean pain values for the Experimental and Control Groups using the VAS and the PRI, respectively.
The ANOVA results for the VAS are summarized in Table 4. Neither the univariate nor the multivariate test of the group-by-time interaction was statistically significant. The time main effect was statistically significant, indicating that the combined groups showed a reduction in pain over time. Because the group-by-time interaction was not significant, however, we found no different between the group profiles over time. The group main effect was not statistically significant.
The ANOVA results for the PRI are summarized in Table 5. The univariate test for the group-by-time interaction was not statistically significant. One of the symmetry conditions, however, was not met; therefore, the statistically significant multivariate test of interaction was used. Tests of simple main effects showed that the Experimental and Control Group mean pain values different significantly (p [is less than] .05) at each posttreatment measurement time but did not differ significantly at the baseline measurement. At each posttreatment measurement time, the Experimental Group mean was lower than the Control Group mean (Tab. 3, Fig. 3). Tests of simple main effects also showed that the means for the various measurement times differed significantly for the Experimental Group but not for the Control Group. For the Experimental Group, Tukey's HSD test showed that the baseline mean differed significantly (p [is less than] .05) from each of the posttreatment means, but that none of the posttreatment means differed significantly from each other. As shown in Table 3 and Figure 3, each posttreatment mean was lower than the baseline mean. The differences at the posttreatment measurement times can also be seen by comparing the differences between the mean percentages of pain reduction of the two groups (Tab. 6).
The Pearson product-moment correlation coefficient between the VAS and the PRI for pooled data ( 4 X 15 = 60) was .16. This value represents a weak positive relationship between the two measures.
The hypothesis of this study stated that a single treatment of acupuncture-like TENS to appropriate auricular points would significantly reduce pain associated with various distal extremity pathologies and injuries. This hypothesis was supported by the results for the PRI but not by the results for the VAS.
Discussion
The results for the PRI and the VAS are conflicting, but the results from the PRI alone suggest that a single treatment of auricular acupuncture-like TENS significantly reduced distal extremity pain of various etiologies. The results also suggest that the reduction in pain lasted for at least 30 minutes. Chun and Heather used electrical auriculotherapy on patients with chronic pain. Eighty-four percent of their patients received pain relief, as judged by subjective descriptions of pain in regard to severity, frequency of attack, and necessity of taking analgesics. [21] Leo used electrical auricular stimulation to treat a child with reflex sympathetic dystrophy and reported that symptoms were alleviated, as determined by physical examination and patient report. [2] In patients with ankle inversion sprains, Paris and associates used auricular TENS along with electrical stimulation of certain body loci and found decreases in pain, as rated on a subjective five-point scale, and decreased rehabilitation time. [1]
It is difficult to compare our results concerning the persistence of the treatment effect over time to the other auriculotherapy studies because of the very different methods used. The patient in the study by Leo received auricular stimulation treatments over a six-day period and was completely asymptomatic by the sixth day, with a follow-up three months later showing no increase in symptoms. [2] Patients in the study by Paris et al received several treatments over a 9- to 17-day period. [1] Although Paris et al conducted no follow-up to show any continued effects over an increased time period, the focus of their study was on difference in time of rehabilitation with the addition of the auricular treatment; pain was only one of many factors considered in criteria for release. Noling et al, using a method very similar to ours with healthy subjects, found that changes in mean experimental pain threshold after one auricular electrical stimulation treatment significantly increased between 0 and 10 minutes posttreatment and between 5 and 10 minutes posttreatment. The increase of mean pain threshold between 0 and 5 minutes posttreatment was not statistically significant. [8] Although indications are that the effects of auricular stimulation persist or even increase over time, more studies are needed to address this question specifically.
The results of this clinical study correlate with results of previous studies of experimentally induced pain in healthy subjects conducted at The University of Alabama at Birmingham. [6-8] Oliveri and co-workers stimulated appropriate ear points unilaterally for wrist pain and observed a significant increase in experimental pain threshold. [6] Krause and associates stimulated appropriate auricular points corresponding to the wrist and reported significant increases in experimentally induced pain threshold with unilateral and bilateral stimulation. [7] Noling and colleagues observed that elevations in experimental pain threshold after auricular stimulation to points appropriate for wrist pain lasted at least 10 minutes poststimulation, [8] as previously discussed.
The correlation between the VAS and the PRI was weak in this study. Many possible explanations exist for this poor relationship. The sex of the subjects may have affected the correlation of the two pain measures, and some subjects may have had poor understanding of what the pain questionnaire required. Kroth, [32] Janke, [33] and Neighbors et al [34] reported strong correlations between the VAS and the PRI in young, adult, college-educated female subjects. Our subjects were older and consisted of men and women, and their level of education was unknown. The age range for subjects in this study was 24 to 78 years, approximately six decades, offering another possible reason for a poor correlation.
The differences obtained between the two groups in this study were small but indicate that the use of auricular acupuncture-like TENS for distal extremity pain was more effective than a placebo pill. The age and sex differences betwee the two groups and the small sample size limit our ability to generalize the conclusions to a large population. In addition, there was unequal sampling with reference to the involved extremity. Only two Experimental Group subjects had pain in the upper extremity, whereas five Control Group subjects had upper extremity pain. To assess the value of auricular TENS on pain, additional clinical studies are necessary using better control of sampling distribution of the following factors: age, sex, and involved extremity.
Conclusions
In a small group of subjects experiencing distal extremity pain, statistically significant pain reduction occurred after application of high intensity, low frequency TENS to auricular acupuncture points. These results suggest that bilateral auricular stimulation may be an effective analgesic technique for distal extremity pain. Although few well-controlled studies have been conducted regarding the efficacy of auricular TENS for pain management, these studies do suggest this technique may be a viable alternative to invasive or addictive methods of pain management. Further research is necessary to substantiate the results of these studies and to further explore the therapeutic efficacy of this technique.
(*1) Staodynamics, Inc, PO Box 1379, Longmont, CO 80501.
References
[1] Paris DL, Baynes F, Gucker B: Effect of the Neuroprobe in the treatment of second-degree ankle inversion sprains. Phys Ther 63:35-40, 1983
[2] Leo KC: Use of electrical stimulation at acupuncture points for the treatment of reflex sympathetic dystrophy in a child: A case report. Phys Ther 63:957-959, 1983
[3] Sjolund BH, Eriksson MBE: Electroacupuncture and endogenous morphines. (Letter to the editor.) Lancet 2:1085, 1976
[4] Kajdos V: Experiences with auricular acupuncture. American Journal of Acupuncture 4:130-136, 1976
[5] Kitade T, Hyodo M: The effects of stimulation of ear acupuncture points on the body's pain threshold. Am J Chin Med 7:241-252, 1979
[6] Oliveri AC, Clelland JA, Jackson J, et al: Effects of auricular transcutaneous electrical nerve stimulation on experimental pain threshold. Phys Ther 66:12-16, 1986
[7] Krause AW, Clelland JA, Knowles CJ, et al: Effects of unilateral and bilateral auricular transcutaneous electrical nerve stimulation on cutaneous pain threshold. Phys Ther 67:507-511, 1987
[8] Noling LB, Clelland JA, Jackson JR, et al: Effect of transcutaneous electrical nerve stimulation at auricular points on experimental cutaneous pain threshold. Phys Ther 68:328-332, 1988
[9] Leung CY, Spoerel WE: Effect of auriculo-acupuncture on pain. Am J Chin Med 2: 247-260, 1974
[10] Oleson TD, Kroening RJ: A comparison of Chinese and Nogier auricular acupuncture points. American Journal of Acupuncture 11:205-233, 1983
[11] Nogier PFM: Treatise of Auriculotherapy. Maisonneuve, France, Moulin-les-Metz, 1972
[12] Chan P: Ear Acupressure. Monterey Park, CA, Chan's Corporation, 1981, pp 13-18, 33-37
[13] Lee TN: Lidocaine injections in auricular acupuncture: Treatment and tonification. American Journal of Acupuncture 5:137-143, 1977
[14] Sun EL: Weight reduction and auricular acupressure. American Journal of Acupuncture 7:311-314, 1979
[15] Chen JYP: Treatment of cigarette smoking by auricular acupuncture: A report of 184 cases. American Journal of Acupuncture 7:229-234, 1979
[16] Steinberger A, Mihavil P: The treatment of Meniere's disease by acupuncture. Am J Chin Med 11:102-105, 1983
[17] Gaal CL, Freebairn C: Ear acupuncture relaxation therapy in alcoholics. Med J Aust 2:179-180, 1979
[18] Spears CE: Auricular acupuncture: New approach to treatment of cerebral palsy. American Journal of Acupuncture 7:49-54, 1979
[19] Chow DK, So SY, Lam WK, et al: Effect of acupuncture on exercise-induced astham. Lung 161:321-326, 1983
[20] Jichova E, Konigova R, Prusik K: Acupuncture in patients with thermal injuries. Acta Chir Plast 25:102-108, 1983
[21] Chun S, Heather AJ: Auriculotherapy: Micro-current application on the external ear--clinical analysis of a pilot study on 57 chronic pain syndromes. Am J Chin Med 2:399-405, 1974
[22] Coffey GH, Mahon MV: Pain theories and a new approach to treatment. J Natl Med Assoc 74:147-153, 1982
[23] Revill SI, Robinson JO, Rosen M, et al: The reliability of a linear analogue for evaluating pain. Anaesthesia 31:1191-1198, 1976
[24] Seymour RA, Simpson JM, Charlton JE, et al: An evaluation of length and end-phrase of visual analogue scales in dental pain. Pain 21:177-185, 1985
[25] Torgerson WS: What objective measures are there for evaluating pain? J Trauma 24:187-197, 1984
[26] Huskisson EC: Visual analogue scales. In Melzack R (ed): Pain Measurement and Assessment. New York, NY, Raven Press, 1983, pp 33-37
[27] Melzack R: The McGill pain questionnaire: Major properties and scoring methods. Pain 1:277-299, 1975
[28] Melzack R: The McGill pain questionnaire. In Melzack R (ed): Pain Measurement and Assessment. New York, NY, Raven Press, 1983, pp 41-46
[29] SPSS Inc: SPSS-X User's Guide: A complete Guide to SPSS-X Language and Operations. New York, NY, McGraw-Hill Book Co, 1983, pp 522-527
[30] Kirk RE: Experimental Design: Procedures for the Behavioral Sciences. Belmont, CA Brooks/Cole Publishing Co, 1968, pp 88-90
[31] Cohen J: Statistical Power Analysis for the Behavioral Sciences, rev ed. New York, NY, Academic Press Inc, 1977
[32] Kroth MF: The Effects of Transcutaneous Electrical Never Stimulation on Females Experiencing Pain from Dysmenorrhea: Preliminary Findings. Master's Thesis. Birmingham, AL, The University of Alabama at Birmingham, 1983
[33] Janke CL: Transcutaneous Electrical Nerve Stimulation for Pain Relief in Dysmenorrhea. Master's Thesis. Birmingham, AL, The University of Alabama at Birmingham, 1984
[34] Neighbors LE, Clelland JA, Jackson RJ, et al: Transcutaneous electrical nerve stimulation for pain relief in primary dysmenorrhea. Clinical Journal of Pain 3:17-22, 1987
A Longobardi, MS, is Staff Physical Therapist, St Vincent's Hospital, 2701 9th Ct S, Birmingham, AL 35205. He was a gradute student, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham, Birmingham, AL 35294, when this study was conducted. This study was completed in partial fulfillment of the requirements for Mr Longobardi's master's degree at The University of Alabama at Birmingham. Address correspondence to 7709-G Eastridge Circle, Birmingham, AL 35210 (USA).
J Clelland, MS, is Associate Professor and Associate Director, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham.
C Knowles, MS, is Assistant Professor, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham.
J JAckson, PhD, is Assistant Professor, Office of Educational Development, School of Medicine, The University of Alabama at Birmingham.
This article was submitted February 13, 1987; was with the authors for revision for 47 weeks; and was accepted August 15, 1988.
The therapeutic effects of electroacupuncture and auricular plasters in 32 cases of chronic fatigue syndrome
By: Yuemei, Li
Chronic fatigue syndrome is a disease whose pathogenesis is still uncertain, although it is probably related to dysfunction of the nervous, immune and motor systems as a result of viral infection. In TCM theory it is classified as 'consumptive disease', and is caused by physical and mental overwork, excessive emotional stimulation and an unhealthy lifestyle. It is characterised by long-term fatigue, poor concentration, low-grade fever, insomnia and systemic pain, all of which have a serious impact on normal daily functioning. In this study 64 patients were selected according to established diagnostic criteria and divided equally into two statistically comparable groups. Their ages ranged from 20-62 years and the disease duration was 8 months--16 years. The treatment group was given electro-acupuncture on 8-10 of the Huatojiaji M-BW-35 points between T1 and L5. Qihai REN-6 and Zusanli ST-36 were added for physical fatigue and Sishencong M-HN-1 for mental fatigue and treatment was given daily for 30 minutes. Press studs were also applied to ear Shenmen, Sympathetic, and Subcortex, with 2-3 additional points selected from ear Heart, Liver, Spleen, Lung and Kidney according to the diagnosis. Each point was pressed for five minutes, three times daily. The treatment group was given three 10-day treatment courses with an interval of three days between courses. The control group was given a daily dose of hydrocortisone for a course of 10 days, followed by diminishing doses of the drug for two further courses. The results showed a total effectiveness rate of 93.75% in the treatment group, compared to 75% in the control.
Chronic fatigue syndrome is a disease whose pathogenesis is still uncertain, although it is probably related to dysfunction of the nervous, immune and motor systems as a result of viral infection. In TCM theory it is classified as 'consumptive disease', and is caused by physical and mental overwork, excessive emotional stimulation and an unhealthy lifestyle. It is characterised by long-term fatigue, poor concentration, low-grade fever, insomnia and systemic pain, all of which have a serious impact on normal daily functioning. In this study 64 patients were selected according to established diagnostic criteria and divided equally into two statistically comparable groups. Their ages ranged from 20-62 years and the disease duration was 8 months--16 years. The treatment group was given electro-acupuncture on 8-10 of the Huatojiaji M-BW-35 points between T1 and L5. Qihai REN-6 and Zusanli ST-36 were added for physical fatigue and Sishencong M-HN-1 for mental fatigue and treatment was given daily for 30 minutes. Press studs were also applied to ear Shenmen, Sympathetic, and Subcortex, with 2-3 additional points selected from ear Heart, Liver, Spleen, Lung and Kidney according to the diagnosis. Each point was pressed for five minutes, three times daily. The treatment group was given three 10-day treatment courses with an interval of three days between courses. The control group was given a daily dose of hydrocortisone for a course of 10 days, followed by diminishing doses of the drug for two further courses. The results showed a total effectiveness rate of 93.75% in the treatment group, compared to 75% in the control.
Fifty six cases of acne treated by auricular needle-embedding
By: Huixian, Hou
Fifty Six Cases of Acne Treated by Auricular Needle-Embedding, by Hou Huixian et al: 8 males and 48 females, aged between 16-42 years, suffering from acne from between 6 months and 4 years, were treated with auricular acupuncture using Endocrine, Lung, Stomach and Cheek points. Most cases (31) were papular acne, but for the 19 pustular type cases, Heart and Adrenals were added, for the 5 cystic acne cases Spleen was added and Subcortex used for the single case of nodular acne. Ring-form needles were applied unilaterally and kept in situ for 3-5 days with adhesive plaster. The patient was asked to press the needles 3-5 times a day. A course of 5 sessions using alternating sides was performed one to five times. A paste of San Huang San was also applied for 20 minutes. A cure rate of 70% was obtained, and improvement of symptoms in a further 21% of cases.
Fifty Six Cases of Acne Treated by Auricular Needle-Embedding, by Hou Huixian et al: 8 males and 48 females, aged between 16-42 years, suffering from acne from between 6 months and 4 years, were treated with auricular acupuncture using Endocrine, Lung, Stomach and Cheek points. Most cases (31) were papular acne, but for the 19 pustular type cases, Heart and Adrenals were added, for the 5 cystic acne cases Spleen was added and Subcortex used for the single case of nodular acne. Ring-form needles were applied unilaterally and kept in situ for 3-5 days with adhesive plaster. The patient was asked to press the needles 3-5 times a day. A course of 5 sessions using alternating sides was performed one to five times. A paste of San Huang San was also applied for 20 minutes. A cure rate of 70% was obtained, and improvement of symptoms in a further 21% of cases.
Auricular acupuncture in the Treatment of Xerostomia
By: Morganstein, Warren M.
Abstract
Xerostomia, abnormal dryness of the mouth due to decreased secretion of saliva, is a distressing condition which can significantly impair quality of life in sufferers. In this article, the aetiology, pathology and treatment of xerostomia by Western medicine is discussed and existing studies into its treatment by acupuncture are reviewed. The author then describes the treatment of seven xerostomia patients who were treated using a simple acupuncture protocol. Actual outcomes exceeded the author's expectations with all patients reporting an increase in salivary flow and the ability to eat and speak, as well as improved sleep.
Keywords: xerostomia, acupuncture, dry mouth.
Introduction
Xerostomia, abnormal dryness of the mouth due to decreased secretion of saliva, is a distressing condition which can significantly impair quality of life in sufferers. As well as dryness of the mouth, it is associated with rampant dental caries, oral mucosal infections, difficulty in speaking, eating, and swallowing, ulceration or soreness of the oral cavity, altered sense of taste and difficulty in wearing dentures (1). Xerostomia affects approximately one quarter of the population and approximately 40% of adults over 50 (2). In a study of elderly individuals living in retirement homes, it was found that three quarters were using at least one medication for xerostomia (3).
Aetiology
A number of different factors can give rise to xerostomia.
* It is commonly found as a side effect of medications, especially opioids, diuretics, anticholinergic drugs and antihistamines.
* It can be caused by endocrine disorders and autoimmune diseases such as Sjogren's syndrome.
* More than 120,000 patients annually are diagnosed with cancer
of the head and neck in the USA (4) and their treatment by radiotherapy gives rise to xerostomia in almost all cases (5).
* Cancer patients generally exhibit a high prevalence of xerostomia. According to a 1999 study, more than 70% of seriously ill cancer patients suffered from xerostomia (6).
It is thought that the decreased salivary secretion among xerostomia patients is due to atrophy of the secretory cells of the salivary gland and/or dysfunctional changes in the vascular and connective tissues of the salivary glands (7). Studies have reported that salivary production usually does not improve for xerostomia patients and that there is a gradual decrease in salivary gland function (8,9).
Treatment
Treatment for xerostomia is primarily palliative and includes promoting saliva production by increasing water consumption, using sugarless mints and gum or salivary substitutes, and utilising prescription medications such as oral pilocarpine (10,11). Treatment results have been short-term at best. Pilocarpine therapy has been found to be ineffective for a high percentage of patients (30-70% in one study) and may give rise to adverse reactions such as sweating, dizziness, headache, rhinitis, nausea, urinary frequency, tachycardia and visual impairment (12).
Amifostine has been used during radiation therapy via intravenous injection in an attempt to minimise the possibility of xerostomia (as well as mucositis) occuring during treatment through protection against radiation by the scavenging of free radicals. However, amifostine's impact on the efficacy of the radiation treatment (due to possible tumour protection) is controversial because there is the possibility that the drug may protect the tumour from the radiation treatment. In addition, the potential for adverse reactions is significant. Nausea, vomiting, hypertension and allergic reactions were the most common side effects, with 53% of those patients who received amifostine experiencing at least one episode of nausea and/or vomiting (13,14).
Acupuncture and xerostomia Existing studies
Previous studies have demonstrated that acupuncture might serve as an effective long-term approach to the treatment of xerostomia and can significantly reduce untoward effects (15,16).
The use of acupuncture as a treatment for xerostomia was first reported by the Western medical literature in 198117, and since 1992, Blom et al have published numerous articles concerning the effectiveness of acupuncture in its treatment (1,9,15,18). A 1997 study showed a significant increase in saliva (compared to baseline levels) both during and after manual acupuncture stimulation. By contrast, electroacupuncture had no effect (19). In a 1992 study, patients suffering from severe xerostomia, primarily associated with Sjogren's syndrome and other systemic disease, were randomly divided into treatment and control groups to determine the effect of acupuncture on salivary flow rates (18). The control group patients received placebo treatment through superficial intradermal placement of acupuncture needles. Patients in the treatment group exhibited improved salivary flow rates both during and after treatment. These results lasted throughout the one-year post-treatment observation period. While salivary flow rates improved for patients in the control group during the experiment, these changes disappeared after the placebo acupuncture treatment was completed (18).
A long-term study by Blom and Lundeberg followed 70 patients who had been treated with acupuncture for xerostomia due to primary and secondary Sjogren's syndrome, irradiation and other causes. Patients were needled at local points including Juliao ST-3, Daying ST-5, Jiache ST-6, Xiaguan ST-7, Tianrong SI-17, Futu L.I.-18, Yifeng SJ-17 and Baihui DU-20, and distal points including Shenmen HE-7, Neiguan P-6, Sanjian L.I.-3, Hegu L.I.-4, Quchi L.I.-11, Waiguan SJ-5, Zusanli ST-36, Sanyinjiao SP-6, Zulinqi GB41, Taichong LIV-3, Taixi KID-3 and Shuiquan KID-5. All patients received a minimum of twelve and a maximum of fifteen needles. Results acquired over an observational period as long as three years indicated that acupuncture improved salivary flow rates. Compared to patients who chose not to continue acupuncture, the rates remained consistently higher for patients who received an additional series of 5-12 acupuncture treatments, as needed (9). A 1999 study of patients in a hospital-based home care setting investigated how acupuncture affected patients in late-stage palliative care with symptoms of xerostomia and related problems. The results indicated that "acupuncture had a dramatic effect on xerostomia and subsequently on dysphagia and articulation." (6)
Patients with xerostomia due to radiation therapy for head and neck cancer have shown increased salivary flow rates after acupuncture treatment (15). Patients who had received more than 50 Gy of radiation were assigned at random to a treatment group receiving real acupuncture or a control group receiving placebo (superficial) acupuncture. Both groups showed a significant increase in salivary flow rates during the one-year observation period, although the control group demonstrated both a smaller and slower improvement. The results of this study show the difficulty in using superficial acupuncture as a placebo.
Possible mechanisms of action of acupuncture It has been suggested that acupuncture increases the release of neuropeptides and stimulates the autonomic nervous system, enhancing salivary secretion both in healthy subjects and those with xerostomia. Radio immunoassay analysis has been used to examine xerostomia patients and has determined that acupuncture significantly increases both vasoactive intestinal polypeptide (VIP) and calcitonin generelated peptide (CGRP) in their saliva (1,19,20.)
Both the sympathetic and parasympathetic nervous systems influence the function of salivary glands and the rate and nature of salivary flow. Sensory, sympathetic and parasympathetic nerve fibres innervate the salivary glands. Sympathetic system stimulation produces a low, viscous, protein-rich flow of saliva while parasympathetic system stimulation has the primary influence on salivary secretion and yields a strong increase of salivary flow with a low protein content (21,22).
Acupuncture has also been shown to increase blood flow to the skin overlying the parotid gland. Blom et al studied a group that had received acupuncture and a control group that had received superflcial acupuncture. Using laser Doppler flowmetry, they discovered that blood flow to the skin overlying the parotid gland increased significantly (both during and after acupuncture) for the experimental (acupuncture) group (23).
A new acupuncture treatment for xerostomia
Most of the treatment provided in research that relates to acupuncture and xerostomia has involved placing needles at numerous points both locally (in the area of the major salivary glands) and distally (that is, on the arms and legs). In some studies, the number of treatment sessions has ranged from 20-24 (9,24).
In recent years, an acupuncture treatment protocol for xerostomia has been developed that involves fewer acupuncture points and a great reduction in the number of treatment sessions (5,16). This protocol limits the number of acupuncture points to three on each ear and one on each index finger, reducing the total number of needles used from 14-24 to 8. The average number of treatments also has been reduced from 20-24 to approximately 6 (5,16).
The xerostomia inventory (XI) is an instrument that is utilised to evaluate a patient's subjective sensation of dry mouth (25,26). Johnstone et al used the XI to demonstrate a significant improvement in the symptoms of xerostomia as perceived by patients after treatment with the minimally invasive acupuncture protocol described above (5,16).
Case reports
Seven patients with xerostomia subsequent to head and neck radiation therapy were referred to the author for acupuncture. Six of the patients had undergone surgery prior to receiving radiation therapy, five for squamous cell carcinoma of the tongue and one for squamous cell carcinoma of the ear. The seventh patient received radiation therapy without surgery for nasopharyngeal cancer. The time between the completion of radiation therapy and the initiation of acupuncture treatment ranged from two months to ten years, with a median of nine months.
Three of the patients were men and four were women, ranging in age from 41-62, with an average age of 51.5 and a median age of 59. Two of the patients had not used pilocarpine to stimulate salivary secretion, while two had stopped using it due to adverse reactions and a lack of effectiveness. Three patients who had been taking pilocarpine at the time of their first acupuncture visit decreased usage and subsequently stopped it during and after the acupuncture treatment. Two patients received amifostine initially during radiation therapy but discontinued it due to severe nausea and vomiting.
Patients typically came to their first acupuncture appointment with a bottle of water and, on occasion, a bottle of artificial saliva. All of the patients reported suffering from the xerostomia-related symptoms discussed earlier. In addition, all of the patients awoke frequently throughout the night to drink water. During each patient's first visit, the need for a rigorous oral hygiene home care/prevention program was discussed. At that time, the patient received written information describing various artificial saliva products and medications designed to help patients suffering from xerostomia (27). Patients were advised to work closely with their oral health care professionals to develop an appropriate programme.
The seven patients were treated with the acupuncture protocol developed by Niemtzow (5,16). Three points were needled on each ear: Shenmen (to calm the mind, reduce inflammation and hypersensitivity and to support other auricular points (28)), point Zero (designed to bring about homeostasis (29)), and Salivary Gland 2/Prime. In addition, an extra point was needled bilaterally at the radial end of the distal phalangeal crease of the index finger, on the border of the red and white skin. Patients were given sugarless mints during treatment to help stimulate salivary flow, although the mints usually produced little, if any, saliva without the use of acupuncture.
Patients were usually treated once a week for four to five weeks, followed by two or three biweekly sessions, each treatment session lasting 45-50 minutes. The number of treatment sessions for the seven patients ranged from 6-14, with a mean of 8 visits. Salivary flow often improved during the first visit and the duration of improvement increased with each subsequent visit. In the eight months after treatment, all of the patients continued to report a reduction in the symptoms of xerostomia, the need to awaken at night for water and difficulty in eating and swallowing. Increases were reported in the flow of saliva, the ability to speak for longer periods of time and the ability to eat a wider range of food.
Studies have demonstrated that although acupuncture increases the volume of saliva, salivary flow does not reach the full level exhibited prior to radiation treatment (5,16). While all of the patients in this study have reported being pleased with the results of treatment to some degree, none of the patients reported 100% return of saliva.
Both before the start of treatment and at its completion, patients were asked to subjectively rate their level of salivary flow against their pre-radiation/presurgery level. These levels were rated with a Visual Analog Scale (VAS), in which 0 indicated no saliva and 10 indicated a level of saliva equivalent to pre-radiation/ pre-surgery treatment levels. VAS scores prior to acupuncture treatment ranged from 0.0-2.5, with a mean score of 0.86. VAS scores after acupuncture treatment ranged from 2.5-7.0, with a mean score of 3.5. One patient reported that the increased flow of saliva was intermittent instead of continual, while another patient reported that sugarless mints were necessary to stimulate maximum salivary flow.
Conclusion
All of the patients treated by the author, including those patients inconvenienced by the need to travel from surrounding states for their appointments, have indicated that they were pleased they elected to pursue acupuncture treatment for their xerostomia. For these patients, xerostomia was only part of a series of traumatic life events with potentially serious physical and emotional consequences. Others included the diagnosis of a malignancy, surgical intervention, radiation treatment, pain, disfigurement and dysfunction. Acupuncture could play a significant role in enhancing the guality of life of these individuals and others suffering from xerostomia as well as many of the sequelae of cancer and its treatment.
Note
The acupuncture protocol used in this study was developed by Dr. Richard Niemtzow. More information on the treatment is available at http://www.n5ev.com
References
(1.) Dawidson I, Angmar-Mansson B, Blom M, Theodorsson E, Lundeberg T. Sensory stimulation (acupuncture) increases the release of calcitonin gene-related peptide in the saliva of xerostomia sufferers. Neuropeptides 1999;33:244-250.
(2.) Sreebny LM, Banoczy J, Baum BJ, Edgar WM, Epstein JB, Fox PC, Larmas M. Saliva: Its role in health and disease. Int Dent J 1992;42:291-304.
(3.) MacInnis WA, Ismail A, MacDonald RM, Friars CA. Oral health status and treatment needs of an insured elderly population. J Can Dent Assoc 1993;59:465-475.
(4.) Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin 2000;50:7-33.
(5.) Johnstone PA, Peng YP, May BC, Inouye WS, Niemtzow RC. Acupuncture for pilocarpineresistant xerostomia following radiotherapy for head and neck malignancies. Int J Radiat Oncol Biol Phys 2001;50:353-357.
(6.) Rydholm M, Strang P. Acupuncture for patients in hospital-based home care suffering from xerostomia. J Pall Care 1999;15:20-23.
(7.) Greenspan D. Oral complications of cancer therapies. Management of salivary dysfunction. NCI Monogr 1990;9:159-161.
(8.) Baum BJ, Bodner L, Fox PC, Izutsu KT, Pizzo PA, Wright WE. Therapy-induced dysfunction of salivary glands: Implications for oral health. Spec Care Dentist 1985;5:274-277.
(9.) Blom M, Lundeberg T. Long-term follow-up of patients treated with acupuncture for xerostomia and the influence of additional treatment. Oral Dis 2000;6:15-24.
(10.) Fox PC. Management of dry mouth. Dent Clin North Am 1997;41:863-875.
(11.) LeVeque FG, Montgomery M, Potter D, Zimmer MB, Rieke JW, Steiger BW, Gallagher SC, Muscoplat CC. A multicenter, randomized, double-blind, placebo-con-trolled, dose-titration study of oral pilocarpine for treatment of radiation-induced xerostomia in head and neck cancer patients. J Clin Oncol 1993;11:11241131.
(12.) Johnson JT, Ferretti GA, Nethery WJ, Valdez IH, Fox PC, Ng D, Muscoplat CC, Gallagher SC. Oral pilocarpine for post-irradiation xerostomia in patients with head and neck cancer. N Engl J Med 1993;329:390-395.
(13.) Lindegaard JC, Grau C. Has the outlook improved for amifostine as a clinical radio protector? Radiother Oncol 2000;57:113-118.
(14.) Brizel DM, Wasserman TH, Henke M, Strnad V, Rudat V, Monnier A, Eschwege F, Zhang J, Russell L, Oster W, Sauer R. Phase III randomized trial of amifostine as a radioprotector in head and neck cancer. J Clin Oncol 2000;55:3339-3345.
(15.) Blom M, Dawidson I, Fernberg JO, Johnson G, Angmar-Mansson B. Acupuncture treatment of patients with radiation-induced xerostomia. Eur J Cancer B Oral Oncol 1996;32B:182-190.
(16.) Johnstone PA, Niemtzow RC, Riffenburgh RH. Acupuncture for xerostomia: Clinical update. Cancer 2002;94:1151-1156.
(17.) Perminova IS, Goidenko VS, Rudenko IV. [Experience with using reflexotherapy in treating Sjogren's syndrome]. Stomatologiia (Mosk) 1981;60:37-38.
(18.) Blom M, Dawidson I, Angmar-Mansson B. The effect of acupuncture on salivary flow rates in patients with xerostomia. Oral Surg Oral Med Oral Pathol 1992;73:293-298.
(19.) Dawidson I, Blom M, Lundeberg T, Angmar-Mansson B. The influence of acupuncture on salivary flow rates in healthy subjects. J Oral Rehab 1997;24:204-208.
(20.) Dawidson I, Angmar-Mansson B, Blom M, Theodorsson E, Lundeberg T. The influence of sensory stimulation (acupuncture) on the release of neuropeptides in the saliva of healthy subjects. Life Sci 1998;63:659-674.
(21.) Emmelin N. Nerve interactions in salivary glands. J Dent Res 1987;66:509-517.
(22.) Garrett JR. The proper role of nerves in salivary secretion: A review. J Dent Res 1987;66:387-397
(23.) Blom M, Lundeberg T, Dawidson I, Angmar-Mansson B. Effects on local blood flux of acupuncture stimulation used to treat xerostomia in patients suffering from Sjogren's syndrome. J Oral Rehab 1993;20:541-548.
(24.) List T, Lundeberg T, Lundstrom I, Lindstrom F, Ravald N. The effect of acupuncture in the treatment of patients with primary Sjogren's syndrome. A controlled study. Acta Odontol Scand 1998;56:95-99.
(25.) Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The Xerostomia Inventory: A multi-item approach to measuring dry mouth. Community Dent Health 1999;16:12-17.
(26.) Thompson WM, Williams SM. Further testing of the xerostomia inventory. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:46-50.
(27.) Wynn RL, Meiller TF. Artificial saliva products and drugs to treat xerostomia. Gen Dent 2000;48:630-636.
(28.) Oleson, T. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture, 2nd edition. Los Angeles: Health Care Alternatives, inc.1996:56.
(29.) Ibid.
Dr. Morganstein, DDS, MPH, is Director, Enrichment Program, and Dean's Faculty and Clinical Professor, Health Promotion and Policy, Baltimore College of Dental Surgery, University of Maryland Dental School. Dr. Morganstein completed his training in acupuncture at the UCLA Medical School/Helm's Medical Institute, Medical Acupuncture for Physicians Program, where he now serves as a clinical faculty preceptor. He practised acupuncture for oral and craniofacial disorders in the Brotman Facial Pain Center at the University of Maryland Dental School during the time of this study and is currently doing the same in private practice. He is presently continuing his training in acupuncture at the Tai Sophia Institute for the Healing Arts in Laurel, Maryland, USA.
Abstract
Xerostomia, abnormal dryness of the mouth due to decreased secretion of saliva, is a distressing condition which can significantly impair quality of life in sufferers. In this article, the aetiology, pathology and treatment of xerostomia by Western medicine is discussed and existing studies into its treatment by acupuncture are reviewed. The author then describes the treatment of seven xerostomia patients who were treated using a simple acupuncture protocol. Actual outcomes exceeded the author's expectations with all patients reporting an increase in salivary flow and the ability to eat and speak, as well as improved sleep.
Keywords: xerostomia, acupuncture, dry mouth.
Introduction
Xerostomia, abnormal dryness of the mouth due to decreased secretion of saliva, is a distressing condition which can significantly impair quality of life in sufferers. As well as dryness of the mouth, it is associated with rampant dental caries, oral mucosal infections, difficulty in speaking, eating, and swallowing, ulceration or soreness of the oral cavity, altered sense of taste and difficulty in wearing dentures (1). Xerostomia affects approximately one quarter of the population and approximately 40% of adults over 50 (2). In a study of elderly individuals living in retirement homes, it was found that three quarters were using at least one medication for xerostomia (3).
Aetiology
A number of different factors can give rise to xerostomia.
* It is commonly found as a side effect of medications, especially opioids, diuretics, anticholinergic drugs and antihistamines.
* It can be caused by endocrine disorders and autoimmune diseases such as Sjogren's syndrome.
* More than 120,000 patients annually are diagnosed with cancer
of the head and neck in the USA (4) and their treatment by radiotherapy gives rise to xerostomia in almost all cases (5).
* Cancer patients generally exhibit a high prevalence of xerostomia. According to a 1999 study, more than 70% of seriously ill cancer patients suffered from xerostomia (6).
It is thought that the decreased salivary secretion among xerostomia patients is due to atrophy of the secretory cells of the salivary gland and/or dysfunctional changes in the vascular and connective tissues of the salivary glands (7). Studies have reported that salivary production usually does not improve for xerostomia patients and that there is a gradual decrease in salivary gland function (8,9).
Treatment
Treatment for xerostomia is primarily palliative and includes promoting saliva production by increasing water consumption, using sugarless mints and gum or salivary substitutes, and utilising prescription medications such as oral pilocarpine (10,11). Treatment results have been short-term at best. Pilocarpine therapy has been found to be ineffective for a high percentage of patients (30-70% in one study) and may give rise to adverse reactions such as sweating, dizziness, headache, rhinitis, nausea, urinary frequency, tachycardia and visual impairment (12).
Amifostine has been used during radiation therapy via intravenous injection in an attempt to minimise the possibility of xerostomia (as well as mucositis) occuring during treatment through protection against radiation by the scavenging of free radicals. However, amifostine's impact on the efficacy of the radiation treatment (due to possible tumour protection) is controversial because there is the possibility that the drug may protect the tumour from the radiation treatment. In addition, the potential for adverse reactions is significant. Nausea, vomiting, hypertension and allergic reactions were the most common side effects, with 53% of those patients who received amifostine experiencing at least one episode of nausea and/or vomiting (13,14).
Acupuncture and xerostomia Existing studies
Previous studies have demonstrated that acupuncture might serve as an effective long-term approach to the treatment of xerostomia and can significantly reduce untoward effects (15,16).
The use of acupuncture as a treatment for xerostomia was first reported by the Western medical literature in 198117, and since 1992, Blom et al have published numerous articles concerning the effectiveness of acupuncture in its treatment (1,9,15,18). A 1997 study showed a significant increase in saliva (compared to baseline levels) both during and after manual acupuncture stimulation. By contrast, electroacupuncture had no effect (19). In a 1992 study, patients suffering from severe xerostomia, primarily associated with Sjogren's syndrome and other systemic disease, were randomly divided into treatment and control groups to determine the effect of acupuncture on salivary flow rates (18). The control group patients received placebo treatment through superficial intradermal placement of acupuncture needles. Patients in the treatment group exhibited improved salivary flow rates both during and after treatment. These results lasted throughout the one-year post-treatment observation period. While salivary flow rates improved for patients in the control group during the experiment, these changes disappeared after the placebo acupuncture treatment was completed (18).
A long-term study by Blom and Lundeberg followed 70 patients who had been treated with acupuncture for xerostomia due to primary and secondary Sjogren's syndrome, irradiation and other causes. Patients were needled at local points including Juliao ST-3, Daying ST-5, Jiache ST-6, Xiaguan ST-7, Tianrong SI-17, Futu L.I.-18, Yifeng SJ-17 and Baihui DU-20, and distal points including Shenmen HE-7, Neiguan P-6, Sanjian L.I.-3, Hegu L.I.-4, Quchi L.I.-11, Waiguan SJ-5, Zusanli ST-36, Sanyinjiao SP-6, Zulinqi GB41, Taichong LIV-3, Taixi KID-3 and Shuiquan KID-5. All patients received a minimum of twelve and a maximum of fifteen needles. Results acquired over an observational period as long as three years indicated that acupuncture improved salivary flow rates. Compared to patients who chose not to continue acupuncture, the rates remained consistently higher for patients who received an additional series of 5-12 acupuncture treatments, as needed (9). A 1999 study of patients in a hospital-based home care setting investigated how acupuncture affected patients in late-stage palliative care with symptoms of xerostomia and related problems. The results indicated that "acupuncture had a dramatic effect on xerostomia and subsequently on dysphagia and articulation." (6)
Patients with xerostomia due to radiation therapy for head and neck cancer have shown increased salivary flow rates after acupuncture treatment (15). Patients who had received more than 50 Gy of radiation were assigned at random to a treatment group receiving real acupuncture or a control group receiving placebo (superficial) acupuncture. Both groups showed a significant increase in salivary flow rates during the one-year observation period, although the control group demonstrated both a smaller and slower improvement. The results of this study show the difficulty in using superficial acupuncture as a placebo.
Possible mechanisms of action of acupuncture It has been suggested that acupuncture increases the release of neuropeptides and stimulates the autonomic nervous system, enhancing salivary secretion both in healthy subjects and those with xerostomia. Radio immunoassay analysis has been used to examine xerostomia patients and has determined that acupuncture significantly increases both vasoactive intestinal polypeptide (VIP) and calcitonin generelated peptide (CGRP) in their saliva (1,19,20.)
Both the sympathetic and parasympathetic nervous systems influence the function of salivary glands and the rate and nature of salivary flow. Sensory, sympathetic and parasympathetic nerve fibres innervate the salivary glands. Sympathetic system stimulation produces a low, viscous, protein-rich flow of saliva while parasympathetic system stimulation has the primary influence on salivary secretion and yields a strong increase of salivary flow with a low protein content (21,22).
Acupuncture has also been shown to increase blood flow to the skin overlying the parotid gland. Blom et al studied a group that had received acupuncture and a control group that had received superflcial acupuncture. Using laser Doppler flowmetry, they discovered that blood flow to the skin overlying the parotid gland increased significantly (both during and after acupuncture) for the experimental (acupuncture) group (23).
A new acupuncture treatment for xerostomia
Most of the treatment provided in research that relates to acupuncture and xerostomia has involved placing needles at numerous points both locally (in the area of the major salivary glands) and distally (that is, on the arms and legs). In some studies, the number of treatment sessions has ranged from 20-24 (9,24).
In recent years, an acupuncture treatment protocol for xerostomia has been developed that involves fewer acupuncture points and a great reduction in the number of treatment sessions (5,16). This protocol limits the number of acupuncture points to three on each ear and one on each index finger, reducing the total number of needles used from 14-24 to 8. The average number of treatments also has been reduced from 20-24 to approximately 6 (5,16).
The xerostomia inventory (XI) is an instrument that is utilised to evaluate a patient's subjective sensation of dry mouth (25,26). Johnstone et al used the XI to demonstrate a significant improvement in the symptoms of xerostomia as perceived by patients after treatment with the minimally invasive acupuncture protocol described above (5,16).
Case reports
Seven patients with xerostomia subsequent to head and neck radiation therapy were referred to the author for acupuncture. Six of the patients had undergone surgery prior to receiving radiation therapy, five for squamous cell carcinoma of the tongue and one for squamous cell carcinoma of the ear. The seventh patient received radiation therapy without surgery for nasopharyngeal cancer. The time between the completion of radiation therapy and the initiation of acupuncture treatment ranged from two months to ten years, with a median of nine months.
Three of the patients were men and four were women, ranging in age from 41-62, with an average age of 51.5 and a median age of 59. Two of the patients had not used pilocarpine to stimulate salivary secretion, while two had stopped using it due to adverse reactions and a lack of effectiveness. Three patients who had been taking pilocarpine at the time of their first acupuncture visit decreased usage and subsequently stopped it during and after the acupuncture treatment. Two patients received amifostine initially during radiation therapy but discontinued it due to severe nausea and vomiting.
Patients typically came to their first acupuncture appointment with a bottle of water and, on occasion, a bottle of artificial saliva. All of the patients reported suffering from the xerostomia-related symptoms discussed earlier. In addition, all of the patients awoke frequently throughout the night to drink water. During each patient's first visit, the need for a rigorous oral hygiene home care/prevention program was discussed. At that time, the patient received written information describing various artificial saliva products and medications designed to help patients suffering from xerostomia (27). Patients were advised to work closely with their oral health care professionals to develop an appropriate programme.
The seven patients were treated with the acupuncture protocol developed by Niemtzow (5,16). Three points were needled on each ear: Shenmen (to calm the mind, reduce inflammation and hypersensitivity and to support other auricular points (28)), point Zero (designed to bring about homeostasis (29)), and Salivary Gland 2/Prime. In addition, an extra point was needled bilaterally at the radial end of the distal phalangeal crease of the index finger, on the border of the red and white skin. Patients were given sugarless mints during treatment to help stimulate salivary flow, although the mints usually produced little, if any, saliva without the use of acupuncture.
Patients were usually treated once a week for four to five weeks, followed by two or three biweekly sessions, each treatment session lasting 45-50 minutes. The number of treatment sessions for the seven patients ranged from 6-14, with a mean of 8 visits. Salivary flow often improved during the first visit and the duration of improvement increased with each subsequent visit. In the eight months after treatment, all of the patients continued to report a reduction in the symptoms of xerostomia, the need to awaken at night for water and difficulty in eating and swallowing. Increases were reported in the flow of saliva, the ability to speak for longer periods of time and the ability to eat a wider range of food.
Studies have demonstrated that although acupuncture increases the volume of saliva, salivary flow does not reach the full level exhibited prior to radiation treatment (5,16). While all of the patients in this study have reported being pleased with the results of treatment to some degree, none of the patients reported 100% return of saliva.
Both before the start of treatment and at its completion, patients were asked to subjectively rate their level of salivary flow against their pre-radiation/presurgery level. These levels were rated with a Visual Analog Scale (VAS), in which 0 indicated no saliva and 10 indicated a level of saliva equivalent to pre-radiation/ pre-surgery treatment levels. VAS scores prior to acupuncture treatment ranged from 0.0-2.5, with a mean score of 0.86. VAS scores after acupuncture treatment ranged from 2.5-7.0, with a mean score of 3.5. One patient reported that the increased flow of saliva was intermittent instead of continual, while another patient reported that sugarless mints were necessary to stimulate maximum salivary flow.
Conclusion
All of the patients treated by the author, including those patients inconvenienced by the need to travel from surrounding states for their appointments, have indicated that they were pleased they elected to pursue acupuncture treatment for their xerostomia. For these patients, xerostomia was only part of a series of traumatic life events with potentially serious physical and emotional consequences. Others included the diagnosis of a malignancy, surgical intervention, radiation treatment, pain, disfigurement and dysfunction. Acupuncture could play a significant role in enhancing the guality of life of these individuals and others suffering from xerostomia as well as many of the sequelae of cancer and its treatment.
Note
The acupuncture protocol used in this study was developed by Dr. Richard Niemtzow. More information on the treatment is available at http://www.n5ev.com
References
(1.) Dawidson I, Angmar-Mansson B, Blom M, Theodorsson E, Lundeberg T. Sensory stimulation (acupuncture) increases the release of calcitonin gene-related peptide in the saliva of xerostomia sufferers. Neuropeptides 1999;33:244-250.
(2.) Sreebny LM, Banoczy J, Baum BJ, Edgar WM, Epstein JB, Fox PC, Larmas M. Saliva: Its role in health and disease. Int Dent J 1992;42:291-304.
(3.) MacInnis WA, Ismail A, MacDonald RM, Friars CA. Oral health status and treatment needs of an insured elderly population. J Can Dent Assoc 1993;59:465-475.
(4.) Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin 2000;50:7-33.
(5.) Johnstone PA, Peng YP, May BC, Inouye WS, Niemtzow RC. Acupuncture for pilocarpineresistant xerostomia following radiotherapy for head and neck malignancies. Int J Radiat Oncol Biol Phys 2001;50:353-357.
(6.) Rydholm M, Strang P. Acupuncture for patients in hospital-based home care suffering from xerostomia. J Pall Care 1999;15:20-23.
(7.) Greenspan D. Oral complications of cancer therapies. Management of salivary dysfunction. NCI Monogr 1990;9:159-161.
(8.) Baum BJ, Bodner L, Fox PC, Izutsu KT, Pizzo PA, Wright WE. Therapy-induced dysfunction of salivary glands: Implications for oral health. Spec Care Dentist 1985;5:274-277.
(9.) Blom M, Lundeberg T. Long-term follow-up of patients treated with acupuncture for xerostomia and the influence of additional treatment. Oral Dis 2000;6:15-24.
(10.) Fox PC. Management of dry mouth. Dent Clin North Am 1997;41:863-875.
(11.) LeVeque FG, Montgomery M, Potter D, Zimmer MB, Rieke JW, Steiger BW, Gallagher SC, Muscoplat CC. A multicenter, randomized, double-blind, placebo-con-trolled, dose-titration study of oral pilocarpine for treatment of radiation-induced xerostomia in head and neck cancer patients. J Clin Oncol 1993;11:11241131.
(12.) Johnson JT, Ferretti GA, Nethery WJ, Valdez IH, Fox PC, Ng D, Muscoplat CC, Gallagher SC. Oral pilocarpine for post-irradiation xerostomia in patients with head and neck cancer. N Engl J Med 1993;329:390-395.
(13.) Lindegaard JC, Grau C. Has the outlook improved for amifostine as a clinical radio protector? Radiother Oncol 2000;57:113-118.
(14.) Brizel DM, Wasserman TH, Henke M, Strnad V, Rudat V, Monnier A, Eschwege F, Zhang J, Russell L, Oster W, Sauer R. Phase III randomized trial of amifostine as a radioprotector in head and neck cancer. J Clin Oncol 2000;55:3339-3345.
(15.) Blom M, Dawidson I, Fernberg JO, Johnson G, Angmar-Mansson B. Acupuncture treatment of patients with radiation-induced xerostomia. Eur J Cancer B Oral Oncol 1996;32B:182-190.
(16.) Johnstone PA, Niemtzow RC, Riffenburgh RH. Acupuncture for xerostomia: Clinical update. Cancer 2002;94:1151-1156.
(17.) Perminova IS, Goidenko VS, Rudenko IV. [Experience with using reflexotherapy in treating Sjogren's syndrome]. Stomatologiia (Mosk) 1981;60:37-38.
(18.) Blom M, Dawidson I, Angmar-Mansson B. The effect of acupuncture on salivary flow rates in patients with xerostomia. Oral Surg Oral Med Oral Pathol 1992;73:293-298.
(19.) Dawidson I, Blom M, Lundeberg T, Angmar-Mansson B. The influence of acupuncture on salivary flow rates in healthy subjects. J Oral Rehab 1997;24:204-208.
(20.) Dawidson I, Angmar-Mansson B, Blom M, Theodorsson E, Lundeberg T. The influence of sensory stimulation (acupuncture) on the release of neuropeptides in the saliva of healthy subjects. Life Sci 1998;63:659-674.
(21.) Emmelin N. Nerve interactions in salivary glands. J Dent Res 1987;66:509-517.
(22.) Garrett JR. The proper role of nerves in salivary secretion: A review. J Dent Res 1987;66:387-397
(23.) Blom M, Lundeberg T, Dawidson I, Angmar-Mansson B. Effects on local blood flux of acupuncture stimulation used to treat xerostomia in patients suffering from Sjogren's syndrome. J Oral Rehab 1993;20:541-548.
(24.) List T, Lundeberg T, Lundstrom I, Lindstrom F, Ravald N. The effect of acupuncture in the treatment of patients with primary Sjogren's syndrome. A controlled study. Acta Odontol Scand 1998;56:95-99.
(25.) Thomson WM, Chalmers JM, Spencer AJ, Williams SM. The Xerostomia Inventory: A multi-item approach to measuring dry mouth. Community Dent Health 1999;16:12-17.
(26.) Thompson WM, Williams SM. Further testing of the xerostomia inventory. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:46-50.
(27.) Wynn RL, Meiller TF. Artificial saliva products and drugs to treat xerostomia. Gen Dent 2000;48:630-636.
(28.) Oleson, T. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture, 2nd edition. Los Angeles: Health Care Alternatives, inc.1996:56.
(29.) Ibid.
Dr. Morganstein, DDS, MPH, is Director, Enrichment Program, and Dean's Faculty and Clinical Professor, Health Promotion and Policy, Baltimore College of Dental Surgery, University of Maryland Dental School. Dr. Morganstein completed his training in acupuncture at the UCLA Medical School/Helm's Medical Institute, Medical Acupuncture for Physicians Program, where he now serves as a clinical faculty preceptor. He practised acupuncture for oral and craniofacial disorders in the Brotman Facial Pain Center at the University of Maryland Dental School during the time of this study and is currently doing the same in private practice. He is presently continuing his training in acupuncture at the Tai Sophia Institute for the Healing Arts in Laurel, Maryland, USA.
Comparison of effects of transcutaneous electrical nerve stimulation of auricular, somatic, and the combination of auricular and somatic acupuncture
Comparison of effects of transcutaneous electrical nerve stimulation of auricular, somatic, and the combination of auricular and somatic acupuncture points on experimental pain threshold
By: Lein, Donald H., Jr.,Clelland, Jo Ann,Knowles, Cheryl J.,Jackson, James R.
This study compared the effects of high intensity, low frequency transcutaneous electrical nerve stimulation of auricular, somatic, and combined auricular and somatic acupuncture points on experimental pain threshold measured at the wrist. Sixty-seven healthy adults, aged 18 to 39 years, were assigned randomly to one of four groups: 1) the Auricular Group (n = 17) received TENS to auricular acupuncture points, 2) the Somatic Group (n = 17) received TENS to somatic acupuncture points, 3) the Combined Group (n = 17) received TENS to both auricular and somatic acupuncture points, and 4) the Control Group (n = 16) received no TENS and served as controls. Pain threshold was measured immediately before and after treatment or rest. Pain threshold significantly increased (p [is less than] .05) in the Auricular, Somatic, and Combined Groups following treatment, with no statistically significant differences in mean pain threshold change scores among treatment groups. The Control Group demonstrated no statistically significant change in pain threshold. The results indicate that TENS applied to any of the three sets of acupuncture points equally increases pain threshold, thus possibly increasing options in choosing stimulation sites for treating patients with pain. [Lein DH Jr, Clelland JA, Knowles CJ, et al: Comparison of effects of transcutaneous electrical nerve stimulation of auricular, somatic, and the combination of auricular and somatic acupuncture points on experimental pain threshold. Phys Ther 69:671-678, 1989] Key Words: Acupressure/acupuncture, Electric stimulation, Pain, Transcutaneous electrical nerve stimulation. Pain is a problem confronted by physical therapists daily, often preventing treatment of accompanying or underlying disorders until analgesia is achieved. Physical therapists use various methods to relieve pain, including transcutaneous electrical nerve stimulation. Low frequency, high intensity TENS applied to somatic acupuncture points is called "acupuncture-like" TENS. Like acupuncture, high intensity TENS delivers intense peripheral stimulation. The practice of acupuncture in various forms has been used to relieve pain for thousands of years.[1] Studies have shown that somatic acupuncture point stimulation decreases both experimental[2,3] and clinical pain.[4-7] Berlin et al found that healthy subjects' pain tolerances, as measured by a pain-terminating response, significantly increased after electrical stimulation of appropriate somatic acupuncture points, whereas electrical stimulation of inappropriate points did not increase pain tolerance.[2] These results suggested that pain relief from acupuncture point stimulation was a physiological effect and not a placebo effect.[2] Ashton et al showed that acupuncture to somatic points significantly elevated cold-induced experimental pain threshold in 46 healthy, young volunteers.[3] Somatic acupuncture point stimulation also has been reported to produce analgesia in patients with various pain complaints, including pain secondary to tennis elbow,[4] menstrual pain,[5] and chronic pain.[6,7] Stimulation of acupuncture points on the auricle, or auriculotherapy, also is used for pain relief. Studies performed by Oliveri et al,[8] Krause et al,[9] and Noling et al[10] showed that low frequency, high intensity TENS applied to appropriate auricular points increased experimental pain threshold in healthy subjects. These studies indicated that auriculotherapy possibly could decrease pain in patients. Auricular TENS significantly decreased pain in 15 patients suffering with various distal extremity disorders.[11] Abbate et al found that after auricular electroacupuncture, 12 patients tolerated decreased dosages of anesthetics during thoracic surgery and decreased analgesic use during recovery.[12] Chun and Heather observed that in 46 patients with chronic pain, 84% of the patients' 57 chronic pain syndromes improved at least 25% after auricular electroacupuncture.[13] Melzack and Katz, however, conducted a controlled crossover study of 31 patients with chronic pain and found that electrical stimulation of appropriate auricular points did not give any greater pain relief than electrical stimulation to either inappropriate or placebo auricular points.[14] Stimulating a combination of auricular and somatic acupuncture points is a third method reported to decrease pain.[15-17] After several electrical stimulation treatments to both somatic and auricular acupuncture points, a child with reflex sympathetic dystrophy was able to perform all activities of daily living without pain.[15] Three months later the child was still asymptomatic.[15] Paris et al stimulated both auricular and somatic points, in addition to providing conventional physical therapy, to treat second-degree ankle inversion sprains.[16] When compared with conventional physical therapy alone, the addition of acupuncture decreased both pain and rehabilitation time.[16] The reduction of rehabilitation time, however, was the only statistically significant finding between these two variables.[16] Following electroacupuncture stimulation to both auricular and somatic acupuncture points, 20 patients with chronic pain reported significant improvement of both pain and psychiatric symptoms.[17] Researchers have proposed similar mechanisms for analgesia after either somatic acupuncture point stimulation or auriculotherapy. In addition to the Chinese meridian theory,[1] researchers have linked both somatic acupuncture and auriculotherapy to the release of morphine-like substances known as endogenous opiates. Sjolund et al observed that after acupuncture-like TENS, patients with chronic pain experienced analgesia with a concurrent segmental increase in cerebrospinal fluid [Beta]-endorphins.[7] Malizia et al found increased amounts of [Beta]-endorphins secreted in the blood following electroacupuncture.[18] Abbate and co-workers observed a significant increase of [Beta]-endorphin immunoreactivity following auriculotherapy to patients undergoing thoracic surgery.[12] Other studies have suggested that serotonin[6] and met-enkephalin[17] also might be involved in relief of pain following acupuncture. Chapman et al found that the opiate antagonist naloxone failed to reverse dental acupuncture analgesia, indicating a mechanism other than release of endogenous opiates.[19] Terman et al found that both opioid and nonopioid analgesic systems exist in the midbrain.[20] The mescencephalon, through descending pathways, is believed to modulate the transfer of nociceptive information from peripheral nerve fibers to ascending paths.[20] Terman et al showed that stimulation of both the periaqueductal gray and the dorsal raphe area of the midbrain produced analgesia, but only stimulation of the dorsal raphe was blocked by naloxone.[20] Perhaps acupuncture can cause analgesia through stimulation of several different peptide transmitters as well as opioid and nonopioid areas.[3] Only one study indicated differences between the effects of auricular acupuncture point stimulation and somatic acupuncture point stimulation. Kitade and Hyodo observed that LI 4 stimulation in five healthy men increased pain threshold more rapidly than stimulation of auricular points.[21] The internal validity of this study, however, could be questioned because the authors failed to mention whether they controlled for the effects of time or for carry-over effects from previous stimulation. No studies have compared the effects of the combination of auricular and somatic acupuncture point stimulation with the effects of auricular or somatic acupuncture points stimulation alone. If one of these treatments could be determined to be more effective than the other, physical therapists might attain better clinical results when treating patients with pain. The purpose of our study was to compare the effects of unilateral high intensity TENS on experimental pain threshold when applied to auricular acupuncture points, somatic acupuncture points, and a combination of auricular and somatic acupuncture points. We expected statistically significant changes would occur in experimental pain threshold, measured at the wrist, after stimulation of either auricular, somatic, or the combination of auricular and somatic acupuncture points. We hypothesized that these changes would be significantly greater than changes in experimental pain thresholds measured after a rest period in a control group.
Comparison of Effects of Transcutaneous Electrical Nerve Stimulation of Auricular, Somatic, and the Combination of Auricular and Somatic Acupuncture Points on Experimental Pain Threshold
This study compared the effects of high intensity, low frequency transcutaneous electrical nerve stimulation
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of auricular, somatic, and combined auricular and somatic acupuncture points on experimental pain threshold measured at the wrist. Sixty-seven healthy adults, aged 18 to 39 years, were assigned randomly to one of four groups: 1) the Auricular Group (n = 17) received TENS to auricular acupuncture points, 2) the Somatic Group (n = 17) received TENS to somatic acupuncture points, 3) the Combined Group (n = 17) received TENS to both auricular and somatic acupuncture points, and 4) the Control Group (n = 16) received no TENS and served as controls. Pain threshold was measured immediately before and after treatment or rest. Pain threshold significantly increased (p [is less than] .05) in the Auricular, Somatic, and Combined Groups following treatment, with no statistically significant differences in mean pain threshold change scores among treatment groups. The Control Group demonstrated no statistically significant change in pain threshold. The results indicate that TENS applied to any of the three sets of acupuncture points equally increases pain threshold, thus possibly increasing options in choosing stimulation sites for treating patients with pain. [Lein DH Jr, Clelland JA, Knowles CJ, et al: Comparison of effects of transcutaneous electrical nerve stimulation of auricular, somatic, and the combination of auricular and somatic acupuncture points on experimental pain threshold. Phys Ther 69:671-678, 1989] Key Words: Acupressure/acupuncture, Electric stimulation, Pain, Transcutaneous electrical nerve stimulation. Pain is a problem confronted by physical therapists daily, often preventing treatment of accompanying or underlying disorders until analgesia is achieved. Physical therapists use various methods to relieve pain, including transcutaneous electrical nerve stimulation. Low frequency, high intensity TENS applied to somatic acupuncture points is called "acupuncture-like" TENS. Like acupuncture, high intensity TENS delivers intense peripheral stimulation. The practice of acupuncture in various forms has been used to relieve pain for thousands of years.[1] Studies have shown that somatic acupuncture point stimulation decreases both experimental[2,3] and clinical pain.[4-7] Berlin et al found that healthy subjects' pain tolerances, as measured by a pain-terminating response, significantly increased after electrical stimulation of appropriate somatic acupuncture points, whereas electrical stimulation of inappropriate points did not increase pain tolerance.[2] These results suggested that pain relief from acupuncture point stimulation was a physiological effect and not a placebo effect.[2] Ashton et al showed that acupuncture to somatic points significantly elevated cold-induced experimental pain threshold in 46 healthy, young volunteers.[3] Somatic acupuncture point stimulation also has been reported to produce analgesia in patients with various pain complaints, including pain secondary to tennis elbow,[4] menstrual pain,[5] and chronic pain.[6,7] Stimulation of acupuncture points on the auricle, or auriculotherapy, also is used for pain relief. Studies performed by Oliveri et al,[8] Krause et al,[9] and Noling et al[10] showed that low frequency, high intensity TENS applied to appropriate auricular points increased experimental pain threshold in healthy subjects. These studies indicated that auriculotherapy possibly could decrease pain in patients. Auricular TENS significantly decreased pain in 15 patients suffering with various distal extremity disorders.[11] Abbate et al found that after auricular electroacupuncture, 12 patients tolerated decreased dosages of anesthetics during thoracic surgery and decreased analgesic use during recovery.[12] Chun and Heather observed that in 46 patients with chronic pain, 84% of the patients' 57 chronic pain syndromes improved at least 25% after auricular electroacupuncture.[13] Melzack and Katz, however, conducted a controlled crossover study of 31 patients with chronic pain and found that electrical stimulation of appropriate auricular points did not give any greater pain relief than electrical stimulation to either inappropriate or placebo auricular points.[14] Stimulating a combination of auricular and somatic acupuncture points is a third method reported to decrease pain.[15-17] After several electrical stimulation treatments to both somatic and auricular acupuncture points, a child with reflex sympathetic dystrophy was able to perform all activities of daily living without pain.[15] Three months later the child was still asymptomatic.[15] Paris et al stimulated both auricular and somatic points, in addition to providing conventional physical therapy, to treat second-degree ankle inversion sprains.[16] When compared with conventional physical therapy alone, the addition of acupuncture decreased both pain and rehabilitation time.[16] The reduction of rehabilitation time, however, was the only statistically significant finding between these two variables.[16] Following electroacupuncture stimulation to both auricular and somatic acupuncture points, 20 patients with chronic pain reported significant improvement of both pain and psychiatric symptoms.[17] Researchers have proposed similar mechanisms for analgesia after either somatic acupuncture point stimulation or auriculotherapy. In addition to the Chinese meridian theory,[1] researchers have linked both somatic acupuncture and auriculotherapy to the release of morphine-like substances known as endogenous opiates. Sjolund et al observed that after acupuncture-like TENS, patients with chronic pain experienced analgesia with a concurrent segmental increase in cerebrospinal fluid [Beta]-endorphins.[7] Malizia et al found increased amounts of [Beta]-endorphins secreted in the blood following electroacupuncture.[18] Abbate and co-workers observed a significant increase of [Beta]-endorphin immunoreactivity following auriculotherapy to patients undergoing thoracic surgery.[12] Other studies have suggested that serotonin[6] and met-enkephalin[17] also might be involved in relief of pain following acupuncture. Chapman et al found that the opiate antagonist naloxone failed to reverse dental acupuncture analgesia, indicating a mechanism other than release of endogenous opiates.[19] Terman et al found that both opioid and nonopioid analgesic systems exist in the midbrain.[20] The mescencephalon, through descending pathways, is believed to modulate the transfer of nociceptive information from peripheral nerve fibers to ascending paths.[20] Terman et al showed that stimulation of both the periaqueductal gray and the dorsal raphe area of the midbrain produced analgesia, but only stimulation of the dorsal raphe was blocked by naloxone.[20] Perhaps acupuncture can cause analgesia through stimulation of several different peptide transmitters as well as opioid and nonopioid areas.[3] Only one study indicated differences between the effects of auricular acupuncture point stimulation and somatic acupuncture point stimulation. Kitade and Hyodo observed that LI 4 stimulation in five healthy men increased pain threshold more rapidly than stimulation of auricular points.[21] The internal validity of this study, however, could be questioned because the authors failed to mention whether they controlled for the effects of time or for carry-over effects from previous stimulation. No studies have compared the effects of the combination of auricular and somatic acupuncture point stimulation with the effects of auricular or somatic acupuncture points stimulation alone. If one of these treatments could be determined to be more effective than the other, physical therapists might attain better clinical results when treating patients with pain. The purpose of our study was to compare the effects of unilateral high intensity TENS on experimental pain threshold when applied to auricular acupuncture points, somatic acupuncture points, and a combination of auricular and somatic acupuncture points. We expected statistically significant changes would occur in experimental pain threshold, measured at the wrist, after stimulation of either auricular, somatic, or the combination of auricular and somatic acupuncture points. We hypothesized that these changes would be significantly greater than changes in experimental pain thresholds measured after a rest period in a control group.
Method
Subjects
Sixty-seven healthy female and male subjects, aged 18 to 39 years, participated in this study. Most of these subjects were students, staff, or faculty from The University of Alabama at Birmingham (Birmingham, Ala). Any subjects who were pregnant, used cardiac pacemakers, had neurological disorders, or took opiate pain medications or central nervous system depressants or stimulants were excluded from this study. All subjects were naive to the study's procedure and the anticipated effects. We received informed consent from each subject. The Institutional Review Board for Human Use at The University of Alabama at Birmingham approved this study.
Instrumentation
We determined experimental pain threshold with a TECA CH3 chronaxie meter,(*) which produces a measurable low voltage direct current. The stimulating electrode was a 2-mm diameter pencil electrode; the dispersive electrode was a 10- x 8-cm electrode pad moistened with water. We used a Staodyn Insight TENS unit,([dagger]) equipped with a 1-mm diameter spring-loaded pencil probe for stimulation and a 4- x 5-cm dispersive electrode to stimulate both auricular and somatic acupuncture points. A Staodyn point locator stimulator([dagger]) was used to help locate somatic acupuncture points. The reference electrode was 4 x 5 cm, and the tip of the probe was 3 mm in diameter.
Procedure
Subjects were assigned randomly to one of four groups. The Auricular Group subjects (n = 17) received unilateral TENS for four auricular points: wrist, shenmen, lung, and dermis (Fig. 1). These auricular points were the same as those used in studies by Oliveri et al,[8] Krause et al,[9] and Noling et al,[10] which resulted in elevated experimental pain threshold at the wrist. In the Somatic Group (n = 17), unilateral TENS was applied to four somatic points: 1) Waiguan (SJ 5), 2) Yangchi (SJ 4), 3) Yangxi (LI 5), and 4) Hegu (LI 4) (Fig. 2). All of the somatic acupuncture points are indicated for wrist pain.[1] All eight auricular and somatic acupuncture points were stimulated unilaterally on subjects in the Combined Group (n = 17). The Control Group (n = 16) served as controls. The subjects in this group received no TENS but instead rested for 15 minutes, the maximum amount of time needed to complete the treatment for subjects in the three stimulation groups. All subjects lay supine on a treatment table, and experimental pain threshold was measured immediately before and after treatment or rest. To reduce skin resistance, electrode sites were cleaned with cotton gauze and isopropyl alcohol before electrode placement. Pain threshold measurement. Before the experiment began, the subjects were allowed to feel the electrical current at their right wrists to familiarize themselves with the sensation. We instructed the subjects to recognized and verbally report the instant they perceived any electrical sensation at the right wrist and then again when they experienced a mildly painful pinprick sensation. To determine each subject's experimental pain threshold, electrical stimulation was applied to the skin over the distal end of the left radius (Fig. 3); the dispersive electrode was applied behind the subject's neck, between the levels of the seventh cervical vertebra and the upper thoracic vertebrae. The point over the distal radius was marked with ink to ensure that all measurements were taken at the same point. Acupuncture point LI 5, located near the distal end of the radius, was avoided. The current consisted of 100-Hz rectangular waves of 5-msec duration. The intensity was increased systematically by 0.25-mA increments at one-second intervals until the subject verbally reported a distinct painful pinprick sensation. This sensation was recorded as the subject's experimental pain threshold. We obtained and averaged three pain threshold measurements in each session to determine each subject's mean experimental pain threshold. The reliability of this mean was found to be .98 for pretreatment measurements using an intraclass correlation coefficient (ICC[3,k])[22] as the index of reliability. Treatment. The subjects removed all jewelry before treatment. Each subject held the dispersive electrode in the left hand. With the assistance of somatic and auricular acupuncture point charts and an audio or visual signal from the stimulating unit to detect decreased skin resistance, we located appropriate auricular and somatic acupuncture points for each subject according to group assignment. If the stimulating unit was not sensitive enough to locate the somatic acupuncture points, we used the Stayodyn point locator stimulator to locate them. The TENS current used to stimulate the acupuncture points was a positive-polarity direct current with a maximum output of 1,000 [Mu]A, delivered at a frequency of 1 Hz. The current duration was constant, as preset in the TENS unit. Subjects responded verbally when they first began to feel the stimulus and then again when the intensity reached each subject's tolerance. Each point was stimulated for 60 seconds at this intensity. Stimulus intensity was lowered slightly during treatment if requested by the subject. Experimental pain thresholds were measured again immediately after treatment or rest. This treatment technique and the experimental pain threshold determination technique were similar to those used previously by Oliveri et al,[8] Krause et al,[9] and Noling et al.[10]
Data Analysis
Descriptive statistics for pain threshold were calculated by group for the pretreatment and posttreatment measurements and for the change between measurements. A two-factor analysis of variance (ANOVA) was used to test the data for statistical significance. The two factors were group (Auricular, Somatic, Combined, and Control Groups) and time of measurement (pretreatment, posttreatment); the time of measurement was a repeated-measures factor. For this design, the interaction effect in the ANOVA is a test of the difference among the mean pretreatment-posttreatment changes for the four groups. The ANOVA also provides tests of simple main effects, which can be used to determine the difference among pretreatment-posttreatment group means as well as the differences between the pretreatment and posttreatment means within each group. Pair-wise comparisons between groups were made with Tukey's Honestly Significant Difference (HSD) test. An alpha level of .05 was selected for all tests.
Results Each group's demographic information is depicted in Table 1. Mean pain threshold values are shown in Table 2. The ANOVA showed a statistically significant interaction effect; therefore, there was a statistically significant difference among the groups in terms of pretreatment-posttreatment change (Tab. 3). Pair-wise comparisons using Tukey's HSD test showed that the mean change for each of the stimulation groups was significantly different (p [is less than] .05) from the Control Group; however, the stimulation groups did not differ significantly from each other. Tests of simple main effects revealed that the group means were not different at the pretreatment measurement session and that each of the stimulation groups showed a statistically significant increase (p [is less than] .05) from pretreatment to posttreatment measurement. The mean pretreatment and posttreatment pain threshold are shown in Figure 4 for all four groups. This study supported our expectation that significant changes would occur in experimental pain threshold, measured at the wrist, after stimulation of auricular, somatic, and the combination of both types of acupuncture points. The hypothesis that these changes in experimental pain threshold would be significantly greater than the changes in experimental pain threshold in the control group also was supported. No significant differences were found among the three stimulation groups' mean change values from pretreatment to posttreatment measurement.
Discussion Other studies have shown that stimulation of auricular[8-10,21] or somatic[2,3,19,21] acupuncture points resulted in statistically significant increases in experimental pain threshold. We also found statistically significant pain threshold elevation following either auricular or somatic acupuncture point stimulation. In addition, stimulation of the combination of auricular and somatic acupuncture points significantly increased experimental pain threshold. No other studies have evaluated the effect of the combination of auricular and somatic acupuncture point stimulation on experimental pain threshold. Stimulation of the combined acupuncture sites, however, resulted in decreased clinical pain in disorders such as reflex sympathetic dystrophy,[15] ankle sprains,[16] and chronic pain.[17] Individual stimulation of either auricular[11-13] or somatic[4-7] acupuncture points has also lowered pain in various clinical syndromes. The results of our study suggest that stimulation of auricular, somatic, or the combination of both types of these acupuncture points is equally effective in increasing experimental pain threshold. In our study, somatic acupuncture point stimulation resulted in the greatest pain threshold change (Tab. 2). This change, however, was not significantly different from the pain threshold changes in the other two groups that received TENS. Clinically, this finding implies that a physical therapist may legitimately stimulate the set of acupuncture points (ie, auricular, somatic, combination of both) that is most convenient, tolerable, and accessible on each individual patient. The analgesic effects may be the same after stimulation of any one of these three sets of acupuncture points. The increases in mean pain threshold observed in the three stimulation groups were all less than 1 mA (Tab. 2). This increase, however, represented mean pain threshold changes of 30.9%, 46.2%, and 41.5% in the Auricular, Somatic, and Combined Groups, respectively. Significant increases in mean pain threshold of 16.3% and 11.7% were reported by Oliveri et al[8] and Noling et al,[10] respectively, immediately following auricular TENS. Similar to our study, Berlin and colleagues found that pain tolerance significantly increased immediately after 20 minutes of somatic electroacupuncture.[2] No other study has measured experimental pain threshold immediately following combined stimulation of auricular and somatic acupuncture points. Our study, however, suggested that immediate increases in experimental pain threshold should be anticipated. Other studies have shown that a delay exists before maximum analgesia occurs in experimental pain threshold following either auricular or somatic acupuncture point stimulation.[3,10,21] Noling et al reported that the change in mean pain threshold increased from 11.7% immediately following auricular acupuncture point stimulation to 25.6% 10 minutes after treatment.[10] Ashton et al found that cold-induced pain threshold increased with time, reaching a maximum 35 minutes following somatic acupuncture point acupuncture.[3] Kitade and Hyodo measured experimental pain threshold both during and after either auricular or somatic acupuncture point stimulation.[21] They also reported that maximum analgesia was not achieved immediately posttreatment.[21] Kitade and Hyodo observed that experimental pain threshold reached its maximum at 30 or 50 minutes into somatic acupuncture point stimulation.[21] In all of these studies, maximum pain threshold levels were not achieved immediately, regardless of whether pain threshold was measured following or during either auricular or somatic acupuncture point stimulation.[3,10,21] This delay before maximum analgesia could be the time required for the maximal release and function of endorphins. All of these studies also showed that pain threshold remained elevated after cessation of either auricular or somatic acupuncture point stimulation.[3,10,21] Our study showed that auricular, somatic, or the combination of auricular and somatic acupuncture point stimulation resulted in immediate increases in experimental pain threshold; further posttreatment measurements were not taken. Future studies should determine whether experimental pain threshold will continue to increase or remain significantly elevated over time following either individual or combined stimulation of auricular and somatic acupuncture points. Further research should also examine whether auricular, somatic, or the combination of auricular and somatic acupuncture point stimulation increases pain threshold to its maximum level more rapidly over time. Kitade and Hyodo observed that auricular acupuncture point stimulation did not increase pain threshold as quickly as somatic acupuncture point stimulation.[21] Our study showed that mean pain threshold changes from pretreatment to posttreatment measurement were not significantly different among the stimulation groups. Rather than insertion of needles to apply 50 minutes of electro-acupuncture, we used surface electrodes and stimulated the acupuncture points for only 60 seconds.[21] Comparisons between our study and that of Kitade and Hyodo[21] are difficult to make because different methods of acupuncture point stimulation were used. Different methods of acupuncture point stimulation have yielded various degrees of analgesia.[2-19,21] Duration of treatment also has been shown to be a factor in effective auricular acupuncture point stimulation. Oliveri et al[8] and Noling et al[10] stimulated the same four auricular points used in our study for 90 seconds and observed 16.3% and 11.7% increases, respectively, in mean pain threshold. Krause et al also stimulated the same four auricular points for 45 seconds and found mean pain threshold increased by 12.2%.[9] In our study, the application of auricular TENS for 60 seconds resulted in a 30.9% increase in experimental pain threshold. Other studies should be conducted to determine whether 60 seconds of auricular TENS achieves the greatest increases in pain threshold. Studies should also be performed to determine the duration of treatment required to achieve optimal increases in pain threshold with TENS to somatic and the combination of somatic and auricular acupuncture points. Studies should be performed to compare the effects of individual and combined stimulation of auricular and somatic acupuncture points in specific patient populations. Comparisons between experimental pain and clinical pain were not made in this study because they may differ in their response to acupuncture point stimulation. Clinical studies may show that, of the sets of acupuncture points investigated in this study, one set may be more effective in alleviating clinical pain. Nonetheless, experimental pain suppression studies, such as this study, may be an important first step in evaluating and understanding potentially effective means of pain alleviation in the clinic.[9]
Conclusion In a group of 67 healthy subjects, low frequency, high intensity TENS administered to auricular, somatic, or the combination of auricular and somatic acupuncture points resulted in statistically significant increases in experimental pain threshold. The Control Group demonstrated no significant increase in experimental pain threshold following 15 minutes of rest. No statistically significant differences existed in the elevated pain threshold change values among the three stimulation groups following TENS treatment, but changes in all stimulation groups were significantly greater than the Control Group changes. These results suggest that auricular, somatic, and the combination of auricular and somatic acupuncture point stimulation are equally effective for increasing experimental pain threshold. Because these results imply that stimulation of any of the cited sets of acupuncture points might be equally effective, the clinician could select appropriate acupuncture points in terms of acupuncture point accessibility, patient tolerance, and clinician convenience. Further research to compare the efficacy of auricular, somatic, and the combination of auricular and somatic acupuncture points with patients with specific pain conditions is needed. [Figures 1 to 4 Omitted] [Tabular Data 1 to 3 Omitted]
(*)TECA Instruments Corp, 3 Campus Dr, Pleasantville, NY 10570. ([dagger])Staodynamics, Inc, PO Box 1379, Longmont, CO 80502.
References [1]Essentials of Chinese Acupuncture. Beijing, China, Foreign Languages Press, 1980, pp 1-37, 48-59, 111-117, 217-222, 399-414 [2]Berlin FS, Bartlett RL, Black JD: Acupuncture and placebo: Effects on delaying the terminating response to a painful stimulus. Anesthesiology 42:527-531, 1975 [3]Ashton H, Ebenezer I, Golding JF, et al: Effects of acupuncture and transcutaneous electrical nerve stimulation on cold-induced pain in normal subjects. J Psychosom Res 28:301-308, 1984 [4]Brattburg G: Acupuncture therapy for tennis elbow. Pain 16:285-288, 1983 [5]Neighbors LE, Clelland JA, Jackson JR, et al: Transcutaneous electrical nerve stimulation for pain relief in primary dysmenorrhea. Clinical Journal of Pain 3:17-22, 1987 [6]Mao W, Ghia JN, Scott DS, et al: High versus low intensity acupuncture analgesia for treatment of chronic pain: Effects on platelet serotonin. Pain 8:331-342, 1980 [7]Sjolund BH, Terenius L, Ericksson MBE: Increased cerebrospinal fluid levels of endorphins after electro-acupuncture. Acta Physiol Scand 100:382-384, 1977 [8]Oliveri AC, Clelland JA, Jackson JR, et al: Effects of auricular transcutaneous electrical nerve stimulation on experimental pain threshold. Phys Ther 66:12-16, 1986 [9]Krause AW, Clelland JA, Knowles CJ, et al: Effects of unilateral and bilateral auricular transcutaneous electrical nerve stimulation on cutaneous pain threshold. Phys Ther 67:507-511, 1987 [10]Noling LB, Clelland JA, Jackson JR, et al: Effect of transcutaneous electrical nerve stimulation at auricular points on experimental cutaneous pain threshold. Phys Ther 68:328-332, 1988 [11]Longobardi AG, Clelland JA, Knowles CJ, et al: Effects of auricular transcutaneous electrical nerve stimulation on distal extremity pain: A pilot study. Phys Ther 69:10-17, 1989 [12]Abbate D, Santamaria A, Brambilla A, et al: [Beta]-Endorphin and electroacupuncture. Lancet 2:1309, 1980 [13]Chun S, Heather AJ: Auriculotherapy: Micro-current application on the external ear--Clinical analysis of a pilot study on 57 chronic pain syndromes. Am J Chin Med 2:399-405, 1974 [14]Melzack R, Katz J: Auriculotherapy fails to relieve chronic pain: A controlled crossover study. JAMA 251:1041-1043, 1984 [15]Leo KC: Use of electrical stimulation at acupuncture points for the treatment of reflex sympathetic dystrophy in a child: A case report. Phys Ther 63:957-959, 1983 [16]Paris DL, Baynes F, Gucker B: Effects of the Neuroprobe in the treatment of second-degree ankle inversion sprains. Phys Ther 63:35-40, 1983 [17]Kiser RS, Gatchel RJ, Bhatia K, et al: Acupuncture relief of chronic pain syndrome correlates with increased plasma met-enkephalin concentrations. Lancet 2:1394-1396, 1983 [18]Malizia E, Andreucci G, Paolucci D, et al: Electroacupuncture and peripheral [Beta]-endorphin and ACTH levels. Lancet 2:535-536, 1979 [19]Chapman CR, Benedetti C, Colpitts YH, et al: Naloxone fails to reverse pain thresholds elevated by acupuncture: Acupuncture analgesia reconsidered. Pain 16:13-31, 1983 [20]Terman GW, Shavit Y, Lewis JW, et al: Intrinsic mechanisms of pain inhibition: Activation by stress. Science 226:1270-1276, 1984 [21]Kitade T, Hyodo M: The effects of stimulation of ear acupuncture points on the body's pain threshold. Am J Chin Med 7:241-252, 1979 [22]Shrout PE, Fleiss J: Intraclass correlations: Uses in assessing rater reliability. Psychol Bull 86:420-428, 1979
D Lein, MS, PT, is Physical Therapist, University of Alabama Hospitals, 619 19th St, Birmingham, AL 35294 (USA). He was a graduate student, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham, Birmingham, AL 35294, when this study was completed in partial fulfillment of the requirements of his Master of Science degree. J Clelland, MS, PT, is Associate Professor and Associate Director, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham. C Knowles, MS, PT, is Assistant Professor, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham. J Jackson, PhD, is Assistant Professor, Office of Educational Development, School of Medicine, The University of Alabama at Birmingham.
By: Lein, Donald H., Jr.,Clelland, Jo Ann,Knowles, Cheryl J.,Jackson, James R.
This study compared the effects of high intensity, low frequency transcutaneous electrical nerve stimulation of auricular, somatic, and combined auricular and somatic acupuncture points on experimental pain threshold measured at the wrist. Sixty-seven healthy adults, aged 18 to 39 years, were assigned randomly to one of four groups: 1) the Auricular Group (n = 17) received TENS to auricular acupuncture points, 2) the Somatic Group (n = 17) received TENS to somatic acupuncture points, 3) the Combined Group (n = 17) received TENS to both auricular and somatic acupuncture points, and 4) the Control Group (n = 16) received no TENS and served as controls. Pain threshold was measured immediately before and after treatment or rest. Pain threshold significantly increased (p [is less than] .05) in the Auricular, Somatic, and Combined Groups following treatment, with no statistically significant differences in mean pain threshold change scores among treatment groups. The Control Group demonstrated no statistically significant change in pain threshold. The results indicate that TENS applied to any of the three sets of acupuncture points equally increases pain threshold, thus possibly increasing options in choosing stimulation sites for treating patients with pain. [Lein DH Jr, Clelland JA, Knowles CJ, et al: Comparison of effects of transcutaneous electrical nerve stimulation of auricular, somatic, and the combination of auricular and somatic acupuncture points on experimental pain threshold. Phys Ther 69:671-678, 1989] Key Words: Acupressure/acupuncture, Electric stimulation, Pain, Transcutaneous electrical nerve stimulation. Pain is a problem confronted by physical therapists daily, often preventing treatment of accompanying or underlying disorders until analgesia is achieved. Physical therapists use various methods to relieve pain, including transcutaneous electrical nerve stimulation. Low frequency, high intensity TENS applied to somatic acupuncture points is called "acupuncture-like" TENS. Like acupuncture, high intensity TENS delivers intense peripheral stimulation. The practice of acupuncture in various forms has been used to relieve pain for thousands of years.[1] Studies have shown that somatic acupuncture point stimulation decreases both experimental[2,3] and clinical pain.[4-7] Berlin et al found that healthy subjects' pain tolerances, as measured by a pain-terminating response, significantly increased after electrical stimulation of appropriate somatic acupuncture points, whereas electrical stimulation of inappropriate points did not increase pain tolerance.[2] These results suggested that pain relief from acupuncture point stimulation was a physiological effect and not a placebo effect.[2] Ashton et al showed that acupuncture to somatic points significantly elevated cold-induced experimental pain threshold in 46 healthy, young volunteers.[3] Somatic acupuncture point stimulation also has been reported to produce analgesia in patients with various pain complaints, including pain secondary to tennis elbow,[4] menstrual pain,[5] and chronic pain.[6,7] Stimulation of acupuncture points on the auricle, or auriculotherapy, also is used for pain relief. Studies performed by Oliveri et al,[8] Krause et al,[9] and Noling et al[10] showed that low frequency, high intensity TENS applied to appropriate auricular points increased experimental pain threshold in healthy subjects. These studies indicated that auriculotherapy possibly could decrease pain in patients. Auricular TENS significantly decreased pain in 15 patients suffering with various distal extremity disorders.[11] Abbate et al found that after auricular electroacupuncture, 12 patients tolerated decreased dosages of anesthetics during thoracic surgery and decreased analgesic use during recovery.[12] Chun and Heather observed that in 46 patients with chronic pain, 84% of the patients' 57 chronic pain syndromes improved at least 25% after auricular electroacupuncture.[13] Melzack and Katz, however, conducted a controlled crossover study of 31 patients with chronic pain and found that electrical stimulation of appropriate auricular points did not give any greater pain relief than electrical stimulation to either inappropriate or placebo auricular points.[14] Stimulating a combination of auricular and somatic acupuncture points is a third method reported to decrease pain.[15-17] After several electrical stimulation treatments to both somatic and auricular acupuncture points, a child with reflex sympathetic dystrophy was able to perform all activities of daily living without pain.[15] Three months later the child was still asymptomatic.[15] Paris et al stimulated both auricular and somatic points, in addition to providing conventional physical therapy, to treat second-degree ankle inversion sprains.[16] When compared with conventional physical therapy alone, the addition of acupuncture decreased both pain and rehabilitation time.[16] The reduction of rehabilitation time, however, was the only statistically significant finding between these two variables.[16] Following electroacupuncture stimulation to both auricular and somatic acupuncture points, 20 patients with chronic pain reported significant improvement of both pain and psychiatric symptoms.[17] Researchers have proposed similar mechanisms for analgesia after either somatic acupuncture point stimulation or auriculotherapy. In addition to the Chinese meridian theory,[1] researchers have linked both somatic acupuncture and auriculotherapy to the release of morphine-like substances known as endogenous opiates. Sjolund et al observed that after acupuncture-like TENS, patients with chronic pain experienced analgesia with a concurrent segmental increase in cerebrospinal fluid [Beta]-endorphins.[7] Malizia et al found increased amounts of [Beta]-endorphins secreted in the blood following electroacupuncture.[18] Abbate and co-workers observed a significant increase of [Beta]-endorphin immunoreactivity following auriculotherapy to patients undergoing thoracic surgery.[12] Other studies have suggested that serotonin[6] and met-enkephalin[17] also might be involved in relief of pain following acupuncture. Chapman et al found that the opiate antagonist naloxone failed to reverse dental acupuncture analgesia, indicating a mechanism other than release of endogenous opiates.[19] Terman et al found that both opioid and nonopioid analgesic systems exist in the midbrain.[20] The mescencephalon, through descending pathways, is believed to modulate the transfer of nociceptive information from peripheral nerve fibers to ascending paths.[20] Terman et al showed that stimulation of both the periaqueductal gray and the dorsal raphe area of the midbrain produced analgesia, but only stimulation of the dorsal raphe was blocked by naloxone.[20] Perhaps acupuncture can cause analgesia through stimulation of several different peptide transmitters as well as opioid and nonopioid areas.[3] Only one study indicated differences between the effects of auricular acupuncture point stimulation and somatic acupuncture point stimulation. Kitade and Hyodo observed that LI 4 stimulation in five healthy men increased pain threshold more rapidly than stimulation of auricular points.[21] The internal validity of this study, however, could be questioned because the authors failed to mention whether they controlled for the effects of time or for carry-over effects from previous stimulation. No studies have compared the effects of the combination of auricular and somatic acupuncture point stimulation with the effects of auricular or somatic acupuncture points stimulation alone. If one of these treatments could be determined to be more effective than the other, physical therapists might attain better clinical results when treating patients with pain. The purpose of our study was to compare the effects of unilateral high intensity TENS on experimental pain threshold when applied to auricular acupuncture points, somatic acupuncture points, and a combination of auricular and somatic acupuncture points. We expected statistically significant changes would occur in experimental pain threshold, measured at the wrist, after stimulation of either auricular, somatic, or the combination of auricular and somatic acupuncture points. We hypothesized that these changes would be significantly greater than changes in experimental pain thresholds measured after a rest period in a control group.
Comparison of Effects of Transcutaneous Electrical Nerve Stimulation of Auricular, Somatic, and the Combination of Auricular and Somatic Acupuncture Points on Experimental Pain Threshold
This study compared the effects of high intensity, low frequency transcutaneous electrical nerve stimulation
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of auricular, somatic, and combined auricular and somatic acupuncture points on experimental pain threshold measured at the wrist. Sixty-seven healthy adults, aged 18 to 39 years, were assigned randomly to one of four groups: 1) the Auricular Group (n = 17) received TENS to auricular acupuncture points, 2) the Somatic Group (n = 17) received TENS to somatic acupuncture points, 3) the Combined Group (n = 17) received TENS to both auricular and somatic acupuncture points, and 4) the Control Group (n = 16) received no TENS and served as controls. Pain threshold was measured immediately before and after treatment or rest. Pain threshold significantly increased (p [is less than] .05) in the Auricular, Somatic, and Combined Groups following treatment, with no statistically significant differences in mean pain threshold change scores among treatment groups. The Control Group demonstrated no statistically significant change in pain threshold. The results indicate that TENS applied to any of the three sets of acupuncture points equally increases pain threshold, thus possibly increasing options in choosing stimulation sites for treating patients with pain. [Lein DH Jr, Clelland JA, Knowles CJ, et al: Comparison of effects of transcutaneous electrical nerve stimulation of auricular, somatic, and the combination of auricular and somatic acupuncture points on experimental pain threshold. Phys Ther 69:671-678, 1989] Key Words: Acupressure/acupuncture, Electric stimulation, Pain, Transcutaneous electrical nerve stimulation. Pain is a problem confronted by physical therapists daily, often preventing treatment of accompanying or underlying disorders until analgesia is achieved. Physical therapists use various methods to relieve pain, including transcutaneous electrical nerve stimulation. Low frequency, high intensity TENS applied to somatic acupuncture points is called "acupuncture-like" TENS. Like acupuncture, high intensity TENS delivers intense peripheral stimulation. The practice of acupuncture in various forms has been used to relieve pain for thousands of years.[1] Studies have shown that somatic acupuncture point stimulation decreases both experimental[2,3] and clinical pain.[4-7] Berlin et al found that healthy subjects' pain tolerances, as measured by a pain-terminating response, significantly increased after electrical stimulation of appropriate somatic acupuncture points, whereas electrical stimulation of inappropriate points did not increase pain tolerance.[2] These results suggested that pain relief from acupuncture point stimulation was a physiological effect and not a placebo effect.[2] Ashton et al showed that acupuncture to somatic points significantly elevated cold-induced experimental pain threshold in 46 healthy, young volunteers.[3] Somatic acupuncture point stimulation also has been reported to produce analgesia in patients with various pain complaints, including pain secondary to tennis elbow,[4] menstrual pain,[5] and chronic pain.[6,7] Stimulation of acupuncture points on the auricle, or auriculotherapy, also is used for pain relief. Studies performed by Oliveri et al,[8] Krause et al,[9] and Noling et al[10] showed that low frequency, high intensity TENS applied to appropriate auricular points increased experimental pain threshold in healthy subjects. These studies indicated that auriculotherapy possibly could decrease pain in patients. Auricular TENS significantly decreased pain in 15 patients suffering with various distal extremity disorders.[11] Abbate et al found that after auricular electroacupuncture, 12 patients tolerated decreased dosages of anesthetics during thoracic surgery and decreased analgesic use during recovery.[12] Chun and Heather observed that in 46 patients with chronic pain, 84% of the patients' 57 chronic pain syndromes improved at least 25% after auricular electroacupuncture.[13] Melzack and Katz, however, conducted a controlled crossover study of 31 patients with chronic pain and found that electrical stimulation of appropriate auricular points did not give any greater pain relief than electrical stimulation to either inappropriate or placebo auricular points.[14] Stimulating a combination of auricular and somatic acupuncture points is a third method reported to decrease pain.[15-17] After several electrical stimulation treatments to both somatic and auricular acupuncture points, a child with reflex sympathetic dystrophy was able to perform all activities of daily living without pain.[15] Three months later the child was still asymptomatic.[15] Paris et al stimulated both auricular and somatic points, in addition to providing conventional physical therapy, to treat second-degree ankle inversion sprains.[16] When compared with conventional physical therapy alone, the addition of acupuncture decreased both pain and rehabilitation time.[16] The reduction of rehabilitation time, however, was the only statistically significant finding between these two variables.[16] Following electroacupuncture stimulation to both auricular and somatic acupuncture points, 20 patients with chronic pain reported significant improvement of both pain and psychiatric symptoms.[17] Researchers have proposed similar mechanisms for analgesia after either somatic acupuncture point stimulation or auriculotherapy. In addition to the Chinese meridian theory,[1] researchers have linked both somatic acupuncture and auriculotherapy to the release of morphine-like substances known as endogenous opiates. Sjolund et al observed that after acupuncture-like TENS, patients with chronic pain experienced analgesia with a concurrent segmental increase in cerebrospinal fluid [Beta]-endorphins.[7] Malizia et al found increased amounts of [Beta]-endorphins secreted in the blood following electroacupuncture.[18] Abbate and co-workers observed a significant increase of [Beta]-endorphin immunoreactivity following auriculotherapy to patients undergoing thoracic surgery.[12] Other studies have suggested that serotonin[6] and met-enkephalin[17] also might be involved in relief of pain following acupuncture. Chapman et al found that the opiate antagonist naloxone failed to reverse dental acupuncture analgesia, indicating a mechanism other than release of endogenous opiates.[19] Terman et al found that both opioid and nonopioid analgesic systems exist in the midbrain.[20] The mescencephalon, through descending pathways, is believed to modulate the transfer of nociceptive information from peripheral nerve fibers to ascending paths.[20] Terman et al showed that stimulation of both the periaqueductal gray and the dorsal raphe area of the midbrain produced analgesia, but only stimulation of the dorsal raphe was blocked by naloxone.[20] Perhaps acupuncture can cause analgesia through stimulation of several different peptide transmitters as well as opioid and nonopioid areas.[3] Only one study indicated differences between the effects of auricular acupuncture point stimulation and somatic acupuncture point stimulation. Kitade and Hyodo observed that LI 4 stimulation in five healthy men increased pain threshold more rapidly than stimulation of auricular points.[21] The internal validity of this study, however, could be questioned because the authors failed to mention whether they controlled for the effects of time or for carry-over effects from previous stimulation. No studies have compared the effects of the combination of auricular and somatic acupuncture point stimulation with the effects of auricular or somatic acupuncture points stimulation alone. If one of these treatments could be determined to be more effective than the other, physical therapists might attain better clinical results when treating patients with pain. The purpose of our study was to compare the effects of unilateral high intensity TENS on experimental pain threshold when applied to auricular acupuncture points, somatic acupuncture points, and a combination of auricular and somatic acupuncture points. We expected statistically significant changes would occur in experimental pain threshold, measured at the wrist, after stimulation of either auricular, somatic, or the combination of auricular and somatic acupuncture points. We hypothesized that these changes would be significantly greater than changes in experimental pain thresholds measured after a rest period in a control group.
Method
Subjects
Sixty-seven healthy female and male subjects, aged 18 to 39 years, participated in this study. Most of these subjects were students, staff, or faculty from The University of Alabama at Birmingham (Birmingham, Ala). Any subjects who were pregnant, used cardiac pacemakers, had neurological disorders, or took opiate pain medications or central nervous system depressants or stimulants were excluded from this study. All subjects were naive to the study's procedure and the anticipated effects. We received informed consent from each subject. The Institutional Review Board for Human Use at The University of Alabama at Birmingham approved this study.
Instrumentation
We determined experimental pain threshold with a TECA CH3 chronaxie meter,(*) which produces a measurable low voltage direct current. The stimulating electrode was a 2-mm diameter pencil electrode; the dispersive electrode was a 10- x 8-cm electrode pad moistened with water. We used a Staodyn Insight TENS unit,([dagger]) equipped with a 1-mm diameter spring-loaded pencil probe for stimulation and a 4- x 5-cm dispersive electrode to stimulate both auricular and somatic acupuncture points. A Staodyn point locator stimulator([dagger]) was used to help locate somatic acupuncture points. The reference electrode was 4 x 5 cm, and the tip of the probe was 3 mm in diameter.
Procedure
Subjects were assigned randomly to one of four groups. The Auricular Group subjects (n = 17) received unilateral TENS for four auricular points: wrist, shenmen, lung, and dermis (Fig. 1). These auricular points were the same as those used in studies by Oliveri et al,[8] Krause et al,[9] and Noling et al,[10] which resulted in elevated experimental pain threshold at the wrist. In the Somatic Group (n = 17), unilateral TENS was applied to four somatic points: 1) Waiguan (SJ 5), 2) Yangchi (SJ 4), 3) Yangxi (LI 5), and 4) Hegu (LI 4) (Fig. 2). All of the somatic acupuncture points are indicated for wrist pain.[1] All eight auricular and somatic acupuncture points were stimulated unilaterally on subjects in the Combined Group (n = 17). The Control Group (n = 16) served as controls. The subjects in this group received no TENS but instead rested for 15 minutes, the maximum amount of time needed to complete the treatment for subjects in the three stimulation groups. All subjects lay supine on a treatment table, and experimental pain threshold was measured immediately before and after treatment or rest. To reduce skin resistance, electrode sites were cleaned with cotton gauze and isopropyl alcohol before electrode placement. Pain threshold measurement. Before the experiment began, the subjects were allowed to feel the electrical current at their right wrists to familiarize themselves with the sensation. We instructed the subjects to recognized and verbally report the instant they perceived any electrical sensation at the right wrist and then again when they experienced a mildly painful pinprick sensation. To determine each subject's experimental pain threshold, electrical stimulation was applied to the skin over the distal end of the left radius (Fig. 3); the dispersive electrode was applied behind the subject's neck, between the levels of the seventh cervical vertebra and the upper thoracic vertebrae. The point over the distal radius was marked with ink to ensure that all measurements were taken at the same point. Acupuncture point LI 5, located near the distal end of the radius, was avoided. The current consisted of 100-Hz rectangular waves of 5-msec duration. The intensity was increased systematically by 0.25-mA increments at one-second intervals until the subject verbally reported a distinct painful pinprick sensation. This sensation was recorded as the subject's experimental pain threshold. We obtained and averaged three pain threshold measurements in each session to determine each subject's mean experimental pain threshold. The reliability of this mean was found to be .98 for pretreatment measurements using an intraclass correlation coefficient (ICC[3,k])[22] as the index of reliability. Treatment. The subjects removed all jewelry before treatment. Each subject held the dispersive electrode in the left hand. With the assistance of somatic and auricular acupuncture point charts and an audio or visual signal from the stimulating unit to detect decreased skin resistance, we located appropriate auricular and somatic acupuncture points for each subject according to group assignment. If the stimulating unit was not sensitive enough to locate the somatic acupuncture points, we used the Stayodyn point locator stimulator to locate them. The TENS current used to stimulate the acupuncture points was a positive-polarity direct current with a maximum output of 1,000 [Mu]A, delivered at a frequency of 1 Hz. The current duration was constant, as preset in the TENS unit. Subjects responded verbally when they first began to feel the stimulus and then again when the intensity reached each subject's tolerance. Each point was stimulated for 60 seconds at this intensity. Stimulus intensity was lowered slightly during treatment if requested by the subject. Experimental pain thresholds were measured again immediately after treatment or rest. This treatment technique and the experimental pain threshold determination technique were similar to those used previously by Oliveri et al,[8] Krause et al,[9] and Noling et al.[10]
Data Analysis
Descriptive statistics for pain threshold were calculated by group for the pretreatment and posttreatment measurements and for the change between measurements. A two-factor analysis of variance (ANOVA) was used to test the data for statistical significance. The two factors were group (Auricular, Somatic, Combined, and Control Groups) and time of measurement (pretreatment, posttreatment); the time of measurement was a repeated-measures factor. For this design, the interaction effect in the ANOVA is a test of the difference among the mean pretreatment-posttreatment changes for the four groups. The ANOVA also provides tests of simple main effects, which can be used to determine the difference among pretreatment-posttreatment group means as well as the differences between the pretreatment and posttreatment means within each group. Pair-wise comparisons between groups were made with Tukey's Honestly Significant Difference (HSD) test. An alpha level of .05 was selected for all tests.
Results Each group's demographic information is depicted in Table 1. Mean pain threshold values are shown in Table 2. The ANOVA showed a statistically significant interaction effect; therefore, there was a statistically significant difference among the groups in terms of pretreatment-posttreatment change (Tab. 3). Pair-wise comparisons using Tukey's HSD test showed that the mean change for each of the stimulation groups was significantly different (p [is less than] .05) from the Control Group; however, the stimulation groups did not differ significantly from each other. Tests of simple main effects revealed that the group means were not different at the pretreatment measurement session and that each of the stimulation groups showed a statistically significant increase (p [is less than] .05) from pretreatment to posttreatment measurement. The mean pretreatment and posttreatment pain threshold are shown in Figure 4 for all four groups. This study supported our expectation that significant changes would occur in experimental pain threshold, measured at the wrist, after stimulation of auricular, somatic, and the combination of both types of acupuncture points. The hypothesis that these changes in experimental pain threshold would be significantly greater than the changes in experimental pain threshold in the control group also was supported. No significant differences were found among the three stimulation groups' mean change values from pretreatment to posttreatment measurement.
Discussion Other studies have shown that stimulation of auricular[8-10,21] or somatic[2,3,19,21] acupuncture points resulted in statistically significant increases in experimental pain threshold. We also found statistically significant pain threshold elevation following either auricular or somatic acupuncture point stimulation. In addition, stimulation of the combination of auricular and somatic acupuncture points significantly increased experimental pain threshold. No other studies have evaluated the effect of the combination of auricular and somatic acupuncture point stimulation on experimental pain threshold. Stimulation of the combined acupuncture sites, however, resulted in decreased clinical pain in disorders such as reflex sympathetic dystrophy,[15] ankle sprains,[16] and chronic pain.[17] Individual stimulation of either auricular[11-13] or somatic[4-7] acupuncture points has also lowered pain in various clinical syndromes. The results of our study suggest that stimulation of auricular, somatic, or the combination of both types of these acupuncture points is equally effective in increasing experimental pain threshold. In our study, somatic acupuncture point stimulation resulted in the greatest pain threshold change (Tab. 2). This change, however, was not significantly different from the pain threshold changes in the other two groups that received TENS. Clinically, this finding implies that a physical therapist may legitimately stimulate the set of acupuncture points (ie, auricular, somatic, combination of both) that is most convenient, tolerable, and accessible on each individual patient. The analgesic effects may be the same after stimulation of any one of these three sets of acupuncture points. The increases in mean pain threshold observed in the three stimulation groups were all less than 1 mA (Tab. 2). This increase, however, represented mean pain threshold changes of 30.9%, 46.2%, and 41.5% in the Auricular, Somatic, and Combined Groups, respectively. Significant increases in mean pain threshold of 16.3% and 11.7% were reported by Oliveri et al[8] and Noling et al,[10] respectively, immediately following auricular TENS. Similar to our study, Berlin and colleagues found that pain tolerance significantly increased immediately after 20 minutes of somatic electroacupuncture.[2] No other study has measured experimental pain threshold immediately following combined stimulation of auricular and somatic acupuncture points. Our study, however, suggested that immediate increases in experimental pain threshold should be anticipated. Other studies have shown that a delay exists before maximum analgesia occurs in experimental pain threshold following either auricular or somatic acupuncture point stimulation.[3,10,21] Noling et al reported that the change in mean pain threshold increased from 11.7% immediately following auricular acupuncture point stimulation to 25.6% 10 minutes after treatment.[10] Ashton et al found that cold-induced pain threshold increased with time, reaching a maximum 35 minutes following somatic acupuncture point acupuncture.[3] Kitade and Hyodo measured experimental pain threshold both during and after either auricular or somatic acupuncture point stimulation.[21] They also reported that maximum analgesia was not achieved immediately posttreatment.[21] Kitade and Hyodo observed that experimental pain threshold reached its maximum at 30 or 50 minutes into somatic acupuncture point stimulation.[21] In all of these studies, maximum pain threshold levels were not achieved immediately, regardless of whether pain threshold was measured following or during either auricular or somatic acupuncture point stimulation.[3,10,21] This delay before maximum analgesia could be the time required for the maximal release and function of endorphins. All of these studies also showed that pain threshold remained elevated after cessation of either auricular or somatic acupuncture point stimulation.[3,10,21] Our study showed that auricular, somatic, or the combination of auricular and somatic acupuncture point stimulation resulted in immediate increases in experimental pain threshold; further posttreatment measurements were not taken. Future studies should determine whether experimental pain threshold will continue to increase or remain significantly elevated over time following either individual or combined stimulation of auricular and somatic acupuncture points. Further research should also examine whether auricular, somatic, or the combination of auricular and somatic acupuncture point stimulation increases pain threshold to its maximum level more rapidly over time. Kitade and Hyodo observed that auricular acupuncture point stimulation did not increase pain threshold as quickly as somatic acupuncture point stimulation.[21] Our study showed that mean pain threshold changes from pretreatment to posttreatment measurement were not significantly different among the stimulation groups. Rather than insertion of needles to apply 50 minutes of electro-acupuncture, we used surface electrodes and stimulated the acupuncture points for only 60 seconds.[21] Comparisons between our study and that of Kitade and Hyodo[21] are difficult to make because different methods of acupuncture point stimulation were used. Different methods of acupuncture point stimulation have yielded various degrees of analgesia.[2-19,21] Duration of treatment also has been shown to be a factor in effective auricular acupuncture point stimulation. Oliveri et al[8] and Noling et al[10] stimulated the same four auricular points used in our study for 90 seconds and observed 16.3% and 11.7% increases, respectively, in mean pain threshold. Krause et al also stimulated the same four auricular points for 45 seconds and found mean pain threshold increased by 12.2%.[9] In our study, the application of auricular TENS for 60 seconds resulted in a 30.9% increase in experimental pain threshold. Other studies should be conducted to determine whether 60 seconds of auricular TENS achieves the greatest increases in pain threshold. Studies should also be performed to determine the duration of treatment required to achieve optimal increases in pain threshold with TENS to somatic and the combination of somatic and auricular acupuncture points. Studies should be performed to compare the effects of individual and combined stimulation of auricular and somatic acupuncture points in specific patient populations. Comparisons between experimental pain and clinical pain were not made in this study because they may differ in their response to acupuncture point stimulation. Clinical studies may show that, of the sets of acupuncture points investigated in this study, one set may be more effective in alleviating clinical pain. Nonetheless, experimental pain suppression studies, such as this study, may be an important first step in evaluating and understanding potentially effective means of pain alleviation in the clinic.[9]
Conclusion In a group of 67 healthy subjects, low frequency, high intensity TENS administered to auricular, somatic, or the combination of auricular and somatic acupuncture points resulted in statistically significant increases in experimental pain threshold. The Control Group demonstrated no significant increase in experimental pain threshold following 15 minutes of rest. No statistically significant differences existed in the elevated pain threshold change values among the three stimulation groups following TENS treatment, but changes in all stimulation groups were significantly greater than the Control Group changes. These results suggest that auricular, somatic, and the combination of auricular and somatic acupuncture point stimulation are equally effective for increasing experimental pain threshold. Because these results imply that stimulation of any of the cited sets of acupuncture points might be equally effective, the clinician could select appropriate acupuncture points in terms of acupuncture point accessibility, patient tolerance, and clinician convenience. Further research to compare the efficacy of auricular, somatic, and the combination of auricular and somatic acupuncture points with patients with specific pain conditions is needed. [Figures 1 to 4 Omitted] [Tabular Data 1 to 3 Omitted]
(*)TECA Instruments Corp, 3 Campus Dr, Pleasantville, NY 10570. ([dagger])Staodynamics, Inc, PO Box 1379, Longmont, CO 80502.
References [1]Essentials of Chinese Acupuncture. Beijing, China, Foreign Languages Press, 1980, pp 1-37, 48-59, 111-117, 217-222, 399-414 [2]Berlin FS, Bartlett RL, Black JD: Acupuncture and placebo: Effects on delaying the terminating response to a painful stimulus. Anesthesiology 42:527-531, 1975 [3]Ashton H, Ebenezer I, Golding JF, et al: Effects of acupuncture and transcutaneous electrical nerve stimulation on cold-induced pain in normal subjects. J Psychosom Res 28:301-308, 1984 [4]Brattburg G: Acupuncture therapy for tennis elbow. Pain 16:285-288, 1983 [5]Neighbors LE, Clelland JA, Jackson JR, et al: Transcutaneous electrical nerve stimulation for pain relief in primary dysmenorrhea. Clinical Journal of Pain 3:17-22, 1987 [6]Mao W, Ghia JN, Scott DS, et al: High versus low intensity acupuncture analgesia for treatment of chronic pain: Effects on platelet serotonin. Pain 8:331-342, 1980 [7]Sjolund BH, Terenius L, Ericksson MBE: Increased cerebrospinal fluid levels of endorphins after electro-acupuncture. Acta Physiol Scand 100:382-384, 1977 [8]Oliveri AC, Clelland JA, Jackson JR, et al: Effects of auricular transcutaneous electrical nerve stimulation on experimental pain threshold. Phys Ther 66:12-16, 1986 [9]Krause AW, Clelland JA, Knowles CJ, et al: Effects of unilateral and bilateral auricular transcutaneous electrical nerve stimulation on cutaneous pain threshold. Phys Ther 67:507-511, 1987 [10]Noling LB, Clelland JA, Jackson JR, et al: Effect of transcutaneous electrical nerve stimulation at auricular points on experimental cutaneous pain threshold. Phys Ther 68:328-332, 1988 [11]Longobardi AG, Clelland JA, Knowles CJ, et al: Effects of auricular transcutaneous electrical nerve stimulation on distal extremity pain: A pilot study. Phys Ther 69:10-17, 1989 [12]Abbate D, Santamaria A, Brambilla A, et al: [Beta]-Endorphin and electroacupuncture. Lancet 2:1309, 1980 [13]Chun S, Heather AJ: Auriculotherapy: Micro-current application on the external ear--Clinical analysis of a pilot study on 57 chronic pain syndromes. Am J Chin Med 2:399-405, 1974 [14]Melzack R, Katz J: Auriculotherapy fails to relieve chronic pain: A controlled crossover study. JAMA 251:1041-1043, 1984 [15]Leo KC: Use of electrical stimulation at acupuncture points for the treatment of reflex sympathetic dystrophy in a child: A case report. Phys Ther 63:957-959, 1983 [16]Paris DL, Baynes F, Gucker B: Effects of the Neuroprobe in the treatment of second-degree ankle inversion sprains. Phys Ther 63:35-40, 1983 [17]Kiser RS, Gatchel RJ, Bhatia K, et al: Acupuncture relief of chronic pain syndrome correlates with increased plasma met-enkephalin concentrations. Lancet 2:1394-1396, 1983 [18]Malizia E, Andreucci G, Paolucci D, et al: Electroacupuncture and peripheral [Beta]-endorphin and ACTH levels. Lancet 2:535-536, 1979 [19]Chapman CR, Benedetti C, Colpitts YH, et al: Naloxone fails to reverse pain thresholds elevated by acupuncture: Acupuncture analgesia reconsidered. Pain 16:13-31, 1983 [20]Terman GW, Shavit Y, Lewis JW, et al: Intrinsic mechanisms of pain inhibition: Activation by stress. Science 226:1270-1276, 1984 [21]Kitade T, Hyodo M: The effects of stimulation of ear acupuncture points on the body's pain threshold. Am J Chin Med 7:241-252, 1979 [22]Shrout PE, Fleiss J: Intraclass correlations: Uses in assessing rater reliability. Psychol Bull 86:420-428, 1979
D Lein, MS, PT, is Physical Therapist, University of Alabama Hospitals, 619 19th St, Birmingham, AL 35294 (USA). He was a graduate student, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham, Birmingham, AL 35294, when this study was completed in partial fulfillment of the requirements of his Master of Science degree. J Clelland, MS, PT, is Associate Professor and Associate Director, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham. C Knowles, MS, PT, is Assistant Professor, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham. J Jackson, PhD, is Assistant Professor, Office of Educational Development, School of Medicine, The University of Alabama at Birmingham.
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