Auricular acupuncture for pain relief after total hip arthroplasty – a randomized controlled study (2022)


Corporate sign inSign in / register


  • Access throughyour institution


Volume 114, Issue 3,

April 2005

, Pages 320-327


Auricular acupuncture (AA) is known to be effective in treatment of various pain conditions, but still there have been no randomized controlled studies of AA for treatment of acute postoperative pain. Therefore we tested whether AA of specific points is superior to sham acupuncture for complementary analgesia after total hip arthroplasty in a patient–anesthesiologist–evaluator–analyst blinded study. The patients were randomly allocated to receive true AA (lung, shenmen, thalamus and hip points) or sham procedure (4 non-acupuncture points on the auricular helix). Permanent press AA needles were retained in situ 3 days after surgery. Postoperative pain was treated with intravenous piritramide (opioid receptor agonist with analgesic potency of 0.7 compared with morphine) using a patient-controlled analgesia (PCA) pump. The time to the first analgesic request, the amount of postoperative piritramide via PCA and pain intensity on a 100-mm visual analogue scale (VAS-100) were used to evaluate postoperative analgesia. Intraoperative anesthetic requirement, incidence of analgesia-related side effects, inflammation parameters and success of patients' blinding were also recorded. Fifty-four patients (29 AA and 25 controls) completed the study. Piritramide requirement during 36h after surgery in AA group was lower than in control: 37±18 vs. 54±21mg; mean±SD; P=0.004. Pain intensity on VAS-100 and incidence of analgesia-related side effects were similar in both groups. The differences between the groups as regard patients' opinions concerning success of blinding were not significant. Findings from our study demonstrate that AA could be used to reduce postoperative analgesic requirement.


Effective relief of acute pain has been associated with increased patient satisfaction in addition to shortened hospital stays and decreased morbidity and mortality (Ballantyne et al., 1998, Tsui et al., 1997).

Despite a better understanding of the pathophysiology of pain, the pharmacology of analgesics and the development of numerous analgesic techniques, many patients continue to experience distressing pain after elective surgery. A recent review of 165 papers, including nearly 20,000 patients, has shown that 29% still experienced moderate pain and 11% severe postoperative pain (Dolin et al., 2002). Even when patient-controlled analgesia (PCA) was used, which is considered to satisfy the individual patients' analgesic demand, the incidence of moderate pain was 35.8% and that of severe pain was 10.4%. Moreover, systemic opioids administered via PCA pumps can cause numerous side effects such as respiratory depression, decreased intestinal motility, nausea, vomiting and itching, which can all lead to decreased life quality after major surgery and may result in significant morbidity and even mortality (Ashburn et al., 1994, Ballantyne et al., 1998, Schug and Torrie, 1993). In order to achieve better postoperative pain relief, various complementary non-pharmacological analgesic techniques, including acupuncture, have been tested (Chen et al., 1998, Kotani et al., 2001, Lao et al., 1999).

Auricular acupuncture (AA), an old chinese therapeutic technique, is reported to be effective in treatment of pain syndromes of various origins (Alimi et al., 2003, Simmons and Oleson, 1993, Vorobiev and Dymnikov, 2000). AA was first introduced into clinical western medicine by Nogier (1972), who empirically identified AA points.

In the last decade AA found its place as a complementary technique in perioperative medicine. Randomized controlled trials (RCT) have shown AA to decrease preoperative anxiety in patients scheduled for ambulatory surgery (Wang et al., 2001), reduce anesthetic requirement in healthy individuals (Taguchi et al., 2002) and relieve chronic pain in cancer patients (Alimi et al., 2003). To our knowledge, there has been no RCT assessing AA effectiveness in relief of acute postoperative pain. Designing control procedures in acupuncture studies is difficult (Usichenko et al., 2003b). A placebo using non-inserted needles has been reported to be a valid control procedure for evaluation of postoperative analgesic effect of acupuncture (Lao et al., 1999). However, it does not account for the non-specific physiological response of intradermal needle penetration, which has been reported in experimental and clinical studies to have analgesic properties (Le Bars et al., 1979, Lewith and Machin, 1983). To investigate whether the acupuncture has any specific effects beyond the physiological reaction of needle penetration, the control group should always receive sham acupuncture, defined as a needle insertion either into sites other than traditional points or meridians, or into inappropriate acupuncture points (White et al., 2002).

(Video) Suburban Hospital Grand Rounds 1/11- Medical Acupuncture in Clinical Practice

Therefore we performed the following study to test whether the AA of specific points is superior to sham acupuncture for complementary analgesia after total hip arthroplasty (THA).

Section snippets

Study design and randomization

This prospective randomized patient–anesthesiologist–evaluator–analyst blinded, sham acupuncture controlled study was approved by the local ethics committee. It was performed at the Departments of Anesthesiology and Orthopedic Surgery, University of Greifswald, Germany, from November 2002 to September 2003. Sixty-one patients scheduled for elective THA performed under general anesthesia were enrolled in the study.

The preoperative anesthesiologic evaluation along with the patients' randomization

Patients characteristics

Sixty-one out of 75 patients who initially agreed to take part in this study met the inclusion criteria and were randomized. The groups were well balanced for age, weight and gender (Table 1). All patients in this study were Caucasians who had never previously received AA. Fifty-four patients completed the study: 29 patients in AA group and 25 in the control group. The difference between the study groups regarding withdrawal rate was not statistically significant. One patient from the control

Analgesic properties of AA

Auricular acupuncture applied to specific acupuncture points appeared to be more effective than sham acupuncture in reducing postoperative piritramide requirement after elective THA. In order to obtain reliable results in pain measurement using PCA requirement, the piritramide titration was adjusted to achieve similar pain values on VAS (McQuay and Moore, 1999). We found the mean reduction of VAS to be 44mm, 36h after THA procedure in both groups. Although it was slightly higher than the


Findings from our study demonstrate that AA could be used to reduce postoperative analgesic requirement. Further large-scale randomized investigation of this treatment modality comparing it with standard therapy and placebo acupuncture (non-inserted needle) appears to be necessary.


The authors thank M. Groth for discussion of study design, the personnel of the University Hospital of Greifswald and the patients who participated in this study.

References (34)

  • S.A. Schug et al.Safety assessment of postoperative pain management by an acute pain service



  • N. Rawal et al.Organization of acute pain services: a low-cost model



  • T. Oleson et al.An experimental evaluation of auricular diagnosis: the somatotopic mapping of musculoskeletal pain at ear acupuncture points



  • H. MacPherson et al.Standards for reporting interventions in controlled trials of acupuncture: the STRICTA recommendations

    Complement Ther Med


  • G.T. Lewith et al.On the evaluation of the clinical effects of acupuncture



  • E. Leibing et al.Acupuncture treatment of chronic low-back pain—a randomized, blinded, placebo-controlled trial with 9-month follow-up



  • D. Le Bars et al.Diffuse noxious inhibitory controls (DNIC). I. Effects on dorsal horn convergent neurones in the rat



  • C.J. Hogeboom et al.Variation in diagnosis and treatment of chronic low back pain by traditional Chinese medicine acupuncturists

    Complement Ther Med


  • S.J. Dolin et al.Effectiveness of acute postoperative pain management: I. Evidence from published data

    Br J Anaesth


  • D. Alimi et al.

    Analgesic effect of auricular acupuncture for cancer pain: a randomized, blinded, controlled trial

    J Clin Oncol


  • M.A. Ashburn et al.

    Respiratory-related critical events with intravenous patient-controlled analgesia

    Clin J Pain


  • J.C. Ballantyne et al.

    The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials

    Anesth Analg


    (Video) The Future of Pain: Optimizing Multimodal Analgesia in a New Era for Managing Pain

  • M. Bland

    An introduction to medical statistics


  • L. Chen et al.

    The effect of location of transcutaneous electrical nerve stimulation on postoperative opioid requirement: acupoint versus non-acupoint stimulation

    Anesth Analg


  • B. Grammel

    Die Verbrauchsreduzierung postoperativer Analgetika durch intraoperative Applikation von Dauernadeln im OP-Korrespondenzgebiet des Ohres

    Der Akupunkturarzt/Aurikulotherapeut


  • N. Kotani et al.

    Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses



  • L. Lao et al.

    Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial

    Arch Otolaryngol Head Neck Surg


  • Cited by (117)

    • Development and validation of an evidence-based auricular acupressure intervention for managing chemotherapy-induced nausea and vomiting in breast cancer patients

      2020, Complementary Therapies in Medicine

      Auricular therapy (AT) has been utilized as a promising complementary health approach to alleviating chemotherapy-induced nausea and vomiting (CINV) in breast cancer patients. However, current evidence on AT for CINV management has been inconclusive, and relevant AT treatment protocols have varied considerably in the intervention dosage and acupoint formula without an evidence-informed intervention protocol tailored to CINV symptoms. This study aimed to develop an evidence-based AT intervention protocol for CINV management in breast cancer patients receiving chemotherapy.

      This study adopted the Medical Research Council Framework for Developing and Evaluating Complex Interventions (the MRC framework) to guide the AT intervention development process. The process consists of four steps: identification of the evidence base, identification of theories and practice standards, identification of cancer symptom characteristics, and modelling and validation. The preliminary AT intervention was then evaluated through a content validity study to identify its theoretical and practical appropriateness. The content validity index (CVI) was used to determine the consensus level of the panel.

      A preliminary AT intervention protocol, including a true AT intervention and a sham AT intervention, was developed based on research evidence identified from five systematic reviews, the homuncular reflex theory, the zang-fu organs and meridian theory, relevant AT practice standards, and the natural symptom progress of CINV. The true AT was designed as a daily manual acupressure for five consecutive days. While the sham AT was designed with the same intervention duration and acupoint formula as the true AT without manual acupressure. The content validity study demonstrated excellent consensus among the expert panel to support the AT intervention as a theoretically and practically feasible program with the item-level CVI ranging from 0.83 to 1.0 and the scale-level CVI reaching 1.0.

      This study followed the MRC framework to develop an evidence-based AT intervention for CINV management which is well supported by systematic review research evidence, AT theories and practice standards, CINV symptom characteristics, and expert panel consensus. The AT intervention would be further evaluated in a pilot randomised controlled trial to confirm its utility, feasibility and acceptability in clinical settings.

    • Auriculotherapy in primary health care: A large-scale educational experience in Brazil

      2019, Journal of Integrative Medicine

      Auriculotherapy consists of physical stimuli applied to the outer ear and is commonly associated with traditional Chinese medicine (TCM). The authors present and discuss the development of a course that offers a semi-on-site auriculotherapy course for Brazilian primary health care (PHC) professionals. The course was funded by the Brazilian Ministry of Health and developed at the Federal University of Santa Catarina in 2015 by a team of experts in auriculotherapy. It consisted of 75 h of distance learning (five sequential modules) and 5 h of on-site learning. The modules included the following items: (1) introduction to integrative practices; (2) ear reflexology; (3) introduction to TCM; (4) biomedical view of auriculotherapy; and (5) auriculotherapy in PHC. The teaching material included a workbook for each module, 14 video lectures and an interactive ear (online resource) to study location and application to the main auricular points. The on-site lectures follow a structured script of ear palpation techniques, auricular seed insertion practice and clinical case discussions, under the supervision of trained instructors. The course was offered in 2016 and 2017 and on-site lectures took place in 25 cities, covering all Brazilian regions, in coordination with municipal or state boards of health. A total of 4273 health professionals concluded the training and their evaluation of the course was highly positive. The Brazilian experience of large-scale training shows the potential to disseminate auriculotherapy in the context of PHC, given that its practice is fast, easy to learn, safe, effective for different health problems and well accepted by the patients.

    • Increasing Access to Auricular Acupuncture for Postoperative Nausea and Vomiting

      2017, Journal of Perianesthesia Nursing

      Two studies directly examine the effect of AA on PONV. Other studies examine the effect of AA on postoperative pain, while including PONV as secondary data.6,11,28,31 The model for this project is described in a 2003 prospective randomized controlled trial.6

      Postoperative nausea and vomiting (PONV) affects more than 30% of surgical patients. Auricular acupuncture (AA) has been shown to decrease the incidence of PONV in select populations.

      An evidence-based quality improvement project made AA available to all adult surgical patients, and the results were recorded in a database. A retrospective between-groups analysis of 210 database entries was conducted, of those 25 receiving AA.

      (Video) Acupuncture in Oncology - by Susie Mee

      More risk factors for PONV were present in the AA group (P<.001). Both groups experienced a less-than-expected rate of PONV. Similar rates were shown between groups for PONV, postanesthesia care unit length of stay, and opioid consumption. Patient satisfaction was 96% with AA. The AA group was treated with less antiemetic medication (P < .001), yet PONV rates remained similar.

      A multimodal approach treating patients at risk for PONV is recommended. Administration of multiple antiemetics may result in unnecessary cost or unfavorable side effects when effective and less costly alternatives exist. AA is a viable treatment for PONV, considering cost and patient satisfaction.

    • Auricular Acupuncture Analgesia in Thoracic Trauma: A Case Report

      2017, JAMS Journal of Acupuncture and Meridian Studies

      We report a case of thoracic trauma (rib fractures with pneumothorax and pulmonary contusions) with severe chest pain leading to ineffective ventilation and oxygenation. The patient presented to our emergency department. The patient had chronic obstructive pulmonary disease and was completely unable to take deep breaths and clear secretions from his bronchial tree. After obtaining informed consent, we applied auricular acupuncture to ameliorate pain and hopefully improve his functional ability to cough and breathe deeply. Within a few minutes, his pain scores diminished considerably, and his ventilation and oxygenation indices improved to safe limits. Auricular acupuncture analgesia lasted for several hours. Parallel to pain reduction, hemodynamic disturbances and anxiety significantly resolved. A second treatment nearly a day later resulted in almost complete resolution of pain that lasted at least 5 days and permitted adequate ventilation, restored oxygenation, and some degree of mobilization (although restricted due to a compression fracture of a lumbar vertebra). Nonopioid and opioid analgesics were sparsely used in low doses during the entire hospitalization period. Hemodynamic alterations and anxiety also decreased, and the patient was soon ready to be discharged.

    • Acupuncture and related techniques during perioperative period: A literature review

      2016, Complementary Therapies in Medicine

      After knee arthroscopy, ibuprofen consumption by the acupuncture group was significantly less than the control group (500 mg vs. 800 mg, respectively).41 In the other study, 36-h piritramide requirements were 37 mg and 54 mg in the acupuncture and control groups, respectively.42 However, a recent systematic review of auricular acupuncture for postoperative pain noted that the quality of these studies was poor, although most of them concluded positive results.49

      Acupuncture has been used in the Far East for more than 2000 years. Since the early 1970s, this technique has been gaining popularity among Western medical community. A number of studies suggest that its mechanism of effect can be explained in biomedical terms. In this context, a number of transmitters and modulators including beta-endorphin, serotonin, substance P, interleukins, and calcitonin gene-related peptide are released. For that reason, acupuncture can be used in a wide variety of clinical conditions. Studies showed that acupuncture may have beneficial effect in perioperative period. It relieves preoperative anxiety, decreases postoperative analgesic requirements, and decreases the incidence of postoperative nausea and vomiting. In this review article, we examine perioperative use of acupuncture for a variety of conditions.

    View all citing articles on Scopus

    Recommended articles (6)

    • Research article

      Biological Treatment for Osteoarthritis of the Knee: Moving from Bench to Bedside—Current Practical Concepts

      Arthroscopy: The Journal of Arthroscopic & Related Surgery, Volume 34, Issue 5, 2018, pp. 1719-1729

      Biological-based therapies for cartilage pathology have gained considerable recognition in the last few decades due to their potential benefits including their minimal invasiveness, capacity for unprecedented healing, and potential for rapid recovery. Consequently, these therapies are likely to have the most noteworthy impact on patients with degenerative joint changes who want to remain active. Currently, the most researched treatments include platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and cell-based therapies. Although further basic science research and well-designed randomized clinical trials are needed to elucidate the long-term role of these therapies in the treatment of osteoarthritis, there is compelling evidence for their use for certain indications. This article aims to review the existing literature for biological-based treatment options for osteoarthritis, critically assessing the current evidence-based recommendations and identify potential avenues for development.

    • Research article

      Non-pharmacological treatments for pain relief: TENS and acupuncture

      Joint Bone Spine, Volume 84, Issue 6, 2017, pp. 657-661

      Acupuncture and transcutaneous electrical nerve stimulation (TENS) are non-pharmacological methods that have been used for millennia to relieve pain. As with all complementary treatments, efficacy evaluations face two hurdles: the non-feasibility of double-blinding and the difficulty in identifying the optimal control population or treatment. Nevertheless, recent studies of good methodological quality have demonstrated benefits in many types of pain compared to conventional treatment. The mechanisms of action of acupuncture and TENS, which are increasingly well understood, involve endogenous pain control systems, cerebral plasticity, and nonspecific effects (e.g., expectations and placebo effect). No serious adverse effects have been reported. These data support the more widespread use of non-pharmacological pain management, most notably in patients with chronic pain inadequately relieved by medications alone.

    • Research article

      Acupressure, reflexology, and auricular acupressure for insomnia: A systematic review of randomized controlled trials

      Sleep Medicine, Volume 13, Issue 8, 2012, pp. 971-984

      (Video) Energy Medicine Modalities Stimulate Healing - Dr. Sebastian (Physiatrist in Estero Southwest FL)

      Previous randomized controlled trials (RCTs) have shown that acupuncture may be efficacious for insomnia. Instead of needling, acupressure, reflexology, and auricular acupressure are procedures involving physical pressure on acupoints or reflex areas. These variants of acupuncture are gaining popularity, perhaps due to their non-invasive nature. A systematic review has therefore been conducted to examine their efficacy and safety for insomnia. Two independent researchers searched five English and 10 Chinese databases from inception to May 2010. Forty RCTs were identified for analysis. Only 10 studies used sham controls, four used double-blind design, nine studies scored three or more by the Jadad scale, and all had at least one domain with high risk of bias. Meta-analyses of the moderate-quality RCTs found that acupressure as monotherapy fared marginally better than sham control. Studies that compared auricular acupressure and sham control showed equivocal results. It was also found that acupressure, reflexology, or auricular acupressure as monotherapy or combined with routine care was significantly more efficacious than routine care or no treatment. Owing to the methodological limitations of the studies and equivocal results, the current evidence does not allow a clear conclusion on the benefits of acupressure, reflexology, and auricular acupressure for insomnia.

    • Research article

      The effects of auricular acupressure on the sleep of the elderly using polysomnography, actigraphy and blood test: Randomized, single-blind, sham control

      Complementary Therapies in Clinical Practice, Volume 45, 2021, Article 101464

      This study was conducted to examine the effects of auricular acupressure on sleep in elderly people with sleep disorders.

      This was a randomized, double-blind, sham-controlled study. The participants aged over 65 years old were randomly assigned to the experimental group (n=21) and the sham control group (n=21). The participants in the experimental group and the sham control group received auricular acupressure on sleep-disorder-related points or to sleep-disorder-unrelated points, respectively. The intervention was implemented for a total of eight weeks. To validate the effects of the treatment, polysomnography with the Alice portable sleep diagnostic system; actigraphy with Fitbit Alta; and melatonin, serotonin, and cortisol blood tests were conducted.

      Non-Rapid Eye Movement sleep stage 3 duration change (Z=−2.187, p= .029) and Non-Rapid Eye Movement sleep stage 3 ratio change (Z=−2.423, p= .014), measured by polysomnography, of the experimental group showed a significant increase over time compared to the sham control group.

      Auricular acupressure applied for eight weeks was found to be effective in increasing Non-Rapid Eye Movement sleep stage 3 duration and Non-Rapid Eye Movement sleep stage 3 ratio among sleep stages of the elderly. Consequently, it showed that auricular acupressure can be used as a proven nursing intervention method for sleep disorder in elders to increase deep sleep duration and ratio.

    • Research article

      Effects of Auricular Acupressure on Korean Children Who are Obese

      Journal of Pediatric Nursing, Volume 51, 2020, pp. e57-e63

      This study aimed to examine the effects of auricular acupresure on reducing obesity in children who are obese.

      The study design was a randomized controlled trial design. Participants aged between 9 and 11 years were 65 children who are obese, divided into the experimental group (n = 31) and control group (n = 34). The sessions continued for 8 weeks. The participants in the experimental and control groups received auricular acupressure using ear pellets (seeds) on 5 acupoints known to be either effective in obesity treatment or ineffective. Outcome measures included body image score, children's depression inventory, Rosenberg self-esteem scale, and anthropometric indices (waist circumference, hip circumference, BMI, etc.).

      Children in the experimental group showed significant improvement in waist circumference and hip circumference after 8 weeks compared with those in the control group (p < .001). But no statistically significant difference in body image score, depression score, or self-esteem score emerged before or after auricular acupressure in the experimental and control groups.

      Auricular acupressure using ear pellets for eight weeks was effective in decreasing waist and hip circumferences in children who are obese.

      Auricular acupressure can be used as an intervention method for children to control obesity.

    • Research article

      The Effectiveness of Acupressure on Relieving Pain: A Systematic Review

      Pain Management Nursing, Volume 15, Issue 2, 2014, pp. 539-550

      Acupressure is a complementary treatment that uses fingers and hands to stimulate acupoints and maintains the balance of energy. The objective of this study was to review the application of acupressure in managing different pains and the effectiveness of acupressure on relieving pain in various settings. A systematic review of English articles using the databases of MEDLINE, PubMed, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was performed using the search terms of “acupressure” and “pain.” Studies during which acupressure was applied as an intervention and assessed for its effectiveness on relieving pain were selected. The studies selected were those published from January 1, 1996 to December 31, 2011 that met the inclusion and exclusion criteria. The participants included patients with dysmenorrhea, labor pain, low back pain, chronic headache, and other traumatic pains. The Oxford 2011 Levels of Evidence was used to appraise the literature. Fifteen studies were extracted for reducing dysmenorrhea (menstrual distress), labor pain, low back pain, chronic headache, and other traumatic pain. These papers were further reviewed for their study design, adequacy of randomization and concealment of allocation, blinding of participants, interventions, and outcome measurements. Acupressure has been shown to be effective for relieving a variety of pains in different populations. The review begins to establish a credible evidence base for the use of acupressure in pain relief. The implication for health care providers would be incorporating acupressure into their practice as an alternative therapy to facilitate patients who suffer from pain.

      (Video) AUA Quality Summit 2018 Session 2: Understanding Postoperative Pain

    View full text

    Copyright © 2004 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.


    1. Live With Dr. Warner - Knee Pain 101
    (Warner Orthopedics & Wellness)
    2. Peter Wu, MD, PhD - "Physiatry Across Disciplines: A Perspective"
    (UCSF Orthopaedic Surgery)
    3. Lessons from Grenfell - Dr Nagata - 10Jun2020
    (London School of Paediatrics)
    (Velji Neven)
    5. Upper Limb Injection Lecture - Tips and Tricks
    (Prof. Bijayendra Singh - Kent Orthopaedic Practice)
    6. PCP Lecture Series Low Back Pain Basics, Joint Replacement and Orthopedic Urgent Care Update
    (Central Ohio Primary Care)

    You might also like

    Latest Posts

    Article information

    Author: Rueben Jacobs

    Last Updated: 07/01/2022

    Views: 5851

    Rating: 4.7 / 5 (57 voted)

    Reviews: 88% of readers found this page helpful

    Author information

    Name: Rueben Jacobs

    Birthday: 1999-03-14

    Address: 951 Caterina Walk, Schambergerside, CA 67667-0896

    Phone: +6881806848632

    Job: Internal Education Planner

    Hobby: Candle making, Cabaret, Poi, Gambling, Rock climbing, Wood carving, Computer programming

    Introduction: My name is Rueben Jacobs, I am a cooperative, beautiful, kind, comfortable, glamorous, open, magnificent person who loves writing and wants to share my knowledge and understanding with you.