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8/9/17
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PainManagementwithAuricularTherapy/AuricularAcupuncture
KarenWilliams,MSN,RN,FNP-BC(K1)KDWHealthManagement
KarenSova,MSN,RN,ANP-BC,COHN-S(K2)NationalInstitutesofHealth
TNP2017BFAWorkshop
Objectives
• Overviewofhistoryofacupuncture
• Reviewoftypesofacupuncture
• DiscusshistoryandsignificanceofAuricularAcupuncture/Auriculotherapy
• ReviewparticularsofAuricularAcupuncture/Auriculotherapy
• DemonstrateBattlefieldAcupunctureProtocol
• Casepresentations
Disclosures
• TheviewsexpressedinthispresentationarethoseoftheauthoranddonotreflecttheofficialpolicyoftheDepartmentoftheVeteransAffairs,DepartmentofDefense,orU.S.Government
• Thiscourseisforanintroductiontoauricularacupunctureonlyandisnotforcredentialingpurposes.Thiscoursedoesnotcredentialtheparticipanttoperformauricularacupuncture
WhichOneAmITalkingAbout?!
• Auriculotherapy
• AuricularTherapy
• AuricularAcupuncture
Auriculotherapy/AuricularAcupunctureEvolveswithChineseAcupuncture
• Meridianbasedmedicine- Seekstorestoreharmonyandbalance:Qi- lifeforceenergy- travelsalong12mainpathwaysormeridianswithinthebody
• Qiisprofoundlydisturbedbytraumaticstress
• HistoricallyevolvedinChinaover5000yearsago
• YellowEmperor’sInnerClassic- earliestmajormedicalsourcedatingbackto206BC- 220AD1
History(continued)
• China– isolatedfromrestofworldbecauseofinternalfeudingforpower.
• 1800’s- OutsidetradeandinfluxofChristianityandWesternmedicine
• 1822- QingEmperorordersteachingofacupuncturetostopatImperialMedicalcollege
• RestrictionsonacupuncturecontinuedresultinginthedeclineoftraditionalChinesemedicine.
• 1949- RiseofMaoZedong- poorruralhealthcarecreatedneedfor‘BarefootDoctors’1
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InterestinAcupunctureBeginsintheUnitedStates
• OnatriptoChinawithPresidentRichardNixon,NYTimesreporter,JamesReston,sufferedappendicitis
• 1971- FrontpageofNYTimes,JamesRestonreportedonhisemergencyappendectomyinChina- postoppainrelievedby3needles2
• 3monthslaterareportinJournalofAmericanMedicalAssociation3
• NationalInstitutesofHealthsponsoredphysicianstostudyChinesehealthcareandresearchacupuncture4 (NICAM)
DifferentTypesofAcupuncture
• TraditionalChineseAcupuncture(TCM)
• MedicalAcupuncture
• Japanese Acupuncture
• Korean Hand Acupuncture
• Scalp Acupuncture
• AuricularAcupunctureandAuriculotherapy
• VeterinaryAcupuncture
DescriptionofTypesofAcupuncture• JapaneseAcupuncture:usesthinner,fewerneedlessometimesonly
touchingneedletoskinsurfaceand/oronlyusingoneneedle
• KoreanHandAcupuncture:utilizesthehandasahomunculus/microcosmrepresentationoftheentirebody.Usesneedlesortapingofspecificpoints
• ChineseScalpAcupuncture(CSA):usesthescalpasthemicrocosm–especiallyeffectiveformotorandspinalimpairment
• VeterinaryAcupuncture:usedonanimalsofallkinds– requiresspecialtraining,veryeffective
• FiveElementAcupuncture:Meridianbased– emphasizingconnectednesstotheuniverseandtheeverchangingseasons
TraditionalChineseMedicine(TCM)
• TCMMostcommonformofacupunctureintheUS– usesthe12meridiansplusseveral‘curious’meridiansthattransversethebody
• All12meridiansatsomepointpassthroughtheear
• Herbsaswellasacupuncturecanbeused
• Diagnosisbasedon8principles:YIN YANG
InteriorExterior,DeficiencyExcess,ColdHeat
MedicalAcupuncture
• SimplifiedversionofTCMfrequentlyaddressesmoreacuteissues.
• 300-500hoursoftraining.
• Physician,NursePractitionersandPhysicianAssistantsusingthismodality.
• AddedtreatmentmodalityinWesternmedicine– gainingmomentuminmilitaryandVAfacilitiesforpaintreatment,PTSD/mooddisorders,headinjury
• NationalInstitutesofHealth– usedasawellnessinitiativeforemployeesaswellaspainmanagementinoccupationalinjury,stressmanagementforworkinhighlevelcontainmentlabsandafterdeploymenttoworkinemerginginfectiousdiseaseareas.
Auriculotherapy/AuricularAcupunctureTheory
• Utilizestheearasahomunculus/microcosmrepresentationofhumanbodywithspecificcorrespondingacupuncturepointsonear
• 12Meridianspassthroughears
• Embryologicaldevelopmentoftheearallowsaccesstobrainandsubsequentlythebodyorgans
• Stimulationofnerveendingssendssignalstothebrainandthentothebody
• Byobservingtheearonecanidentifyspecificissues/diseaseprocesses5
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HistoryofAuriculotherapy
WithpermissionfromTerryOleson,Ph.D
EmbryologicalAuricularDevelopmentandAreasofInfluence
WithpermissionfromTerryOleson,Ph.D
EarlyDocumentedUseofAuriculotherapy
• Egypt,GreeceandRome500BCto100AD- HippocratesandGalenusedearringsandotherformsofearstimulation
• Persiansin200ADafterthefallofRome,recordedcauterizationforsciaticapain
• 1500to1700theDutchEastIndiaCompany
• 1957Dr.PaulNogier(French)noticedscarringonpatientsears,whichwasusedforthetreatmentofsciatica5
EarlyDocumentedUse(continued)
• 1958theChineselearnedofDr.Nogier’schartsandverifiedtheaccuracyofthepoints5
• 1980– Dr.TerryOlesonfromUCLAverifiedthescientificaccuracyoftheauriculardiagnosis6
• 1990WHOstandardizedtheterminology 5
• 2001Col.RichardNiemtzow,MD,PhDdevelops‘BattlefieldAcupuncture”
Auriculotherapy/AuricularAcupuncture
WithpermissionfromTerryOleson,Ph.D
AnatomyofAnEar-AGuidetoFindingthePoints
Posterior Periphery PP Back of Scaphoid Fossa and Helix
Anatomical Regions of the Ear
Auricular Landmarks
WithpermissionfromTerryOleson,Ph.D
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AuricularZones– MoreSpecificPointLocations
WithpermissionfromTerryOleson,Ph.D
Auriculotherapy/AuricularAcupunctureuse
• Treatmentforsubstanceabuse(NADAprotocol)andmorerecentlyforPTSD,TBI,andbattlefielduse
• Widerangeofdisorderstoincludeheadache,chronicbackpain,asthma,allergicrhinitis,dentalpain,anxiety,insomnia
• Pointscanbeneedled,seeded,electricallystimulated
• Allowsquickandeasyaccessfortreatment
• Treatmentstakeaslittleas20minutes,providerelieffordaystoweeks
• Easytolearn5
EasyAuricularAcupunctureProtocols
• NationalAcupunctureDetoxificationAssociation(NADA)– Lung,Liver,Kidney,ShenMen,AutonomicPoint
• BattlefieldAcupuncture(BFA)– Cingulategyrus,Thalamus,Omega2,PointZero,ShenMen
• AuricularTraumaProtocol(ATP)– MasterCerebral,Amygdala,Hypothalamus,Hippocampus,Insula,Vagus,PointZero,
ShenMen12
Howbigaretheneedles?
DoesItWork?- Research-
• Efficacyinpainmanagement:Meta–analysisof13studiesonAuricularTherapy(Acupressure,AcupunctureandElectro-acupuncture)showedagreaterdecreaseinpainscorethanshamorcontrolgroup7
• Pilotstudyof87activedutymilitarypersonnelwithacutepain- theacupuncturegroupshoweda23%reductioninpainversesthestandardmedicalcaregroup8
• Postconcussiveheadachesinactivedutyservicemembers.Randomizedexploratorystudyevaluated:usualcare,TCMandAuricularAcupuncture.Acupunctureimprovedheadacherelatedqualityoflifemorethanusualcare9
Research(continued)
• Ratswerestressedinordertoinducedepression- dividedintoacupuncture,antidepressant,notreatment.Theacupuncturegroupandantidepressantgroupsshowedreducedglutamateinthehippocampus,preventeddamagetohippocampalneuronsandimprovedbehavior10
• ClinicalobservationintheTempleVAheadacheclinic- acupunctureuseddailytostoptheheadacheandgeneralpainreduction,improvemoodandhelpwithsleep.Nouseofnarcotics.
• ClinicalanecdotalobservationatNIH– acrossthespectrumofdiverseproblems– successwithpainreduction,musclerelaxation,lesseningofacutepresentationsandimprovementinsleepandstressreduction– nouseofnarcotics
• Furtherresearchisdefinitelyneeded,someofthedifficultyishavingacontrolgroup.
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AcupunctureSystemicReviews
• NIHsystemicreview2012– Acupunctureiseffectivefor
chronicpaintreatmentandcanbeconsideredareasonableoption
– Chronicpaintoincludebackandneckpain,osteoarthritis,chronicheadacheandshoulderpain13
• Cochranesystemicreview2016– Acupunctureshouldbe
consideredformigrainepatientsforprevention,particularlyifhavingadverseeffectsfrommedications
– Acupunctureeffectsizewasstaticallysignificantlylargerinrealacupunctureversesshamacupunctureforchronicheadaches
– Acupunctureshouldbeconsideredfortreatingepisodicorchronictensionheadaches14
"WithPermissionfromDr RichardC.Niemtzow"
BFAScience
AnteriorCingulateCortexandThalamicNuclei
Painstimulation Painstimulation w/acupuncture
BattlefieldAcupunctureprotocol
• Cingulategyrus• Thalamus• Omega2• Pointzero• ShenMen
BFAPointLocations- CTOPS
ShenMen
PointZero
Thalamus
CingulateGyrus
Omega2
KDWHealthManagementLLC
SignificanceofPoints/BFA
• Cingulategyrus-memoryandemotionwithpain
• Thalamus- Communicationofnervoussystemtocerebralcortex(GrandCentralstation),reducingshock,restoringtranquility
• Omega2 Psychosomaticd/o&paininlimbs
• Pointzero- Generalbodyhomeostasis/autonomicbraincontrollingvisceralorgans
• ShenMen- Parasympatheticswitch,alleviatesexcessivesensitivity,calming,painreduction,insomnia– supportsotherauricularreflexpoints
KDWHealthManagementLLC
Precautions
• Knowwhatyouaretreating
• Donotrelievepainifitisneededtolimitthepatientsactivity
• Donotuseduringpregnancy
• Needlecautiouslywithbleedingdisorders
• Donotuseelectriccurrentwithacardiacpacemaker
• NoETOH,drugsbeforetreatment
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Precautions(continued)
• Avoidtreatingthosethatareextremelyweak,anemic,tired,hungryorhaveeatenabigmeal- treatmentwillnotbeeffective
• Thosethatareweakafter,needtorestbeforeleaving
• Needleshock- vasovagalreaction(uncommon,butcanhappen)
• Treatwithantibioticsifinfectiondevelops(veryrare)
• Mostcommonsideeffectisredortenderear
Procedure
• Consent(goodfor1year)
• Washhandsorusehandsanitizer
• Wipeearswithalcoholswap
• Accesspainlevelpriortoplacementofneedle
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Needlepractice
KDWHealthManagementLLC
AnatomyDifferences
KDWHealthManagementLLC
BFACingulategyrus
CingulateGyrus
KDWHealthManagementLLC
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PointPracticeCingulateGyrus
KDWHealthManagementLLC
BFAThalamus
Thalamus
KDWHealthManagementLLC
PointPracticeThalamus
KDWHealthManagementLLC
BFAOmega2
Omega2
KDWHealthManagementLLC
PointPracticeOmega2
KDWHealthManagementLLC
BFAPointZero
PointZero
KDWHealthManagementLLC
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PointPracticePointZero
KDWHealthManagementLLC
BFAShenMen
ShenMen
KDWHealthManagementLLC
PointPracticeShenMen
KDWHealthManagementLLC
BFACTOPS
ShenMen
PointZero
Thalamus
CingulateGyrus
Omega2
KDWHealthManagementLLC
Reasonstostopthetreatment
• Patientasks
• Painisat0– 1/10
• LightheadednessSTOP
PatientDischargeInstructions
• Drinkplentyofwater
• Avoidstrenuousactivitiesforrestofday
• Avoidheavymeals
• Avoidalcoholandsexfor6hours
• Continuemedicationsasdirected
• Monitorresponsetothetreatment
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CostofAcupuncture
• Thecostactuallyvariesbythetypeofprovider(physicianvs"other"(NP))andthetypeofPatient.ThePriceQuote:asofJan17th 2013.Theratetablesarechanged1-2timeseachyearandratesdogoupanddown,usuallyonlyslightly.
• Pricequoteforacupuncturewithoutstimulation
• 97810- $35.74(Physician)$30.38(ExtraMedical/NP)-first15minutes
• 97811- $26.89(Physician)$22.86(ExtraMedical/NP)-additional15minutes
• Pricequoteforacupuncturewithstimulation
• 97813- $38.12(Physician)$32.40(ExtraMedical/NP)-first15minutes
• 97814- $30.63(Physician)$26.04(ExtraMedical/NP)-additional15minutes
RelativeValueUnit(RVU)foracupuncture
Acupuncturewithoutelectricstimulation• 97810- 0.6RVU’s- first15minutes
• 97811- 0.5RVU’s-additional15minutes
• Acupuncturewithelectricstimulation
• 97813– 0.65RVU’s- first15minutes
• 97814– 0.5RVU’s– additional15minutes
GreatNews!
• TheTexasBoardofNursinghasgrantedapprovalforuseofAuricularacupuncture,ifyouhavetakentheappropriatecourses.TheuseofauricularacupuncturedoesnotoverlapintotheterritoryoftheLicensedAcupuncturist,accordingtoTexasMedicalBoarddefinitionofacupuncturist.
• PossibilityforlearningthisvaluableskillTheAuriculotherapy CertificationInstitutewww.auriculotherapy.org*Thiscertificatedoesnotreplacetheneedforstatelicensureinaspecifichealthcarefield,butitdoesacknowledgespecialtyoftraininginthisparticularhealthcaremodality.
CasePresentations
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RefractoryMigraine
FailedtreatmentinER
HistoryandTreatment
• 38yr.oldfemalewitha2weekshistoryofmigraine
• FailedallabortivetreatmentsoftriptansandIVmedicationintheER
• PlacedBFAprotocolbilaterally,for20minutes
• Resolutionofthemigraine
Occipitalneuralgiaandneckpain
Chronicpain
History
• 40yearoldmalewithahistoryofmultipleconcussions,neckandlowbackpainrelatedtomultipledeployments:toincludehardlandingswithparachutejumps,headstrikesonvehiclesandmultipleblastsfromIdentifiedexplosivedevices(IED)
• Chronicposterioroccipitalpainwithjabandjoltforwardbehindtheeyes.Occurring2-3timesperweeklasting2hours,ratedas7/10.Headacheshavebeenoccurringsince2006(10years)
• Priortreatmentswithacupunctureandmassagetobackhelpful,nottolerantofTopamax,Robaxin- wouldprefertostayawayfrommedications
• Pastmedicalhistory- Migraines,PTSD,SleepApnea,Insomnia,Lowbackpain,Neckpain,Tinnitus,GERD
AuricularAcupuncturetreatment
• Placementofneedlesatthefollowingpoints:• Shenmen,Amygdala,MasterCerebral,Vagus,Hypothalamus,
Hippocampus,Thalamus,Cingulategyrus,pointzero,Cervical(Sensory&Motor),Lumbar(Motor)
• Painpriortotreatment:7/10neckandshoulders,mildoccipitalpain• Anxietypriortotreatment:6/10
• Needlesleftinfor20minutes
• Painaftertreatment:4/10neckandshoulders,occipitalpainresolved• Anxietyaftertreatment:3/10
Occipitalneuralgiaandanxiety
Pre-procedurepain
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History
• 38yr.oldfemalewithaHx ofoccipitalneuralgia/tensionheadachesoccurringsince1998- unsureoftriggerotherthanwasonactivedutyasamedicattimeofonset.Inadditionhadamedicationoverusecomponenttohercurrentheadaches(takingdailyExcedrin/Imitrexfor3weeks)
• failedmultiplemedicationstoincludePaxil,Celexa,nortriptyline,Topamax,Depakote,Motrin
• Medicalhistory- PTSD,Sexualassaultinadolescence/MST,Anxiety,Insomnia,Constipation,Allergicrhinitis,Asthma,GERD,Lowbackpain,Dizziness,Polyarthralgia
• SeeninclinicfortrialofBotox- attimeofappthada5/10headachelocatedintheleftoccipitalarearadiatingtobehindherlefteye.InadditionshewasextremelyanxiousabouttheadministrationofBotox.Ratedanxietyas10/10
Treatment
• Auricularacupunctureadministeredatthefollowingsites:Tranquilizer,Shenmen,Pointzero,Amygdala,Hypothalamus,Hippocampus,MasterCerebral,Insula,Lesseroccipital– needlesleftinfor20minutes
• Alpha-stimAID(micro-currentappliedbywayofeartabs)wasappliedtohelpwithanxiety
• Herheadacheresolvedafter10minutesandanxietywasreducedto3/10
• ShewasabletocompletetheadministrationofBotoxwithoutissue,herheadachedidnotreturnthatdayandheranxietyremainedlow
Dentalpain
Acutepain
HistoryandTreatment
• 51yr.oldmalewith3dayhistoryofrightsidedjawpainfollowingrootcanal.Ratespainas8/10,constantthrobbinganddistractinghimfromworking
• AcupunctureneedleplacedatDentalanalgesiapoint• Painresolvedbeforemyhandwasawayfromhisear- paindidnotreturn
• 75yr.oldmalewith2dayhistoryleftjawpainfollowingtoothextraction,“drysocket”.Ratedpainas9/10,unabletoeatorevenbrushhisteeth
• AcupunctureneedleplacedatDentalAnalgesiapointx2,Thalamus,ShenMen
• Painresolvedover5minutes- paindidnotreturn
DentalPain(continued)
• 35yr.oldfemalewith10daysofleftfacialpain.Foundtohaveinfectionintooth,nowneedingdentalsurgeryastheinfectionhadsurpassedtheabilitytodoarootcanal.Inadditionshewasdxwithsinusinfectionastoothrootwasintothesinuscavity.TakingT&C#3every4hours- reducedherpainto5/10
• PlacedauricularneedlesatDentalAnalgesia,JawandThalamus- painresolvedover3minutes.Needlesremovedandgoldstudsplaced.
• Patientleftpainfreeandhappy,afterbeingintheofficeatotalof10minutes.Pain0-2/10for3days,noneedtotakeT&C#3.Paincamebackwhengoldstudsfellout,neededtogobackonT&C#3untilsurgeryasshecouldnotgetbackintotheoffice.
OccupationalInjury– BackStrainHistory
• 44yr.oldmalehelpingtotransporta300lb.anesthetizedpigbacktopenwhenpigsuddenlyawokeandinthestrugglethatensuedtheemployeeinjuredhisback.
• Presentsinacutepain,unabletofindapositionofcomfort,unabletostandorsit,lyingonsidewithoutrelief.
• Healthy,alertmale:Nomeds,NKA,PMH:NC
• Pain:10/10P:96BP:156/84
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BackStrain- Treatment
• NPandPTunabletoexamemployeeincurrentstateofpain– restlessinfetalposition
• NeedledpointsBFAplusmusclerelaxation,sacralandlumbarspineinonlyoneear– encouragedtodeepbreathe– coldpacktoback
• Inlessthan5minutes,suddenlypulledhimselftothesideofthebed,stoodupstillbendingslightlyforwardandsaid(smiling)‘you’reawitch’hispainhadgoneto5/10withincreasedmobilityandabilitytowithstandfurtherevaluationP:76BP:132/74
• WasabletotreatwithNSAIDsandPhysicaltherapywithAuriculotherapyforaddedpainmanagement.Onlightdutyreturnedtofulldutyin2weeks.
OccupationalExposure– AllergyHistory
• 36yr.oldfemalepresentswithmildresp.distressaftersustainingamousebitewhilemovingthemousetoadifferentcage
• EmployeewasworkingwithHPAI(HighPathAvianInfluenza)mousehadnotbeeninfected
• PMHxofseasonalandcatdanderallergies.Meds:prnLoratadine– nonetakeninpast7days
• P=104R=28audiblewheezing,BP=146/82
Allergy- Treatment
• Alertfemalebegins15min.scrubofbitemarkonrightindexfinger
• Whilescrubbing,needlesquicklyplacedinBFAinbothearsandwithallergyandantihistaminepointsbilaterally
• R=20(nowheezingeitheraudibleoronauscultation)P=76BP=128/76after15min.scrubwithneedlesinplace
• Oralantihistaminegiven.Employeeabletoreturntoworkinanhour.Work-upformouseallergies
PostDeploymentInsomniaHistory
• 52yr.oldmaleintheU.S.PublicHealthServicerecentlyreturnedfromdeploymentinAfricaduringEbolaepidemicfor3months.Heisunabletosleepthroughthenightwaking5-6times
• PMHx:Hypertension,hyperlipidemia
• Meds:Losartan50mgqd,Rosuvastatin10mgqd
Insomnia- Treatment
• Firsttreatment:BFAinoneearandATP(auriculartraumaprotocol)inotherearwithInsomnia1,Insomnia2,inboth.Leftneedlesinfor45minutes.Hefellasleepandreportedhe‘feltasifIhaven’tsleptthiswellinmonths’
• Continuedtohavesleepdisruptionbutonly3-4timesanight.After2similartreatmentshewaswaking0-2timesanightandstatedfelt‘lessanxious’
WordsofWisdom
"Anyonewhoistrainedandlicensedtogiveinjectionsordosuturescouldlearntouseafewsimpleacupunctureprotocolsinamatterofweeks,andcouldrelieveanenormousamountofsuffering." 11
‘AcupunctureislikeChinesenoodles’:communitybasedacupunctureconcept
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KarenWilliams,MSNRNFNP-BCKDWHealthManagement@gmail.com
704-706-5519
KarenSova,MSN,RN,ANP-BC,COHN-Skmsova2@gmail.com
301-980-8062
73
References
1. HelmsJ.AcupunctureEnergeticsAclinicalApproachforPhysicians.NewYork:Thieme publishers,2007:3-17.
2. RestonJ.NowaboutmyoperationinPiking.TheNewYorkTimes,July26,1991:1,6.
3. DiamondEG.AcupunctureAnesthesia:westernmedicineandChinesetraditionalmedicine.JournaloftheAmericanMedicalAssociation,2181971:1558-1563.
4. ChenJYP.Acupuncture.InMedicineandPublicHealthinthePeople’sRepublicofChina.EditedbyJ.R.Quinn.U.S.Dept.ofHealth,EducationandWelfare:NationalInstitutesofHealth,JohnS.FogartyInternationalCenter.1972:65-90.
5. Oleson T.Auriculotherapy Manual:ChineseandWesternSystemsofEarAcupuncture,3rd edition.NewYork:ChurchillLivingston,2003:2-19.
References
6. Oleson T,Kroening R,Bresler D.Anexperimentalevaluationofauriculardiagnosis:thesomatotpic mappingofthemusculoskeletalpainatearacupuncturepoints.Pain1980;8:217-229
7. Yeh CH,etal.EfficacyofAuricularTherapyforPainManagement:ASystematicReviewandMeta- Analysis.Evidence-BasedComplimentaryandAlternativeMedicine2014;20141-14.
8. GoertzCM,NiemtzowR,BurnsSM,Fritts MJ,CrawfordCC,JonasWB.Auricularacupunctureinthetreatmentofacutepainsyndromes:Apilotstudy.MilMed2006Oct171(10):1010-4.
9. JonasWB,etal.ARandomizedExploratoryStudytoevaluateTwoAcupunctureMethodsforthetreatmentofHeadachesAssociatedwithtraumaticBrainInjury.MedicalAcupuncture2016;28:113-130.
References
10. FanL,etal.GlutamateofHippocampusInvolvedinRemissionofDepressionbyAcupunctureinRats.MedicalAcupuncture2016;28:71-78.
11. Rohleder L,EtAl. Acupunctureislikenoodles.Oregon:WorkingClassAcupuncture,2009:122.
12. RobertL.Koffman,&JosephM.Helms.(2013).AcupunctureandPTSD:‘Comefortheneedles,stayforthetherapy’. PsychiatricAnnals,43(5),236.doi:10.3928/00485713-20130503-09.
13. Vickers,A.J.,Cronin,A.M.,Maschino,A.C.,Lewith,G.,MacPherson,H.,Foster,N.E.,...AcupunctureTrialists'Collaboration.(2012).Acupunctureforchronicpain:Individualpatientdatameta-analysis. ArchivesofInternalMedicine,172(19),1444-1453.doi:10.1001/archinternmed.2012.3654.
14. Coeytaux,R.R.,&Befus,D.(2016).Roleofacupunctureinthetreatmentorpreventionofmigraine,tension-typeheadache,orchronicheadachedisorders. Headache:TheJournalofHeadandFacePain,56(7),1238-1240.doi:10.1111/head.12857.
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