Pre-Conference Workshop (2nd NUS-NUH International Nursing Conference & 18th Singapore-Malaysia Nursing Conference,

National University of Singapore, Singapore. (21-23 November 2013)

Is there a place for auriculotherapy () in the realm of nursing? (Part I)

Speaker: Dr. Lorna Suen Associate Professor, School of Nursing, The Hong Kong Polytechnic University

Definition

Auricular therapy (Auriculotherapy) is a therapeutic method by which specific points on the auricle are stimulated to treat various disorders of the body.

Auricular therapy can activate meridians & collaterals, regulate the Qi & blood, help to achieve the balance between Yin & Yang status of internal organs, and is suitable for treating many disorders of the body.

History and Development of Auricular Therapy

The ear is first mentioned in the earliest Chinese medical book, Yellow Emperors Classics of Internal Medicine (), published more than 2,000 years ago.

It states that the ear is related to all parts of the human body and internal organs, and that all meridians converge at the ear.

In 1957, Dr. Paul Nogier, a well-known French neurosurgeon, made a careful study of the ear and found that the ear is thought to simulate an inverted fetus within the womb.

Figure: The ear represents a simulation of an inverted fetus within the womb.

To have a common language for study and exchange of ideas, the Chinese Association of Acupuncture and Moxibustion, was entrusted by the WHO Western Pacific Regional Office, for the standardization of auriculo-acupoints in 1982.

In May 1993, the Chinese Standard Ear-Acupoints which consists of 91 acupoints (acupoints mainly represented by zones) was established and widely adopted in China (Guan et al., 1994) ().

However, some overseas countries, including Europe and USA, are still adopting the ear atlas originally discovered by Dr. Paul Nogier for diagnosis and treatment. Many successful examples using auricular therapy on smoking cessation and drug addiction were widely reported.

The Chinese Standard Ear-Acupoints Model (91 points)

Anatomical Nomenclature Ear lobe (/): head & face Helix (): diaghragm, excretory organs,

external genitals

Antihelix (): truck (superior crus - lower limbs; inferior crus buttocks & sciatic nerve)

Inferior concha (): thoracic cavity Superior concha (): abdominal cavity

Triangular fossa (): pelvic cavity, & the internal genitals

Scapha (): upper limbs Tragus (): throat, internal nose etc. Antitragus (): head, brain Intertragic notch (): endocrine Dorsal surface of auricle (): liver,

heart, spleen, lung, kidney

Homuncular Reflex Theory []

Based on the neuro-embryal theory, Dr. Paul Nogier came to view the auricle as a homunculus of the human body similar in shape to an inverted fetus, with the head located on the lower lobe, the feet at the upper rim of the ear, and the body in the middle.

Meridian Theory [] Traditional Chinese medicine (TCM) holds that the five viscera

(Wu Zang ) and six bowels (Liu Fu ), the nine body orifices (Jiu Qiao ), four extremities (Si Zhi ) and all bones of the body (Bai Hai ) are closely linked with the ears through the channels and collaterals (Jing Luo).

The ear is directly or indirectly related to the 12 main pairs of meridians that run over the body.

Common Ear Modalities

Palpation & Massage

Palpation is the process of detecting tender points for diagnosis or treatment by pressing on the ear point.

A healthy ear point should not be tender when pressed or palpated by a ear probe. Tenderness through pressure indicates a problem in the area being tested.

These same points can be treated by rubbing or applying pressure to the point using the probe employed as a massage device.

Ear massage is a relaxing, enjoyable, noninvasive, and clinically effective modality for the treatment of most health disorders.

Massage can encompass the entire auricle or it can focus on specific treatment points.

Ear massage direction for the anterior & poster aspects of ear.

Anterior aspect Posterior aspect

Abbate, 2004

Pressing therapy Semen Vaccariae (), Semen Impatients (), Liushen pills (

), or White Mustard Seed () are all suitable for use in auricular pressing. Semen Vaccariae () is a small round seed which is commonly used for

auricular taping. The diameter of each semen was ~ 0.13cm. The average retention time of the seeds is 3-5 days. Patients are instructed to press on the seeds 3-5 times a day for 1-2 minutes on

each point.

Magnethotherapy

The mechanisms for the interaction of magnetic fields with biological tissues resulting in functional changes may be due to some underlying principles of physics, such as Faradays law, Hall effect that a magnetic field will exerted some force on the moving ions of blood.

According to the above principles, auricular therapy using magnetic pearls might promote the circulation of Qi and blood in the meridians, regulate functions of the Zang Fu organs, thus obviously improving the physiological functions of the body.

Using magnetic pearls (pellets)

Using magnetic tube ()

~4200 gauss For ear or body acupoint stimulation

Another magnetic tube ()

3000 gauss For ear or body acupoint stimulation

Auricular Acupuncture Needling is one of the most common ear modality practiced under the use of

aseptic techniques. Stabilize the patients ear by supporting the back of the area to be needled.

Care must be taken not to penetrate through the entire ear with the needle. Acupuncture needles are typically retained for 15 to 20 minutes; while some

needles (such as press (embedded) needles, semi-permanent needle (France), intradermal needles etc) can be retained for several days.

1-inch acupuncture needle

Press needle Intradermal needles

Semi-permanent needle

Bloodletting (Bleeding) It is an effective ear modality when applied to certain ear points. The

therapeutic effects are to reduce excess heat and fire, stimulates qi and blood flow, and to move stagnant qi and blood.

Examples : hypertension, eye infections, fever. Select a regular 28 gauge, half-inch acupuncture needle, or sometimes use

three-edged needle (), puncture quickly on the selected acupoint of the ear. Absorb the droplets of blood elicited by placing a cotton ball over the point and pressing lightly.

Tapping by Plum-Blossom Needle ()

Plum blossom needling therapy of the auricle is sometimes used to induce bleeding for the various therapeutic usages of bleeding.

Care must be taken to protect the auricle from infection with this method to tap the ear, as infection could develop when the small holes are produced in the ear skin.

Points on the lobe are most commonly treated with this method.

Moxibustion

Moxa provides the powerful therapeutic effects of tonifying the qi and yang, removing cold, and increasing the flow of qi and blood in the channels.

Laser irradiation

The cold laser has been found useful for conditions treatable through the ear.

Since the laser is a form of light therapy, the laser does not pierce the skin, and the therapy is painless.

In addition, the laser can precisely target the point.

Electrotherapy When disease or disorder is present in the body, the electrical resistance in

the corresponding auricular points will decrease obviously; and areas where the electrical resistance is lower than the standard are claimed as positive, or highly conductive, electrical points ()(Feng et al., 1994).

The sensitive point were detected by means of an Electrical detector (Pointer

PlusTM) to measure auricular electrical resistance. Once the detector had identified a sensitive point, the indicator light flashed.

Other more sophisticated electric device can also be used, such as the Electro Medical Stim Flex 400A (US).

Magic Needle-Pain Reliever

Clinical Applications and Research on Auricular therapy

Examples:

Weight reduction Hypertension Cocaine addiction Smoking cessation Pain killer Insomnia

For details, please refer to reference list

Precautions If the objects, such as seeds or magnetic pearls, should be placed on

the ear continuously for treatment purpose, both ears should be treated alternately to avoid fatigue of acupoints.

The objects for stimulation should be replaced every 3-4 days to avoid the possibility of local irritation of auricular points under treatment.

Pressure on the retained seeds should not be too hard and rubbing should be avoided to prevent injury to the skin which may result in infection.

Magnets pearls of lower gauss should be chosen in order to avoid possible side-effects due to overstimulation, e.g. dizziness, sweating, nausea & vomiting.

If needles are used for stimulation, aseptic techniques should be strictly observed.

If electrical therapy is applied, the current output should be kept to a comfortable level in which the client can tolerate.

If the patient is allergic to the zinc oxide adhesive tape, use other auricular therapeutic methods.

Contraindications: ear infections, wearing pace maker (for magnetic therapy), etc.

Diagnostic Value of the Auricles

The use of auricular points in the diagnosis of diseases as an objective and painless method for early diagnosis is also of great practical and theoretical significance.

Due to the reflexive property of the ear, various reactions may appear on the auricle when there are disorders of the internal organs or other parts of the body.

Such reactions include variations in shape, color, size, and sensation; the appearance of papules, rashes, and discolorations; and increased tenderness or decreased electrical conductivity.

Close observation of these changes increases the doctors diagnosis and treatment (Abbate, 2004).

References & Bibliography (on Auriculotherapy)

Abbate, S. (2004). Chinese auricular acupuncture. Boca Raton: CRC Press. Alkaysi, G.K., Leindler, L., Bajusz, H., Szarvas, F. & Karacsonyi, S. (1991). The

treatment of pathological obesity by a new auricular acupuncture method: a five-year clinical experience. American Journal of Acupuncture, 19:4, 323-328.

Feng, C.X., X.H. Bai and Y. Du. (1994). Chinese auricular therapy []. Beijing: Scientific and Technical Documents Publishing House, 1994. (Chinese-English edition)

(Ho, S.Y.) (1994): Huang, L.C. (1999). Auricular diagnosis with color photos. Bellaire, Texas: Longevity

Press. Huang, L.C. (2001). Auricular treatment: Formulae and prescriptions. Florida:

Auricular Medicine International Research and Training Center. Kitade, T. & Hyodo, M. (1979). The effects of stimulation of ear acupuncture points

on the bodys pain threshold. American Journal of Chinese Medicine, 7:3, 241-252.

Margolin, A., Chang, P., Avants, S.K. & Kosten, T.R. (1993). Effects of sham and real auricular needling: implications for trials of acupuncture for cocaine addiction. American Journal of Chinese Medicine, 21:2, 103-111.

Oleson, T. (2003). Auriculotherapy manual: Chinese and western systems of ear acupuncture (3rd ed.). Philadelphia: Churchill Livingstone

Shan, Q.H. (1996). Auricular point pressing therapy. Jinan, China: Shandong Science and Technology Press.

Strittmatter, B. (2003). Ear acupuncture: A precise pocket altas based on the works of Nogier. Stuttgart: Thieme.

Relevant Research Studies (Examples on Auriculotherapy)

Ceccherelli, F., Tortora, P., Nassimbeni, C., Casale, R., Gagliardi, G. & Giron, G. (2006). The therapeutic efficacy of somatic acupuncture is not incresaed by auriculotherapy: A randomised, blind control study in cervical myofascial pain. Complementary Therapies in Medicine, Mar; 14(1): 47-52.

Reuben, C., Chen, T.J., Blum, S.H., Braverman, E., Waite, R., Miller, J. et al. (2005). Acupuncture and auriculotherapy: Valuable natural treatment modailities for addiction. Townsend Letter for Doctors and Patients, Dec; 269:81-84.

Suen, L.K.P., Wong, T.K.S. & Leung, A.W.N. (2001). Is there a place for auricular therapy in the realm of nursing? Complementary Therapies in Nursing and Midwifery, August, 7(3): 132-139.

Suen, L.K.P., Wong, T.K.S. & Leung, A.W.N. (2002). Auricular therapy using magnetic pearls on sleep : a standardized protocol for the elderly with diverse traditional Chinese diagnosis on insomnia. Clinical Acupuncture and Oriental Medicine, March, 3(1): 39-50.

Suen, L.K.P., Wong, T.K.S. & Leung, A.W.N. (2002). Effectiveness of auricular therapy using magnetic pearls on sleep promotion in the elderly. The American Journal of Chinese Medicine, 30(4): 429449.

Suen, L.K.P., Wong, T.K.S. & Leung, A.W.N. (2003). The long-term effects of auricular therapy using magnetic pearls on elderly with insomnia. Complementary Journal of Medicine, 11(2): 85-92.

Visetti, E. & Costa, P. (1995). Auriculotherapy for intra-operative hiccup in anesthetized patients. American Journal of Acupuncture, 23(2): 105-108.

Zhou, R.X., Zhang, Y.H., Wang, J.L., Chang, H. , Fang, J., Chen, E.Z., Xie, J.G. & Liu, M.R. (1991). Anti-hypertensive effect of auriculo-acupoint pressing therapy: clinical analysis of 274 cases. Journal of Traditional Chinese Medicine, 11:3, 189-192.

(Publications) Suen, L.K.P., Chair, S.Y., Thompson, D.R., Yu, C.M., Lin, Z.X., Lee, P.W. & Chu, T.S.K. Traditional Auriculotherapy for

Hypertension: A Pilot Randomized Trial. Accepted for publication on 18 Oct 2013, Journal of Cardiovascular Disease. (in press).

Yeh, C.H., Chien, L.C., Balaban, D., Sponberg, R., Primavera, J., Morone, N.E., Glick, R., Albers, K.M., Cohen, S.M., Ren, D.X., Huang, L.C. & Suen, L.K.P. (2013). A randomized clinical trial of auricular point acupressure for chronic low back pain: A feasibility study, Evidence-based Complementary and Alternative Medicine, vol. 2013, Article ID 196978, http://dx.doi.org/10.1155/2013/196978.

Suen, L.K.P., Lau, Y.K., Ma, H.C., Lai, K.W. & Holroyd, E. Predictive value of auricular diagnosis on coronary heart disease. (2012). Accepted for publication by the Evidence-based Complementary and Alternative Medicine, vol. 2012, Article ID 706249, http://dx.doi.org/doi:10.1155/2012/706249.

Li, M.K., Lee, D.T.F. & Suen, L.K.P. (2012). Auriculotherapy in relieving symptoms of constipation and improving quality of life for the elderly: a pilot project. Hong Kong Medical Journal, Supplement 6, December, 18(6), 30-33.

Li, M.K., Lee, D.T.F. & Suen, L.K.P. (2010). A review on the complementary effects of auriculotherapy in managing constipation. The Journal of Alternative and Complementary Medicine, 16(4): 435-447.

Suen, L.K.P., Chair, S.Y., Yu, C.M., Thompson, D.R., Lin, Z., Lee, A.P.W. & Chu, T.S.K. (2010). An integrated approach to treatment using auriculotherapy (AT) and Western medication for uncontrolled hypertension. European Heart Journal Supplements, 12 (Supplement A), February: S25.

35

(cont) (Publications)

Li, M.K., Lee, D.T.F. & Suen, L.K.P. (2010). A review on the complementary effects of auriculotherapy in managing constipation. The Journal of Alternative and Complementary Medicine, 16(4): 435-447.

Lee, M.S., Shin, B.C., Suen, L.K.P., Park, T.Y. & Ernst, E. (2008). Auricular acupuncture for insomnia: A systematic review.

International Journal of Clinical Practice, 62(11): 1744-1752. Suen, L.K.P. & Wong, E.M.C. (2008). Longitudinal changes in disability level of elderly with low back pain after auriculotherapy.

Complementary Therapies in Medicine, 16: 28-35. Suen, L.K.P. & Wong, E.M.C. (2007). Auriculotherapy with magnetic pellets produces longitudinal changes in sleep patterns of

elderly patients with insomnia. The Journal of Alternative and Complementary Medicine, April, 13(3): 306-307. Suen, L.K.P., Wong, T.K.S., Chung, J.W.Y. & Yip, V.Y.B. (2007). Auriculotherapy on low back pain in the elderly. Complementary

Therapies in Clinical Practice, 13: 63-69. Suen, L.K.P. (2007). Auriculotherapy as energy healing in Rogers conceptual model. Asian Journal of Nursing, 10(4): 237-242. Suen, L.K.P. (2007). A clinical trial to evaluate the effect of auriculotherapy on low back pain in the elderly. Chinese Acupuncture

& Moxibustion. 27(2), 112-114. (in Chinese) / 20074272112-114

(cont) (Publications)

Suen, L.K.P. (2005). To evaluate the effectiveness of a standardized protocol of auricular therapy using magnetic pearls on sleep promotion in the elderly. Chinese Acupuncture & Moxibustion, 25(4), 257-258. (in Chinese) / (2005)20054254257-258

Suen, L.K.P. (2005). A clinical trial to evaluate the effect of auricular therapy on sleep promotion in the elderly. Journal of Clinical Acupuncture and Moxibustion, January 21(1), 36-38. (in Chinese) /

200521136-38

Suen, L.K.P., Wong, T.K.S. & Leung, A.W.N. (2003). The long-term effects of auricular therapy using magnetic pearls on elderly with insomnia. Complementary Therapies in Medicine, 11(2): 85-92.

Suen, L.K.P., Wong, T.K.S. & Leung, A.W.N. (2002). Effectiveness of auricular therapy using magnetic pearls on sleep promotion in the elderly. The American Journal of Chinese Medicine, 30(4): 429449.

Suen, L.K.P., Wong, T.K.S. & Leung, A.W.N. (2002). Auricular therapy using magnetic pearls on sleep : a standardized protocol for the elderly with diverse traditional Chinese diagnosis on insomnia. Clinical Acupuncture and Oriental Medicine, March, 3(1): 39-50.

Suen, L.K.P., Wong, T.K.S. & Leung, A.W.N. (2001). Is there a place for auricular therapy in the realm of nursing? Complementary Therapies in Nursing and Midwifery, August, 7(3): 132-139.

37

Q & A

38

39

Demonstration & Practice

Pre-Conference Workshop (2nd NUS-NUH International Nursing Conference & 18th Singapore-Malaysia Nursing Conference,

National University of Singapore, Singapore. (21-23 November 2013)

Is there a place for auriculotherapy in the realm of nursing? (Part II)

Speaker: Dr. Lorna Suen Associate Professor, School of Nursing, The Hong Kong Polytechnic University

Shenmen

Kidney

Heart

Subcortex (internal

acupoints)

Liver

Occiput

Spleen

Selected acupoints for sleep improvement

Selection of Auricular Acupoints Ear shenmen - tranquilize the mind Heart - calm the mind Kidney - tonify the essence Liver - soothe the liver and regulate the flow of Qi Spleen - promote digestion and fluid drainage Occiput - tranquilize the mind, and effective in

treating headache and dizziness Subcortex - harmonizes excitement and inhibition

of the cortex

Shenmen [ ] On the triangular fossa superior to the origin of the superior and inferior crus of the helix.

Heart [] On the centre of the inferior concha.

Kidney [] On the superior concha inferior to the origin of the superior and inferior crus of the antihelix.

Liver [] On the posterio-superior portion of the superior concha.

Spleen [] On the posterio-superior portion of the inferior concha.

Occiput [] On the posterio-superior portion of the external side of the antitragus.

Subcortex [ ] On the medial side of the antitragus.

Procedures The auricle of the participant should be cleaned prior to

the administration of the therapy.

Both ears were treated alternately. Magnetic pellets will be replaced every 4-7 days days to

avoid the possibility of local irritation of auricular points under treatment.

The total treatment course is suggested to be 3-4 weeks. To enhance effect, pressing on the pellets could be done

2-3 times a day (including one time before sleep). Gentle pressure is to be applied to each pellet for one minute in each pressing.

6

Demonstration & Practice

Binder1.pdfPre-conference workshop_Lorna Suen_1_to NUS.pdfDefinitionHistory and Development of Auricular TherapySlide Number 4Slide Number 5Slide Number 6Slide Number 7Anatomical NomenclatureSlide Number 9Slide Number 10Homuncular Reflex Theory [] Meridian Theory [] Common Ear ModalitiesPalpation & MassageSlide Number 15Pressing therapyMagnethotherapySlide Number 18Slide Number 19Auricular AcupunctureBloodletting (Bleeding)Tapping by Plum-Blossom Needle ()MoxibustionLaser irradiationElectrotherapySlide Number 26Slide Number 27Clinical Applications and Research on Auricular therapyPrecautionsSlide Number 30Diagnostic Value of the AuriclesReferences & Bibliography(on Auriculotherapy)Slide Number 33Relevant Research Studies (Examples on Auriculotherapy) (Publications)(cont) (Publications)(cont) (Publications)Q & ADemonstration & Practice

Pre-conference workshop_Lorna Suen_2_to NUSPre-Conference Workshop (2nd NUS-NUH International Nursing Conference & 18th Singapore-Malaysia Nursing Conference, National University of Singapore, Singapore. (21-23 November 2013)Is there a place for auriculotherapy in the realm of nursing? (Part II)Speaker: Dr. Lorna SuenAssociate Professor, School of Nursing, The Hong Kong Polytechnic UniversitySlide Number 2Selection of Auricular AcupointsSlide Number 4Procedures Demonstration & Practice