Pain Medicine 2017; 18: 551564
doi: 10.1093/pm/pnw215
INTEGRATIVE MEDICINE SECTION
Review Article
Ear Acupuncture for Immediate Pain Relief
A Systematic Review and Meta-Analysis of
Randomized Controlled Trials
M. Murakami, DO,* L. Fox, MD,, and
Marcel P. Dijkers, PhD
When work was completed, *Department of
Rehabilitation Medicine, Icahn School of Medicine at
Mount Sinai NY, NY USA, Department of
Anesthesiology at University of California San Diego
San Diego, CA USA; Department of Emergency
Medicine, Icahn School of Medicine at Mount Sinai
NY, NY USA; Department of Rehabilitation Medicine,
Icahn School of Medicine at Mount Sinai NY, NY USA;
Department of Toxicology, New York University NY,
NY USA
Correspondence to: M. Murakami, DO, Comprehensive
Spine and Sports Center 3425 South Bascom Ave.
Suite 200 Campbell, CA 95008 USA; E-mail:
research@mikikomurakami.com.
Abstract
Objective. To systematically review the literature on
the effectiveness of ear acupuncture (EA) for imme-
diate pain relief.
Data sources. AMED, CINAHL, Cochrane Reviews,
Embase, PsycINFO, PubMed, Scopus Web of
Science, from inception through March 2015.
Study selection. English publications, randomized
controlled trials on human subjects involving EA as
a treatment for pain, with outcomes recorded within
48 hours.
Data extraction and design. Two authors indepen-
dently assessed trial eligibility, quality, results, and
side effects, and extracted data; a third author
checked final data. Effect size (d), mean difference
(MD), and 95% confidence interval (CI) were
C 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V 551
calculated. The Physiotherapy Evidence Database
(PEDro) scoring system was used to assess study
quality. Meta-analysis was performed for two pri-
mary outcomes measurespain intensity score
and analgesic requirements.
Results. Ten studies met inclusion criteria. Quality
per PEDro scores: four excellent, four good, two fair.
Based on their primary outcome measures, six stud-
ies showed EA being superior to its comparator,
three showed no difference to comparators (which in
all cases were analgesics), and one study showed
significant pain decrease at the first time point and
no significant decrease at the second. Meta-analysis
was completed for the three studies that evaluated
pain intensity as a primary outcome measure, and
EA was superior to comparator (MD 5 -0.96, 95% CI
5 -1.82 -0.11), but the MD was small. Meta-analysis
was completed for the six studies that evaluated an-
algesic requirements, and EA was superior (MD 5 -
1.08, 95% CI 5 -1.78 -0.38]), again with a small MD.
Six studies reported side effects; all were minor and
transient.
Conclusions. Ear acupuncture may be a promising
modality to be used for pain reduction within
48 hours, with a low side effect profile. Rigorous re-
search is needed to establish definitive evidence of
a clinically significant difference from controls or
from other pain treatments.
Key Words. Acupuncture; Alternative Therapies;
Analgesic; Pain Management; Pain Medicine; Acute
Pain; Alternative Medicine; Postoperative Pain
Introduction
In the United States alone, pain affects approximately
100 million adults, costing $560$635 billion per year,
which is more than the annual costs of heart disease
($309 billion), cancer ($243 billion), and diabetes ($188
billion) [1]. The burden of pain extends beyond the pain
Murakami et al.
itself, with such sequelae as lost productivity and multi-
ple side effects from analgesic medications and other
treatments. In the United States, 44 people per day die
from prescription painkillers [2], and 7,000 people per
day are treated in the emergency department (ED) for
misusing these medications [3]. There has been a sharp
increase in overdoses of prescription opioids paralleling
the rising sales of these medications. Prescription drug
registering and monitoring policies, as well as safe pre-
scribing practices, have recently been implemented [4],
but deaths related to narcotic overdoses, with statistics
worsened by heroin-related deaths [5], continue to be
an ongoing epidemic. There is a need for safer, more
cost-effective pain remedies to be researched and im-
plemented in clinical practice.
Many Americans are now seeking out complementary
and alternative medicine (CAM), which includes acu-
puncture, to supplement their allopathic care; the top
four reasons for seeking CAM treatments are various
pain conditions [6]. Based on the 2012 National Health
Interview Survey, there has been a significant linear in-
crease in use of this modality [7] (page 2). An increas-
ing number of hospitals are also now offering
acupuncture as a result of patient demand [6].
Ear acupuncture (EA) is less well known than full-body
acupuncture. Its history dates back to the 1950s, when
Paul Nogier, a French physician, created an EA map.
By the 1970s, various ear maps had appeared around
the world (e.g., Germany, United States, China) [8].
World Health Organization (WHO) panels met on several
occasions regarding the various proposed auricular
maps, and using three set criteria standardized 39
points in 1990. Since that time, the United States mili-
tary has introduced battlefield acupuncture (BFA) in an
effort to treat wounded soldiers in the field without se-
dating them. After the 9/11 attacks, Richard Niemtzow,
a military physician, created this five-point ear protocol
using ASP semipermanent needles, which is now being
taught to military medical providers who are not certified
or licensed acupuncturists. The military published a
study in 2012 to show the feasibility of bringing EA to
the frontline of aeromedical evacuation care; trained
nurses were able to perform BFA without the protocol
interfering with their other medical duties, and wounded
soldiers obtained pain relief, the majority stating they
would choose to receive the BFA treatment again [9].
Compared with full-body acupuncture, the literature on
EA and electro-auricular acupuncture is limited in num-
ber, with small sample sizes. The quality of studies also
varies, with prior reviews rating the quality of studies 1
to 4 on the Jadad scale [10] or poor to good using as the treatment for pain; 4) were randomized and con-
the US Preventive Services Task Force scale [11].
Usichenko et al. published a systematic review of ran-
domized controlled (RCTs) trials of EA for postoperative
pain and interpreted their results as promising but not
compelling [10] (page 1343). In a systematic review
and meta-analysis of EA for acute and chronic pains,
Asher et al. concluded that it may be effective to treat
552
various types of pains but that further well-designed
studies are warranted for determining a more accurate
effect size [11]. Ashers study included nonacupuncture
modalities applied to the ear, such as acupressure or a
TENS unit for the ear, as well as EA combined with
other treatments. It is very difficult to set up double-
blinded RCTs trials for EA, and also challenging to find
systematic literature reviews with EA being investigated
as the sole modality (i.e. without the additional or substi-
tuted use of body acupuncture, herbs, supplements,
acupressure, ear seeds, or a TENS unit).
The present authors wanted to evaluate the clinical utility
of EA in the outpatient, perioperative, and ED settings, to
see if EA could relieve pain prior to and/or after dis-
charge. The existing literature reviews on EA include stud-
ies of non-EA modalities (i.e., modalities that stimulate the
Chinese meridians through the ear without the use of
needles) and also include primary outcome measures
that are recorded many months after the treatment
[10,11]. The primary objective of the present study was to
conduct a systematic literature review and meta-analysis
of the efficacy of EA or electro-EA as a stand-alone mo-
dality, with primary pain outcomes recorded within
48 hours. The period of 48 hours was chosen, as an ex-
pedited discharge from the ED as well as expedited dis-
charge after an outpatient procedure reduces health care
costs and decreases the risk of nosocomial infection.
Methods
Literature Search Strategy
The electronic databases AMED, CINAHL, Embase (also
using its equivalent Emtree terms), Cochrane Database
of Systematic Reviews, PsycINFO, PubMed (also using
its equivalent MeSH terms), Scopus, and Web of
Science were searched by an experienced medical li-
brarian from inception through March 2015 for the
terms/concepts ear AND acupuncture (or electro-
auricular acupuncture) AND pain. Additional studies
were identified through scanning systematic literature re-
views [10,11] on EA. All citations were imported into
End Note 7.2.1, and duplicates were deleted.
Study Selection
Abstracts of articles were reviewed by two independent
authors, and studies were selected if they met the fol-
lowing inclusion criteria based on title and abstract: 1)
involved human subjects; 2) were published in the
English language; 3) investigated EA or electro-auricular
acupuncture, with or without conventional analgesics,
trolled; 5) had primary outcomes that measured effect
on pain within 48 hours.
In order to investigate EA as a sole modality for pain re-
duction, excluded were studies that combined EA with
body acupuncture, or EA with any other CAM modalities
(including herbs, supplements, exercise, manual

therapies). Authors also excluded studies that stimulated
the ear using other modalities, such as seeds or TENS
units. Studies that compared EA with electro-auricular
acupuncture were also not included, as the purpose of
this study was not to determine the efficacy of adding
an electrical unit to EA.
Full-text articles of remaining citations were retrieved
and assessed for inclusion by the same two authors us-
ing the same criteria. Disagreements were resolved by
discussion.
Data Extraction and Assessment of Study Quality
A structured data extraction form was created in Excel.
The same two authors extracted the data independently
and compared their results. A third author reviewed the
final data, comparing them to the full texts. The data for
the outcome designated as the primary by authors of
the respective studies was extracted, unless there was
both an analgesic use report and a pain level report, in
which case both were extracted. When insufficient data
for meta-analysis was provided in an article, its authors
were contacted for additional information or the authors
conducted further calculations. This involved the
following:
1. Usichenko (2007)ibuprofen and tramadol require-
ments were reported as median values, presumably
because of non-normal distributions. The author was
contacted to obtain mean and standard deviation
(SD) values.
2. Usichenko (2005 pilot)median ibuprofen and tra-
madol use were reported. The author was contacted
to obtain mean and SD values.
3. Goertz (2006)the mean pre/post-EA difference on
a numeric rating scale (NRS) with its SD was re-
ported for EA and comparator groups. The authors
calculated the mean post-EA NRS using the baseline
mean NRS and the mean differences after the treat-
ment; the original SD for the post-treatment NRS dif-
ference was used.
4. Xudong (1993)s study was not included in the meta-
analysis because efforts to contact the author were
not successful.
The methodological quality of the studies was assessed
using the Physiotherapy Evidence Database (PEDro)
Scoring System, which involves 11 items (coded 1 if
present, 0 if absent); item 1 (inclusion criteria) is not
scored [12]. If the paper did not include enough infor-
mation for one of the PEDro items to be assessed, the
authors rated it as a 0. The following descriptors were
used for the methodological quality of a study: total
score 9 or 10 excellent; 68 good; 4 or 5 fair;
and less than 4 poor.
Ear Acupuncture for Pain: Systematic Review
Data Synthesis and Analysis
Some of the primary studies determined the effect of EA
through pain severity ratings, some by quantifying the
use of supplemental analgesics, and a few used both
methods. Effect sizes were calculated for all studies for
which a mean and SD were available, separately for: 1)
Analgesia requirements; 2) Pain intensity. For those
studies with multiple data points (i.e., times of measur-
ing pain severity and/or quantifying analgesic use over
the first 48 hours after acupuncture administration), the
data point with the smallest effect size was used for
meta-analysis. REVMan 5.3 software was used to cal-
culate mean differences (MDs), to compute the hetero-
geneity of study effects, and to test for the pooled
effect. Since statistical heterogeneity was evident for
both types of primary outcome measures, a random-
effects model was used to pool the data from the pri-
mary studies.
Results
The search (Figure 1) resulted in 2,757 duplicated cita-
tions (including four obtained by reading systematic liter-
ature reviews [13]). Ten full text articles met the
inclusion criteria, and nine [9] studies were included in
the meta-analysis.
General Characteristics of Studies and Patients
The 10 studies (Table 1) were published between 1986
and 2012 and performed in the outpatient, periopera-
tive, and ED settings. Five of the studies employed
sham acupuncture as a comparator, four used analge-
sics as the comparator, and one used distraction. Aside
from two studies, all were done on both males and fe-
males age 18 years or older. In terms of the PEDro
scale (Table 2), of the 10 studies, four were excellent,
four were good, and two were fair in quality. Sample
sizes ranged from 20160. None of the acupuncturists
were blinded; six studies attempted to blind subjects.
Six studies blinded the assessors who were asking pa-
tient pain levels and/or providing analgesic medications.
Study Findings
The following summarizes the findings of the studies;
complete detail on outcomes is found in Table 3.
1. Usichenko (2006) compared EA (N 30 patients)
with sham (N 27) for intra-operative pain from hip
arthroplasty and showed that less fentanyl was re-
quired in the acupuncture group [14].
2. Usichenko (2007) compared EA (N 61) with sham
(N 59), for postoperative pain associated with vari-
ous knee surgeries and found that less ibuprofen
was required in the acupuncture group [15].
553
Murakami et al.

Titles and abstracts idened in Addional records idened from

bibliographic database searches systemac reviews
(n = 2753) (n = 4 )

Abstracts aer duplicates removed

(n = 981)

Abstracts screened Abstracts excluded

(n = 981) (n = 871)

Full-text arcles screened Full-text arcles excluded

(n = 110) (n = 100)

RCTs included in systemac review

(n = 10)

RCTs included in meta-analysis

(n = 9)

RCT: Randomized Controlled Trial

Figure 1 Flow chart of screened, excluded, and analyzed studies. RCT randomized controlled trial.

3. Wigram (1986) contrasted postoperative EA (N 19)
with conventional treatment using an anesthetic
(N 15) for various abdominal surgeries and con-
cluded that the EA group required less papavere-
tum, but not significantly so [16]. Pain outcomes
were also recorded in this study, which revealed
higher maximum visual analog scale (VAS) pain in-
tensity scores (P 0.01) and higher average VAS
scores (P 0.05) for the EA group.
7. Usichenko (2005) compared EA (N 29) with sham
(N 25), for postoperative hip arthroplasty pain and
calculated that less piritamide was required in the
EA group [20].
8. Wang (2012) compared EA (N 120) with conventional
treatment (N 40) for pain associated with in vitro
fertilization (IVF) egg retrieval and noted that pain was
lower in the EA group, but not significantly so [21].

4. Usichenko (2005 Pilot) compared true EA (N 10)
to sham EA (N 8) for postoperative knee arthros-
copy pain and showed that less ibuprofen was re-
quired in the acupuncture group [17].
5. Allais (2011) judged EA (N 43) against sham
(N 46), for acute migraine and concluded that
pain was significantly lower in the EA group [18].
6. Xudong (1993) contrasted EA (N 30) with conven-
tional treatment using an anesthetic (N 18) for
pain associated with acute biliary colic and noted
that pain was higher in the EA group, but not signif-
icantly so [19].
9. Goertz (2006) compared EA (N 50) with distraction
(N 50) for various acute pains presented in the ED
and showed that the mean pre- to post-EA NRS
change was significantly higher in the EA group
prior to discharge from the ED; however, 24-hour
follow-up results showed no significant difference
[22].
10. Taguchi (2002) compared intra-operative EA plus
desflurane with desflurane alone in a two-phase
crossover study (N 10) in the intra-operative set-
ting for physician-provoked leg pain under anesthe-
sia and calculated that less desflurane was required
in the EA phase [23].

554
 Table 1 Indication, setting, intervention and comparator for all studies included

Intervention group Comparator group

First author Age range Age range
(year (or mean 6 (or mean 6 Sex
published) Indication Setting Intervention SD), y Sex M#/F# Comparator SD), y M#/F#

Usichenko Hip Intra-operative 0.22 mm gauge, 1.5 mm
(2006) arthroplasty depth carbo needles.
Ipsilateral shenmen, hip,
lung, and thalamus placed
the evening before sur-
gery, and kept for
24 hours after surgery.
Points were stimulated
during surgery by anes-
thesiologist, who had no
acupuncture experience.
Usichenko Knee Postoperative Disposable steel acupunc-
(2007) arthroscopy ture needles: 0.22 mm di-
ameter, 1.5 mm length.
Ipsilateral knee joint point,
shen men, lung point in
the evening before sur-
gery. Patients encouraged
to stimulate points postop-
eratively when they expe-
rienced pain. Needles
removed the morning af-
ter surgery.
Wigram Various abdom- Postoperative Ear acupuncture papaver-
(1986) inal etum every 30 minutes, as
surgeries needed. Two 1/2 inch nee-
dles inserted obliquely
(unclear location) for
48 hours with pulsed e-
stim at 10Hz.
68 6 9 14/16 0.22 mm gauge, 1.5 mm 67 6 9 14/13
depth carbo needle.
Four points on ipsilat-
eral helix placed the
evening before surgery,
and kept for 24 hours
after surgery. Points
were stimulated during
surgery by anesthesiol-
ogist, who had no acu-
puncture experience.
42 6 15 33/28 Disposable steel acu- 44 6 13 38/31
puncture needles:
0.22 mm diameter,
1.5 mm length. Three
ipsilateral points on he-
lix prior to the evening
before surgery. Patients
encouraged to stimu-
late points postopera-
tively when they
experienced pain.
Needles removed the
morning after surgery.
Mean age 5/14 Papaveretum every Mean age 50.8 4/11
53.7 (no 30 minutes, as needed. (no SD given)
SD given)
(continued)

555
Ear Acupuncture for Pain: Systematic Review
 Table 1 Continued

556
Intervention group Comparator group
First author Age range Age range
(year (or mean 6 (or mean 6 Sex
published) Indication Setting Intervention SD), y Sex M#/F# Comparator SD), y M#/F#
Murakami et al.

Usichenko Knee Postoperative 0.22 mm diameter, 1.5 mm
(2005 arthroscopy long steel needles in one
Pilot) ear, on shenmen, lung,
knee, placed preopera-
tively and kept till morning
after surgery. Points were
stimulated during surgery
by anesthesiologist, who
had no acupuncture expe-
rience. Patients encour-
aged to stimulate points
postoperatively when they
experienced pain.
Allais (2011) Acute migraine Outpatient ASP 0.7 mm gauge, 2 mm
depth needle. Ipsilateral
antitragus region for
24 hours.
Xudong Acute biliary Outpatient 0.2 depth, unclear gauge.
(1993) colic Erzhong point. Manual
stimulation every
20 minutes.
Usichenko Hip arthroplasy Postoperative 0.22 mm gauge, 1.5 mm
(2005) length carbo needles.
Ipsilateral hip, shenmen,
lung and thalamus, placed
pre-operatively and kept
till 36 hours after surgery.
Patients encouraged to
stimulate points postoper-
atively when they experi-
enced pain.
33 6 13 4/6 0.22 mm diameter, 45 6 15 5/3
1.5 mm long steel nee-
dle in three helix points,
placed pre-operatively
and kept till morning af-
ter surgery. Points were
stimulated during sur-
gery by anesthesiolo-
gist, who had no
acupuncture experi-
ence. Patients encour-
aged to stimulate
points postoperatively
when they experienced
pain.
1560 Mean 0/43 ASP 0.7mm gauge, 2mm 16-58 Mean age 0/46
age depth needle. Bilateral 33.2 (no SD
35.9 (no helix region for given)
SD given) 24 hours.
2864 Mean 9/21 IM atropine sulfate 0.5 mg 3458 Mean age 6/12
age and IM phenergan 49.8 (no SD
47.0 (no 25 mg. given)
SD given)
68 6 10 12/17 0.22 mm gauge, 1.5 mm 66 6 11 12/13
length carbo needles.
Ipsilateral nonacupunc-
ture points of the helix,
placed pre-operatively
and kept till 36 hours
after surgery. Patients
encouraged to stimu-
late points postopera-
tively when they
experienced pain.
(continued)
 Table 1 Continued
Intervention group Comparator group
First author Age range Age range
(year (or mean 6 (or mean 6 Sex
published) Indication Setting Intervention SD), y Sex M#/F# Comparator SD), y M#/F#

Wang IVF egg Outpatient 25 mm length, unclear NS 0/120 Pethidine Hydrochloride NS 0/40
(2012) retrieval gauge needles. Bilateral (Dolantin) 50 mg
Genitalia (TF2) and
Shenmen (TF4) with elec-
tro stimulation for duration
for surgery.
Goertz Various acute Outpatient ASP semipermanent nee- 30 6 10 29/21 Encouraged to ambulate 33 6 7 18/32
(2006) pains in ED dles at two points: cingu- in ED room to be dis-
late, thalamic, till they fell tracted from pain.
out.
Taguchi Induced nox- Intra-operative 0.2 mm gauge, 12 mm 26 6 6 9/1 Desflurane only. Same as intervention
(2002) ious leg pain depth serin needle. Right (crossover RCT)
with electric ear shenmen, thalamus,
stimuli tranquilizer, master cere-
bral points during OR
time. With Desflurane.

ED emergency department; OR operating room; RCT randomized controlled trial.

557
Ear Acupuncture for Pain: Systematic Review
Murakami et al.

Score Descriptor
Heterogeneity and Test for Overall Effect

Excellent
Excellent

Excellent

Excellent
Good
Good
Good

Good
PEDro score

As statistical heterogeneity was evident for the primary

Fair

Fair
outcomes (designated as such by authors of the re-
spective studies) in both types, a random-effects model
was used to pool the data from the studies. The overall

9
9
5
8
6
6
8
6
5
9
effect of EA was significant in the Analgesia
variability for 1

Requirement group of studies (mean difference [MD]

key outcome
measures of
measures &

-1.08, 95% confidence interval [CI] -1.78 -0.38,

P 0.003). The Pain Intensity studies had a signifi-
cantly greater pain reduction in the EA group (MD -
Point

0.96, 95% CI -1.82 -0.11, mean P 0.03) (Figure 2).

11

1
1
1
1
1
1
1
1
1
1
If Wigrams study, which utilized medication requirement
comparison

as a primary outcome and pain intensity as a secondary

Statistical

specified allocation concealed of groups of subjects therapists assessors of subjects treat analysis outcome

outcome, were included the Pain Intensity group, the

for 1

EA effect would be insignificant (MD -0.50, 95% CI

10

1
1
1
1
1
1
1
1
1
1 -1.570.58, P 0.37).
Intention-to-

Adverse Events
9

1
1
1
1
0
1
0
1
0
1

Adverse events for the EA groups were recorded in six

of the studies, consisting of local pain, bleeding, head-
Blinding of Blinding of for >85%
Outcome

ache, and intraoperative bradycardia. Adverse events in

the comparator groups consisted of intra-operative bra-
8

1
1
1
1
1
1
1
1
1
1

dycardia, local pain, nausea, dizziness, and bleeding

(Table 3). Of the six studies with side effects reported,
three were rated excellent, two good, and one fair using
the PEDro scoring system. Details are as follows:
7

1
1
0
1
1
0
1
0
0
1

Usichenko (2006)in both the ear acupuncture and

the comparator (sham acupuncture) groups, intraoper-
ative bradycardia during hip arthroplasty was noted.
6

0
0
0
0
0
0
0
0
0
0

Usichenko (2007)no adverse events in the ear acu-

puncture group. In the comparator group (sham acu-
Eligibility Random Allocation similarities Blinding

puncture), one patient reported local pain at site of

insertion. One patient noted nausea/dizziness, with
symptoms resolving within 10 minutes after withdrawal
5

1
1
0
1
1
0
1
0
0
1

of the needles. Both of these patients thought they

Baseline

had received true EA and stated they would repeat it

for future complementary perioperative analgesia.
Wigram (1986)in the electro-ear acupuncture group,
4

1
1
0
0
0
1
1
1
1
1

two patients requested that the needles be removed

PEDro item scores and total score

due to pain. A questionnaire was administered five to

seven days postoperatively, where most of the pa-
tients recalled mild discomfort and no other side ef-
3

1
1
0
1
0
0
1
0
0
1

fects were noted.

Usichenko (2005 Pilot)two patients from both the
true EA and the sham EA groups required atropine
2

1
1
1
1
1
1
1
1
1
1

due to bradycardia, but no patient-reported side ef-

fects from EA or pharmacological analgesia.
Allais (2011)two people from both the EA and sham
EA groups had local ear pain.
1

1
1
1
1
0
0
1
0
1
1

Usichenko (2005): EA was performed the night prior

Usichenko (2005 Pilot)

to hip arthroplasty. The EA group reported local pain

Usichenko (2006)
Usichenko (2007)

Usichenko (2005)

(N 1), minor ear bleeding (N 1), and headache the

(year published)

Wigram (1986)

Xudong (1993)

Taguchi (2002)

morning prior to the surgery, which resolved postop-

Goertz (2006)
Wang (2012)
Allais (2011)
First author

eratively (N 1). The sham acupuncture control group

Table 2

reported local pain (N 2) and minor ear bleeding

(N 1). Self-reported side effects were noted up to
three days postoperatively.

558
 Table 3 Statistical results and original authors interpretation
Ear acupuncture Control Results

First Adverse events Adverse events

author Outcome measure(s) N Mean SD Other (# patients) N Mean SD Other (# patients) Significance Effect size

Usichenko Fentanyl requirement adjusted 30 3.9 1.4 Intraoperative 27 4.93 1.2 Intraoperative P 0.005 (-)0.76
(2006) to weight to keep cardio- bradycardia bradycardia (3)
vascular parameters within (6)
20% of baseline,
mcg/kg
Usichenko Mean ibuprofren required to 61 372 421 No adverse 59 557 409 Local pain (1) NS (-)0.4456
(2007) keep VAS < 40 mm, mg events related nausea/
Median ibuprofren required to 200 to acupuncture 600 dizziness (1) P 0.012
keep VAS < 40 mm, mg (IQR (IQR
0600) 200800)
Mean additional 0.16 0.505 0.24 0.619
tramadol required to keep
VAS < 40 mm, mg
Patients needing 1,400 1,000 P 0.57
tramadol, %
Pirtramide dose in recovery 7.6 3.7 7.7 3.5 P 0.91 (-)0.02
room, mg
Wigram Papaveretum required, mg/kg 19 1.3 0.4 Local pain (2) 15 1.4 0.6 NS P 0.55 (-)0.20
(1986) VAS maximum pain 5 2.1 3.4 1.4 P 0.01
VAS pain average 3 1.6 2 1.2 P 0.05
Usichenko Mean ibuprofren required to 10 500 356 Bradycardia (2) 8 825 198 Bradycardia (2) (-)1.029
(2005 keep VAS < 40 mm, mg
pilot) Median ibuprofren required to 500 800 P 0.043
keep VAS < 40 mm, mg
Mean additional tramadol, mg 0 0 0.25 0.463
Patients needing tramadol, % 0 25 Not significant
(no P values
provided)
Median Piritramide, mg 3.75 3.5 Not significant
(IQR (IQR (no P values
07) 05) provided)
Allais VAS after 10 min 43 1.9 1.51 Pain 46 4.3 1.49 Pain P < 0.001 (-)1.60
(2011) VAS after 30 min 1.9 1.97 5.2 1.63 (-)1.96
VAS after 60 min 2 2.16 4.2 2.17 (-)1.01
VAS after 120 min 2.1 2.43 3.7 1.9 (-)0.73
Patients with >50% VAS re- 65 13 P 0.00001
duction at 2 h, %

(continued)

559
Ear Acupuncture for Pain: Systematic Review
560
Murakami et al.

Table 3 Continued
Ear acupuncture Control Results

First Adverse events Adverse events

author Outcome measure(s) N Mean SD Other (# patients) N Mean SD Other (# patients) Significance Effect size

Patients pain free at 2 h, % 23 4 P 0.009

Xudong Pain relieved or decreased, % 30 93 NS 18 94 NS P > 0.05 Unable to
(1993) calculate
Usichenko Piritamide requirement 36 h 29 37 18 Local pain, 25 54 21 Local pain, P 0.004 (-)0.874
(2005) postoperatively, mg bleeding, bleeding
VAS pain intensity 36 h 44 17 headache 44 22 Not significant 0
postoperatively
Wang VAS 120 2.86 1.84 NS 40 3.12 2.06 NS P > 0.05 (-)0.14
(2012) Total effective analgesia rate, 93 92 Not significant
%
Goertz Difference in NRS pre- and 50 2.33 1.999 NS 50 0.15 0.591 NS P < 0.0005
(2006) immediately post-ED visit
Mean NRS immediately after 4.65 1.999 7.63 0.591 (-)2.02
intervention
Difference in NRS pre- and 41 3.415 2.32 NS 43 3.047 2.68 NS P 0.503
24 h post-ED visit
Mean NRS 24hrs after ED 3.565 2.32 4.733 2.68 (-)0.47
discharge
Taguchi Desflurane required, vol% 10 4.4 0.8 NS 10 4.9 0.7 NS P 0.003 (-)0.67
(2002)

Calculated by reviewer based on information in the text.

 Data point with smallest effect size utilized for meta-analysis.
EA ear acupuncture; ED emergency department; IQR interquartile range; NRS numeric rating scale; NS not stated; VAS visual analog scale.

Figure 2 Meta-analysis of Pain Intensity Outcomes (Panel 1) and of Analgesia Requirement Outcomes (Panel 2). CI
confidence interval.
The four studies in which no adverse events were noted
did not have a system in place to record or report them,
which was listed under Methods.
Discussion
Ear Acupuncture Effectiveness and Study Quality
Of the 10 studies included in this systematic review, six
showed that EA was superior to the comparator, of
which five evaluated medication use as a primary out-
come measure [14,15,17,18,20,23] and one evaluated
pain level [18]. Three studies showed no significant dif-
ference between EA and comparators, of which two
evaluated medication use [16,19] and one evaluated
pain intensity [21]. One study that evaluated change in
pain intensity had different results at two time pointsa
significantly larger decrease in pain in the EA group
while in the ED and no significant difference at 24-hour
follow-up [22].
There are a few points that weaken our findings. One
would expect an increase in medication use to be
paired with a higher level of pain prior to the pain medi-
cation administration and a decrease in pain score after
medication administration. Wigrams study recorded an-
algesia requirement as a primary outcome and recorded
both maximum and mean pain scores. In the analysis of
analgesic requirements, the study did show that EA was
better than the comparator in the analysis of analgesic
requirements, but not significantly so. In the analysis of
pain scores, the EA group had more pain (more maxi-
mum pain, P 0.001; more mean pain, P 0.05). It is
not clear whether or not the pain intensity scores, which
were requested every eight hours, were recorded before
Ear Acupuncture for Pain: Systematic Review
or after analgesics were given, which could explain the
fact that less medication was used but higher pain lev-
els were recorded in the EA group. It is also not clear if
the electro-acupuncture itself was contributing to pain
scores. In addition, for our meta-analysis of medication
use, four of the five studies were completed by the
same author group (Usichenko), which somewhat weak-
ens our findings due of the possibility of investigator
bias.
There are also some points that strengthen our findings.
In the meta-analysis of primary outcome measures, the
overall effect of EA was statistically significant in the
Analgesia Requirement outcome group (P 0.003), as
well as in the Pain Intensity outcome group (P 0.03).
In this latter group, the pooled NRS difference was
about one point. Although a two-point difference is gen-
erally accepted as clinically significant difference be-
tween a pain treatment and its comparator, any
increase in difference would indicate that EA is at least
as effective as controls, which themselves have been
known to cause pain reduction [24,25]. Allais (2011) and
Goertz (2006) reported outcomes for multiple time
points. The point with the lowest effect size was utilized
for the meta-analysis. If the other data points had been
utilized, EA would have been even more favored in the
pain intensity meta-analysis.
The quality of the studies, assessed using the PEDro
score, was generally good or excellent (Table 2).
However, many had a small sample size, and none of
the studies, except for one, could claim blinded acu-
puncturists. To be clear, even for Usichenkos 2006
study, which is presented as a double-blind study, the
present authors conservatively did not rate PEDro item
561
Murakami et al.
6 (blinding of all therapists who administered the ther-
apy) as a 1 (meaning yes), as the study used experi-
enced acupuncturists, who would likely be able to
identify a helix EA treatment as sham. If the GRADE
methodology [26] were applied to our findings, the two
primary outcomes used would likely be designated criti-
cal (pain intensity) and important (analgesic medication
usage). The information on side effects is too limited to
be incorporated in a formal analysis, but it would seem
that they are neither serious nor common.
The evidence for these two outcomes is based on a
body of RCTs, the quality of which, because of lack of
blinding, inverse relationship of the two outcomes, lim-
ited consistency of effect sizes, and predominance of a
single investigator, should be designated low to moder-
ate. (Except for the first point, these aspects of the
quality of evidence as a whole are, by definition, not
captured in the PEDro ratings.) Phrasing our conclusion
in GRADE terminology: The true effect of EA is likely to
be close to the estimate for both outcomes, but might
deviate.
Adverse Events
The side effects of our current treatments for pain (e.g.,
acetaminophen, nonsteroidal anti-inflammatories
[NSAIDS], steroids, opioids, and anesthetics) include
liver failure, GI bleed, renal failure, cardiotoxicity, seda-
tion, addiction, and respiratory depression. The side ef-
fects of EA seem mild in comparison. Six out of 10
RCTs recorded adverse events, consisting of local pain
at the site of the acupuncture needle, dizziness, and
nausea. The other four studies did not mention adverse
events. Usichenkos 2005 pilot and 2006 study reported
transitory circulatory complications. It should be noted
that these studies authors were hesitant to explain bra-
dycardia as a possible result of ear needling, at least in
the patients from the comparator group, as this group
only got needled in the helix of the ear, which is not in-
nervated by the vagus nerve [17]. The limited data avail-
able in our review do not suggest that EA results in
more serious or more frequent adverse events than the
various comparators. The adverse effects noted in the
six RCTs have been well documented previously. A
2013 systematic literature review noted adverse events
for EA, which include short-term local pain, skin irrita-
tion, minor bleeding, and dizziness [27]. There are also
case reports that include the following adverse events:
slight fever, dry mouth, upper limb numbness [28], peri-
chondritis [2935], and basal cell carcinoma [36]. To
note, although EA manuals warn about abortion as a
possible side effect, the current authors found no cases
of abortion documented in the English-language litera-
ture. To the contrary, the NADA (nada, Spanish for
nothing) protocol, an EA protocol for drug addiction,
has been studied in an RCT to show that it can actually
be safely used on pregnant women with chemical de-
pendence [37].
562
Despite only 60% of our studies reporting side effects,
given the minimal side effects reported in these studies,
and taking into consideration the EA side effect literature
review, we conclude that the side effect profile of EA is
at least as safe as, if not more safe than, allopathic
medications and procedures for pain.
Comparators Used in Ear Acupuncture
The comparators used in acupuncture studies have
been long debated. Five out of 10 of our studies used
sham acupuncture as a comparator. Cutaneous nee-
dling anywhere in the body, irrespective of acupuncture
points, has been found to result in diffuse noxious inhib-
itory control [24]. Traditional Chinese medicine practi-
tioners will state that stimulating acupuncture points
using ear seeds, TENS, or acupressure will have a posi-
tive effect on pain as the Chinese meridians are being
activated.
Both EA and full-body acupuncture are often compared
with no acupuncture and sham acupuncture. There
have been numerous studies on the effectiveness of
placebo analgesia. The expectation of being treated for
pain [25], physician characteristics, the color of a pill,
even the packaging of a medication [38] can all affect
pain. A recent meta-analyses of 25 neuroimaging stud-
ies on placebo analgesia and expectancy-based pain
modulation revealed that placebo effects and expecta-
tions can stimulate regions of the brain that control pain
pathways and also affect the regions of the brain that
affect mood [25].
Given the effectiveness of placebo analgesia, as well as
the positive physiological effects of the needling of any
body points for pain reduction [24,25], the present au-
thors conclude that while EA cannot be stated to be
clinically superior to comparators, if EA is at least as ef-
fective as the comparators used in the studies, which
include sham acupuncture, pain medications, and dis-
traction, EA may be considered for pain reduction.
Cost of Supplies and Ease of Administration
EA can be a low-cost modality compared with other
pain interventions and medications. It is also easy to
perform. For example, a feasibility study in the military
showed that nonphysicians and nonacupuncturists can
effortlessly learn the battlefield acupuncture protocol
[39], a five-point EA pain protocol for which the military
has now created a short certification course for nonacu-
puncturist providers. The protocol can be easily admin-
istered in less than five minutes, with experienced
providers doing this in less than one minute. Using
stainless steel ASP needles, completing a five-point BFA
ear protocol uses roughly $2.00 in supplies. State regu-
lations determine whether or not a medical provider has
to be licensed or certified to perform acupuncture (i.e.,
an acupuncturist may not need to be added to staff).

Conclusions
This systematic literature review and meta-analysis of
RCTs shows that EA may be effective for immediate relief
of pain. Taking into consideration that EA 1) is at least as
effective as analgesic comparators, 2) has fewer side ef-
fects than current pain treatment regimens, and 3) is
quick, affordable, and easy to perform, it can be con-
cluded that EA may be a reasonable and promising mo-
dality for health care providers to consider using in the
outpatient, intra-operative, and ED setting for pain reduc-
tion. Our recommendation would be made with more en-
thusiasm if further research were to show a greater, that
is, a clinically significant, reduction in pain intensity.
Acknowledgments
Rachel Pinotti, MLIS, Icahn School of Medicine at Mount
Sinai, Department of Information and Education
Servicescontribution: systematic literature review. Allan
Kozlowski, PhD, Icahn School of Medicine at Mount Sinai,
Department of Rehabilitation Medicinecontribution: ad-
vice on meta-analysis.
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