J Acupunct Meridian Stud 2018;11(4):137e144

Available online at www.sciencedirect.com

Journal of Acupuncture and Meridian Studies

journal homepage: www.jams-kpi.com

Research Article

Effect of the Auricular Acupoint Associated

with Physical Exercise in Elderly People: A
Randomized Clinical Test
Rogéria Gonçalves de Carvalho Fonseca 1, Andréia Maria Silva 2,
Luiza Faria Teixeira 3, Valéria Regina Silva 4,
Luciana Maria dos Reis 2, Adriana Teresa Silva Santos 2,*

1
Physiotherapist e Vale do Sapucaı´ University (UNIVÁS), Pouso Alegre MG, Brazil
2
Physiotherapy, Department of Physical Therapy of the Federal University of Alfenas,
Alfenas MG, Brazil
3
Physiotherapy, Department of Physical Therapy of the Vale Do Sapucaı´ University (UNIVÁS),
Pouso Alegre MG, Brazil
4
Physical Education Course Teacher e José do Rosário Vellano University (UNIFENAS),
Alfenas MG, Brazil
Available online 16 May 2018

Received: Jan 23, 2018 Abstract

Revised: Apr 25, 2018 Objective: To analyze the effect of auricular acupoint associated with physical exercise on
Accepted: May 4, 2018 balance, mobility, and fear of falling in the elderly.
Method: The study is characterized as a clinical, controlled, and randomized trial with 22
KEYWORDS elderly people divided into two groups: kinesiotherapy group (n Z 11) and kinesiother-
aging; apy/auriculotherapy group (n Z 11). The instruments used for evaluation were Falls Ef-
auriculotherapy; ficacy Scale International; Berg Balance Scale, and Timed up and Go Test. The
balance; intervention was performed with frequency 2/week for 8 weeks. In the kinesiother-
elderly; apy/auriculotherapy group, in addition to kinesiotherapy, auriculotherapy was applied
falls; in specific acupoints. The ShapiroeWilk test was used to determine the normality of
rehabilitation the data, and for comparison, analysis of variance was used for repeated measures of
two factors.

* Corresponding author. Universidade Federal de Alfenas, Endereço: Avenida Jovino Fernandes Sales, 2600, Alfenas, MG, CEP-37132-038,
Brazil.
E-mail: adrianat.silva@yahoo.com.br (A.T. Silva Santos).
pISSN 2005-2901 eISSN 2093-8152
https://doi.org/10.1016/j.jams.2018.05.003
ª 2018 Medical Association of Pharmacopuncture Institute, Publishing services by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
138
Results: There was a significant intragroup reduction for the Timed up and Go Test
(p Z 0.00) and Falls Efficacy Scale International (p Z 0.00), and significant intragroup
Berg Balance Scale (p Z 0.00) for both groups.
Conclusion: The auricular acupoint did not influence the balance, mobility, and fear of
falling in the elderly studied.
1. Introduction
The elderly face numerous limitations, with an increase
in life expectancy, negatively affecting the quality of life
and overall health status [1]. Decreased mobility and bal-
ance associated with fear of falling can lead to functional
decline in the elderly community [2].
Falling in the elderly has become one of the major
public health problems because of increased morbidity,
mortality, and costs for the family and for society [1,3]. In
Brazil, the systematic review, carried out between 2003
and 2012, highlights a high prevalence and incidence of
falls in institutionalized elderly people and in the com-
munity; falls are considered multifactorial, recurrent, and
often underestimated by the elderly, representing a sig-
nificant risk of death or disabling for activities of daily
living [4]. The main risk factors for falls in this population
are related to functional limitation, previous history of
falls, increased age, muscle weakness, use of psychotropic
medications, environmental risks, and sensory deficits
[2,5,6].
The aging process compromises the ability of the central
nervous system to process sensory information from the
vestibular, visual, and somatosensory systems, responsible
for maintaining balance and decreasing the capacity of
adaptive reactions, thus limiting the elderly person’s ac-
tivities of daily life [7]. To prevent falls, it is necessary to
have good conditions to receive afferent information
(vestibular, visual, and somatosensory systems) and
efferent information (muscles) to maintain balance; one of
the means capable of stimulating this information is the
practice of physical exercises [7].
Inactivity is a strong predictor of physical disability in
the elderly; however, longitudinal studies suggest that
regular physical activity is associated with reduced mor-
tality and prevents or improves the underlying conditions of
disability in the elderly, including falls, hip fractures, car-
diovascular disease, and diabetes [8,9,10].
The American College of Sports Medicine’s position
states that participation in regular physical activity causes
a number of favorable responses that contribute to healthy
aging [11]. In this sense, physical exercise has demon-
strated its beneficial effects such as reduced frailty, num-
ber of falls, decreased cognitive function, decreased
cardiac and pulmonary function, decreased physical func-
tion such as balance, gait, and mobility, and decreased
muscle power and functional capacity [12].
On the other hand, there are alternative and comple-
mentary health therapies that can also aid in healthy aging
[13,14]. Experimental studies in rats that used acupuncture
were able to slow down the aging process by regulating the
expression of various genes by strengthening inflammatory
R.G. de Carvalho Fonseca et al.
and immune functions as well as protecting cells and
inhibiting apoptosis and anti-oxidative stress [13,14]. In
studies in humans, the application of acupuncture was able
to influence postural balance in healthy individuals [15] and
improve postural control in the elderly [3].
Among the alternative and complementary health ther-
apies, auriculotherapy stands out, which can be defined as
a system of diagnosis and treatment based on the regula-
tion of the dysfunctions that affect the body, stimulating
points located in the ear. These points are called acupoints
and when stimulated produce biochemical and functional
responses to treat various physical and mental diseases
[16e19].
It has been shown by some researchers that dermal
stimulation of various parts of the body activate respective
areas of the cerebral cortex [20], modifications in elec-
troencephalographic patterns [21], hemodynamic changes
observed by functional resonance [22] after application of
acupuncture at specific points of the body, and also mod-
ulations of neurotransmitter responses [23].
To date, there is much scientific evidence on the effect
of physical exercise to slow down the aging process
[24,25]. However, there is little evidence about the effect
of auriculotherapy for improved balance [3] being
observed in studies with scalp acupuncture in stroke pa-
tients [26], as well as improved performance and recovery
after exercise [27]. Until this day, existing research has
used auriculotherapy, systemic acupuncture, and physical
exercise in an isolated form, and in some studies, the
authors highlight the small sample size with inconsistent
results [3,10,15].
Thus, the objective of this study was to investigate the
effect of auricular acupoint associated with physical exer-
cise on balance, mobility, and fear of falling in the elderly.
2. Methodology
2.1. Study design
This study is characterized by a randomized controlled
clinical trial. All participants agreed to participate in the
study by signing the free and informed consent term
following the guidelines of National Health Code of the
Resolution 466/12 with the approval of the Ethics and
Research Committee of the Vale do Sapucaı́ University under
the 39554314.7.0000.5102.
2.2. Sample
The participant recruitment occurred between the
period November 2014 and April 2015. Seventy-two elderly
Acupoint Associated with Physical Exercise in the Elderly: A Randomized Clinical Test 139

community members were recruited from the primary
health-care unit of a city in the south of Minas Gerais and
were invited to participate in the study. From this
recruitment, 50 elderly people did not meet the inclusion
criteria: the elderly of both genders aged over 60 years,
practicing physical activity (twice a week during an hour),
with a history of at least one fall in the last year, and with
preserved visual and auditory acuity. Also excluded were
the elderly with disabling musculoskeletal and neurolog-
ical conditions and cognitive deficits (analyzed by the
Mini-Mental State Test).Twenty-two elderly people of the
community remained in the study and were randomized
blindly (using the Randomizer programdwww.random.
org) and allocated to two groups: intervention
groupdkinesiotherapy/auriculotherapy group (KAG,
n Z 11) and control groupdkinesiotherapy group (KG,
n Z 11). There was a sample loss of one elderly person
in KAG due to a prescheduled varicose vein removal
surgery. See the Fig. 1.
2.3. Evaluation and revaluation instruments
2.3.1. Berg’s balance scale
This instrument evaluates the balancing ability in 14
different situations, for example: lift, sit, rotate around
themselves, load transfer forward and sideways, and pick-
ing up an object from the ground, among others, in
different situations of support base layout [28]. Scoring is
based on an individual’s ability to perform each task inde-
pendently and meet certain time or distance requirements.
Each item of the test is subdivided into five alternatives
with a score of 0 to 4. The total score is 56 points and
minimum zero, and the higher the score the better the
result [29]. This scale indicates significantly high intra-
observer and interobserver correlations for all components
[29].
2.3.2. Timed Up and Go
The Timed Up and Go (TUG) assesses functional mobility
through sitting balance, transfers from sitting to standing
position, stability in walking, and gait changes without
using compensatory strategies [30]. The execution time is
the determining factor of the test: time less than 10 sec-
onds, there is a risk of minimum drop; time between 10 and
20 seconds presents a slight impairment of mobility but are
generally independent; and duration of 20 seconds or more
is indicative of postural instability and high risk of falls [30].
The TUG is a safe instrument with good reproducibility for
physical performance measurement for hospitalized elderly
[31].
2.3.3. Falls efficacy Scale-International Brazil
The Falls Efficacy Scale-International Brazil (FES-I Brazil)
is a possible test indicator of fall occurrence [32]. It eval-
uates the concern of the possibility of falls in the accom-
plishment of 16 daily activities, graduated from one to four.

Population of
volunteers
n= 72

Excluded n= 50
volunteers because
they did not meet the
inclusion criteria

Eligible and agreed to

participate in the
study
n= 22

Randomization by draw

n= 11, were selected for n= 11 were selected for

the control group the intervention group

1 participant was
excluded due to
vascular surgery

Figure 1 Study design and CONSORT diagram showing the flow of participants.
140
The total score may range from 16 (no concern) to 64
(extreme worry) [32]. Points above or equal to 23 are
associated with sporadic falls and above 31, recurrent falls.
The items on the scale have adequate internal consistency
and intra- and inter-rater reliability [32].
3. Intervention
3.1. Kinesiology group
The intervention was performed twice a week, with a
total duration of 1 hour for 8 weeks. All exercises were
performed at a moderate intensity. The protocol that was
used followed all the recommendations established by the
American College of Medicine and Sports for healthy elderly
people, which included aerobic exercises, strengthening
exercises, flexibility, and static and dynamic balance ex-
ercises [33]. Static balance exercises were carried out with
the eyes open for five sessions and then with eyes closed,
initially on a stable surface, also for five sessions and then
on unstable surfaces without external disturbances Table 1.
3.2. Kinesiotherapy/auriculotherapy group
The KAG first received the intervention with kinesi-
otherapy and rested for 20 minutes, and soon after that,
the auricular acupuncture was applied. For the application
of auriculotherapy, the asepsis of the ear was performed
with alcohol 70% and the mustard seed was applied in the
acupoint mentioned in the table below [34]. The elderly
were oriented to stimulate the acupoints 5 times a day, for
1 minute on each point, and for each application, the ear
was alternated weekly [35] The type of acupuncture chosen
was Chinese and the application was performed by a pro-
fessional with 8 years of experience with the technique.
The application with auriculotherapy followed all the
Table 1 Description of the kinesiotherapy group protocol.
Types of exercises Muscle group Series/repetitions
Warm up e e
Active stretching Flexion/extension/abduction/ 3 30 seconds
adduction shoulders
Flexion/extension/abduction/
adduction hips
Flexion/extension knees
Dorsiflexion/ankle flexion
Isotonic strengthening Flexion/extension/abduction/ 3/15
adduction shoulders
Flexion/extension/abduction/
adduction hips
Flexion/extension knees
Dorsiflexion/ankle flexion
Static balance e 3
Dynamic exercise e 3
R.G. de Carvalho Fonseca et al.
recommendations of the standards according to STRICTA
[36] (Table 2).
The application of auriculotherapy was initiated at the
Shenmen point, followed by the kidney and then the sym-
pathetic point, which are considered points that initiate
any program of auriculartherapy [34]. Subsequently, other
points were applied: subcortex, inner ear, forehead, and
occipital because they are points indicated for changes in
balance [34].
The intervention was performed frequently twice a
week, lasting 1 hour and 40 minutes, totaling 8 weeks.
4. Statistical analysis
The descriptive data were used to characterize the
sample, presented in mean, standard deviation, and per-
centage. The ShapiroeWilk test was used to determine the
normality of the data. Then, the two-way repeated mea-
sure analysis of variance test and independent t test were
applied. All analyses were performed by the SPSS statistical
software (version 20.0), and the significance level was 5%.
The power of the sample used was 95% and a Z 0.05. The
GPower 3.1.7 sofware (Franz Faut, Universitat Kiel Ger-
many, 2008) was used for analyses.
5. Results
Table 3 describes the anthropometric variables analyzed
in the study, and it is noted that there is no statistical
difference between the variables (p > 0.05), showing them
to be similar.
Table 4 describes the intergroup and intragroup com-
parison of the studied variables. There was statistically
difference before and after intragroup and intergroup in-
terventions there was no difference. In the TUG and FES-I
Brazil tests, there was a decrease in both the execution
time and the scale score; for the Berg balance test, there
Description of each exercise
Walk with upper limb movementd5 minutes
e
Bipodal supportd2 minutes
One-leg support with extended kneed2 minutes
Unipodal support flexed kneed2 minutes
One-leg knee support flexed on tiptoed1 minutes
Walk in zig zagd2 minutes
Acupoint Associated with Physical Exercise in the Elderly: A Randomized Clinical Test
Table 2 Location of auricular acupoints the according to
Souza [34].
Auricular Location of points
acupoints
Shenmen Point located at the vertex of the angle
formed by the lower root and the upper root
of the antihelix.
Simpatico Point located in the middle of the lower
root below the helix membrane.
Kidney Point located in the cimba shell, next to the
junction of this with the inferior root of the
antihelix, in the same line of the point
shenmen.
Subcortex Point located in the upward curve towards
the apex of the antitrago, on the upper
edge of the shell.
Internal ear Located at the lower edge of the lobe, 2 mm
from the throatetonsil point
Front Located about 2 mm above and 1 mm next
to the upper palate point in a straight line,
connecting the throat, eye and mouth
points.
Occipital Located 2 mm from the point of allergy,
1 mm from the anti-gore limit with the anti-
helix
was an increase in the scale score. That is, the two in-
terventions influenced the physical functional data of the
elderly, but only within the same groups.
6. Discussion
The main finding of this study was that auricular acu-
point did not promote changes in the studied variables.
However, there was improvement in intragroup variables.
Responses are justified because of the fact that regular
practice of physical exercise is capable of promoting
physiological adaptation of the body [37]. Several studies
have highlighted the beneficial effects of physical exercise
such as improved cardiovascular [38], musculoskeletal [39],
and sensorimotor conditioning, decreased body fat [40],
improved bone density, functional capacity [41], and pre-
vention of osteoporosis [40]. Even after 65 years, physical
activity favors longevity, reduction in mortality rate,
Table 3 Analysis of the anthropometric variables.
Variable KG
Age (year) (CI) 69.36  7.0 (64.77e73.95)
Sex (%)
Male 30
Female 70
BMI (Kg/m2) (CI) 27.9  3.93 (25.26e30.55)
Mental state examination (CI) 21,54  2.91 (19.59e23.50)
BMI, body mass index; CI Z confidence interval; KAG Z kinesiotherapy/auriculotherapy group; KG Z kinesiotherapy group.
*Independent t test.
141
prescription of medications, prevention of cognitive
decline, reduction in the frequency of falls, and improve-
ment of self-esteem [42].
Although no intergroup difference has been observed,
some studies show that acupuncture is able to retard the
effects of aging [43], improve postworkout performance
and recovery and restore Qi from the body promoting en-
ergy balance [44,45]. The stimulation of specific acupoints
evoke responses in various areas of the central and pe-
ripheral nervous system [46], such as remodeling the ar-
chitecture of the neural networks of any motor system as
well as improving the connection between the cerebellum
and primary sensory motor cortex and facial nerve recovery
[47].
In this study, physical activity was emphasized for lower
limbs and balance training, this is justified on the basis of
scientific evidence pointing to a reduction of muscle mass
from 30 to 50% between 40 and 80 years [48,49], being
higher in the lower limbs than in the upper limbs [50,51]. In
addition, according to Ikezoe [49], there is also a reduction
in neural processing, vestibular excitability, vision sensi-
tivity, and proprioceptive sensors that contribute to inse-
curity and fear of falling [52].
Mobility is related to balance, gait velocity, and func-
tional capacity, being predictive factors for fall [53]. In
the present study, after the intervention, there was a
reduction in the response time analyzed by the TUG test in
both groups; however, the participants in the preassess-
ment presented values less than 10 seconds, indicating
that they were already considered independent regarding
mobility.
Regarding the Berg balance test, it was observed that
both groups presented minimal risk of falls. After the
intervention, there was an increase in the intragroup score.
This result may be related to the low sensitivity of the test
for the study participants because it is a predictor of risk of
falling, but not very sensitive to detect changes in elderly
exercise practitioners [54].
The FES-I Brazil test indicated in the present study that
both groups presented in the preassessment a sporadic risk
of falls, with a reduction in mean values after the inter-
vention. This result can be justified as a result of partici-
pants already practicing physical activity.
The exercise protocol for the kinesiotherapy group fol-
lowed all the recommendations established by the Amer-
ican College of Medicine and Sport in accordance with the
proposal of this study. However, the authors describe that
no physical activity will disrupt the biological aging
KAG p*
67.8  3.19 (65.51e70.08) 0.51
20 e
80 e
26.9  4.0 (24.11e26.69) 0.56
22.40  2.79 (20.39e24.40) 0.50
142 R.G. de Carvalho Fonseca et al.

Table 4 Intragroup and intergroup comparison of the studied variables.

Variables KG (n Z 11) KAG Intergroups
Before After Before After
(95% CI) (95% CI) Before/after Before/after d d power
(pa) Groups (pa)
TUG 9.72  2.19 7.45  1.12 9.00  1.63 7.90  1.59 0.00* 0.12 0.90 0.97
(8.25e11.20) (6.69e8.21) (7.83e10.16) (6.75e9.04)
FES-I Brasil 27.54  11.15 21.81  8.91 26.20  6.49 19.50  2.50 0.00* 0.66 3.24 1.00
(20.05-35.04) (15.82e27.81) (21.55e30.84) (17.70e21.29)
EEBerg 50.45  4.56 55.00  1.34 52.30  3.77 55.10  1.59 0.00* 0.31 1.9 1.00
(47.38e53.52) (54.09e55.90) (49.60e54.99) (53.95e56.24)
ANOVA, analysis of variance; CI Z confidence interval; d Z effect size; EEBerg Z Berg balance scale; FES-I Brazil Z Falls Efficacy Scale-
International Brazil; KAG Z kinesiotherapy/auriculotherapy group; KG Z kinesiotherapy group; power Z sample power; TUG Z Time
Up Go.
*p  0.05.
a
Repeated measure ANOVA tests.

process, but there is scientific evidence that regular ex- References

ercise can minimize physiological effects by increasing life
expectancy and limiting the progression of chronic dis-
eases, as well as the psychological and cognitive benefits
[33].
In the intergroup comparison, it is observed that the
auricular acupuncture did not influence the responses of
mobility, balance, and fear of falling. Such results could be
justified by the fact that all variables presented minimal
risks in the scales analyzed and did not present sufficient
sensitivity for the difference between the groups. It is
observed, in the study Santos et al [54], that these scales
are sensitive for the elderly who are not physically active; it
is then suggested that this study be carried out with elderly
people who are not physically active and with less func-
tional capacity.
The limitations of the present study were (a) absence of
a group without intervention due to the fact that all groups
practiced physical exercise, (b) progression in the intensity
of the exercise, because the protocol was maintained with
the same intensity during the 8 weeks, and (c) low sensi-
tivity of the evaluation instruments for the physically active
population, suggesting the accomplishment of the study
with nonphysically active elderly and instrument that pre-
sents greater sensitivity for the physically active
population.
The results found may contribute to scientific evidence
of the technique and to evidence-based practice of new
rehabilitation resources for physical therapy professionals.
Conclusion
The auricular acupoint did not influence the balance,
mobility, and fear of falling in the studied elderly.
Disclosure statement
The authors declare that there are no conflicts of
interest.
[1] Tiernan C, Lysack C, Neufeld S, Goldberg A, Lichtenberg PA.
Falls efficacy and self-rated health in older African American
adults. Arch Gerontol Geriatr 2014;58:88e94.
[2] Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which
factors are associated with fear of falling in community-
dwelling older people? Age Ageing 2014;43:76e84.
[3] Pasquetti P, Apicella L, Mangone G. Pathogenesis and treat-
ment of falls in elderly. Clin Cases Miner Bone Metabol 2014;
11(3):222e5.
[4] Paula Júnior NF, Santo SMA. Epidemiologia do evento queda
em idoso: traçado histórico entre os anos de 2003 e 2012. Rev
Min Enferm 2015;19(4):994e1004.
[5] Evitt CP, Quigley PA. Fear of falling in older adults: a guide to
its prevalence, risk factors and consequences. Rehabil Nurs
2004;29:207e10.
[6] Sandoval RA, Sá ACAM, Menezes RL, Nakatani AYK,
Bachion MM. Falls in the non-institutionalized elderly: a sys-
tematic literature review. Rev Bras Geriatr Gerontol 2013;16:
855e63.
[7] Avelar NCP, Bastone AC, Alcântara MA, Gomes WF. Efetividade
do treinamento de resistência à fadiga dos músculos dos
membros inferiores dentro e fora d’água no equilı́brio estático
e dinâmico de idosos. Rev Bras Fisioter 2010;14(3):229e36.
[8] Llamas-Velasco S, Villarejo-Galende A, Contador I, Lora
Pablos D, Hernández-Gallego J, Bermejo-Pareja F. Physical
activity and long-term mortality risk in older adults: a pro-
spective population based study (NEDICES). Prev Med Rep
2016;4:546e50.
[9] Ou SM, Chen YT, Shih CJ, Tarng DC. Impact of physical activity
on the association between lipid profiles and mortality among
older people. Sci Rep 2017;7(8399):1e9.
[10] Fielding RA, Guralnik JM, King AC, Pahor M, McDermott MM,
Tudor-Locke C, et al. Dose of physical activity, physical
functioning and disability risk in mobility-limited older adults:
results from the LIFE study randomized trial. PLoS One 2017;
12(8):1e20.
[11] American College of Sports Medicine, Chodzko-Zajko WJ,
Proctor DN, Fiatarone Singh MA, Minson CT, Nigg CR, et al.
American college of sports medicine position stand, Exercise
and physical activity for older adults. Med Sci Sports Exerc
2009;41(7):1510e30.
[12] Labra C, Guimaraes-Pinheiro C, Maseda A, Lorenzo T, Millán-
Calenti JC. Effects of physical exercise interventions in frail
Acupoint Associated with Physical Exercise in the Elderly: A Randomized Clinical Test
older adults: a systematic review of randomized controlled
trials. BMC Geriatr 2015;15:154.
[13] Yu F, Jian-chun Y, Xiao-rong D. Jingoxian H Effects of
Acupuncture on Expressions of the Transcription Factors NF-
E2, YB-1, LRG47 in the SAMP10Mice. J Traditional Chin Med
2009;29(1):54e9.
[14] Fu Y, Yu JC, Ding XR, Han JX. Study on expression of brain
aging-relative genes HSP86 and HSP84 and effects of
acupuncture in the SAMP10 mouse. Zhongguo Zhen Jiu 2006;
26(4):283e6.
[15] Fernandes T, Carvalho L, Santos MJ, Ramos B, Greten H,
Machado J. Can acupuncture in S34 improve postural stability
in healthy subjects? Exp Pathol Health Sci 2016;8(2):105e10.
[16] Sampaio-Filho H, Sotto-Ramos J, Pinto EH, Cabral MR,
Longo PL, Tortamano IP, et al. Evaluation of low-level laser at
auriculotherapy points to reduce postoperative pain in infe-
rior third molar surgery: study protocol for a randomized
controlled trial. Trials 2016;17:432.
[17] Johnston MF, Sánchez EO, Vujanovic NL, Li W. Acupuncture
may stimulate anticancer immunity via activation of natural
killer cells. Evid Based Compl Alternative Med 2011;2011,
481625.
[18] Choi EM, Jiang F, Longhurst JC. Point specificity in acupunc-
ture. Chin Med 2012;7:4.
[19] Cheng KJ. Neurobiological mechanisms of acupuncture for
some common Illnesses: a clinician’s perspective. J Acupunct
Meridian Stud 2014;7(3):105e14.
[20] Rasmussen F, Penfield W. Further studies of the sensory and
motor cerebral certex of man. Federation Proc 1947;6:
452e60.
[21] Qin W, Bai L, Jin L, Tian J. Findings of acupuncture mecha-
nisms using EEG and MEG. In: Tian J, editor. Multi-modality
neuroimaging study on neurobiological mechanisms of
acupuncture. Singapore: Springer; 2018. p. 91e124.
[22] Guo A, Hao F, Li F, Wang B, Liu L, Zhao Z, et al. Basal ganglia
cerebral infarction patient fMRI imaging analysis before and
after acupuncture-medicine therapy. Biomed Res 2017;
28(22):9779e83.
[23] Dimitrov N, Atanasova D, Tomov N, Sivrev D, Lazarov N.
Acupuncture causes serotonin release by mast cells. Rom J
Morphol Embryol 2017;58(3):961e8.
[24] Kam D, Smulders E, Weerdesteyn V, Smits-Engelsman BC. Ex-
ercise interventions to reduce fall-related fractures and their
risk factors in individuals with low bone density: a systematic
review of randomized controlled trials. Osteoporos Int 2009;
20:2111e25.
[25] Liu-Ambrose T, Khan KM, Eng JJ, Janssen PA, Lord SR,
Mckay HA. Resistance and agility training reduce fall risk in
women aged 75 to 85 with low bone mass: a 6-month
randomized, controlled trial. J Am Geriatr Soc 2004;52:
657e65.
[26] Chu JM, Bao YH, Zhu M, Zhen ci yan jiu. Effects of acupunc-
ture intervention combined with rehabilitation on standing-
balance-walking ability in stroke patients. Acupunct Res
2015;40(6):474e8.
[27] Urroz P, Colagiuri B, Smith CA, Cheema BS. Effect of acute
acupuncture treatment on exercise performance and post-
exercise recovery: a systematic review. J Alternative Compl
Med 2013;19:9e16.
[28] Leonardi MM, Lopes GJ, Bezerra PP, Borges APO. Impact of
static and dynamic imbalance in the risk of falls in paients
with spinocerebellar ataxia. Rev Neurol 2009;17(2):178e82.
[29] Miyamoto ST, Lombardi Junior I, Berg KO, Ramos LR, Natour J.
Brazilian version of the Berg balance scale. Braz J Med Biol Res
2004;37:1411e21.
[30] Podsiadlo D, Richardson S. The timed “Up & Go”: a test of
basic functional mobility for frail elderly persons. J Am Ger-
iatr Soc 1991;39:142e8.
143
[31] Martinez BP, Santos MR, Simões LP, Ramos IR, Oliveira CS,
Forgiarini Júnior LA, et al. Safety and reproducibility of the
timed up and go test in hospitalized elderly. Rev Bras Med
Esporte 2016;22:408e11.
[32] Camargos FFO, Dias RC, Dias JM, Freire MTF. Cross-cultural
adaptation and evaluation of the psychometric properties
of the Falls Efficacy Scale e International Among Elderly
Brazilians (FES-I-BRAZIL). Rev Bras Fisioter 2010;14:
237e43.
[33] American College of Sports Medicine, Chodzko-Zajko WJ,
Proctor DN, Singh MAF, Minson CT, Nigg CR, et al. American
College of Sports Medicine position stand. Exercise and phys-
ical activity for older adults. Med Sci Sports Exerc 2009;41(7):
1510e30.
[34] Souza MP. Tratado de Auriculoterapia. 2007. Brası́lia: Novo
Horizonte.
[35] Iunes DH, Chaves EDCL, Moura CDC, Côrrea B, Carvalho LC,
Silva AM, de Carvalho EC. Role of auriculotherapy in the
treatment of temporomandibular disorders with anxiety in
university students. Evid Based Compl Alternative Med
2015.
[36] MacPherson H, White A, Cummings M, Jobst KA, Rose K,
Niemtzow RC, et al. Standards for reporting interventions in
controlled trials of a acupuncture: the STRICTA recommen-
dations. J Alternative Compl Med 2002;8(1):85e9.
[37] Pedrosa MIA, Rodrigues LM. About the importance of physical
exercise in human physiology. Biomed Biopharm Res 2011;8:
273e98.
[38] Vigorito C, Giallauria F. Effects of exercise on cardiovascular
performance in the elderly 2014;5(51):1e8.
[39] Distefano G, Goodpaster BH. Effects of exercise and aging on
skeletal muscle. Cold Spring Harb Perspect Med 2018;8:1e15.
[40] Kong S, So WY. Gender differences in body composition,
physical activity level, physical fitness, and bone mineral
density among elderly individuals living alone compared to
those living with their spouses. J Men’s Health 2017;13(2):
60e7.
[41] Vorup J, Pedersen MT, Melcher PS, Dreier R, Bangsbo J. Effect
of floorball training on blood lipids, body composition, muscle
strength, and functional capacity of elderly men. Scand J Med
Sci Sports 2017;27:1489e99.
[42] Chou CH, Hwang CL, Wu YT. Effect of exercise on physical
function, daily living activities, and quality of life in the frail
older adults: a meta-analysis. Arch Phys Med Rehabil 2012;93:
237e44.
[43] Bai L, Harris RE, Kong J, Lao L, Napadow V, Zhao B. Neuro-
biological mechanisms of acupuncture 2014. Evid Based Compl
Alternative Med 2014:1e2.
[44] Senna-Fernandes V, França D, Cortez Silva G, Pereira F. Ki-
netic acupunture: systematic therapy of face neuromuscular
and locomotor system by acupunture associated to kinesi-
therapy. Fisioter Bras 2003;4(3):185e94.
[45] França DM, Senna-Fernandes V, Aguiar C, Amaral G,
Oliveira R, Cortez C, et al. Acupuncture for rehabilitation of
old people. Fisioter Bras 2006;7(6):433e9.
[46] Pariente J, White P, Frackowiak RS, Lewith G. Expectancy and
belief modulate the neuronal substrates of pain treated by
acupuncture. Neuroimage 2005;25:1161e7.
[47] Guo A, Hao F, Li F, Wang B, Liu L, Zho Z, et al. Basal ganglia
cerebral infarction patient fMRI imaging analysis before and
after acupuncture-medicine therapy. Biomed Res 2017;
28(22):9779e83.
[48] Akima H, Kano Y, Enomoto Y, Ishizu M, Okada M, Oishi Y, et al.
Muscle function in 164 men and women aged 20e84 yr. Med Sci
Sports Exerc 2001;33:220e6.
[49] Ikezoe T, Mori N, Nakamura M, Ichihashi N. Age-related muscle
atrophy in the lower extremities and daily physical activity in
elderly women. Arch Gerontol Geriatr 2011;53:e153e7.
144
[50] Janssen I, Heymsfield SB, Wang Z, Ross R. Skeletal muscle
mass and distribution in 468 men and women aged 18e88 yr. J
Appl Physiol 2000;89:81e8.
[51] Speers RA, Kuo AD, Horak FB. Contributions of altered
sensation and feedback responses to changes in coordination
of postural control due to aging. Gait Posture 2002;16:20e30.
[52] Elward K, Larson EB. Benefits of exercise for older adults. A
review of existing evidence and current recommendations dor
the general population. Clin Geriatr Med 1992;8:35e50.
R.G. de Carvalho Fonseca et al.
[53] Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the timed up
and go test a useful predictor of risk of falls in community
dwelling older adults: a systematic review and meta-analysis.
BMC Geriatr 2014;14:14.
[54] Santos GM, Souza ACS, Virtuoso JF, Tavares GMS, Mazo GZ.
Predictive values at risk of falling in physically active and no
active elderly with Berg Balance Scale. Rev Bras Fisioter 2011;
15:95e101.