Systematic Review Article

Medical indications for Auriculotherapy

Andreia Vieira1,7, Ana Mafalda Reis13, Jorge Machado1,3, António Moreira1,4
Doctoral Biomedical Sciences Programme, Abel Salazar Institute for Biomedical Sciences, University of Porto, Porto, Portugal; (2)
Physiotherapist Department, Hospital Santa Maria, Porto, Portugal; (3) Abel Salazar Institute for Biomedical Sciences, University of
Porto, Porto, Portugal; (4) Superior School of Sports of Rio Maior, Portugal.

Correspondence should be addressed to Andreia Vieira; andreiarsv@gmail.com

Abstract

The aim of this study was to investigate the indications require robust scientific evidence to support auriculotherapy.
We have conducted a systematic review (2007-2017) to determine in which pathologies auriculotherapy can be an
effective therapeutic help strategy. Only systematic reviews with meta-analyses and high methodological quality
described according AMSTAR (Assessment of Multiple Systematic Reviews) criteria were selected. Its main objective
was to evaluate the effectiveness of auriculotherapy in the management of any disease. Most of the 14 selected reviews
focus on management of insomnia, smoking cessation and pain-related diseases, mainly in the disciplines of
Neurology, Orthopaedics and Rheumatology. We suggest the use of auriculotherapy combined with conventional
treatments of insomnia, chronic and acute pain. The remaining pathologies still require further good quality studies.

Keywords: Auriculotherapy, Auricular acupuncture, auriculopressure, Medical Indications, Systematic Review

Background

Auriculotherapy is a therapeutic method by which specific points on the ear are stimulated [1, 2].
Various methods currently exist already for ear stimulation, such as auricular acupuncture:
needles with or without bloodletting and auricular acupressure: vaccaria seeds, magnetic pellets,
lasers, ultrasound, moxibustion, electrotherapy or pressure/massage in ear with hands [2-4]. The
auricle is a secondary organ located on the side of the head, whose main function is the capturing
and filtering of sound[5]. It presents an extensive sensory innervation of vegetative nerve centers
that receive information from internal organs through impulses from Alpha, Beta and Gamma
fibers. In turn, these are disseminators of sensations that are sensitive to touch, pressure,
temperature and proprioception, reaching the sensory nuclei of the cranial nerves and the
posterior horn of the Spinal Cord. The information that comes from the thermal, algic and
proprioceptive stimuli is transmitted from the auricular pavilion by the fibers of the nerves:
trigémeo; Auricular magnum and minor occipital (sensitive branch of the cervical plexus) and the
vagus nerve [2, 4-8]. Subsequently, the impulse is transmitted to other Upper nervous systems
structures (e.g., cranial nerve nuclei, the limbic system, the thalamus, the hypothalamus, the
reticular formation, the cerebellum and the cerebral cortex). Therefore, this whole process is
activated in order to modulate and regulate the information transmitted to the Sympathetic and
Parasympathetic nervous system and, consequently, to the stimulated organ via the peripheral
nerves[9].
For this reason, the microsystem of acupuncture is a convenient and basic method used for
treating many conditions (e.g., substance abuse, pain, obesity, anxiety, epilepsy, and sleep
disorders), however the effectiveness of auriculotherapy has only been tested in a relatively small
number of evidence-based trials [4].
For this reason, the aim of this article is to establish therapeutic indications based on scientific
evidence. To achieve this, we performed a systematic study of existing evidences to help
determining in which uses auriculotherapy has proven to be effective.

Methods

Search strategy

The literature was searched using the following databases from their inception from 1st January
2007 to 31st April 2017: the Cochrane Library, PubMed/Medline and B-on. These databases were
searched by using the following Medical Subject Heading terms and text words: (‘‘Review’’’) AND
(‘‘auriculotherapy’’ OR ‘‘auricular point sticking’’ OR ‘‘auriculotherapies’’ OR ‘‘auricular point
therapy’’ OR ‘‘auricular plaster therapy’’ OR ‘‘ear acupressure’’ OR ‘‘ear point’’ OR ‘‘auricular
pressing therapy’’ OR “ear therapy acupuncture” OR “auricular Therapy acupuncture” OR
“auricular acupuncture” OR “auriculoacupuncture” OR “acupressure”).
The first pre-selection of items, once all duplicates were removed, was made from the
corresponding title and abstract. Two independent authors reviewed all shortlisted studies.
Disagreements between reviewers were resolved by consensus.

Inclusion criteria

Of the selected articles, only systematic reviews and meta-analyses that have met the inclusion
criteria were included:
- Systematic reviews with meta-analyses of high quality according to the criteria established
by Assessment of Multiple Systematic Reviews [10].
- Analyzed variable: efficacy of auriculotherapy versus placebo, sham acupuncture or usual
treatment, in any type of pathology.
- Any type of ear-acupuncture or ear-acupressure (such as needles inserting into ear
acupoints, electric stimulation on the ear acupoints, seeds or magnetic pellets attached on ear
acupoints, or prick blood-letting technique on ear acupoints.
- Publication language: English, Spanish and Portuguese.

Exclusion criteria

Of the selected articles, systematic reviews and meta-analyses excluded:

-Narrative reviews and systematic reviews of low methodological quality;

- Publication data before 2007.

Fig. 1- Flow chart of screened, excluded and analyzed information through different phases of
systematics reviews.

3. Results
From 707 potential titles for review, 209 references were selected from titles and abstracts. Of
the remaining 47 studies, 14 systematic reviews with meta analyses examined the efficacy of
auriculotherapy and were included in this review (Fig.1).
Neurology, especially the insomnia disease is the 1st medical specialty that has a greater number
of reviews identified, followed by traumatology, psychiatry and rheumatology (table 1).

Table 1 Number of high quality reviews identified, grouped by medical specialty. Studies which
conclude that Auriculotherapy is effective and lack of efficacy, according to the criteria established
are specified.

Medical specialty and pathologies Lack of

efficacy
Number
Efficacy
of reviews

Neurology: Insomnia. 4 [11]; -

[12];

[13]; [14]

Traumatology: perioperative pain; 3 [15]; [16]; [17] -

acute pain.

3 [18]; [20]
Psychiatry: smoking cessation;
cocaine dependence [19]

Rheumatology: Low back pain, 3 [17]; -

chronic tension headache; chronic [21];
neck pain; Knee osteoarthritis; [16]
Rheumatoid arthritis; chronic non-
specific spinal pain; posterior pelvic
pain.
 Gastroenterology: constipation 1 [22] -

Immunology: allergic rhinitis 1 [23] -

Obstetrics: nausea and vomiting in 1 [24] -

early pregnancy

Ophthalmology: glaucoma 1 [25] -

Efficacy of Auriculotherapy

The Table 1 summarizes the study design of all 14 selected studies. It also samples the size of
the studies ranged from 3313 to 785, with a total of 20434 subjects. A total of 13 reviews (93%),
among the identified ones, conclude that auriculotherapy can improve some of the symptoms of
the treated pathologies. Moreover, 1 review concludes that auriculotherapy has no effect different
from placebo or from the usual treatment. The reviews that do not identify any associated effect
using auriculotherapy with the study Drug and Alcohol checklist in patients with cocaine
dependence [20].

Regarding the conditions in which auriculotherapy can be effective, we highlight Neurologic

conditions, such as insomnia (Table 2), rheumatic such as a chronic pain, trauma such as a
traumatic injury or acute pain (Table 3) and even psychiatric conditions such as a Smoking
cessation (Table 4). In the rest of the pathologies, the number of studies included in the reviews
is lower or some of the reviews that prove certain effect of auriculotherapy and others studies did
not notice any effect (Table 5). Commented [1]: passado ou presente? escolher um
ou outro e ser consistente ate o fim da descriçao.
In the field of neurology, with 4 systematic reviews, auriculotherapy seems to be effective in Commented [2]: passado... did not?
treating insomnia. The results describe the overall quality of sleep parameters after a meta-
analysis of 15 interventions with auriculotherapy (n=1428). Although a small sample when
compared to the conventional medication group they presented greater total sleep time, greater
sleep efficiency and clinical efficacy, lower score in the Pittsburgh Sleep Quality Index (PSQI),
lower sleep-onset latency, lower frequency and no adverse events [11]. Other meta-analyzes
performed, the first one with 6 studies (n = 673) showed an advantage of auriculotherapy in
relation to conventional medication as well as to the control group [14]. The second meta-analyzes
with 10 studies (n = 792) suggested beneficial effects on a sleep evaluation in conjunction with
the sham group as well as no conventional drug group (e.g., estazolam or diazepam) [13]. Finally,
a review with 40 studies (n = 4115) on reflexology reported one research with auriculotherapy
efficacy in longer total sleep efficiency by actigraphy compared to sham and in the treatment
group in terms of PSQI score reduction [12].

As far as pain assessment is concerned, auriculotherapy shows positive results in all included
studies. Recently, some authors reported in 6 studies (n =159) that the effect of auriculotherapy
was superior, compared to sham treatment and conventional analgesic medication up to 48 hours
after surgery [15]. Concerning to the two types of pain (acute and chronic), auriculotherapy in 13
studies (n = 806) was effective in relation to the control group and sham [16]. The effect of
auriculotherapy also remained positive in both types of pain: acute pain (2 studies, n = 111) as
well as in chronic pain (5 studies, n = 261), reducing pain intensity in relation to the sham group
and still being perioperative pain (5 studies, n = 412) reduction of conventional analgesics [17].
Another study shows that auriculotherapy is effective in reducing pain in patients with various
types of chronic pain (4 studies, n=206), especially chronic low back pain (4 studies, n=193) and
headaches (2 studies, n=150) caused by muscle tension. The intervention groups compared with
those in the control and sham groups, shows differences in pain relief in 0 to <3 weeks (7 studies,
n=363); 3 to <6 weeks (6 studies, n=327), > 6 weeks (4 studies, n=181), and one month (5 studies,
n=293) follow-up periods [21]. We have found one review which suggested that auriculotherapy
has proven to be also effective in reducing postoperative pain [26]. However, the study was
excluded because the meta-analytic approach was not possible. Commented [3]: parece que está a faltar algo aqui.
not possible how? why?
In relation to psychological pathologies, significant improvements were detected in two reviews
concerning smoking cessation. One of them concluded that acupressure in the correct points was
more effective for short-term cessation in 3 studies (n=253) than sham acupressure [19]. The
other study showed that auriculotherapy was superior to control group at end of treatment with
cessation rates were 22.7% (test) vs. 12.6% (control), 3 months follow-up and the cessation rates
were 15.8% (test) vs.10.1% (control), with 12.5% biochemically confirmed benefit, and 6 months
follow with cessation rates of 12.4% (test) vs. 6.1% (control), based on data without biochemical
confirmation [18].

In the rest of the pathologies, the number of studies included in the reviews is lower or there are
reviews that prove certain effect of acupuncture and others that do not observe any effect. In the
field of Ophthalmology, one review included the results of 1 study (n=33) in the treatment of
glaucoma. The difference in intraocular pressure in the acupressure group was significantly less
than that in the sham group at four weeks but was not statistically different at any other follow-up
time points, including the longest follow-up time at eight weeks [25]. In the Immunology
pathologies, 5 studies (n=804) showed that auriculotherapy has a significantly higher short-term
effect (4 weeks) when compared to Chinese herbal medicine and significantly better long-term
effect (6 months) than anti-histamine medication in the treatment of allergic rhinitis [23]. Regarding
gastroenterology field, review with 17 studies (n=474) concludes improvement rate of
auriculotherapy for constipation, but for other symptoms associated with constipation (e.g.,
abdominal distension or anorexia) showed no statistical significance [22]. Furthermore, 41
reviews (n=5449) have been identified among reviews related to acupuncture applied to nausea
and vomiting in early pregnancy [24]. However, about auriculotherapy revised in only 1 study, it
showed differences compared to sham on day 6 (3 days after treatment started) but not
differences in number of anti-emetic drugs used on day 6 (n = 91).

Table 2: Characteristics of identified systematic reviews that detect efficacy of acupuncture in Neurology pathologies.

Relative effect (95% CL) Adverse

Effects:

Methodological quality of include evidence according modification of the Jadad scale: Low Commented [4]: esta frase está sentido. o que
quality [Lee et al. (2008)]. Auricular acupuncture for insomnia: a systematic review AMSTAR querem dizer aqui?
score: 10/11b
Commented [5]: Pois, tens razão ... cada estudo (A)
avaliou outros estudos (B): "Low quality"
... e nos avaliamos os estudos A: 10/11 p.e.
 Auriculotherapy Better than Sham (p<0,05): Adverse
With MP, n=122 (2 studies): MD= 7.5, 95% CI [2.2 to 12.9] events were
2
I = 0%) for sleep efficiency. mentioned in
Auriculotherapy Better than Conventional medications three studies
(p<0,05): such as pain.
-1 study reported significant beneficial effects of MP on
symptoms and emoticons related to sleep compared with
diazepam and 3 studies that used SV, showed significant
improvement in nocturnal sleeping time.
-2 studies tested auriculotherapy with thumbtack-type needle
vs. no treatment and found beneficial effects on the sleep
score and self satisfaction scale compared with no
treatment.

Methodological quality of include evidence according to the Cochrane reviewers’ handbook:

LOW [Chen, Shi [14]]
AMSTAR score: 9/11a,b

Auriculotherapy Better than Control group (p<0,05): None of the

-Total recovery and improvement rates; studies
RR= 1.93 (95% CI [1.40–2.66 n= 390 (5 studies). mentioned
-Increasing sleep time to 6 hours, RR= 2.64 (95% CI [1.22– adverse
5.72] effects.
- SV were statistically favored over the controls RR = 1.80;
95% CI [1.42–2.28]) n= 122 (2 studies).
- Auriculotherapy Better than Diazepam, RR= 1.41 (95% CI
[1.12–1.77] n= 211 (3 studies).

Methodological quality of include evidence based on Jadad Score: MODERATE [

Yeung, Chung (2012)]
Acupressure, reflexology, and auricular acupressure for insomnia: A systematic
review of randomized controlled trials AMSTAR score: 10/11b

Auriculotherapy Better than Sham (p<0,05):

MD= 52.7, 95% CI: [16.9 to 88.5], RR= 0.69, 95% CI:[ 0.3 to NR
1.1;
- Sleep efficiency: MD=11.6%, 95% CI:[ 5.5 to 17.6], RR=
0.94, 95% CI: [0.5 to 1.4] n= 60 (1 studies).
Auriculotherapy Better than no treatment (p<0,05):
MD=-2.5, 95% CI: [-4.2 to -0.8], effect size: -0.82, 95% CI: [-
1.4 to -0.3] n= 10 (1 studies).

Methodological quality of include evidence based on GRADE system: LOW [Lan

et al., 2015]
AMSTAR score: 11/11
 Auriculotherapy Better than Sham (p<0,05) n= 661 (5 -Less
studies): adverse
- Clinical effective Rate: RR = 1.40, 95% CI [1.07 to 1.83]); effect:
- Sleep duration: MD = 56.46, 95% CI [45.61 to 67.31];
- Sleep efficiency: MD = 12.86, 95% CI [9.67 to 16.06]; RR = 0.11,
- Global score on PSQI: MD = -3.41, 95% CI [-3.93 to -2.89]; 95% CI [0.04
- Number of awakenings: MD = -3.27, 95% CI [-6.30 to - to 0.26]
0.25]);
- Sleep onset latency: MD = -10.35, 95% CI [-14.37 to -6.33].
Auriculotherapy Better than Convencional medications
(p<0,05) n= 575 (8 studies):
-Effective rate RR = 1.24, 95% CI [1.15 to 1.34];
- Sleep efficiency MD = 21.44, 95% CI [16.30 to 26.58];
- Lower PSQI score: MD = -3.62, 95% CI [-4.59 to -2.65].

Abbreviations: 95% Cl: 95% Confidence Interval; MD: Mean Difference; RR- Relative Risk; I2 – Heterogeneity; SV- Semen
Vaccariae Attachment; MP- Magnetic Pearls Attachment; PSQI- Pittsburgh Sleep Quality Index; NR- Not Related.

AMSTAR (Assessment of Multiple Systematic Reviews) grades of evidence: HIGH (9-11); MEDIUM (5-8); LOW (0-4)
a) The authors should state that they searched for reports regardless of their publication type (e.g. grey literature). The authors should
state whether or not they excluded any reports (from the systematic review), based on their publication status, language etc.
b) An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tests) and/or
statistical tests (e.g., Egger regression test, Hedges-Olken).
Table 3: Characteristics of identified systematic reviews that detect efficacy of acupuncture in orthopaedic pathologies and in
rheumatic diseases.

Relative effect (95% CL) Adverse

Effects:

Methodological quality of include evidence based on the criteria of the U.S. Preventive
Services Task Force and the National Health Service Centre for Reviews and Dissemination
(U.K.): 35% were good quality, 24% were fair quality, and 41% were poor quality [17] .
Auriculotherapy for Pain Management: A Systematic Review and Meta-Analysis of
Randomized Controlled Trials - AMSTAR score: 10/11a

Auriculotherapy Better than Control group (p<0,05) -Ear pain (n=16)

n=466 (8 studies): and tiredness
- Pain intensity SMD=1.56; (95% CI): 0.85, 2.26]. (n=16); local minor
-For perioperative pain, auriculotherapy reduced analgesic use bleeding (n=2),
SMD, 0.54 [95% CI: 0.30, 0.77]; 5 studies n=412). dizziness and
-Acute pain, MD=1.35 [95% CI: 0.08, 2.64] n=111 (2 studies); nausea (n=1), and
- Chronic pain, MD= 1.84 [95% CI: 0.60, 3.07] n=261 (5 headache (n=1).
studies);

Removal of poor quality studies did not alter the conclusions.

Methodological quality of include evidence based on Methodological Quality: good quality [16]
Efficacy of Auricular Therapy for Pain Management: A Systematic Review and Meta-Analysis
a
- AMSTAR score: 10/11

Auriculotherapy Better than Sham (p<0,05): NR

- SMD was 1.59 (95% CI [−2.36, −0.82]);
- Pain relief: MD = −1.81, 95% CI [−2.92, −0.70], p= 0.001)
n=806 (13 studies).
Auricular eletro-stimulation for pain reduction: SMD = −0.39;
95% CI [−1.05, 0.26] n=494 (7 studies);
-Acupressure for pain relief: MD = −1.85, 95% CI [−3.35, −0.35]
n=275 (4 studies).

Methodological quality of include evidence based on Cochrane Handbook for

Systematic Review for
Intervention: LOW [21]. Auricular therapy for chronic pain management in adults:
A synthesis of evidence AMSTAR score:10/11 c

1. Auriculotherapy Better than Sham (p<0,05): Adverse events

- Chronic pain: (4 studies, n=206); MD = -3.76, 95%CI {-4.97 to such as pain,
-2.54) in pain relief; needle-induced
- Chronic low back pain (4 studies, n=193); MD= -1.70, 95%CI hypotension,
[-2.83 to -0.56}; painful hematoma,
- Chronic tension headaches (2 studies, n=150); MD= -0.63, bleeding or local
95%CI [-0.95 to -0.30]; infection but no
- Acupressure (3 studies, n=180); MD=-0.75, 95%CI [-1.26to - serious adverse
0.25]; events associated
- Auricular electro-stimulation (4 studies, n=131); MD= -3.29, with
95%CI [-5.87 to -0.72]; auriculotherapy
- Chronic neck pain there was no statistically significant change
between groups (2 studies, n=83); MD= -3.03, 95% CI [-9.61 to
3.56].
Acupressure plus bloodletting therapy also reported significant
positive effects of the Auriculotherapy intervention for pain
relief. However, sub-group analysis showed no difference
between groups in chronic pain management.
2. Duration of pain relief:
- Short-term (0 to <3 weeks: 7 studies, n=363); MD= -2.15,
95%CI [-3.29 to -1.01];
- Mid-term (3 to <6 weeks: 6 studies, n=327); MD= -2.05,
95%CI [-3.20 to -0.89];
- Long-term (>6 weeks; 4studies, n=181); MD= -2.47, 95%CI [-
4.72 to -0.22].
3. Follow-up periods:
- One month: 5 studies, n=293; MD= -2.46, 95% CI [-4.32 to -
0.60];
- 3 months: 3 studies, n= 160; MD= -0.97, 95% CI [-2.81 to
0.87].

Methodological quality of include evidence based using the Physiotherapy

Evidence Database (PEDro) Scoring System,: was generally good or excellent
[15]. Ear Acupuncture for Immediate Pain Relief — A Systematic Review and
Meta-Analysis of Randomized Controlled Trials - AMSTAR score: 9/11 a,b
 Auriculotherapy Better than Sham group (p<0,05): Local pain,
-Ear acupuncture was superior in pain intensity (3 studies, bleeding,
n=204); MD= -0.96, 95% CI = [-1.82– -0.11]), but the MD was headache,
small. intraoperative
- Analgesic requirements, ear acupuncture was superior (6 bradycardia,
studies, n=159); MD= -1.08, 95% CI= [ -1.78– -0.38]). náusea and
dizziness in 6
studies.

Abbreviations: 95% Cl: 95% Confidence Interval; NR- Not Related; SMD- standardized mean differences; MD- mean difference.
AMSTAR (Assessment of Multiple Systematic Reviews) grades of evidence: HIGH (9-11); MEDIUM (5-8); LOW (0-4).
a) The authors should state that they searched for reports regardless of their publication type (e.g. grey literature). The auth ors
should state whether or not they excluded any reports (from the systematic review), based on their publication status, language etc.
b) An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tests) a nd/or
statistical tests (e.g., Egger regression test, Hedges-Olken). c) Potential sources of support should be clearly acknowledged in both
the systematic review and the included studies.

Relative effect (95% CL) Adverse Effects:

Methodological quality of include evidence based on Cochrane Risk of Bias: Not described
in article [18]. A meta-analysis of ear-acupuncture, ear-acupressure and
auriculotherapy for cigarette smoking cessation - AMSTAR score: 9/11 a,b

Auriculotherapy Better than Control group (p<0,05): sore ears,

- Cessation rates: were 22.7% (test) vs. 12.6% (control); tenderness,
RR = 1.77, 95% CI [1.39, 2.25], I2= 53%) n=1386 (10 sensation around
studies); residual needles,
bruising, facial
- 3 months follow-up (RR = 1.54, 95% CI [1.14, 2.08], I2=
swelling, headache,
11%) and the cessation rates were 15.8% (test) vs.10.1% dizziness, nausea,
(control), with 12.5% biochemically confirmed benefit giddiness, vomiting,
- 6 months follow-up (RR = 2.01, 95% CI [1.23, 3.28], I2= euphoria,
0%) with cessation rates of 12.4% (test) vs. 6.1% decreased
(control), RD 6.3%; this result was based on data without migraine, and
biochemical confirmation. change in insomnia.

Methodological quality of include evidence based on : [19]. Acupuncture and related

interventions for smoking cessation - AMSTAR score: 11/11
 Auriculotherapy Better than Sham group (p<0,05): NR
RR=1.69, 95% CI [1.32 to 2.16], n=1155 (14 studies);
- Subgroup analysis showed an effect for continuous
acupressure (7 studies, n = 496) RR 2.73, 95% CI 1.78 to
4.18);
- Acupressure to the correct points was more effective for
short-term cessation than acupressure to points deemed
ineffective (3 studies, n=325; RR 2.54, 95% CI 1.27 to
5.08)
Table 4: Characteristics of identified systematic reviews that detect efficacy of acupuncture in physical, emotional, and psychologica l
pathologies.

Abbreviations: 95% Cl: 95% Confidence Interval; RR- Relative Risk; I2 – Heterogeneity; NR- Not Related.

AMSTAR (Assessment of Multiple Systematic Reviews) grades of evidence: HIGH (9-11); MEDIUM (5-8); LOW (0-4).
a) The authors should state that they searched for reports regardless of their publication type (e.g. grey literature). The auth ors
should state whether or not they excluded any reports (from the systematic review), based on their publication status, language etc.

b) An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tests) a nd/or
statistical tests (e.g., Egger regression test, Hedges-Olken).

GRADE Working Group grades of evidence:

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have no important impact on our confidence in the estimate of effect and may change the
estimate.
Low quality: Further research is very likely to have important impact on our confidence in the estimate of effect and is likely to change the
estimate.
Very low quality: We are very uncertain about the estimate.
 Relative effect (95% CL) Adverse Effects:

Methodological quality of include evidence based on the Cochrane risk of bias tool: 2 studies
were high quality; 15 were moderate quality and 1 study was low quality (Yang et al., 2014).
Efficacy of Auriculotherapy for Constipation in Adults: A Systematic Review and Meta-
Analysis of Randomized Controlled Trials AMSTAR score: 9/11a,b

1 of 37 patients and
Auriculotherapy Better than Control group (p<0,05): 2 of 60 patients had
slight localized
RR= 2.06; 95% CI [1.52– 2.79] with total effective rate: redness and damage
(RR=1.28; 95% CI [1.13–1.44]; n=1324 (15 studies). to the skin, 7 of 39
patients had mild,
-For other symptoms associated with constipation, such a tolerable, and short-
abdominal distension or anorexia, results of the meta-analyses term itchiness of the
showed no statistical significance. ear points.

Methodological quality of include evidence based on : 1 study - Low risk for Random
sequence generation, low risk for Allocation concealment; low risk for Blinding of participants
and personnel; High risk for detection bias and low risk for attrition bias unclear risk for
reporting bias and low risk for other bias (Law & Li, 2013). - Acupuncture for glaucoma
AMSTAR score: 10/11b

Auriculotherapy Better than sham group (p<0,05): NR

- Intraocular pressure at four weeks (−3.70, 95% CI [ −7.11 to
−0.29] for the right eye; −4.90, 95% CI [−8.08 to −1.72] for the
left eye, but was not statistically different at any other follow-up
time points, including the longest follow-up time at eight weeks
n=33 (1 study).

Methodological quality of include evidence based on Jadad Scale: low quality [23]
Ear-acupressure for allergic rhinitis: a systematic review AMSTAR score: 9/11a,b
 Auriculotherapy Better than Fitoterapy group (p<0,05): no adverse events
n=108 (1 study) RR= 1.32; 95% CI [1.09, 1.59] and n=400 related to the ear-
(1study) RR= 2.48; 95% CI [1.95, 3.15]; but not than body acupressure
acupuncture: n=66 (1 study) RR=0.98; 95% CI [0.89, 1.08] or treatment.
anti-histamine (cetirizine): n=150 (1study) RR= 0.96; 95% CI
[0.88, 1.04] in a short term (4 weeks). However, is significantly
better long-term (6 months) effect than anti-histamine
medication: n=150 (1study) RR= 3.02; 95% CI [1.54,5.93].
-Auriculotherapy combining with body acupuncture, the effects
were superior to those from body acupuncture alone: n=80 (1
study) RR= 1.22; 95% CI [1.04, 1.43].
-Auriculotherapy had better effects than body acupuncture
treatment for subjects with Lung and Spleen Qi deficiency
syndromes. However, this is not the case for subjects with
phlegm-heat and blood stasis when compared with body
acupuncture: RR= 0.66; 95% CI [0.44, 0.98]. When subjects of
the subgroups are combined, the two treatments showed similar
clinical outcomes: RR= 1.01; 95% CI [0.79, 1.28] n=66 (1study)

Methodological quality of include evidence based on GRADE approach: 1 study -

Low risk for Random sequence generation, unclear risk for Allocation
concealment; high risk for Blinding of participants and personnel; Low risk for
detection bias and low risk for attrition bias low risk for reporting bias and unclear
risk for other bias [24]. Interventions for nausea and vomiting in early pregnancy
(Review) AMSTAR score: 11/11

Auriculotherapy Better than sham group (p<0,05): Adverse maternal

-Nausea/vomiting score combined Rhodes Index score on day 6 and fetal/neonatal
(3 days after treatment started): 1study, n=91; MD= -3.60; 95% outcomes were not
CI); [-6.62, -0.58] for overall effect: Z = 2.34, but not diferences reported.
in Number of anti-emetic drugs used on day 6.

Table 6 Characteristics of identified systematic reviews that detect efficacy of acupuncture in Gastroenterology, Immunology,
Ophthalmology and Gynaecology pathologies.

Abbreviations: 95% Cl: 95% Confidence Interval; RR- Relative Risk.

AMSTAR (Assessment of Multiple Systematic Reviews) grades of evidence: HIGH (9-11); MEDIUM (5-8); LOW (0-4).
a) The authors should state that they searched for reports regardless of their publication type (e.g. grey literature). The auth ors
should state whether or not they excluded any reports (from the systematic review), based on their publication status, langua ge etc.
b) An assessment of publication bias should include a combination of graphical aids (e.g., funnel plot, other available tes ts) and/or
statistical tests (e.g., Egger regression test, Hedges-Olken).

Discussion

The understanding of the mechanisms of actions of auriculotherapy treatments is still in progress

[4, 7]. The great amount of work that has been performed up to the present time to undertake of
auriculotherapy efficacy should be recognized and new work in this area should be encouraged.
Thus, we present a global work of the evidence of systematic reviews available in the literature,
to potentiate the development of scientifically acceptable hypothesis to explain the action of
auriculotherapy.
After analyzing the results related to auriculotherapy, there seems to be unanimity about the
existence of acupuncture points and the efficacy of this therapy, particularly for pain relief.
However, this does not mean that work should cease in this field. It is necessary to recognize the
great amount of work done so far to try to standardize the auricular nomenclature and to
encourage new work with different methodologies, especially in the follow-up.
Following the work published by Juan Muñoz-Ortego et al. In 2016,
The authors find to that the medical indications of systemic acupuncture more frequently are also
the pain, such as tension headaches and migraines, osteoarthritis, low back pain, ankle sprains
as well as in sore throat [27].
Regarding the pathologies of the neurological forum, auriculotherapy showed efficacy in insomnia
in all the systematic reviews included in our study. Although the authors report some medical
indications for acupuncture in the area of neurology but the number of studies included in the
reviews was lower and inserts [27]. In this way, it may be useful in the future to have more studies
with cross-methodologies involving systemic acupuncture and auriculotherapy.
Concerning the area of mental health, conditions as a Smoking cessation seem to have favorable
results with auriculotherapy. However, in systemic acupuncture they only report results on
depression and schizophrenia. In a way, the effect of acupuncture in this area is categorized as
potential and also requires further study [27].
Gates et al., (2006) do not identify any associated effect using auriculotherapy with the study
Auricular acupuncture for cocaine dependence. The author concludes that two studies with a total
of 1,433 participants were included, all of them were of low methodological quality. So, further
randomized trials of auricular acupuncture may be warranted in this field.
In the rest of pathologies, the number of studies included in the reviews is lower or there are
reviews that prove certain effect of acupuncture and others that do not observe any effect.
With regard to methological procedures of reviews included, some aspects deserve our analysis,
like the use of semi-permanent needles comparative than regular acupuncture needles or
auriculopressure. This way, semi-permanent needles would expect a larger effect because of
them creates a continues stimulation to the point for a longer treatment period effect [3, 28].
However, the auriculopressure used by Di et al; White et al and Yeh et al. (2014), show better effects on
pain relief when comparing semi-permanent needles. Also, the stimulation with
electroacupuncture showed no significant evidence in pain relief as well as in smoking session
compared to other forms of auricular acupressure. However, we emphasize the importance of the
authors' care in formulating the conclusions in this type of auricular stimulation. More than 200
acupoints have been identified on the ear. The pathology of the region on the body is believed to
be diagnosable in auriculotherapy by means of inspection, palpation, and electrical skin
conductance of relevant areas on the ear. So, in the presence of pathology, specific auricular
acupoints are said to have comparatively higher or lower resistance than nearby reference
auricular points [29]. Nevertheless, none of the reviews included in this study referred the use of
any assessment by these resources described above.
About the results of this review, we are subject to the limitations of the detected and selected
reviews. In fact, we find high quality according to the criteria established by AMSTAR in our 14
systematic reviews included. However, these systematic reviews found several studies with
limitations and neglected crucial details for methodological evaluation.
 Small sample size under study, randomisation criteria, low heterogeneity of the included studies,
literature search criteria, laboratory experiments on animals, clinical trials, non English or Spanish
or Portuguese language articles, were excluded from the analysis. For this reason, there may be
several studies with positive results excluded, but on the other hand, the advantage of this
approach is the inclusion of quality-guaranteed articles only.
In this sense, it would be interesting to launch cost-effectiveness studies in order to assess the
degree of efficiency that auriculotherapy, could bring the help in the treatment of the disorders
discussed. It would be interesting to encourage studies of various medical indications not
addressed in this review

Conclusions

The synthesis presented in this systematic review states that auriculotherapy has enough
scientific evidence to be indicated in the treatment of chronic pain, mainly headaches, migraines,
back pain, neck pain and osteoarthritis. In order to reach firm conclusions about other potential
pathologies to be treated with auriculotherapy, more researches with higher methodological
quality and following the Standards for Reporting Interventions in Clinical Trials of Acupuncture
(STRICTA criteria) are necessary.
Our findings suggest that auriculotherapy may be used as adjunctive therapy for pain
management as well as insomnia and smoking sessations in order to reduce the use of
conventional medications to minimize potential adverse effects as well as duration of outcomes.

Acknowledgments

We thank financial support for his research from the Institute of Biomedical Sciences of Abel
Salazar of Porto, Portugal and Marina Bertoncello by language review.

[MB1]that currently exist

[MB2]such as auricular…