See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/280869089

Changes in Sleep With Auricular Point Acupressure for Chronic

Low Back Pain

Article in Behavioral Sleep Medicine · August 2015

DOI: 10.1080/15402002.2014.981820 · Source: PubMed

CITATIONS READS

24 459

8 authors, including:

Chao Yeh Lorna K P Suen

Johns Hopkins University Tung Wah College
35 PUBLICATIONS 613 CITATIONS 177 PUBLICATIONS 2,930 CITATIONS

SEE PROFILE SEE PROFILE

Lung-Chang Chien Zhan Liang

University of Nevada, Las Vegas University of Miami
105 PUBLICATIONS 2,022 CITATIONS 46 PUBLICATIONS 495 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Spatiotemporal analysis in Zika virus infection View project

Auricular Therapy for Chemotherapy-Induced Nausea and Vomiting in Female Breast Cancer Patients: A Preliminary Randomized Controlled
Trial View project

All content following this page was uploaded by Lung-Chang Chien on 15 December 2016.

The user has requested enhancement of the downloaded file.

This article was downloaded by: [The University of Texas School of Public Health], [Lung-
Chang Chien]
On: 07 August 2015, At: 13:37
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: 5 Howick Place, London, SW1P 1WG

Behavioral Sleep Medicine

Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/hbsm20

Changes in Sleep With Auricular Point

Click for updates
Acupressure for Chronic Low Back Pain
a b c
Chao Hsing Yeh , Lorna Kwai-Ping Suen , Juan Shen , Lung-Chang
de a f gh
Chien , Zhan Liang , Ronald M. Glick , Natalia E. Morone & Eileen
a
R. Chasens
a
School of Nursing, University of Pittsburgh
b
School of Nursing, Hong Kong Polytechnic University
c
School of Nursing, Suzhou Health College
d
Department of Biostatistics, University of Texas School of Public
Health at San Antonio Regional Campus
e
Research to Advance Community Health Center, University of Texas
Health Science Center at San Antonio Regional Campus
f
Departments of Psychiatry, Physical Medicine, and Rehabilitation,
University of Pittsburgh, School of Medicine
g
Department of Medicine, Division of General Internal Medicine,
University of Pittsburgh, School of Medicine
h
Veterans Administration Pittsburgh Healthcare System, Geriatric
Research, Education, and Clinical Center
Published online: 05 Aug 2015.

To cite this article: Chao Hsing Yeh, Lorna Kwai-Ping Suen, Juan Shen, Lung-Chang Chien,
Zhan Liang, Ronald M. Glick, Natalia E. Morone & Eileen R. Chasens (2015): Changes in Sleep
With Auricular Point Acupressure for Chronic Low Back Pain, Behavioral Sleep Medicine, DOI:
10.1080/15402002.2014.981820
To link to this article: http://dx.doi.org/10.1080/15402002.2014.981820

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the
“Content”) contained in the publications on our platform. However, Taylor & Francis,
our agents, and our licensors make no representations or warranties whatsoever as to
the accuracy, completeness, or suitability for any purpose of the Content. Any opinions
and views expressed in this publication are the opinions and views of the authors,
and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content
should not be relied upon and should be independently verified with primary sources
 of information. Taylor and Francis shall not be liable for any losses, actions, claims,
proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or
howsoever caused arising directly or indirectly in connection with, in relation to or arising
out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Conditions of access and use can be found at http://www.tandfonline.com/page/terms-
and-conditions
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015
 Behavioral Sleep Medicine, 00:1–16, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1540-2002 print/1540-2010 online
DOI: 10.1080/15402002.2014.981820
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

Changes in Sleep With Auricular Point

Acupressure for Chronic Low Back Pain
Chao Hsing Yeh
School of Nursing, University of Pittsburgh

Lorna Kwai-Ping Suen

School of Nursing, Hong Kong Polytechnic University

Juan Shen
School of Nursing, Suzhou Health College

Lung-Chang Chien
Department of Biostatistics, University of Texas School of Public Health at San Antonio
Regional Campus
Research to Advance Community Health Center, University of Texas Health Science
Center at San Antonio Regional Campus

Zhan Liang
School of Nursing, University of Pittsburgh

Ronald M. Glick
Departments of Psychiatry, Physical Medicine, and Rehabilitation, University of
Pittsburgh, School of Medicine

Natalia E. Morone
Department of Medicine, Division of General Internal Medicine, University of
Pittsburgh, School of Medicine
Veterans Administration Pittsburgh Healthcare System, Geriatric Research, Education,
and Clinical Center

Eileen R. Chasens
School of Nursing, University of Pittsburgh

Correspondence should be addressed to Chao Hsing Yeh, RN, PhD, University of Pittsburgh, School of Nursing,
3500 Victoria Street, 440 Victoria Building, Pittsburgh, PA 15261, USA. E-mail: yehc@pitt.edu
Color versions of one or more figures in this article are available online at www.tandfonline.com/hbsm

1
 2 YEH ET AL.

The purpose of this study was to report sleep quality from 4 weeks of auricular point acupressure
that was designed for chronic low back pain and determine the relationship between pain intensity
and sleep quality. Participants were randomized into the APA group .n =30/ or the sham-APA group
.n =31/. At baseline assessment, 87% of the participants reported poor sleep quality. Participants
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

who received APA had decreased daytime disturbance and improved global Pittsburgh Sleep Quality
Index scores at end of intervention (EOI) and 1-month follow up compared to participants in the
sham-APA group. For the APA group, both the sleep duration and wake after sleep onset decreased
gradually during the 4-week APA (0.56% and 0.23% daily change, respectively).

With an annual prevalence estimated at 28%, chronic low back pain (CLBP) is the most
common self-reported pain condition in the United States (National Center for Health Statistics,
2014; Waterman, Belmont, & Schoenfeld, 2012). As such, CLBP imposes a significant societal
and economic burden on the U.S. health care system. The estimated cost of CLBP in the
United States ranges from $84.1 billion (direct—health care) to $624.8 billion (indirect—loss
in productivity) per year (Dagenais, Caro, & Haldeman, 2008; Gore, Sadosky, Stacey, Tai, &
Leslie, 2012; Katz, 2006).
Patients who suffer from CLBP often report the co-occurrence of sleep disorders (Alsaadi,
McAuley, Hush, & Maher, 2011; Marin, Cyhan, & Miklos, 2006). It is estimated that more
than 50% of CLBP patients report sleep disturbances (Alsaadi et al., 2011; Kelly, Blake, Power,
O’Keeffe, & Fullen, 2011). Sleep-related problems have been suggested as an important element
in evaluating the efficacy and effectiveness of pain management outcomes from not only the
recommendations of experts (Turk et al., 2008), but also patients (Casarett, Karlawish, Sankar,
Hirschman, & Asch, 2001). For example, in a study of 367 older adults with osteoarthritis
pain and insomnia, the short-term improvement in sleep (i.e., 2 months) can predict long-term
(i.e., 9 and 18 months) chronic pain improvement (Vitiello et al., 2014). Additionally, in a
study of 1,206 patients experiencing difficulty in resuming work, 74% of patients experiencing
moderate/severe sleep disturbance also reported moderate/severe pain problems (Linder, Jansen,
Ekholm, & Ekholm, 2014). Nonetheless, current clinical research generally does not include
sleep disturbance as a pain management outcome (Vickers et al., 2012; Witt et al., 2012).
Multiple pharmacologic and nonpharmacologic treatments exist that, when implemented
properly, can provide relief for many who experience CLBP (Chang, Gonzalez, & Akuthota,
2008; Dagenais, Tricco, & Haldeman, 2010; Haldeman & Dagenais, 2008; Rubinstein et al.,
2010; White, Arnold, Norvell, Ecker, & Fehlings, 2011). However, even when pain is ag-
gressively treated according to state-of-the-science recommendations, CLBP pain management
remains suboptimal for many (Dagenais et al., 2008; Katz, 2006). Analgesic use is the most
common strategy to treat CLBP, yet this is associated with a variety of adverse side effects.
In addition, a patient’s needs for pain medication can escalate, resulting in dependence and
the potential for drug addiction (Benyamin et al., 2008; Malanga & Wolff, 2008). Therefore, a
growing number of CLBP patients in the United States have sought nonpharmacological pain
management. In 2007, American adults spent an estimated $33.9 billion on complementary
and alternative medicine (CAM) and $11.9 billion on visits to CAM practitioners, including
acupuncturists (Nahin, Barnes, Stussman, & Bloom, 2009). In particular, a 2007 government
survey estimated that more than 3 million American adults had used acupuncture for CLBP
in the previous 12 months (Barnes, Bloom, & Nahin, 2008). While acupuncture can be an
effective therapy for pain management (Vickers et al., 2012), use of this approach is limited
 CHANGES IN SLEEP WITH ACUPRESSURE 3

because (a) patients must travel frequently to receive acupuncture treatment (Lu & Rosenthal,
2010), (b) the cost of treatment often is not covered by insurance (Lind et al., 2005), and
(c) patients may be afraid of needles (Schapira et al., 2014).
Auricular point acupressure (APA), an alternative to acupuncture, utilizes pressure applied to
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

botanical seeds (or pellets) taped onto specific ear acupuncture points to produce acupuncture-
like stimulation effects. In this way, APA can treat disease and illness without using needles
(Huang, 2005; Oleson, 2014). APA is based on reflex theory, which posits that the symptomatic
body can induce tenderness in specific ear points, and the treatment of these ear points can
stimulate the brain to correct related pathological reflex centers, which, in turn, will induce
reflex reactions in the body to relieve pathology (Nogier, 1981; Oleson, 2014). The World
Health Organization (WHO) considers APA a form of micro-acupuncture that can affect the
whole body (World Health Organization, 1990).
Our previous publications describe how APA has been used to manage pain in CLBP
patients. These studies provide preliminary evidence of immediate CLBP relief (i.e., a 40%
reduction in pain intensity) after one day of APA (Yeh, Chien, Chiang, & Huang, 2012)
and even greater and lasting effects on CLBP (i.e., 75% pain relief and 45% better physical
function after a four-week APA treatment, which were statistically significant compared to
the sham APA group; Yeh et al., 2013). Participants in the APA treatments exhibited changes
in inflammatory cytokines (decreased IL-1ˇ, IL-4, IL-10; increased IL-2; Yeh et al., 2014),
decreased pain catastrophizing (Yeh et al., 2013), and reduced fear avoidance after a four-week
APA intervention, when compared with participants in the sham group (Yeh et al., 2013). This
paper describes the sleep quality results of a four-week APA that was designed for CLBP and
sought to determine whether or not there was any relationship between pain intensity and sleep
disturbance.

METHODS

The complete details of the study design, sample, and data collection are described in our
previous publication (Yeh et al., 2013). In brief, 61 participants with CLBP were enrolled;
30 participants were randomized into the APA group, and 31 into the sham APA group.
CLBP was defined as low back pain occurring for at least three months with an average pain
intensity score of at least 4 (on a 0 to 10 scale) for one week before the time of enrollment.
Every participant received weekly APA treatment for four weeks based on his or her group
assignment. Data were collected at baseline, during each of the four office visits for APA
treatment, after the completion of the four-week APA (i.e., end of intervention [EOI]), and one
month after the last treatment. A daily diary was given to each participant to record his or
her APA practices, analgesic use, and pain intensity. Institutional review board approval was
obtained before conducting the study.

Auricular Point Acupressure Treatment Protocol

The selection of ear points for APA treatment includes (a) corresponding points, (b) points
featuring both disharmony of zang organs and disturbance of meridians, and (c) active points
located at the waist triangle, groove of spinal posterior, and groove of sciatic posterior areas
 4 YEH ET AL.
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

FIGURE 1 Ear points selection.

of the ear (Huang & Huang, 2007). The Chinese Standard Ear-Acupoints Chart, which is
recognized by the WHO, is used to locate the points (World Health Organization, 1990).
Figure 1 lists the ear points treated for CLBP. In Figure 1, the ear points corresponding to
the lower back are circled in red on the anterior side of the ear and appear as red points on
the posterior side of the ear. The three points for alleviating stress and pain (i.e., shenmen,
sympathetic, and nervous subcortex), according to disharmony of zang organs and disturbance
of meridians, are located on the anterior ear. The active ear points corresponding to CLBP
(appearing as the waist triangle cluster) and the grooves of the spinal and sciatic posterior
are all located on the posterior side of the ear. An electrical point finder (Auricular Medicine
International Research & Training Center [AMIRCT], Birmingham, AL) was used to locate the
points, which is done by detecting decreased electrical resistance. Vaccaria seeds were placed
on the subject’s ears based on the points indicated by the AMIRCT point finder.
Participants in the sham APA group had Vaccaria seeds taped onto the stomach, mouth,
duodenum, and eye acupoints of both ears. Participants were told (a) to press the seeds on each
ear at least three times a day for 3 min each time using the thumb and forefinger and (b) to
press the seeds whenever they experienced pain. Participants were instructed to remove the
tape and seeds after five days. Doing so ensured that not only the ear was free of tape two days
each week to minimize the risk of an allergic reaction to the tape, but also the acupoints were
allowed time to recover and restore sensitivity prior to the next treatment. Each participant was
given a diary to monitor his or her adherence to the treatment protocol (i.e., the actual times he
or she pressed the seeds each day and the duration of applied pressure), analgesic use, related
 CHANGES IN SLEEP WITH ACUPRESSURE 5

medication and supplements, and pain intensity. All data were collected by a trained collector
who was blinded to the group assignment of the participants.
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

Outcome Measures
The Brief Pain Inventory-short form (BPI-sf; Cleeland & Ryan, 1994) was used to measure
pain intensity. The BPI-sf includes two subscales: pain severity/intensity and pain interferences
during the previous seven days. In the data analysis featured in this paper, only the worst pain
intensity was used. Pain severity/intensity comprises four items (i.e., worst, least, average, and
now) that assess pain on an 11-point scale (i.e., 0 D no pain at all and 10 D pain as bad as
you can imagine). Higher subscale BPI-sf scores indicate more severe pain.
The Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds, Monk, Berman, & Kupfer,
1989) is a 19-item, self-rated quesionnaire to assess subjective sleep quality and disturbances
during the previous month. The PSQI consistents of seven domain scores that include subjective
sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use
of sleep aid medications, and daytime dysfunction. Scores for these domains are combined
to provide a global sleep quality index score. The global PSQI scores potentially range from
0 to 21, with a PSQI score greater than 5 indicating poor sleep quality. In our analysis, the
item pain was removed to avoid possible corrleation with pain intensity. A three-factor scoring
model (i.e., sleep efficiency, perceived sleep quality, and daily disturbance; Cole et al., 2006) is
reflective of how people respond to impaired sleep quality and therefore was used in the final
data analysis. A decrease of three points on the PSQI is considered to be a clinically important
difference (Buysse et al., 2011). The Cronbach’s alpha for the global PSQI was 0.83 in the
study that we are reporting here.
The Daily Sleep Diary (Carney et al., 2012) was used to record self-reported sleep parameters
in addition to daily worst pain intensity, pain medication, and APA practice. These sleep
parameters included time in bed (i.e., the total amount of time in bed at night), nocturnal sleep
time (i.e., the total time the participants slept at night), sleep latency (i.e., the amount of time
it takes to fall asleep after the lights have been turned off), sleep efficiency (i.e., calculated
as self-reported sleep duration divided by time in bed multiplied by 100), wake after sleep
onset (i.e., the amount of time a participant was awake during the night), total sleep time
(i.e., nocturnal sleep time minus sleep latency minus wake after sleep onset), and number of
awakenings (i.e., how many times the participant woke up during the night after sleep onset).
The Demographics and Health History questionnaire designed by the research team queries
age, marital status, education level, living arrangements, ethnicity, disease diagnosis, chronic
condition, related medication, cancer treatment status, and adjunct pain treatments used.

Data Analysis
In order to examine the true effects of the APA, two types of analyses were conducted for
primary outcomes: (a) intent-to-treat (ITT) analysis, which used the data of all participants,
regardless of adherence, treatment received, withdrawal, or devation from protocol (Heritier,
Gebski, & Keech, 2003; Newell, 1992; Wertz, 1995) and (b) per-protocol (PP) analysis, which
included only those participants who adhered to the APA (Heritier et al., 2003; Newell, 1992;
 6 YEH ET AL.

Wertz, 1995). Missing values of the outcome variables were replaced by last observation
carried forward. Descriptive statistics were used to present demographic characteristics and
study measures. A general linear model with post hoc test (using the GLM Procedure in SAS)
was used to capture the main effects of change scores of outcome measures (i.e., baseline to
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

EOI and one-month follow-up, modeling covariance across time) and the group comparison
(i.e., APA and sham APA) and their interaction effect (McGullagh & Nelder, 1989). Moreover,
the joinpoint regression modeling approach was used to estimate the linear trend of daily
sleep parameters over time (Kim, Fay, Feuer, & Midthune, 2000). The model was constructed
by fitting a linear regression to the score of sleep parameters, using the daily mean score
as a regression outcome and calendar day as a predictor, to characterize the trend of change
from baseline (i.e., day 0) to the completion of the four-week APA treatment (i.e., day 28).
This approach can analyze trends with different plots connected at certain joinpoints, and each
joinpoint represents a significant change in the slope of the trend. A permutation test determined
the best number of joinpoints in the final model of each measurement in each group (Kim
et al., 2000). The Pearson correlation coefficient was used to examine the relationship between
outcomes. Differences were considered statistically significant at p < :05. All of the data
analyses were performed using SAS software, version 9.2, and Jointpoint software, version
4.1.0.

RESULTS

Demographic Characteristics
Sixty-one participants were randomized into the APA group (n D 30) and the sham APA group
(n D 31; Table 1). The retention rate was 83% (n D 25) for the APA group and 68% (n D
21) for the sham group. The mean age of the 61 participants was 63.3 years (SD D 16.70;
range 20–90 years), and they were primarily female (n D 41, 67.2%) and white (n D 51,
83.6%). Four participants took sleep medication at the time of data collection, which included
temazepam (n D 1), melatonin (n D 1), and an over-the-counter sleep aid (n D 2). There
were no statistically significant differences in demographic characteristics between the APA
and sham APA groups. In addition, there were no statistically significant differences in pain
intensity (including worst pain, average pain, and current pain) and sleep quality at baseline
assessment between the APA and sham APA groups.

Sleep Quality
The majority of participants displayed poor sleep quality (i.e., the global PSQI score was > 5
for 90% [n D 27] of the APA group and for 84% [n D 26] of the sham APA group). At baseline,
there was no statistically significant difference in sleep efficiency, perceived sleep quality, daily
disturbance, or the global PSQI score between the APA and sham APA groups. These findings
are not presented here, but are available upon request. Table 2 presents the change scores in
outcomes measures from baseline to EOI and to one-month follow-up for both ITT and PP.
For ITT, the average score of worst pain in the APA group decreased 3.53 points from baseline
to EOI, which was a statistically significant change compared to the sham APA group, which
 CHANGES IN SLEEP WITH ACUPRESSURE 7

TABLE 1
Demographic Characteristics of the Participants (n D 61)

Mean (SD) or n (%)

Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

Real (n D 30) Sham (n D 31) p-value

Age
Mean (SD) 60.97 (17.44) (20–82) 65.61 (16.04) (21–90) 0.91
Gender, n (%)
Male 10 (33.3%) 10 (32.3%) 0.93
Female 20 (66.7%) 21 (67.7%)
Race/ethnicity, n (%)
White 26 (86.7%) 25 (80.6%) 0.73
Black/African American 4 (13.3%) 6 (19.4%)
Marital status, n (%)
Married or living with partner 14 (46.7%) 13 (42.0%) 0.78
Divorced or widowed 10 (33.4%) 11 (35.5%)
Never married 6 (20% ) 5 (16.1%)
Employment situation 0.67
Working (full time) 6 (20%) 4 (12.9%)
Working (part time) 2 (6.7%) 2 (6.5%)
Not employed 4 (13.2%) 6 (19.4%)
Retired 15 (50%) 14 (45.1%)
Others 3 (10%) 5 (16.2%)
Education level
< 11th grade 2 (6.7%) 2 (6.5%) 0.62
High school 5 (16.7%) 4 (12.9%)
Technical or vocational school 2 (6.7%) 2 (6.5%)
College and graduate 21 (70.1%) 21 (67.7%)
Missing 2 (6.5%)
Estimated income before taxes 0.25
Less than $10,000 5 (16.7%) 7 (22.6%)
$10,000 to $19,999 2 (6.7%) 5 (16.1%)
$20,000 to $39,999 8 (26.7%) 2 (6.5%)
$40,000 to $59,000 6 (20%) 7 (22.6%)
$60,000 to $100,000 3 (10%) 5 (16.1%)
More than $100,000 3 (10%) 1 (3.2%)
Missing 3 (10%) 4 (12.9%)
Medical diagnosis related to back pain
Osteoporosis 3 (10%) 4 (12.9%)
Osteoarthritis 9 (30%) 9 (29%)
Scoliosis 4 (13.3%) 5 (16.1%)
Kyphosis 1 (3.3%) 0 (0%)
Discherniation 6 (20%) 7 (22.6%)
Spinal stenosis 8 (26.7%) 13 (41.9%)
Spondylitis 1 (3.3%) 0 (0%)
Spondylosis 3 (10%) 0 (0%)
Current pain medication use
Yes 13 (43.3%) 14 (45.2%)
No 17 (56.7%) 17 (54.8%) 0.89
Current sleep medication use
Yes 1 (3.3%) 3 (9.7%)
No 29 (96.7%) 28 (90.3%) 0.89
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

TABLE 2
Outcome Measurement Changes From Baseline to End-of-Intervention and One-Month Follow-Up Between the APA and Sham APA Groups

APA Sham Difference (APA–Sham)

Outcome Duration Mean SD Mean SD Estimate 95% CI p-value Effect

ITT
Worst pain Baseline to End-of-Intervention 3.53 2.66 0.77 1.41 2.76 3.93 1.59 <.0001 1.30
Baseline to 1-Month Follow-up 3.70 2.78 0.84 2.22 2.86 4.03 1.69 <.0001 1.14
Perceived sleep quality Baseline to End-of-Intervention 0.24 0.34 0.08 0.35 0.16 0.36 0.05 0.1300 0.46
Baseline to 1-Month Follow-up 0.26 0.52 0.01 0.38 0.27 0.47 0.06 0.0115 0.58
Sleep efficiency Baseline to End-of-Intervention 0.15 0.89 0.05 0.52 0.10 0.52 0.32 0.6348 0.14
Baseline to 1-Month Follow-up 0.08 1.12 0.15 0.69 0.23 0.65 0.19 0.2864 0.25
Daytime disturbance Baseline to End-of-Intervention 0.20 0.39 0.02 0.33 0.18 0.39 0.02 0.0776 0.51
Baseline to 1-Month Follow-up 0.13 0.51 0.05 0.37 0.08 0.29 0.12 0.4124 0.19
Global PSQI Baseline to End-of-Intervention 1.42 2.08 0.37 1.37 1.05 2.22 0.13 0.0840 0.60
Baseline to 1-Month Follow-up 1.22 3.55 0.21 1.83 1.43 2.60 0.25 0.0191 0.51
PP
Worst pain Baseline to End-of-Intervention 3.21 2.58 0.78 1.72 2.66 4.04 1.29 0.0003 1.27
Baseline to 1-Month Follow-up 3.43 2.90 0.22 2.22 2.77 4.14 1.40 0.0002 1.06
Perceived sleep quality Baseline to End-of-Intervention 0.19 0.31 0.07 0.40 0.17 0.43 0.10 0.2204 0.43
Baseline to 1-Month Follow-up 0.33 0.65 0.26 0.40 0.32 0.59 0.06 0.0202 0.62
Sleep efficiency Baseline to End-of-Intervention 0.11 1.10 0.11 0.70 0.11 0.67 0.45 0.7038 0.13
Baseline to 1-Month Follow-up 0.18 1.54 0.11 0.99 0.31 0.87 0.24 0.2725 0.29
Daytime disturbance Baseline to End-of-Intervention 0.39 0.45 0.17 0.43 0.22 0.48 0.05 0.1177 0.53
Baseline to 1-Month Follow-up 0.32 0.61 0.11 0.60 0.09 0.36 0.18 0.5191 0.17
Global PSQI Baseline to End-of-Intervention 1.57 2.41 0.11 1.45 1.15 2.70 0.39 0.1474 0.59
Baseline to 1-Month Follow-up 2.00 4.76 1.22 1.64 1.77 3.31 0.22 0.0273 0.55

Note. ITT: intention-to-treat; PP: per-protocol; SD D standard deviation; PSQI: Pittsburgh Sleep Quality Index; CI D confidence interval.
Worst pain: higher scores higher pain intensity. Perceived sleep quality factor, sleep efficiency factor, daytime disturbance factor: higher scores indicate poorer
sleep quality.
 CHANGES IN SLEEP WITH ACUPRESSURE 9

only displayed 0.77 points of decrement (p value < .0001). The APA group also displayed
a statistically significant 2.86-point (p value < .0001) decrement compared to the sham APA
group from baseline to one-month follow-up. For sleep quality outcomes, participants in the
APA group displayed statistically significant, decreased scores in perceived sleep quality and
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

the global PSQI score from baseline to one-month follow-up compared to participants in the
sham APA group. Similar findings were also obtained for PP.
In terms of sleep disturbance, 27 participants in the APA group reported sleep disturbance
(global PSQI score > 5) at baseline, but 3 of them (11%) had no sleep disturbance at EOI,
and 4 of them (15%) improved their sleep disturbance at one-month follow-up. However, 26
participants in the sham APA group reported sleep disturbance at baseline, and one of them
(4%) had no sleep disturbance at EOI, and there was no sleep improvement at one-month
follow-up. There was no statistically significant improvement in sleep disturbance between the
APA and the sham groups.
We further examined whether or not the participants who completed the four-week APA
experienced clinically significant improvement of PSQI—defined as a three-point decrease in
the global PSQI score. Only participants who completed the entire study assessment were
examined. Twenty-four percent of participants who completed the four-week APA (n D 6
of 25 total) at EOI and 28% of participants at one-month follow-up (n D 7 of 21 total)
experienced clinically significant improvement in the global PSQI score. The difference in two
proportions (from baseline to EOI and baseline to one-month follow-up) is 4 (95% CI D
28, 20), which indicates there is no statistically significant difference between the change at
EOI and the change at one-month follow-up in the APA group. Additionally, only 10% (n D
2) of participants in the sham APA group at EOI and 5% (n D 1) at one-month follow-up
had changes in scores of three or greater points, but there were no within-groups differences
in the sham group (95% CI D 12, 20). For the between-group differences, the proportional
difference between the APA group and the sham group is not statistically significant (95% CI D
6, 35) from baseline to EOI; however, the proportional difference was 23% from baseline to
one-month follow-up (95% CI D 2, 43), which suggests that the proportion of the participants
in the APA group who exhibited an improved PSQI score is, statistically, significantly higher
compared to the participants in the sham group at one-month follow-up.

Daily Worst Pain and Sleep Diary

Table 3 lists the trends of worst pain, sleep efficiency, sleep latency, time awake after sleep
onset, sleep awakenings, and sleep duration, and these trends are shown in Figure 2. We
observed that both the APA and sham APA groups displayed the same statistically significant
decrease in the time trend of worst pain on day 2, which caused a statistically significant daily
decrease of 1.22 points (p value D 0.0001; 95% CI D 1.71, 0.74) in the APA group and
0.60 points (p value D 0.0151; 95% CI D 1.05, 0.15) in the sham APA group from baseline.
After day 2, the worst pain score increased; however, only the sham APA group displayed a
statistically significant daily increase of 0.02 points (p value D 0.0033; 95% CI D 0.01, 0.03)
until day 28. The APA group had an additionally statistically significant bent on day 9, which
lead to a statistically significant decrease of 0.06 points (p value < .0001; 95% CI D 0.08,
0.04) until day 28.
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

10

TABLE 3
Trends of Worst Pain Score and Sleep Factors

APA Sham APA

Period Period
(Days) Estimate 95% CI p-value (Days) Estimate 95% CI p-value

Worst pain 0–2 1.22 1.71 0.74 0.0001 0–2 0.60 1.05 0.15 0.0151
2–9 0.07 0.03 0.17 0.2004 2–28 0.02 0.01 0.03 0.0033
9–28 0.06 0.08 0.04 <.0001
Sleep duration 0–28 0.55 1.01 0.08 0.0300 0–10 2.80 0.85 4.75 0.0097
10–28 0.89 1.75 0.02 0.0557
Sleep efficiency 0–28 0.0001 0.0001 0.0004 0.3244 0–9 0.0019 0.0001 0.0036 0.0476
9–28 0.0002 0.0007 0.0003 0.4233
Sleep latency 0–28 0.03 0.02 0.07 0.2611 0–28 0.03 0.02 0.07 0.2611
Sleep awakenings 0–12 0.04 0.06 0.02 0.0019 0–7 0.06 0.13 0.01 0.0939
12–15 0.13 0.29 0.54 0.5523 7–28 0.0022 0.0072 0.0117 0.6477
15–28 0.05 0.07 0.03 0.0001
Time awake after sleep onset 0–28 0.23 0.32 0.14 <.0001 0–28 0.09 0.19 0.02 0.1337

Note. CI: confidence interval. Worst pain: negative trend means improvement; positive trend means worsening. Sleep efficiency, sleep latency, sleep awakenings,
time awake after sleep onset: negative trends mean worsening, positive trend means improvement.
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

11

FIGURE 2
The daily change patterns of worst pain intensity and sleep quality.
 12 YEH ET AL.

TABLE 4
Pearson Correlation Between Pain Intensity and Sleep Quality

Perceived Sleep Daytime Global

Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

Worst Pain Sleep Quality Efficiency Disturbance PSQI

Baseline .33* .11 .22 .31*

End-of-intervention .51** .17 .46** .53**
One-month follow-up .44** .34** .45** .58**

*Correlation is significant at the 0.05 level (2-tailed). **Correlation is significant at the

0.01 level (2-tailed).
Note. PSQI: Pittsburgh Sleep Quality Index.

For the other five sleep parameters, there was no statistically significant bent in the APA
group, except for sleep awakenings, which had two statistically significant bents on day 12
and day 15, causing two statistically significantly declining trends: 0.04 times (p value D
0.0019; 95% CI D 0.06, 0.02) per day from baseline to day 12 and 0.05 times (p value D
0.0001; 95% CI D 0.07, 0.03) per day from day 15 to day 28. Even though there was no
statistically significant bent for the other four sleep parameters in the APA group, we examined
significant declinations in sleep duration and time awake after sleep onset. In the sham APA
group, there were three statistically significant bents for sleep duration, sleep efficacy, and
sleep awakenings. The statistically significant bent in sleep duration in the sham APA group
reflects a statistically significantly daily elevation by 2.80 min (p value D 0.0097; 95% CI D
0.85, 4.75) from baseline to day 10; however, there was no statistically significant trend after
day 10. The same situation emerged for sleep efficiency in the sham APA group-a statistically
significant bent was observed on day 9, which produced a statistically significant increment
from baseline to day 9 (p value D 0.0476) but no statistically significant trend after day 9. For
the other two sleep factors without statistically significant bents (i.e., sleep latency and time
awake after sleep onset), we did not observe significant time trends during the study period in
the sham APA group.

Relationship Between Sleep Quality and Worst Pain

The relationships between sleep quality and pain intensity are displayed in Table 4. At baseline,
worst pain had a moderate, positive relationship with worse perceived sleep quality (Pearson’s
r D 0.33, p < 0.05) and the global PSQI score (Pearson’s r D 0.31, p < .05). Simultaneously,
worst pain had a weak positive relationship with the daytime disturbance factor score (Pearson’s
r D 0.22, p D 0.06). Worst pain intensity had a strong positive relationship with worse scores
on the perceived sleep quality factor, the daytime disturbance factor, and the global PSQI score
(Table 4).

DISCUSSION

This is the first study to report the change patterns of sleep quality and sleep parameters in a
four-week APA treatment protocol that was designed to reduce CLBP. The findings indicate
 CHANGES IN SLEEP WITH ACUPRESSURE 13

that participants who received APA designed for CLBP had statistically significant reduced
perceived sleep quality and global PSQI scores (lower scores indicate improved sleep) at
one-month follow-up compared to participants in the sham APA group. Additionally, strong
positive relationships were found among more severe pain intensity, worse perceived sleep
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

quality, increased daytime disturbance, and increased global PSQI scores. For the APA group,
both sleep duration and time awake after sleep onset decreased gradually during the four-week
APA (0.56% and 0.23% daily change, respectively). Sleep efficiency and sleep awakenings
remained relatively constant throughout the four-week APA.
Our interpretation of the study findings is limited by the small sample size, the unblinding of
the therapist and the primary investigator, the lack of inclusion/exclusion criteria related to sleep
disorders, upper age limits, and the lack of comorbidities data, which may affect sleep quality.
Moreover, the sleep of the participants, according to their diaries, was not greatly impaired,
which might have limited the possible effects of the intervention. These shortcomings should
be addressed in a future study. Additionally, the dropout rate (39%) was higher in the sham
APA group, which limits the comparisons that can be made between the two APA groups.
To address this issue, strategies will need to be implemented in any future study to improve
participant retention that could include (a) calling the participants when a treatment session is
missed to discern the cause and (b) providing participant transportation.
Another limitation of the study was that sleep was evaluated with only self-report measures.
No objective measurement of sleep disorders, such as obstructive sleep apnea or restless leg
syndrome, was made. Future research evaluating the effect of auricular therapy for treatment
of insomnia would benefit by the objective evaluation of sleep—possibly with actigraphy.
There was an 87% prevalence of poor sleep quality among participants (90% in the APA
group and 84% in the sham APA group; PSQI global score > 5) at baseline assessment,
which is much higher than the 50% sleep disturbance reported in the literature (Alsaadi et al.,
2011; Kelly et al., 2011). Although there were no statistically significant differences in sleep
efficiency factor scores between the APA and sham APA groups, the daytime disturbance
factor scores and global PSQI scores improved significantly at EOI and one-month follow
up, which provides evidence that APA treatment designed for CLBP can also improve sleep
quality. In the literature, the causal relationship between sleep disturbance and pain intensity
remains unclear (Tang, Goodchild, Sanborn, Howard, & Salkovskis, 2012), but bidirectional
relationships appear to exist between pain intensity and sleep disturbance (Bernardy et al.,
2013; Lew et al., 2010), which suggests that any approach to pain management should take
sleep disturbance into consideration because it likely contributes to pain intensity.
Auricular therapy has shown promising potential for treating insomnia (Suen, Wong, &
Leung, 2002; Suen, Wong, Leung, & Ip, 2003). In a study conducted in Hong Kong that
provided auricular therapy to older adults to help relieve insomnia, patients who received
a three-week APA treatment displayed a significant improvement in nocturnal sleep time
(F2:30;29:90 D 3:63, p < 0.05) and marginal improvements in sleep efficiency (F4;52 D 2:52,
p D 0.05) at baseline, immediately after therapy, and in three follow-up measurements at
one, three, and six months (Suen et al., 2003). In addition to the self-reported data to assess
sleep quality, objective measures of sleep quality assessment can be included. For example,
polysomnography was used to examine the APA effects for 45 patients with sleep apnea
syndrome (Wang, Yuan, & Wang, 2003). Patients who received 10 days of APA displayed a
significantly reduced apnea-hypopnea index, apnea index, and hyponea index as well as an
 14 YEH ET AL.

increased blood oxygen saturation compared to a control group who took vitamin C (100 mg/3
times/daily, p < 0.001; Wang et al., 2003). Additionally, the ear acupuncture points selected
to treat insomnia included shenmen (often used in treating various conditions, including pain,
sedation, addiction treatment, and inflammation; Frank & Soliman, 1999), heart, kidney, liver,
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

spleen, occiput, and subcortex (Suen et al., 2003; Wang et al., 2003). Borrowing from these
results, a future APA treatment protocol should add the heart, kidney, liver, spleen, and occiput
points so that both CLBP and insomnia can be treated simultaneously in a clinical setting.

CONCLUSION

In our APA intervention for CLBP, almost all participants (i.e., 86%) with CLBP reported
sleep problems, which indicates that CLBP and sleep disturbance coexist. The trends in sleep
improvement displayed among our study’s participants suggest that sleep quality should be
considered as an important outcome in the management of CLBP. Moreover, ear acupuncture
points to treat sleep disturbances can be included in the APA treatment designed for CLBP to
increase the maximum treatment effects of APA in a future study.

ACKNOWLEDGMENTS

The authors wish to thank Brian Greene in the Center for Research and Evaluation at the
University of Pittsburgh, School of Nursing for editorial support.

FUNDING

This study was supported by a grant to Dr. Yeh from the Aging Institute of the University of
Pittsburgh Medical Center (UPMC), Senior Services, and the University of Pittsburgh.

REFERENCES

Alsaadi, S. M., McAuley, J. H., Hush, J. M., & Maher, C. G. (2011). Prevalence of sleep disturbance in patients with
low back pain. European Spine Journal, 20(5), 737–743. doi:10.1007/s00586-010-1661-x
Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and
children: United States, 2007. National Health Statistics Reports, 10(12), 1–23.
Benyamin, R., Trescot, A. M., Datta, S., Buenaventura, R., Adlaka, R., Sehgal, N., : : : Vallejo, R. (2008). Opioid
complications and side effects. Pain Physician, 11(2 Suppl), S105–129.
Bernardy, N. C., Lund, B. C., Alexander, B., Jenkyn, A. B., Schnurr, P. P., & Friedman, M. J. (2013). Gender differences
in prescribing among veterans diagnosed with posttraumatic stress disorder. Journal of General Internal Medicine,
28 (Suppl 2), S542–548. doi:10.1007/s11606-012-2260-9
Buysse, D. J., Germain, A., Moul, D. E., Franzen, P. L., Brar, L. K., Fletcher, M. E., : : : Monk, T. H. (2011). Efficacy of
brief behavioral treatment for chronic insomnia in older adults (supplementary online content). Archives of Internal
Medicine, 171(10), 887–895. doi:10.1001/archinternmed.2010.535
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality
Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213.
 CHANGES IN SLEEP WITH ACUPRESSURE 15

Carney, C. E., Buysse, D. J., Ancoli-Israel, S., Edinger, J. D., Krystal, A. D., Lichstein, K. L., & Morin, C. M. (2012).
The consensus sleep diary: Standardizing prospective sleep self-monitoring. Sleep, 35(2), 287–302. doi:10.5665/
sleep.1642
Casarett, D., Karlawish, J., Sankar, P., Hirschman, K., & Asch, D. A. (2001). Designing pain research from the patient’s
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

perspective: What trial end points are important to patients with chronic pain? Pain Medicine, 2(4), 309–316. doi:
10.1046/j.1526-4637.2001.01041.x
Chang, V., Gonzalez, P., & Akuthota, V. (2008). Evidence-informed management of chronic low back pain with
adjunctive analgesics. Spine Journal, 8(1), 21–27. doi:10.1016/j.spinee.2007.10.006
Cleeland, C. S., & Ryan, K. M. (1994). Pain assessment: Global use of the Brief Pain Inventory. Annals of the Academy
of Medicine, Singapore, 23(2), 129–138.
Cole, J. C., Motivala, S. J., Buysse, D. J., Oxman, M. N., Levin, M. J., & Irwin, M. R. (2006). Validation of a 3-factor
scoring model for the Pittsburgh Sleep Quality Index in older adults. Sleep, 29(1), 112–116.
Dagenais, S., Caro, J., & Haldeman, S. (2008). A systematic review of low back pain cost of illness studies in the
United States and internationally. Spine Journal, 8(1), 8–20.
Dagenais, S., Tricco, A. C., & Haldeman, S. (2010). Synthesis of recommendations for the assessment and management
of low back pain from recent clinical practice guidelines. Spine Journal, 10(6), 514–529. doi:10.1016/j.spinee.2010.
03.032
Frank, B. L., & Soliman, N. (1999). Shen men: A critical assessment through advanced auricular therapy. Medical
Acupuncture, 10(2), 17–19.
Gore, M., Sadosky, A., Stacey, B. R., Tai, K. S., & Leslie, D. (2012). The burden of chronic low back pain: Clinical
comorbidities, treatment patterns, and health care costs in usual care settings. Spine, 37(11), E668–E677. doi:10.
1097/BRS.0b013e318241e5de
Haldeman, S., & Dagenais, S. (2008). A supermarket approach to the evidence-informed management of chronic low
back pain. Spine Journal, 8(1), 1–7. doi:10.1016/j.spinee.2007.10.009
Heritier, S. R., Gebski, V. J., & Keech, A. C. (2003). Inclusion of patients in clinical trial analysis: The intention-to-treat
principle. Medical Journal of Australia, 179(8), 438–440.
Huang, L. C. (2005). Auricular medicine: A complete manual of auricular diagnosis and treatment (1st ed.). Orlando,
FL: Auricular International Research & Training.
Huang, L. C., & Huang, W. S. (2007). Handbook of auricular treatment prescriptions & formulae (1st ed.). Orlando,
FL: Auricular International Research & Training.
Katz, J. N. (2006). Lumbar disc disorders and low-back pain: Socioeconomic factors and consequences. Journal of
Bone and Joint Surgery, 88 (Suppl 2), 21–24. doi:10.2106/JBJS.E.01273
Kelly, G. A., Blake, C., Power, C. K., O’Keeffe, D., & Fullen, B. M. (2011). The association between chronic low back
pain and sleep: A systematic review. Clinical Journal of Pain, 27(2), 169–181. doi:10.1097/AJP.0b013e3181f3bdd5
Kim, H. J., Fay, M. P., Feuer, E. J., & Midthune, D. N. (2000). Permutation tests for joinpoint regression with
applications to cancer rates. Statistics in Medicine, 19(3), 335–351. doi:10.1002/(SICI)1097-0258(20000215)19:3
<335::AID-SIM336>3.0.CO;2-Z
Lew, H. L., Pogoda, T. K., Hsu, P. T., Cohen, S., Amick, M. M., Baker, E., : : : Vanderploeg, R. D. (2010). Impact of the
“polytrauma clinical triad” on sleep disturbance in a department of veterans affairs outpatient rehabilitation setting.
American Journal of Physical Medicine & Rehabilitation, 89(6), 437–445. doi:10.1097/PHM.0b013e3181ddd301
Lind, B. K., Lafferty, W. E., Tyree, P. T., Sherman, K. J., Deyo, R. A., & Cherkin, D. C. (2005). The role of alternative
medical providers for the outpatient treatment of insured patients with back pain. Spine, 30(12), 1454–1459.
Linder, J., Jansen, G. B., Ekholm, K. S., & Ekholm, J. (2014). Relationship between sleep disturbance, pain, depression
and functioning in long-term sick-listed patients experiencing difficulty in resuming work. Journal of Rehabilitation
Medicine. doi:10.2340/16501977-1833
Lu, W., & Rosenthal, D. S. (2010). Recent advances in oncology acupuncture and safety considerations in practice.
Current Treatment Options in Oncology, 11(3/4), 141–146. doi:10.1007/s11864-010-0126-0
Malanga, G., & Wolff, E. (2008). Evidence-informed management of chronic low back pain with nonsteroidal anti-
inflammatory drugs, muscle relaxants, and simple analgesics. Spine Journal, 8(1), 173–184. doi:10.1016/j.spinee.
2007.10.013
Marin, R., Cyhan, T., & Miklos, W. (2006). Sleep disturbance in patients with chronic low back pain. American
Journal of Physical Medicine and Rehabilitation, 85(5), 430–435. doi:10.1097/01.phm.0000214259.06380.79
McGullagh, P., & Nelder, J. A. (1989). Generalized linear models: Monographs on statistics and applied probability
(2nd ed.). London, England: Chapman & Hall/CRC.
 16 YEH ET AL.

Nahin, R. L., Barnes, P. M., Stussman, B. J., & Bloom, B. (2009). Costs of complementary and alternative medicine
(CAM) and frequency of visits to CAM practitioners: United States, 2007. National Health Statistics Reports, 18,
1–14.
National Center for Health Statistics. (2014). Summary health statistics for U.S. adults: National health interview
Downloaded by [The University of Texas School of Public Health], [Lung-Chang Chien] at 13:37 07 August 2015

survey, 2012. Hyattsville, MD: Author.

Newell, D. J. (1992). Intention-to-treat analysis: Implications for quantitative and qualitative research. International
Journal of Epidemiology, 21(5), 837–841.
Nogier, P. (1981). Handbook to auriculotherapy (1st ed.). Moulins-les-Metz, France: Maisonneuve.
Oleson, T. (2014). Auriculotherapy manual: Chinese and Western systems of ear acupuncture (4th ed.). Edinburgh,
Scotland: Churchill Livingstone, Elsevier.
Rubinstein, S. M., van Middelkoop, M., Kuijpers, T., Ostelo, R., Verhagen, A. P., de Boer, M. R., : : : van Tulder,
M. W. (2010). A systematic review on the effectiveness of complementary and alternative medicine for chronic
non-specific low-back pain. European Spine Journal, 19(8), 1213–1228. doi:10.1007/s00586-010-1356-3
Schapira, M. M., Mackenzie, E. R., Lam, R., Casarett, D., Seluzicki, C. M., Barg, F. K., & Mao, J. J. (2014). Breast
cancer survivors willingness to participate in an acupuncture clinical trial: A qualitative study. Support Care Cancer,
22(5), 1207–1215. doi:10.1007/s00520-013-2073-3
Suen, L. K. P., Wong, T. K. S., & Leung, A. W. N. (2002). Effectiveness of auricular therapy on sleep promotion in
the elderly. American Journal of Chinese Medicine, 30(4), 429–449.
Suen, L. K., Wong, T. K., Leung, A. W., & Ip, W. C. (2003). The long-term effects of auricular therapy using magnetic
pearls on elderly with insomnia. Complementary Therapies in Medicine, 11(2), 85–92.
Tang, N. K., Goodchild, C. E., Sanborn, A. N., Howard, J., & Salkovskis, P. M. (2012). Deciphering the temporal link
between pain and sleep in a heterogeneous chronic pain patient sample: A multilevel daily process study. Sleep,
35(5), 675–687. doi:10.5665/sleep.1830
Turk, D. C., Dworkin, R. H., Revicki, D., Harding, G., Burke, L. B., Cella, D., : : : Rappaport, B. A. (2008). Identifying
important outcome domains for chronic pain clinical trials: An IMMPACT survey of people with pain. Pain, 137(2),
276–285. doi:10.1016/j.pain.2007.09.002
Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N. E, : : : Linde, K. (2012).
Acupuncture for chronic pain: Individual patient data meta-analysis. Archives of Internal Medicine, 172(19), 1444–
1453. doi:10.1001/archinternmed.2012.3654
Vitiello, M. V., McCurry, S. M., Shortreed, S. M., Baker, L. D., Rybarczyk, B. D., Keefe, F. J., & Von Korff, M.
(2014). Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue
in older adults with comorbid osteoarthritis and insomnia. Pain. doi:10.1016/j.pain.2014.04.032
Wang, X. H., Yuan, Y. D., & Wang, B. F. (2003). Clinical observation on effect of auricular acupoint pressing in
treating sleep apnea syndrome. Zhongguo Zhong Xi Yi Jie He Za Zhi, 23(10), 747–749.
Waterman, B. R., Belmont, P. J., Jr., & Schoenfeld, A. J. (2012). Low back pain in the United States: Incidence and
risk factors for presentation in the emergency setting. Spine Journal, 12(1), 63–70. doi:10.1016/j.spinee.2011.09.002
Wertz, R. T. (1995). Intention to treat: Once randomized, always analyzed. Clinical Aphasiology, 23, 57–64.
White, A. P., Arnold, P. M., Norvell, D. C., Ecker, E., & Fehlings, M. G. (2011). Pharmacologic management of chronic
low back pain: Synthesis of the evidence. Spine, 36(21 [Suppl]), S131–S143. doi:10.1097/BRS.0b013e31822f178f
Witt, C. M., Manheimer, E., Hammerschlag, R., Ludtke, R., Lao, L., Tunis, S. R., & Berman, B. M. (2012). How well
do randomized trials inform decision making: Systematic review using comparative effectiveness research measures
on acupuncture for back pain. PLoS One, 7(2), e32399. doi:10.1371/journal.pone.0032399
World Health Organization. (1990). WHO report of the working group on auricular nomenclature. Lyons, France:
Author.
Yeh, C. H., Chien, L. C., Albers, K. M., Margolis, L., Liu, R. Y., Suen, L., & Ren, D. (2014). Function of auricular
point acupressure in inducing changes in inflammatory cytokines during chronic low back pain: A pilot study.
Medical Acupuncture, 26(1), 31–39.
Yeh, C. H., Chien, L. C., Chiang, Y. C., & Huang, L. C. (2012). Auricular point acupressure for chronic low back
pain: A feasibility study for 1-week treatment. Evidence-Based Complementary and Alternative Medicine. doi:10.
1155/2012/383257
Yeh, C. H., Chien, L. C., Balaban, D., Sponberg, R., Primavera, J., Morone, N. E., : : : Suen, L. K. P. (2013). A
randomized clinical trial of auricular point acupressure for chronic low back pain: A feasibility study. Evidence-
Based Complement Alternative Medicine. Article ID 196974.

View publication stats