Anesthesia&Analgesia:

November2001Volume93Issue5p11781180
doi:10.1097/0000053920011100000024
AMBULATORYANESTHESIA:(SocietyforAmbulatoryAnesthesia):BriefReport

The Use of Auricular Acupuncture to Reduce Preoperative Anxiety

Wang,ShuMingMD*,Peloquin,CarolMD*,Kain,ZeevN.MD*

AuthorInformation
Departmentsof*Anesthesiology,Pediatrics,andChildPsychiatry,YaleUniversitySchoolof
MedicineandYaleNewHavenHospital,NewHaven,Connecticut
ZNKissupportedinpartbytheNationalInstitutesofHealth(R01HD3700701),General
ClinicalResearchCentersProgram,NationalCenterforResearchResources,andPatrickand
CatherineWeldonDonaghueMedicalResearch.
May11,2001.
AddresscorrespondenceandreprintrequeststoShuMingWang,MD,Departmentof
Anesthesiology,YaleUniversitySchoolofMedicine,POBox208051,333CedarSt.,New
Haven,CT06521.Addressemailtoshuming.wang@yale.edu.
IMPLICATIONS:Earacupuncturecandecreasepreoperativeanxietyinadultsundergoing
outpatientsurgery.

Both pharmacologic interventions and psychological preparationPreviously, we demonstrated that ear acupuncture at the relaxation
programs are often used to treat preoperative anxiety (1,2). Thesepoint significantly decreased daily situational anxiety, i.e., transitory
interventions,however,canbetimeconsuming,causeundesirablesidefeelingsofapprehension,tension,andworryrelatedtoworkanddaily
effects,andincreasehealthcarecosts,oracombinationofthese.Thus, living in a group of healthy volunteers (5). Because daily situational
thesearchforthelowcostinterventioncontinues.Earacupuncture,a anxiety probably differs from preoperative anxiety, we designed this
microacupuncturetechniquesimilartoreflexology,wasfirstdescribedfollowup study to determine the effects of ear acupuncture on
in French and Chinese medicine in 1950 (3,4). It was speculated thatpreoperativeanxiety.
the technique worked because groups of pluripotent cells contain
informationfromthewholeorganismandcreateregionalorganization
centers representing different parts of the body (4). Thus, one can
stimulateareflexpointandrelievesymptomsofdistantpathology.

Methods
Participants in this randomized, blinded, controlled trial were 91 Participantswererandomizedtothreeinterventiongroups.
electiveambulatorysurgerypatients(ages1966yr)withASAIandII
physical status, no history of psychiatric illness, and no priorTraditional Chinese Medicine group (TCM): this group received ear
acupuncture experience. Participants were scheduled for both acupuncturebasedonthetraditionalChinesetheorythatthekidneyis
anticipated benign diseases as well as potential malignant diseases. related to fear, the heart is related to anxiety, and the shenmen point
(4,6)
. The kidney point is located at the
Patients taking anxiolytic herbs (e.g., kava kava) or psychotropicwill tranquilize the mind
superior
concha,
the
heart
point is at the most central area of the
medications were excluded. Sedative premedication was not offered to
participants of this study. The Yale University IRB approved theinferiorconcha,andtheshenmenpointisattheinferiorlateralwallof
thetriangularfossa(Fig.1
protocol.

Figure1
).
Relaxation group: this group received ear acupuncture by using theControl group: this group received ear acupuncture needles at three
relaxation (4,5), tranquilizer, and master cerebral points, which arepointsthathavenodocumentedeffectonanxiety(Fig.1).
documented to produce relaxation, general sedation, and anxiety
Uponrecruitment,participantscompletedademographicquestionnaire
diminishment,respectively (4,6).Therelaxationpointislocatedatthe
andabaselineStateTraitAnxietyInventory(STAI) (7).TheSTAIisa
superiorlateralwallofthetriangularfossa,thetranquilizerpointisat
selfreportinstrumentthatcontainstwo20itemsubscalesmeasuring
theinferiortragus,andthemastercerebralpointisatthejointofear
trait anxiety, which is described as relatively stable individual
lobeandface(Fig.1).
differences in the tendency to experience anxiety, and state anxiety
(STAIS), which is described as situational or transitory feelings of
apprehension, tension, and worry. The higher the score, the more
anxious the subject is. Ear acupuncture was performed by the first
author (SMW), who is a trained, licensed acupuncturist, with
occlusivepressneedles(PyonexsmallSeirin,Japan).Allparticipants
received three ear acupuncture press needles at the nondominant side
(theoppositesideofthepatientsdominanthand)oftheirexternalear
for 30 min without any stimulation. The participants stayed in the
holding area during this time, and their activities were not restricted.
Regular preoperative procedures were not altered, nor was sedative

medication administered to any of the subjects. STAI (state) was

reassessed30minaftertheintervention.Thepressneedleswerethen
removed.
Samplesizewascalculatedapriorionthebasisofourpreviousstudy
(5)
. Considering a repeated measures design, a 20% effect of
intervention,anof0.05,andpowerof85%,27patientswereneeded
in each of the three study groups. Data were analyzed by using SPSS
version 10 (SPSS Inc., Chicago, IL). Normally distributed data are
presentedasmeansd.Atwowayanalysisofvariance(ANOVA)with
repeatedmeasureswasusedtoanalyzethechangesinanxiety(STAIS).
AonewayANOVAwiththeSchefftestformultiplecomparisonswas
usedtolocalizedifferencesbetweeninterventiongroups.Comparisons
wereconsideredsignificantifP<0.05.

Results
Ninetyone patients scheduled for elective ambulatory surgical
procedureswererecruitedforthisstudy.Groupsweredemographically
similar and showed no significant differences in type of surgical
procedureorbaselinetraitanxiety(Table1).

Table1
A twoway repeatedmeasures ANOVA demonstrated a significant
group difference (F2,88 =4.5, P = 0.014), a group time interaction
(F2,88=3.5,P=0.02),andatimedifference(F1,88=8.2,P = 0.001) in
anxiety levels among the three study groups. Post hoc analysis with
oneway ANOVA demonstrated no difference in STAIS scores among
thegroupsbeforeintervention(4711versus4612versus4513,P
= not significant). After the intervention, however, there were
significant differences among the three groups (38 9 versus 35 8
versus 40 14, P = 0.014). The Scheff test for multiple comparisons
has demonstrated that patients in the Relaxation group were
significantlylessanxiouscomparedwithpatientsintheControlgroup
(P=0.01)(Fig.2).TheanxietyofpatientsintheTCMgroup,however,
didnotdiffersignificantlyfromthatofthoseintheControlgroup(P=
0.28)orintheRelaxationgroup(P=0.37)(Fig.2).

Figure2

Discussion
PatientswhoreceivedearacupuncturewithrelaxationpointsreportedThere are no data available regarding the exact mechanism of ear
significantlylowerlevelsofanxietyaftertheinterventionascomparedacupuncture. Several studies involving body acupuncture suggest,
with the Control group. The anxiolytic effects of ear acupuncture forhowever, that the release of neurotransmitters such as serotonin may
patientsreceivingtheTCMinterventionwerenotasprofoundasthoseaffecttheemotionalwellbeingofhumans (811).Itisspeculatedthat
of the relaxation intervention. This may be because, according toearacupuncturemayhavesimilarmechanisms.
traditional Chinese theory, the selection of acupuncture points is not
fixed, as it was for the TCM group in this study, and should vary forSeveral methodologic issues involving this investigation have to be
addressed. First, in this study we did not use objective physiologic
eachindividualaccordingtoparticularbodyconstitution.
outcome measures, such as arterial blood pressure and heart rate.
These measures were not used because they were demonstrated in a
previous investigation to be unaffected by acupuncture (5). Second, a
large percentage (70%) of our subject population indicated that they
believeinalternativemedicine.AscanbeseenfromTable1,however,
the three intervention groups did not differ in this respect. Thus, this
largepercentageshouldnothaveanyeffectonthevalidityoftheresults
ofthisstudy.
In conclusion, we demonstrated that ear acupuncture decreasesWethankPaulG.Barash,MD,forhiscriticalreviewofthismanuscript
preoperative anxiety in patients undergoing elective ambulatoryandtoallpatientswhoparticipatedinthisstudy.
procedures. Ear acupuncture is easy to administer (less than one
minute),isrelativelyinexpensive,andhasminimaladverseeffects (5).
Inaddition,allparticipantswereabletoperformtheirregularactivities
without restrictions in the preoperative holding area. Thus, this
interventionmaybeusedforpatientswhoareanxiousbutreluctantto
accept a pharmacologic intervention. Future studies are indicated to
determine exact mechanisms of action and to expand the use of ear
acupunctureindifferentperioperativesettings.

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2001InternationalAnesthesiaResearchSociety