Short Communication

Experimental Pathology and Health Sciences

2016;8 (2): 147-152

Lowering anxiety of university students prior to the

exams by auricular acupuncture – Preliminary study

Andreia Vieira1,7, Karine Silva3, Mariana Hinzmann1,3,Jürgen Stürmer1,8, Maria João Santos1, Nuno Correia,4,5,6,
Henry J. Greten1,2 and Jorge Machado1,3,9
(1) TCM Master Programme, Abel Salazar Institute for Biomedical Sciences, University of Porto, Porto, Portugal;
(2) Heidelberg School of Chinese Medicine, Heidelberg, Germany;
(3) ICBAS- Abel Salazar Institute for Biomedical Sciences, University of Porto, Porto, Portugal;
(4) Internal Medicine, Emergency Department, University Hospital of São João, Porto, Portugal;
(5) Nursing School of Oporto, University of Porto; Porto, Portugal;
(6) Acupuncture Clinic, Alfena Private Hospital, Porto, Portugal;
(7) Physiotherapist Department, Hospital Santa Maria, Porto, Portugal
(8) Deutsche Gesellschaft für Traditionelle Chinesische Medizin.
(9) Labiomep- Laboratório de Biomecânica do Porto, Faculdade de Desporto, University of Porto,

Abstract
High-level students are exposed to various challenges that trigger high anxiety levels in relation to their
academic requirements. Few studies suggest that auricular acupuncture (AA), may improve anxiety.
In this study, we evaluate the potential effect of AA on the anxiety-levels of university students and also try
to assess if the improvement of anxiety status is correlated with some alterations of vital signs, as blood
pressure (BP), heart beat per minutes (HC), oxygen saturation (OS) and temperature (T). This study sug-
gests that AA is effective in reducing exam-related anxiety in university-level students.
Our results show that the experimental group had a reduced in the level of anxiety of just after 30 minutes,
being even greater after 48 hour, with only a single auricular acupuncture treatment, when compared with
control (waiting list) and placebo groups. The selected points showed to be the adequate for the treatment,
since the placebo group, where unspecific points were used did not manifest any improvement; the results
were even very similar to the starting point and similar to the control group.
So, potentially, AA may be used as a complementary or alternative treatment for anxiety prior exams on
high level students. However, this effect needs more deep scientific studies on larger samples. An addi-
tional long-term double-blinded with AA may confirm this results.

Keywords: Anxiety, Acupuncture; Auriculotherapy; Traditional Chinese Medicine; Exames.

Introduction
Anxiety is one of the most frequent clinical be-
havioral disorders, affecting both the physical and
emotional state, inducing changes in behavior and
cognition of individuals [1-4].
Regarding the emotional state, the individual can
express feelings of fear, insecurity, apprehensive
anticipation, catastrophic thinking and increased
time of alert [1, 2, 5].
From the physiological point of view, anxiety is
characterized by activation of the hypothalamic-
pituitary-adrenal (HPA) axis, presenting symptoms
Andreia Vieira
such as insomnia, tachycardia, pallor, sweating,
andreiarsv@gmail.com muscle tension, tremor, dizziness, nervousness,
difficulty with concentration, intestinal disorders
and epigastric discomfort [1, 2, 5, 6].
According to the diagnostic and statistical manual
of mental disorders (DSM-IV), anxiety is a natural
response, resulting in a sign of fundamental alert
in humans, the given threat. However, anxiety can
become pathologic when excessive and uncontrol-
lable. In this sense, physical health is also compro-
mised due to hormonal changes and consequent
decrease of the immune system, which aggravates
the development of various other conditions such
as chronic musculoskeletal pain, respiratory dis-
eases, cardiovascular problems, infectious and
even cancer [7].
In a survey conducted by Rodrigues and Pelisolo
in 2008, which included students in preparation for
the final examination, it was found that 23% of the
Experimental Pathology and Health Sciences

students reported anxiety in moderate to severe cation, and with no known psychiatric or thyroid
degree [8]. The same authors also concluded that disorders.
students attending health courses showed even
higher levels of anxiety. Concomitantly, Cruz and
Pinto (2010) found that 52.3% of nursing students
at Viseu showed moderate anxiety, and 27.1% low-
grade rated by STAY Cruz and Pinto (2010) also
observed the existence of a relationship between
anxiety and academic demands related to oral pre-
sentation of papers, prior the attendance or exam
days, the day of examination or frequency and du-
ration of clinical trials [9].
As Andrade and Gorenstein (1998) stated, there
are several instruments formulated to assess anxi-
ety, each of which emphasize different aspects
such as mood, cognition, behavior, state of hyper-
alertness and somatic symptoms [3]. According to
the literature, Spielberger (1970), has presented a
greater emphasis on the study of anxiety in all in-
dividuals[10]. Of particular importance to determine
whether an instrument will measure the trait anxiety
as a characteristic condition of the individual; or the
assessment of state anxiety will be in a given mo-
ment, before a given situation (e.g., school ratings) Study Design.
[3, 11-13]. Individuals were randomly allocated to the Experi-
As a means to treat anxiety, conventional medicine mental group (EG, n=8): verum AA in points (Fig-
makes use of several drugs, such as benzodiaz- ure2):
epines, antidepressants, barbiturates and antihis- 1. joy,
tamines [14]. However, several authors (Durham 2. lung parenchyma ,
& Higgins, 2012) have emphasized that Western 3. anxiety ,
medicine can’t solve all cases of anxiety[15]. Be- 4. psychosomatic and
sides the risk of side effects, resistance to pharma- 5. diazepam;
cological treatment affects approximately one in
three patients with anxiety disorders[16, 17]. the Placebo group (PG, n=5): sham AA on points
Auricular acupuncture is a therapeutic method of- in neurological segments distinct from the verum
ten used in anxiety treatments, acting directly on AA (Figure 3):
the nervous system, promoting the release of en- 1. articulation of the right hand,
dorphins in the brain and melatonin’s related to re- 2. foot joint right,
laxation, supporting the balance of the autonomic 3. left hand joint,
nervous system[18-22], with already very promis-
sory results, needing only the support of more sci-
entific data to complement and validate this therapy
[23].
Thus, in this context, a small student sample from
an university population will be exposed to the au-
ricular acupuncture (AA), in order to improve from
their anxiety symptoms. The criteria for participa-
tion and psychopathological symptoms were pre-
viously evaluated based on specific and validated
questionnaires. Few physiological parameters
were also accomplished [13]. This assay should
be a prospective, randomized, controlled, single-
blinded study.

Methodology
Selection of Students.
This study was approved by the Ethics Committee
of Piaget University from Vila Nova de Gaia, Portu-
gal. Written informed consents were obtained from
all students before study enrollment.
An experimental, prospective, randomized, con-
trolled and single-blinded study was conducted.
The sample included university students (n=18),
naive to acupuncture, under no psychotropic medi-

148
 2016:8 (2)

4. joint of the left foot and

data, variance was held for each assessed physio-
5. shoulder joint,
logical parameters (blood pressure, cardiac and re-
and the control waiting list group (WL, n=5): without
spiratory rate), an ANOVA for repeated measures,
any AA treatment.
dependent variables: values related to physiologi-
cal parameter observed before the experimental
One week prior to the examination series at the
session and 30 minutes after the experimental
University, subjects were treated with AA using
session, the independent variable: experimental
semi-permanent needles in place for 48 hours.
condition (study group, placebo group and control
Initially, the following documents were delivered to
group).
all those interested in participating in this study: in-
Any significant result was not observed. That is,
formed consent, questionnaire evaluation of the cri-
there were no statistic significant changes in the
teria for participation, inventory psychopathological
values of physiological parameters HB, HC, OS
symptoms (BSI) [25]; Inventory trait-state anxiety
and T collected. Possibly need other accuracy in a
(STAI) [11, 12].
larger population samples and more adequate con-
ditions and specific equipment to obtain consistent
and clear physiological results.
As for the level of anxiety data after verification of
normality and homogeneity of data variance, held a
repeated measures ANOVA (dependent variables:
state anxiety values recorded before the experi-
mental session, 30 minutes after the experimental
session and 48 hours after the trial session). The
results (Figure 5) were that after 48 hours, a big
decrease in anxiety-state values in the study group
(EG – experimental group). None of the other ex-
perimental conditions produced significant changes
in levels of anxiety (either 30 minutes or 48 hours
after experimental session).

Prior to the formation of experimental groups, and

to ensure greater uniformity in the same, students
selected for the study were divided into four groups
according to the level of trait anxiety achieved by
one of STAI (Y2 form) : group of students nothing
anxious, a little anxious, a group of moderately anx-
ious students, and a group a very anxious students.
Assessments were made 5 minutes before (T0), 30
minutes (T1) and 48 hours after (T2) the needling
(Figure 4).

Main Parameters:
Level of anxiety were assessed according to the
The placebo group revealed slightly higher values
state anxiety inventory STAI (form Y1) and a Visual
of anxiety than the control group, thought the study,
Analogue Scale (VAS) for anxiety.
but the standard deviation is too high, to separate
Physiological parameters, as blood pressure (BP),
these two groups (WL and PG).
heart beat per minutes (HC) and oxygen saturation
(OS) and temperature (T) were taken at each study
Discussion
time (0, 30 min and 48 hours) using a monitor Gold-
This study appears in a context, firstly, the sharp
way UT6000A.
interest and growing activity in the preparation of
standards that will regulate the practice of tradicio-
Results
nal chinese medicine (TCM) and on the other hand,
Total of 18 students (13 women; 5 men) were
a marked anxiety installed for socio-economic rea-
included, with age= 21,4±1,85 years, weight=
sons, the current flow will be the increased due to
63,9±8,43kg, height= 1,70±0,07m and body mass
emotional instability of many students in exams
index= 22,17±4,17kg/m2, from which 16,8%
season. However, only few studies indicate that
showed moderate to severe states of anxiety and
acupuncture, including auricular acupuncture, can
14,3% trace of anxiety.
improve anxiety.
After verification of normality and homogeneity of
The results showed a statistically significant de-
149
Experimental Pathology and Health Sciences
crease in mean anxiety levels via the STAI Y1 me-
dium to anxiety in the real auricular acupuncture
group, compared to control and placebo between 5
minutes before the session and 48 hours after ex-
perimental session. Similarly, the average of anxi-
ety levels in real auricular acupuncture group, were
lower than control and placebo groups, between 30
minutes and 48 hours after the session. However,
although it is noted a decrease in mean levels of
anxiety true auricular acupuncture group, 5 min-
utes before the session and 30 min after the ses-
sion were not statistically significant. This means
that although there is a tendency for a reduction of
anxiety levels after 30 minutes, the auricular acu-
puncture effect were more effective after 48 hours.
These results are in agreement with the study of
Wang and Kain (2001), on the effectiveness of
STAI-Y1 way past 48 hours after the headset ses-
sion[19, 20]. However, the tendency to decrease
the anxiety levels after 30 minutes of the session,
even not being statistically significant contradict
with the study of Wang and Kain (2001). On the
other hand, the study by Prado and Silva (2012),
as the only study evaluating auricular acupuncture
anxiety in students found significant differences in
the real auricular acupuncture group, compared to
other groups, only 8th session, 12th session and 15
days after the end of the sessions, so is normal to
have different results, in different studies since the
study population are a very heterogeneous group,
only with bigger study groups and repeating the
same treatment the result can be comparable [26].
Note that these researchers conducted 12 auricular
acupuncture sessions with mustard seeds, 1 time
per week. However, the authors did not take into
account the students phase related to the academ-
ic requirements in the studies conducted by Cruz
and Pinto (2010) and Pilkington (2010) in order to
increase levels of anxiety-state [9, 27, 28].
Relatively to the physiological data BP, HB and OS
there was not statistically significant differences be-
tween the five minutes before the session and 30
minutes after the session, as well as between the
five minutes before the session and 48 hours the
session. It notes that the semi-permanent needles
were maintained for 48 hours. These results go
against those obtained by Wang and Kain (2001)
stating that the increase in level of anxiety is as-
sociated with an increase of physiologic response,
the correlation is still not well defined (SM Wang
and Kain, 2001). Wang and Kain (2001) analyzed
individuals with anxiety levels of day-to-day, relat-
ing the absence of differences in HR and BP in
the absence of any experimental factor of anxiety-
state. In fact, in our study, we were careful to in-
clude a homogeneous sample; there was a predic-
tor of state anxiety (eg, school exams). But even
with a week in advance, it was not possible, due
to ethical issues; make our nearest evaluation of
school exams. However, these results show us that
the auricular acupuncture method presented can
be a safe therapeutic relating to the non variation
of physiological and effective when data related to
the decrease in anxiety levels. With regard to meth-
150
odological procedures, some aspects deserve our
analysis, the use of semi-permanent needles, rath-
er than regular acupuncture needles, since the ef-
fects of the puncture can be maintained for several
days of stimulation, prolonging the treatment effect.
According Landgren (2008) and Umeh (1988) the
semi-permanent needles are more efficient than
regular acupuncture needles as they continue to
stimulate the point for a longer period. On the other
hand, semi-permanent needles have a lower depth
level of the standard stimulus [29, 30]. However,
when comparing semi-permanent needles mustard
seed used by Prado and Silva (2012) at the univer-
sity level of anxiety the first show better effects [26].
Regard to the placebo group, we were careful in
selecting the points according to some criteria:
puncture 5 auricular points in total, as in the study
group; put points without any influence on anxiety,
according to TCM; two points located on the non-
dominant auricular and 3 points in the dominant
ear, to cover nerve trigeminal irrigation zone, i.e.,
outside the dermatomes of auricular points of the
study group. The group of auricular points selected
in the study: "Diazepam" "anxiety," "psychosomat-
ic" and "joy" are located in the pinna at the cervical
plexus irrigation zone; on the other hand the point
"pulmonary parenchyma" is in the dermatome of the
vagus nerve of the ear. Thus, we follow internation-
al recommendations for selecting skipped stitches
(White, Filshie, & Cummings, 2001). White (2001)
suggests that based on acupuncture school in the
nerve endings (medical acupuncture), be defined
checks based on skin spots that are not traditional
acupuncture points and located in different nerve
segments of acupuncture points to be tested. With
these criteria we intended to, on the one hand, not
give any suggestion to the participant of the type
of treatment to which were being subjected, on the
other hand, to prevent puncture dermatomes cov-
ered by true acupuncture points[31, 32].
Conclusions
In this study, although there is a tendency for a re-
duction of anxiety levels after 30 minutes, the au-
ricular acupuncture effect was more effective and
significantly after 48 hours of the experimental ses-
sion. These results are in agreement other studies
regarding the effectiveness of STAI Y1 way past 48
hours atrial session. However, despite a tendency
to anxiety levels decrease after the 30-minute ses-
sion in the preliminary study, this was not statisti-
cally significant, contradicting the study of Wang
and Kain (2001). In this sense, we propose a new
collection with a larger sample and introducing new
variables such as heart rate variability, respiratory
frequency and the salivary cortisol and dermal elec-
tro-conductance.
Potentially, AA may be used as a complementary or
alternative treatment for anxiety prior exams, and
benefit greatly the ones that suffer the most with
this disorder.
Study limitations
The study evaluated the effect in the short and me-

dium term auricular acupuncture, so it is important
to assess larger samples and the long-term effect
in the treatment of anxiety before exams, as well as
others evaluations approaches according with TCM
diagnosis, variable, it would be interesting target for
future studies.
Knowledgments
This work was accomplished under the master pro-
gram of Traditional Chinese Medicine in biomedical
Science Institute – ICBAS-UP. I would like to thanks
all staff of Applied Physiology Laboratory and to the
participant students of Piaget University from Vila
Nova de Gaia.
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