MEDICAL ACUPUNCTURE

Volume 26, Number 2, 2014

# Mary Ann Liebert, Inc.
DOI: 10.1089/acu.2014.1023

Auriculotherapy for Persisting Postoperative Pain

Caused by Total Knee Replacement

Marco Romoli, MD,1,2 Chrissanthi Avgerinos, MD,3 Luigi Baratto, MD,3 and Andrea Giommi, PhD 4

ABSTRACT

Introduction: Total knee replacement (TKR) is a common procedure that entails severe postsurgical trauma,
prolonged hospitalization, and impaired patient rehabilitation, especially in patients who are elderly. Among
the nonpharmacologic methods used with TKR, auriculotherapy/ear acupuncture (AEA) has recently shown a
favorable effect on perioperative/postoperative pain and disability in patients who have undergone TKR.
Objective: The primary aim of this study was to examine the adjuvant effects of one session of auricular
acupuncture on persisting pain and disability in patients hospitalized for TKR postoperative rehabilitation. The
secondary aim was to propose a simplified diagnostic method for selecting the most effective points to treat in
each patient.
Materials and Methods: In 17 patients (14 females and 3 males; mean age 75.2 years) hospitalized for
postoperative TKR rehabilitation, pain level and time for sit-to-stand were measured before, 30 minutes after,
and 6 hours after one session of auricular acupuncture. In each patient, an electric skin resistance test (ESRT)
was performed on both auricles, followed by a pain pressure test (PPT) for identifying the most sensitive points.
A second PPT was consecutively performed on the previously located auricular points and only those ipsilateral
to the operated knee were selected for treatment.
Results: All 17 patients reported a having lower level of pain after the AEA treatment, and this effect was still
maintained after 6 hours. A better performance in the sit-to-stand test was observed after 6 hours following
treatment.
Conclusions: The auricular points, which were effective for reducing pain and disability, were spread out over
a broad area of the upper external ear, which overlaps both the French and Chinese somatotopic auricular
representations of the knee joint.

Key Words: Total Knee Replacement, Postoperative Pain, Auricular Acupuncture Diagnosis, Auriculotherapy

INTRODUCTION impaired patient rehabilitation especially in elderly patients.

More than 50% of patients undergoing surgery report post-

T otal knee replacement (TKR) is a common surgi-

cal procedure that has only low levels of mortality and
entails few surgical complications; however, there may be
severe postsurgical trauma, prolonged hospitalization, and
operative pain as a major concern. Moreover, consequences
of uncontrolled pain can lead to myocardial ischemia and
infarctions, pulmonary infections, paralytic ileus, urinary
retention, thromboembolisms, impaired immune functions,

1
Center for Integrative Medicine, University of Florence, Fierenze, Italy.
2
Associazione Medici Agopuntori Bolognesi (A.M.A.B.), Bologna, Italy.
3
Rehabilitation Department of La Colletta Hospital, Genova, Genova, Italy.
4
Department of Statistics, Informatics and Applications, University of Florence, Firenze, Italy.

97
98 ROMOLI ET AL.

etc.1 A multimodal approach to pain seems the best way to

achieve maximal control of postoperative pain after TKR. In
the conventional medical literature, a combination of dif-
ferent drugs are recommended during the preoperative pe-
riod (nonsteroidal anti-inflammatory drugs [NSAIDS],
cyclooxygenase [COX]–2 inhibitors, anticonvulsants), the
intraoperative period (opioids, local anesthetics), and the
postoperative period (opioids, NSAIDS, COX-2 inhibitors,
a2-agonists, N-methyl-d-aspartate [NMDA] antagonists,
anticonvulsants, and such centrally acting analgesics as
acetaminophen).2 Among the nonpharmacologic techniques,
auriculotherapy/ear acupuncture (AEA) seems to be an in-
teresting method for reducing perioperative/postoperative
pain and disability in patients undergoing TKR. A meta-
analysis of Asher et al. included 17 studies encompassing a
wide variety of AEA interventions, such as acupuncture
needles, indwelling semipermanent needles, electrical and
laser stimulation, acupressure, etc.3 In studies on pain relief
after ambulatory knee surgery arthroscopy and surgery,
Usichenko et al. used disposable indwelling steel auricular
acupuncture needles (0.22-mm diameter · 1.5-mm length),
which were inserted before surgery and retained in situ until
the following morning.4,5 In these studies, the AEA group
had treatment on three points ipsilateral to the surgery site:
Knee joint; Shenmen; and Lung. Three nonacupuncture
points of the helix, ipsilateral to the site of surgery, were FIG. 1. The auricular zones, of the current standardized Chinese
used for the control procedure. Both the acupuncture points map, which were stimulated with acupressure by Chang et al.
(2012)6 and He et al.7 (2013) in patients with postoperative pain
and the nonacupuncture points were located more precisely related to total knee replacement. Areas of interest are shaded in
with an electronic device for detecting zones of low skin gray: Knee joint (AH 4); Shenmen (TF 4); Subcortex (AT 4;
resistance.4,5 Two articles outlined the possibility of man- shown in lower diagram with black line indicating the area); and
aging postoperative pain in patients with TKR by applying Sympathesis (AH 6, at the junction of the terminal part of the
auricular acupressure on some points of the current stan- inferior antihelix with the inner border of the helix, black arrow).
dardized Chinese map. Chang et al. applied magnetic beads
for 3 days on the areas for Shenmen (TF 4) and Subcortex The secondary aim was to propose a simplified diagnostic
(AT 4), pressing the acupoints with the fingertips for method for selecting the most effective points to treat in
3 minutes per point, 3 times per day (at 9 am, 1 pm, and 5 each patient.
pm).6 Vaccaria (Vaccaria spp.) seeds were placed by He
et al. at four standardized Chinese auricular points: Knee
joint (AH 4), Shenmen (TF 4), Subcortex (AT4), Sympath- MATERIALS AND METHODS
esis (AH 6, at the junction of the terminal part of the inferior
antihelix with the inner border of the helix).7 See Fig. 1 for A consecutive group of 17 patients who had undergone
these points. The points were stimulated ipsilaterally to the TKR and who had been admitted to La Colletta Hospital, in
site of surgery, and their efficacy was compared to four Arenzano, Genova, Italy, for postoperative rehabilitation, were
nonacupuncture points on the ipsilateral helix. Acupressure also treated with one session of ear acupuncture. The study was
was applied by repeatedly pressing the acupoints with the approved by the institutional ethical committee, and the pa-
fingertips for 3 minutes per point, four times per day; this tients gave their informed consent the day before to undergo
treatment ended 7 days after surgery. Patients in the treatment the procedure, agreeing in particular to postpone intake of the
group reported lower pain-intensity scores and used less an- prescribed drug (paracetamol/NSAIDS) for 6 hours on the next
algesic medication via patient-controlled analgesia (PCA) morning. A washout of analgesic drugs during at least 6–8
than the patients in the control group.7 hours was necessary, according to Romoli, to prevent a false–
The primary purpose of this study was to examine the negative diagnosis and to identify correctly the specific au-
adjuvant effects of one session of auricular acupuncture on ricular points associated with the investigated pain syndrome.8
persisting pain and disability in patients hospitalized for Exclusion criteria for the current study were as follows:
total knee replacement (TKR) postoperative rehabilitation. mono-compartmental knee replacement; any neurologic
AURICULOTHERAPY AND KNEE PAIN 99

disorder that could interfere with the proposed performance

test; auricular acupuncture in the past; and a numeric rating
scale (NRS) pain score of <4 on the morning of treatment.
In a consecutive group of 25 patients, 8 were excluded (2
with hemiparesis, 1 with diabetic neuropathy, and 5 on the
morning of treatment because they had a pain level of <4 in
a seated position). Of the remaining 17 patients (14 females
and 3 males; average age years 75.7; standard deviation
[SD]: 4.6; range 65–83) all were included and treated be-
tween the eighth and twenty-eighth day after intervention
(average 16.6 days; SD 5.6). On the morning of the treat-
ment session, the patients were informed again about the
procedure and were provided with informed consent forms
to complete. Each patient sat in a standard chair without
armrests. The first physician (C.A.) measured each patient’s
pain level with an NRS (from 0 = no pain to 10 = worst pain)
in sitting and standing positions. The average time for sit-to-
stand was scored on three consecutive standing movements.
The same movement tests were repeated after the auricular
acupuncture session and again 6 hours later. Auricular di-
agnosis was performed by a second physician (M.R.) with a
simplified method for selecting the most effective points for
treatment in each patient. As several areas of the auricle
may be associated with different disorders and dysfunctions
in an elderly patient, auricular diagnosis in these patients
was restrained to the upper and lower crus of the antihelix
and the subtended triangular fossa. This region of the upper
auricle includes ear points where the French and the Chinese
schools of auriculotherapy somatotopically represent the
knee (Fig. 2). Both auricles were examined with an elec-
trical skin resistance test (ESRT) and a pressure pain test
(PPT). ESRT was performed with the commercially avail-
able device Agiscop D Point Detector Sedatelec (France)
for identifying the points with lower resistance, choosing
the threshold value of 1 mega ohm (knob 4). PPT was
performed with the blue pressure-probe of the Sedatelec, FIG. 2. The auricular zone (gray) tested with an electric skin
exerting a 250-g. maximal pressure for identifying the resistance test and double consecutive pain pressure tests in 17
most-sensitive auricular points. A second PPT was con- patients with chronic postoperative pain related to total knee re-
secutively performed on both the previously identified ten- placement. A and B represent the current location of the knee area
der points and the electrically detected points. Only the according to the Chinese (A) and French (B) schools.
points maintaining a tenderness during the second test were
marked with ink. The selected points were transcribed on
the Sectogram of Romoli, which is a graphic tool enabling a treatment (T0), the patients reported a pain level in the
more-correct transcription of the points9 (Fig. 3). Only the sitting position; this level varied from 4.5 to 10 (mean av-
points located on the ear ipsilateral to the operated knee erage of 5.9; SD 1.8). The average sit-to-stand time at T0, on
were treated with acupuncture. Acupuncture was performed three consecutive movements, varied from 2 to 12.6 seconds
by the third physician (L.B.) using Australian needles (mean average of 4.7; SD 2.5; Table 1). After auricular
(Hwato; 20-mm length · 0.25-mm diameter) and left in acupuncture (T1) and 6 hours later after the AEA was
place for 20 minutes without further stimulation. completed (T2), reported pain levels decreased significantly
both in the sitting and standing positions (Table 2A and B).
When transitioning from T1 to T2, there was no significant
RESULTS variation in standing position results (Table 2B). The av-
erage sit-to-stand time did not reach significance at T1
Nine patients of 17 included in the study were operated on ( p = 0.09) but decreased significantly at T2 ( p < 0.005;
the left side and 8 on the right side. On the morning of Table 3).
100 ROMOLI ET AL.

Table 2. Paired t-Test for Differences Between

Average Pain Scores in Two Positions
A: Sitting Position at T0–T1, T0–T2, and T1–T2 intervals

Paired comparisons T p

T0–T1 3.92 < 0.005

T0–T2 4.25 < 0.001
T1–T2 2.37 < 0.05
B: Standing position at T0–T1, T0–T2, and T1–T2 intervals

Paired comparisons T p

T0–T1 4.54 < 0.005

T0–T2 4.31 < 0.005
T1–T2 0.27 NS
T, time; NS, not significant.

Auricular diagnosis and ESRT identified on both auricles

yielded a total of 10 points on average with lower electrical
resistance in the tested area of the upper auricle; 5.7 of the
points were located on the ipsilateral ear and 4.3 of the
points were located on the contralateral ear. PPT identified
on both auricles, at the first test, 10.8 sensitive points on
average; 7.5 of the points were located on the ipsilateral ear
and 3.3 of the points were located on the contralateral ear.
The second consecutive PPT, retained for treatment only,
yielded 4.5 points on average on the ipsilateral ear (2.7 on
the antero-lateral and 1.8 on the postero-medial surface),
showing a reduction of 41.5%, compared to the first PPT.
The selected points for treatment were spread out over a
wide area, larger than commonly expected, but corre-
sponding, however, both to the Chinese and French soma-
totopic representations of the knee.
FIG. 3. Distribution of treated points in 17 consecutive patients
with chronic postoperative pain related to total knee replacement
(black dots on the lateral surface; clear circles on the medial DISCUSSION
surface).

As already reported by the literature AEA seems to have a

positive effect on reducing knee pain after arthroscopy and
surgery. In the current study, a possible adjuvant effect
of auricular acupuncture was observed in elderly patients
Table 1. Mean and SD of NRS and Sit-to-Stand with a tendency to have prolonged hospitalizations. Both
Time at T0, T1 and T2
pain levels (after treatment) and the sit-to-stand times (after
Parameter Mean SD

NRS in sitting position T0 5.88 1.76 Table 3. Paired t-Test for Differences Between
NRS in sitting position T1 3.71 2.80 Average time (seconds) of 3 Consecutive Tests
NRS in sitting position T2 3.65 2.89 in the Sit-To-Stand Performance at T0–T1, T0–T2,
NRS in standing position T0 6.15 2.05 and T1–T2 Intervals
NRS in standing position T1 4.76 2.62 Paired comparisons T p
NRS in standing position T2 3.97 2.80
Sit-to-stand time T0 4.71 2.55 T0–T1 1.34 NS
Sit-to-stand time T1 4.14 1.94 T0–T2 3.18 < 0.005
Sit-to-stand time T2 3.30 0.88 T1–T2 2.34 < 0.05
SD, standard deviation; NRS, numeric rating scale; T, time. T, time; NS, not significant.
AURICULOTHERAPY AND KNEE PAIN 101

6 hours) were reduced, indicating therefore the possibility knees. There are two concepts that are important to consider
to include this kind of treatment in a specific rehabilita- regarding the size of these dimensions. First, a severe sur-
tion program for this category of patients. Maintaining an gical trauma, such as TKR involving an important joint such
evidence-based approach, this pilot study should be fol- as the knee, produces, in the current authors’ opinion, a
lowed in the future by a randomized controlled trial that marked reflex activation (with reduction of electrical re-
would compare usual rehabilitation for TKR with the same sistance and sensitization) of an auricular area that cannot be
program associated with auricular acupuncture. One of expected to have small dimensions. Second, the large
the limits of this present study was not to have scored in identified area tends to overlap with the double represen-
the following hours, at least up to 24 hours, variation of tation of the knee according to both the French and the
the abovementioned parameters. The current authors were Chinese schools of auricular acupuncture.
actually obliged, for ethical reasons, not to withdraw an- The current authors’ hypothesis is that an important joint
algesic drugs from the patients for longer than 6 hours. such as the knee, which is essential for motion and that
With respect to the applied methodology, the following contributes greatly to postural stability in humans, probably
items could be explored: has a much larger representation on the ear as previously
supposed. In the current authors’ opinion, therefore, the
(1) ESRT was performed first, before PPT, because the
somatotopic representation of the body on the auricle should
repetitive mechanical pressure applied by the alg-
be imagined more as homunculuslike image than as a pro-
ometer can, in some cases, cause scraping of the skin,
portioned fetuslike image. In this nondogmatic approach, a
consequently inducing a local higher permeability to
functionally more important or richly innervated structure
an electric current.
(2) PPT was applied twice consecutively, and the second
test reduced significantly the number of tender points.
However, it is possible that PPT applied a third time
would have reduced the number of tender points even
more. In the current authors’ opinion, this method
should be used systematically by the acupuncturist to
raise the ‘‘threshold’’ of tenderness of each point,
thus allowing identification of the most specific and
appropriate points for treatment in different patients
who have the same pain syndrome.
(3) Auricular diagnosis was performed on only a limited
part of the ear, which included the somatotopic, auri-
culotherapy representation of anatomical structures
such as the hip, knee, foot, gluteus, thoracic-lumbar-
sacral spine, etc. ESRT and PPT were applied on the
antero-lateral surface and also on the posterior-medial
surface of the outer ear of each patient, taking into
account the possibility of identifying on this surface
the representation of the posterior part of the knee. In
fact, 40% of the treated points were located on the
posterior-medial surface of the examined area of the
auricle. It has to be remarked that only Western au-
thors have proposed points on the posterior-medial
surface of the ear for treating knee pain.10–15
(4) The selected points for treatment were marked with
nonpermanent ink on the right and left ears, but only
those points located on the ear ipsilateral to the op-
erated side were treated with acupuncture. The pur-
pose of this ipsilateral stimulation, in agreement with
the researchers cited in the introduction to this article,
was to apply acupuncture only for the operated knee FIG. 4. Representation of knee and ankle pain according to
and to measure the effect of this intervention. Maria Caterina Fresi, MD (with permission). Originally printed as
figure 8.5, ref. 8, chapter 8, ‘‘The Needle Contact Test.’’ 1 and
One important issue of this study concerns the dimen- 2 = lateral and medial capsule-ligament complex of the knee; 3
sions of the treated area, which seems to be larger than and 4 = capsule-ligament complex, respectively, of the lateral and
commonly accepted by acupuncturists treating painful medial malleolus.8
102
of the body tends to have a larger representation than others
that are functionally less important or that have less-
developed innervation. The possibility that the knee area
actually could include the double representation of the
French and Chinese schools, was researched also by Maria
Caterina Fresi, MD, who performed a study on patients with
knee and ankle pain caused by bruises or sprains. She ex-
amined 34 patients with knee pain caused by injuries, re-
spectively, of the lateral capsule-ligament complex (14
patients) or of the medial complex (20 patients). In the first
group, the pain syndrome evoked a sensitization of an ex-
tended oval area covering the Chinese hip and knee areas,
whereas, in the second group, the sensitized area was rather
rounded and corresponded to the French thigh and knee areas
(areas 1 and 2 of Fig. 4). A similar topographic observation
was made on 15 patients with ankle pain caused by injury,
respectively of the capsule-ligament complex of the mal-
leolus lateralis (8 patients), or of the complex of the malleolus
medialis (7 patients). In the first group, the sensitized area
corresponded to the Chinese ankle and toe/heel areas,
whereas, in the second group, the sensitized area corre-
sponded to the French foot areas (areas 3 and 4 of Fig. 4).8
CONCLUSIONS
The points identified with ESRT and double PPT may be
effective for reducing pain and disability in elderly people
with prolonged hospitalizations and persistent postopera-
tive pain after TKR. These points are spread out on an area
that tends to overlap with the representations of the knee
joint according to French and Chinese researchers. A larger
and more comprehensive study is warranted to explore the
implications of the current study further.
DISCLOSURE STATEMENT
No competing financial interests exist.
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Address correspondence to:
Marco Romoli, MD
Via Sprone 1/4,
59100-Prato
Italy
E-mail: markro@tin.it