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HERO Ear Acupuncture

  1. PURPOSE. 

1. PURPOSE.  To provide an evidence-informed ear acupuncture protocol consistent with veteran population and expand non-pharmacological tools for acupuncture providers.

2. ISSUE.  Whole Health encourages widespread involvement to help patients become active participants in their well-being.

3. BACKGROUND.  Ear acupuncture is a microsystem of tiny points that deliver a systemic response.  One mechanism of impact is the alteration of neuromuscular and neuropathic disorders attributed to descending pain inhibitory pathways of the central nervous system (Oleson, 2002).  The analgesia produced by acupuncture is caused by complex neurohormonal mechanisms involving endogenous opioids and monoamines with evidence of a sustained depression of neurons in spinal dorsal horn (Vas et al, 2014).

 Stimulation of specific points on the external ear results in neural responses in the brain. Neural modulation cannot be controlled, which can increase pain in those with PTSD (Clausen et al, 2017) and pain dysregulation (Lee & Goto, 2011). Decreasing activity in some areas of the brain, such as the cingulate gyrus, increases pain (Vogt, 2005) and stress (Yücel et al, 2003). Meditation reduces pain-related neural activity by increasing activity (Nakata, Sakamoto, & Kakigi, 2014). The most powerful ear acupuncture points are master points, musculoskeletal points, and neuroendocrine points.

a. Ear acupuncture can be safely administered by using standard needles, ear needles, and high-quality semi-permanent acupuncture needles (ASP) in specific locations of the ear that can be retained up to several days. 

b. There are hundreds of ear acupuncture protocols.

i. Most ear acupuncture protocols consist of 3-5 specific locations in the ear.

ii. The National Acupuncture Detoxification Association (NADA) protocol was designed in 1971 for addiction and comorbidities. 

iii. The Battlefield Acupuncture (BFA) protocol was designed in 2008 for active duty military acute pain, not chronic pain

iv. The Heal Relax Open (HERO) protocol was designed in 2018 for veterans with chronic pain, stress, and mood challenges who are transitioning towards self-care.

c. The HERO ear acupuncture protocol uses ear points that have been vetted by professional acupuncture providers treating veterans using evidence-informed ear points and combinations that corollate to needs of the expanding veteran population. 

4. DISCUSSION.  The HERO protocol is designed for the unique challenges of the veteran community with a base of 3 master ear points with 3 optional pain points.  Master points have powerful systemic influences on the body, the mind, and the mood. Optional points can allow for more individualized veteran care. This protocol is also applicable to a range of other populations, military, first line responders, and healthcare workers.

a. Base Master Points.

i. Shen Men (Heal) is a heart/mind healing point that is often included in anesthesiology to help in recovery of surgery.  It can alleviate insomnia, restlessness, stress, anxiety, depression, and excessive sensitivity. This point is referred to as Spirit Gate, Divine Gate, and Wonder Point because it calms the shen, or mind, to facilitate a connection to one’s spirit.  This is point is also used in both BFA and NADA.  It is located superior and central to the triangular fossa.

ii. Tranquility (Relax) reduces stress through a sedation effect and relieves anxiety, high blood pressure, and chronic stress. This point is also referred to as Valium Point, Hypertensive 2, and Relaxation Point.  It is located on the Inferior Tragus as it joins the face, between the Intertragic Notch the Inferior Tragus Protrusion.

iii. Point Zero (Open) is situated in the center of the ear to bring the whole body into a general state of balance.  Also referred to as Point of Support, Umbilical Cord, Solar Plexus Point.  This points grounds and centers a person to reduce overthinking, worry, and depression.  The point is located in a notch on the Helix Root as it rises from the Concha Ridge.

b. Optional Pain Points.Low Back ear acupuncture point is a quintessential and much researched point for low back pain.  In 2016 (Ushinohama et al), research demonstrated that a single session of ear acupuncture temporarily reduced low back pain and disability momentarily in individuals with low back pain

Neck ear acupuncture point reduces pain in the neck and upper back region instantly. In 2015 (Silva et al), a randomized, single-blinded, sham-controlled, crossover study evaluated the immediate effect of ear acupuncture on pain and electromyographic activity of the upper trapezius muscle in patients with nonspecific neck pain. The study demonstrated immediate effect.

i. Knee ear acupuncture point is a local point for knee. Used with the base master point Shen Men, the combination is powerful for relieving a variety of knee pain presentations.  In 2016 (Suen et al), John Hopkins researched ear acupuncture for osteoarthritic knee among elders and found it both safe and highly effective.

5. INSTRUCTIONS.  Select one or all HERO Master points listed under 4.a., and select one or more of the focused Optional points listed under 4.b..  Both Master and Optional points can be bilateral or on one side as appropriate.  This allows a rotation of points that may be more appropriate during the current visit and prevents point fatigue by not using the same points which can irritate that area of the ear and negate effects.  The practitioner will assess the patient at the next visit to determine the appropriate Master points and Optional points on the appropriate ear. 

6. IMPLEMENTATION AND TRAINING.  Licensed acupuncturist can implement the HERO ear protocol on veterans, military, first line responders, and other populations as suitable.  Licensed acupuncturist, by way of training and scope do not require additional certification.  In addition, licensed acupuncturists and certified BFA trainers may readily teach and certify non-licensed acupuncturists to perform HERO if ear acupuncture falls under the providers’ scope.

VA practitioners can start HERO by using the existing VA Field Implementation and BFA Training Guides for teaching and privileging BFA and HERO ear acupuncture protocols.  The HERO ear acupuncture information can be added to the BFA ear acupuncture education sheet in the patient education section of iMed consent and the BFA ear acupuncture note template that includes a time element as required by some coders.

7. ADVANCED TRAINING.  Dr. Jennifer M. Williams is available to teach and certify HERO and a variety of acupuncture protocols for specific populations.  Training includes assessment, location skills, needle techniques, and documentation.

8. CONCLUSION.  Using a veteran focused ear acupuncture protocol will improve quality of care and result in a better return on investment of time and resources when we teach and certify providers in ear acupuncture.  The widespread use of an evidence informed ear acupuncture protocol designed for veterans can help decrease the number of veterans getting community care acupuncture who benefit from this approach as a way to manage pain, mood, and addiction. 

9. POINT OF CONTACT.  Dr. Jennifer M. Williams, PhD, DACM, L.Ac at 910-759-0057 and Jennifer@woodelement.com.

10.  REFERENCES

Clausen, A., Francisco, A., Thelen, J., Bruce, J., Martin, L., McDowd, J., Simmons, W. & Aupperle, R. (2017). PTSD and cognitive symptoms relate to inhibition-related prefrontal activation and functional connectivity. Depress Anxiety, 34(5):427-436. doi: 10.1002/da.22613

Lee, Y. A. & Goto, Y. (2011). Chronic stress modulation of prefrontal cortical NMDA receptor expression disrupts limbic structure-prefrontal cortex interaction. European Journal of Neuroscience, 34(3), 426-436. doi:10.1111/j.1460-9568.2011.07750.x

Nakata, H., Sakamoto, K., & Kakigi, R. (2014). Meditation reduces pain-related neural activity in the anterior cingulate cortex, insula, secondary somatosensory cortex, and thalamus. Frontiers in Psychology, 5, 1489. http://doi.org/10.3389/fpsyg.2014.01489

Oleson T. (2002). Auriculotherapy stimulation for neuro-rehabilitation. NeuroRehabilitation; 17(1):49-62.

Oleson, T. (2014). Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture. Churchill Livingstone Elsevier, 4th edition,

Silva, et al (2015). Evaluation of the Immediate Effect of Auricular Acupuncture on Pain and Electromyographic Activity of the Upper Trapezius Muscle in Patients with Nonspecific Neck Pain: A Randomized, Single-Blinded, Sham-Controlled, Crossover Study. Evidence-based complementary and alternative medicine: eCAM, 2015, 523851.

Suen, L. K., Yeh, C. H., & Yeung, S. K. (2016). Using auriculotherapy for osteoarthritic knee among elders: a double-blinded randomised feasibility study. BMC complementary and alternative medicine, 16, 257. doi:10.1186/s12906-016-1242-6

Usichenko, el al (2007). Auricular acupuncture for pain relief after ambulatory knee surgery: a randomized trial. CMAJ: Canadian Medical Association Journal, 176(2), 179-83.

Ushinohama, A., Cunha, B. P., Costa, L. O., Barela, A. M., & Freitas, P. B. (2016). Effect of a single session of ear acupuncture on pain intensity and postural control in individuals with chronic low back pain: a randomized controlled trial. Brazilian journal of physical therapy, 20(4), 328-35.

Vas, J., et al (2014). Auricular acupuncture for primary care treatment of low back pain and posterior pelvic pain in pregnancy: study protocol for a multicentre randomised placebo-controlled trial. Trials, 15, 288. doi:10.1186/1745-6215-15-288

Vogt, B. A. (2005). Pain and emotion interactions in subregions of the cingulate gyrus. Nature Reviews. Neuroscience, 6(7), 533–544. http://doi.org/10.1038/nrn1704

Yücel, M., Wood, S., Fornito, A., Riffin, J., Velakoulis, C., & Pantelis, D. (2003). Anterior cingulate dysfunction: Implications for psychiatric disorders? J Psychiatry Neuroscience. 28(5): 350–354.