Out-of-hospital auricular acupressure in elder patients with hip fracture: a randomized double-blinded trial.
ABSTRACT Auricular acupressure is known to decrease the level of anxiety in patients during ambulance transport. The purpose of this randomized, double-blind, sham control study was to determine whether auricular acupressure can decrease not only the level of anxiety but also the level of pain in a group of elder patients with acute hip fracture.
With the assistance of the Vienna Red Cross, 38 patients with acute hip fracture were enrolled into this study. Patients were randomized into two study groups: the true intervention group and the sham control group. Subjects in the true intervention group (n = 18) received bilateral auricular acupressure at three auricular acupressure points for hip pain. Patients in the sham group (n = 20) received bilateral auricular acupressure at sham points. Baseline demographic information, anxiety level, pain level, blood pressure, and heart rate were obtained before the administration of the appropriate acupressure intervention. The level of anxiety, level of pain, hemodynamic profiles, and level of satisfaction were reassessed once the patients arrived at the hospital.
Patients in the true intervention groups had less pain (F = 28, p = 0.0001) and anxiety (F = 4.3, p = 0.018) and lower heart rate (F = 18, p = 0.0001) on arrival at the hospital than did patients in the sham control group. As a result, the patients in the true intervention group reported higher satisfaction in the care they received during the ride to the hospital.
The authors encourage physicians, health care providers, and emergency rescuers to learn this easy, noninvasive, and inexpensive technique for its effects in decreasing anxiety and pain during emergency transportation.
- SourceAvailable from: Maliheh Araghchian[Show abstract] [Hide abstract]
ABSTRACT: Open heart surgery can cause high levels of anxiety in patients. Nowadays, lavender essential oil is widely used in medical research. This study was conducted with an aim to investigate the effects of lavender essential oil to reduce the anxiety of patients after coronary artery bypass surgery. This research is double-blinded randomized controlled trial on 60 patients who had undergone coronary artery bypass surgery in a 2-day intervention targeting reduction of anxiety. This study was conducted in Ekbatan Therapeutic and Educational Center, Hamadan city, Iran, in 2013. The patients in the inhalation aromatherapy group inhaled two drops of 2% lavender essential oil and those in the control group inhaled two drops of distilled water as placebo for 20 min on the 2(nd) and 3(rd) days after surgery. The level of anxiety was evaluated by Spielberger's State Anxiety questionnaire before and after intervention and the vital signs were documented as well. Data were analyzed using Stata 11 (Stata Corp., College Station, TX, USA) by independent t-test for continuous variables and Chi-square test for categorical variables. The mean score of anxiety in the aromatherapy group was 48.73 ± 5.08 and in the control group was 48 ± 6.98 before the intervention (P = 0.64), which reduced after the intervention to 42.6 ± 5.44 and 42.73 ± 7.30, respectively. On the 3(rd) day after surgery, the mean score of anxiety in the aromatherapy group was 46.76 ± 4.07 and in the control group was 46.53 ± 7.05 before the intervention, which reduced to 41.33 ± 3.65 and 41.56 ± 6.18, respectively, after the intervention. However, there was no statistically significant difference in the mean scores of anxiety between the aromatherapy and control groups. Lavender essential oil has no significant effect on anxiety in patients after coronary artery bypass surgery, although it decreased the level of anxiety in the patients.Iranian journal of nursing and midwifery research 11/2014;
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ABSTRACT: Background: Exposure to deployment and battle can induce a constellation of physical, cognitive, psycho-logical, and behavioral symptoms, also referred to as war-related Trauma Spectrum Response (wrTSR). One prevalent cause of this response is traumatic brain injury (TBI) and its ensuing sequelae, such as pain and suffering caused by post-traumatic headache. Current pharmacologic treatment of these headaches is often inadequate and complicated by the multi-component nature of wrTSR. Acupuncture has been found to reduce pain, improve health-related quality of life, prevent migraine headaches, and reduce tension-type and chronic daily headaches. Objective: An ongoing study is endeavoring to advance understanding of the speed and depth of healing induced by two acupuncture approaches, compared to current standard practice and with the aim of providing insights to guide future implementation of acupuncture treatment in the military. Design: A comparative effectiveness study protocol will be used to determine if auricular acupuncture (AA) or semi-standardized traditional Chinese acupuncture (TCA) alleviates headaches and reduces associated co-morbidities more effectively than usual care alone in a cohort of active duty military personnel with mild-to-moderate TBI. Summary: Given that the study is currently underway, no results or conclusions can be reported at present. While current evidence from acupuncture research demonstrates its promising healing impact across the wrTSR, a number of unanswered questions and information gaps remain. It is hoped that the proposed study will address some of these questions and gaps.Medical Acupuncture 12/2011; 23(4).
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ABSTRACT: Delivery is one of the most stressful events in women's life. Excessive anxiety, in turn, increases delivery and pregnancy complications. Mother's positive experience of delivery leads to more effective maternal-fetal attachment in the first few hours of birth. The present study aimed to compare the effects of acupressure at two different acupoints on anxiety level and maternal-fetal attachment in primiparous women. In this study, 150 primiparous women were allocated to acupressure at GB-21 acupoint, acupressure at SP-6 acupoint, and control group. The women in their active phase of delivery were enrolled in the study and pressure was applied to the acupoints for 20 minutes. Mother's anxiety level was assessed using Spielberger's questionnaire before and one hour after the intervention. In addition, maternal-fetal attachment behaviors were evaluated using Avant's questionnaire during the first breastfeeding. Then the data were introduced to the SPSS (v. 13) and were analyzed using t test and one way ANOVA. The results revealed no significant difference among the three groups regarding the anxiety level before the intervention (P > 0.05). One hour after the intervention, this measure was significantly lower in the intervention groups in comparison to the control group (P < 0.001). However, no significant difference was found between the two intervention groups in this regard (P > 0.05). Moreover, maternal-fetal attachment was higher in the intervention groups in comparison with the control group (P < 0.001). Acupressure at both acupoints reduced anxiety level and increased maternal-fetal attachment. This method can be easily used in the delivery room.Nursing and midwifery studies. 09/2014; 3(3):e19948.
Out-of-hospital Auricular Acupressure
in Elder Patients with Hip Fracture:
A Randomized Double-Blinded Trial
Renate Barker, MD, Alexander Kober, MD, Klaus Hoerauf, MD, PhD, Daniela Latzke, MD,
Sharam Adel, MD, Zeev N. Kain, MD, Shu-Ming Wang, MD
Objectives: Auricular acupressure is known to decrease the level of anxiety in patients during ambulance
transport. The purpose of this randomized, double-blind, sham control study was to determine whether
auricular acupressure can decrease not only the level of anxiety but also the level of pain in a group of elder
patients with acute hip fracture.
Methods:With the assistance ofthe ViennaRed Cross, 38patientswithacute hip fracturewere enrolledinto
this study. Patients were randomized into two study groups: the true intervention group and the sham con-
trol group. Subjects in the true intervention group (n = 18) received bilateral auricular acupressure at three
auricular acupressure points for hip pain. Patients in the sham group (n = 20) received bilateral auricular
acupressure at sham points. Baseline demographic information, anxiety level, pain level, blood pressure,
and heart rate were obtained before the administration of the appropriate acupressure intervention. The
level of anxiety, level of pain, hemodynamic profiles, and level of satisfaction were reassessed once the
patients arrived at the hospital.
Results: Patients in the true intervention groups had less pain (F = 28, p = 0.0001) and anxiety (F = 4.3,
p = 0.018) and lower heart rate (F = 18, p = 0.0001) on arrival at the hospital than did patients in the sham
control group. As a result, the patients in the true intervention group reported higher satisfaction in the
care they received during the ride to the hospital.
Conclusions: The authors encourage physicians, health care providers, and emergency rescuers to learn
this easy, noninvasive, and inexpensive technique for its effects in decreasing anxiety and pain during emer-
ACADEMIC EMERGENCY MEDICINE 2006; 13:19–23 ª 2006 by the Society for Academic Emergency
Keywords: ear acupressure, anxiolysis and analgesia, hip fracture
ip fractures in elders are associated with signifi-
cant morbidity and mortality. A study from the
United States indicates that hip fractures reduced
the average life expectancy by six years as compared with
an age- and gender-matched general population.1In fact,
the estimated lifetime cost for all hip fractures in the
United States has been reported to exceed $20 billion.
About 72% of patients with hip fracture reported moder-
ate to serve pain, but only 56% received analgesics.2
Therefore, it is important not only to prevent the occur-
rence of hip fractures but also to appropriately manage
fractures that have occurred.
In central Europe, ambulances are dispatched with
paramedic personnel but without physicians for all pa-
tients who have hip fractures with reported pain of <9
on a visual analog scale (VAS) with a range of 0–10. The
paramedic personnel are not allowed to administer any
pharmacologic interventions or perform any invasive
procedures without the presence of a physician.3As a re-
sult of this policy, many elder patients with hip fractures
experience significant pain and anxiety during the ambu-
lance transport to the hospital.4It is well documented that
From the Department of Anesthesia and Intensive Care, Univer-
sity of Vienna (RB, AK, KH, DL, SA), Vienna, Austria; Vienna
Red Cross, Van Swieten (RB, AK, DL, SA), Vienna, Austria; the
Research Institute of the Vienna Red Cross (RB, AK, DL, SA),
Vienna, Austria; and Departments of Anesthesiology (ZNK,
SW), Pediatrics (ZNK), and Child Psychiatry (ZNK), Yale School
of Medicine, New Haven, CT.
Received February 6, 2005; revision received June 26, 2005;
accepted July 5, 2005.
Address for correspondence and reprints: Klaus Hoerauf,
MD, PhD, Department of Anesthesiology and General Intensive
Care, University Hospital of Vienna, Waehringer Guertel 18-20,
A-1090 Vienna, Austria. Fax: 43 1 40400 2468; e-mail: klaus.
ª 2006 by the Society for Academic Emergency Medicine
PII ISSN 1069-6563583
these pain and anxiety symptoms provoke a sympathetic
response that leads to tachycardia, hypertension, arterio-
lar vasoconstriction, reduced wound perfusion, and
decreased tissue partial pressure.5This sympathetic
response is particularly harmful in elders, where it may
lead to cardiovascular instability and contribute to major
morbidity and mortality. Thus, there is an urgent need for
the introduction of nonpharmacologic interventions that
can be applied by paramedic personnel to elder patients
during transport to the hospital.
Previously, nonpharmacologic interventions such as
local warming were found to be effective treatments for
nausea, vomiting, and pain during ambulance trans-
port.6,7Our research team also demonstrated that auricu-
lar acupressure, performed in an out-of-hospital setting,
is effective for the management of anxiety in patients
with minor injury and medical illnesses.8,9In this follow-
up investigation, we explored the role of auricular acu-
pressureas anout-of-hospitaltreatment forelderpatients
sent various parts of the human body, the selection of
specific auricular acupressure points is needed as a
treatment for various organs involved by the disease.
We therefore designed a prospective, randomized, sham
control trial to determine whether ear acupressure at
three specific preselected auricular acupressure points
can decrease pain and anxiety for elder patients with
This randomized controlled study was conducted on con-
secutive elder patients who had sustained hip fractures
and were transported to the hospital by ambulance. The
institutional review board approved the study protocol,
and informed consent was obtained from all subjects.
Study Setting and Population
Included patients were aged 80–95 years, American Soci-
ety of Anesthesiologists physical status II–III, who sus-
tained an isolated hip fracture without any additional
trauma. A minimum age limit of 80 years was set because
the rate of hip fractures in patients older than 80 years
was 25% greater than that in younger populations.2Pa-
tients were transported to local hospitals by ambulances
staffed by paramedics.The primary outcomes of thestudy
were anxiety and pain level, as determined by psycholog-
ical and physiologic measures. Subjects were randomly
assigned to receive either true auricular acupressure
(true intervention group) or sham auricular acupressure
(sham control group). A repeated-measures design was
used, in which each subject’s pain and anxiety were eval-
uated before and after the auricular acupressure inter-
vention. We excluded all patients who were not fluent in
German, patients with ear deformity, patients with severe
neurologic or psychiatric disorders, and patients who
take sedatives or analgesics on a long-term basis.
VAS. This is a self-reported scale commonly used to as-
sess different levels of various conditions that a person
experiences. The scale consists of a 100-mm line that
represents the extremes of symptoms at either end of
the continuum, ranging from 0 to 100. In this study, we
used this scale to assess the level of pain, anxiety, and
satisfaction with treatment. These were rated as follows:
a VAS-Pain with 0 represents ‘‘no pain’’ and 100 repre-
sents ‘‘extreme pain,’’ a VAS-Anxiety with 0 represents
‘‘not anxious’’ and 100 represents ‘‘extremely anxious,’’
and a VAS-Satisfaction with 0 represents ‘‘not satisfied’’
and 100 represents ‘‘extremely satisfied.’’
Blood Pressure and Heart Rate. The cardiovascular sys-
tem is highly responsive to a variety of psychological and
behavioral states. Both heart rate and blood pressure
have been widely used as dependent variables in be-
havioral studies designed to alter levels of anxiety and
are frequently cited as physiologic indices of stress in
psychology, aviation medicine, and anesthesia.
Once a potential study subject was identified by a tele-
phone triage system, two paramedics, paramedic T (treat-
ment) and paramedic D (data collection), were dispatched
to care for the patient. All patients were treated according
to the guidelines of the Austrian Red Cross Ambulance
Service. These guidelines are accepted as the basis of
paramedical education in Austria. Once the paramedics
arrived at the site of the accident and provided ‘‘standard
of care’’ management, patients were invited to participate
in the study. After obtaining written informed consent,
paramedic T (treatment) left the immediate site of the
accident and paramedic D (data collection) obtained
baseline data on demographic characteristics and hemo-
dynamic parameters (blood pressure and heart rate). The
patient also completed the pain and anxiety VAS before
the acupressure intervention. During evaluation, patients
lay on a stretcher and completed the VAS on a piece of
After paramedic D performed the baseline assess-
ments, paramedic T opened a sealed envelope to deter-
mine the patient’s group assignment and performed
the assigned intervention accordingly. With paramedic
D not present in the immediate area, paramedic T
performed the auricular acupressure based on group
True Intervention Group. Subjects in this group received
bilateral auricular acupressure at three auricular acupres-
sure points for hip pain (Figure 1). All acupressure was
performed with 1-mm acupressure plastic beads covered
with an opaque ear patch to secure the locations of the
beads. All acupressure beads were secured during the
ambulance ride to the hospital.
Sham Control Group. Subjects in this group received
bilateral auricular acupressure at a sham point. A sham
point is defined as an acupuncture point that is not docu-
mented to have any pain-reducing or anxiolytic effect.
The sham acupuncture point of this study is located at
the tip of the concha and is reported to achieve homeo-
stasis of the stomach (Figure 1).
To minimize bias, paramedic T was not told that he was
performing a true or a sham intervention. Instead, he was
instructed that the aim of this study was to compare
Barker et al.?AURICULAR ACUPRESSURE AND HIP FRACTURE
acupressure intervention using two groups of ear points.
None of the paramedics involved in the study had knowl-
edge about or were experienced with acupressure or
similar treatments. To ensure the accuracy of treatment
performance, paramedic T was intensively trained by
a physician with experience in acupressure and acupunc-
ture at the University Hospital of Vienna. Paramedic T
was trained to identify the four ear points used in this
study and to ensure the standardization of applying the
pressure beads. He was not instructed which point had
any specific effect.
Following the administration of the intervention, para-
medic T covered the ears of all subjects with ear patches.
This was done to assure blinding of paramedic D, who
was involved in the outcome assessment. The patient
was next moved to the ambulance. To maintain blinding,
paramedic D sat in thefront of theambulance, while para-
medic T stayed with the patient in the back (sections of the
ambulance are separated by a rigid wall). On arrival at the
hospital, paramedic D reassessed pain, anxiety, and satis-
faction outcomes without the presence of paramedic T.
Finally, the completed datasheets were put into opaque
envelopes and sealed by paramedic D to ensure complete
It is important to note that great care was spent on en-
suring that either treatment or data collection was per-
formed in absence of the other paramedic. The design
of the ambulance provides no possibility for paramedic
D to be aware of the auricular acupressure intervention
during transport. To ensure that the blinding system
was maintained and that the treatment was performed
accurately, a physician otherwise not involved in data
collection or treatment performed ten on-site audits of
the methodology and data collection.
Based on previous investigations,8a sample size of 18
subjects in each group was required to detect a decrease
of 25% in anxiety and pain equal to the difference of one
standard deviation (effect size = 1) with a power of 80%
and an a of 0.05. Normally distributed data are presented
as mean (?SD). Baseline characteristics of the two groups
were analyzed using Student’s t-test for continuous data
and chi-square test for categorical analysis. Two-way re-
peated-measures analysis of variance was used to analyze
the changes in anxiety, pain, and physiologic parameters
(heart rate, systolic blood pressure, diastolic blood pres-
sure) at two different times (baseline and on arrival at
the hospital). Comparisons were considered significant
if p < 0.05. Analysis was conducted using SPSS (version
10.0; SPSS Inc., Chicago, IL).
A total of 38 patients with a hip fracture, transported to
the hospital by ambulance with paramedics only, partici-
pated in this study (Figure 2). The mean (?SD) age of
participants was 86.2 (?4.2) years (range, 80–94 years).
The participants were randomly placed into two groups
(true intervention and sham control groups). There were
18 patients in the true intervention group and 20 patients
in the sham control group. There were no differences in
the demographic data and baseline pain, anxiety, and
hemodynamic parameters (Tables 1 and 2). The out-of-
hospital time of transportation was also comparable in
both groups: 29 ? 12 minutes (true intervention) versus
32 ? 15 minutes (sham control).
Atwo-way repeated-measures analysis of variance per-
formed for anxiety demonstrated a significant time effect
(p = 0.001) and a group ? time interaction (F = 4.3, p =
0.018), showing a change in anxiety scores based on
time and group assignment. Subjects who received acu-
pressure as the true intervention group had significantly
lower anxiety scores on arrival at the hospital as com-
pared with individuals who received the sham control
intervention (Figure 3). Similarly, a two-way repeated-
measures analysis of variance that examined the levels
Figure 1. Acupressure points used in the study.
Figure 2. Consolidated standard for reporting clinical trials:
CONSORT flow diagram.
ACAD EMERG MED?January 2006, Vol. 13, No. 1?www.aemj.org
of pain found a time effect (p = 0.0001) and a group ? time
intervention (F = 28, p = 0.0001). That is, subjects in the
true intervention group experienced significantly less
pain on arrival at the hospital (Figure 4).
Similar to pain and anxiety scores, subjects in the true
intervention group were found to have lower heart rate
on arrival at the hospital (F = 18, p = 0.0001). Interestingly,
there were no differences in systolic blood pressure (re-
peated measure, F = 3.1, p = 0.093) and diastolic blood
pressure (F = 0.9, p = 0.34) between the true intervention
and sham control groups.
Under the conditions of this study, we found that auricu-
lar acupuncture applied at three specific points is effective
in reducing pain and anxiety in elder patients who have
sustained a hip fracture. These findings are significant in
Austria because elder patients are typically transported
to the hospital in an ambulance without a physician, and
thus no pharmacologic intervention can be used.
In Europe, millions of patients are transported to hospi-
tals every year by ambulances that may be staffed either
by paramedics alone or by paramedics and a physician.
Because paramedics are not allowed to administer medi-
cations during ambulance transport, many of these pa-
tients experience significant anxiety and pain during this
period. Over the past few years, our collaborative re-
search team has focused on identifying various interven-
tions that are not only nonpharmacologic and easy to
apply, but also effective in reducing anxiety and pain.6–9
Our results indicate that ear acupressure performed by
paramedics reduces pain and anxiety in a group of elder
patients with hip fracture. Interestingly, the average heart
rate of patients in the true intervention group was signif-
icantly lower than the average heart rate of those in the
sham control group. This is of importance because in-
creased heart rate leads to increased myocardial oxygen
demands. In an elder patient population that may have
an underlying coronary disease, this sudden increase in
myocardial oxygen demand may lead to detrimental
Baseline Demographic Data
86.5 ? 4.0
69.9 ? 17.3
86.0 ? 4.8
67.0 ? 15.3
Age, mean ? SD (yr)
Body weight, mean ? SD (kg)
Side of fracture
Type of fracture
True InterventionSham Intervention
Systolic BP (mmHg,
mean ? SD)
Diastolic BP (mmHg,
mean ? SD)
Heart rate (bpm,
mean ? SD)
124.9 ? 12.2
119.7 ? 18.8
124.7 ? 7.4
126.4 ? 19.5
74.3 ? 9.4
72.5 ? 12.9
78 ? 7.7
80.7 ? 13.3
95.4 ? 8.3*
72.5 ? 9.4
92.3 ? 11.7
90 ? 8
*p = 0.0001.
tion differs from sham intervention significantly (p < 0.001).
Figure 4. Visual analog scale values for pain. True interven-
tion differs from sham intervention significantly (p < 0.001).
Barker et al.?AURICULAR ACUPRESSURE AND HIP FRACTURE
The potential mechanism for the effectiveness of auric-
ular acupressure may be similar to that which has been
documented in the acupuncture literature. Stimulating
a particular point with either a needle or pressure can
activate small myelinated nerve fibers that send impulses
into the spinal cord, midbrain, pituitary, and hypothala-
mus10and cause a measurable release of endorphins
into blood.11Besides this, various neurotransmitters
such as serotonin, norepinephrine, and possibly g-amino-
butyric acid are known to interrupt incoming stress
signals in the central nervous system.
Patients in the true intervention group reported being
more satisfied with the care they received during the
ride to the hospital. One interesting observation noted
in our study is that patients in the sham control group
also reported being relatively satisfied with the care
they received during transportation. With the addition
of this simple, inexpensive technique, the quality of care
given to this patient population in the out-of-hospital
setting has significantly improved. The cost of ear acu-
pressure is minimal (3 cents per patient), but the benefit
may be enormous (lower heart rate, less pain, and less
anxiety). Currently, there is an increased emphasis on
patients’ satisfaction as an important component within
the general medical literature and the health care indus-
Finally, over the recent years, more and more data have
intervention is beneficial for out-of-hospital relaxation
and analgesia in patients with illnesses or trauma.6–9
However, not every nonpharmacologic, noninvasive
intervention is suitable for every condition encountered
during ambulance transport. For example, traditional
body acupressure technique requires undressing the
patients, which may not be feasible for those patients
who have sustained hip fractures.
Our trial could not compare the effect of analgesic drugs
(e.g., nonsteroidal anti-inflammatory drugs or opioids)
with acupressure due to the legal limitations on out-
of-hospital emergency care in central Europe. Further
research is needed to analyze if drug-based analgesia or
acupressure is more effective in acute out-of-hospital
It would have been interesting to see the potential
effects of acupressure in the early hospital phase (e.g.,
during primary radiograph investigation). Our trial
design could not assess these effects due to the lack of
human resources for an intrahospital follow-up. In the
future, research projects dealing with out-of-hospital
analgesia should focus on the early ‘‘posttransport phase’’
of trauma care.
We found that auricular acupuncture applied at three
specific points is effective in reducing pain and anxiety
in elder patients who have sustained a hip fracture. We
encourage clinicians and ambulance personnel to learn
this simple technique and implement this technique in
their routine clinical care. Future studies should also
focus on the effect of this intervention on the overall
outcome of the patients and the basic mechanism of ear
acupressure in decreasing pain and anxiety.
The authors thank the emergency dispatchers of the Vienna Red
Cross who strongly supported this study.
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Bonjour JP, Rizz R. Survival and potential years of
life lost after hip fracture in men and age-matched
women. Osteoporos Int. 2002; 13:731–7.
2. Gerson LW, Emond JA, Camargo CA. US emergency
department visits for hip fracture, 1992-2000. Eur J
Emerg Med. 2004; 11:323–8.
3. Doering GT. Customer care. Patient satisfaction in the
prehospital setting. Emerg Med Serv. 1998; 27:71–4.
4. Forster MC, Pardiwala A, Calthorpe D. Analgesia
requirements following hip fracture in the cognitively
impaired. Injury. 2000; 31:435–6.
5. Akca O, Melischek M, Scheck T, et al. Postoperative
pain and subcutaneous oxygen tension. Lancet. 1999;
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warming: an effective treatment for pain, anxiety
and nausea caused by renal colic. J Urol. 2003;
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ence of local active warming on pain relief of patients
with cholelithiasis during rescue transport. Anesth
Analg. 2003; 96:1447–52.
8. Kober A, Scheck T, Greher M, et al. Prehospital anal-
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a prospective, randomized,
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9. Kober A, Scheck T, Schubert B, et al. Auricular acu-
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10. Hui KK, Liu J, Makris N, et al. Acupuncture modulates
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ACAD EMERG MED?January 2006, Vol. 13, No. 1?www.aemj.org