A Case Series of Auricular Acupuncture in a Veteran’s Population Using a Revised Auricular MapPing-diagnostic Paradigm (RAMP-uP)

Full text

Complementary
Therapies
in
Medicine
27
(2016)
130–136
Contents
lists
available
at
ScienceDirect
Complementary
Therapies
in
Medicine
jo
ur
nal
home
p
ag
e:
www.elsevierhealth.com/journals/ctim
A
case
series
of
auricular
acupuncture
in
a
veteran’s
population
using
a
revised
auricular
mapping-diagnostic
paradigm
(RAMP-uP)
W.
Huanga,b,∗,
S.N.
Halpind,
M.M.
Perkinsc,d
aExtended
Care/Physical
Medicine
and
Rehabilitation,
Atlanta
VA
Medical
Centre,
1670
Clairmont
Road,
Decatur,
GA
30033,
United
States
bDepartment
of
Rehabilitation
Medicine,
Emory
University
School
of
Medicine,
Atlanta,
GA
30322,
United
States
cBirmingham/Atlanta
Geriatric
Research,
Education,
and
Clinical
Centre,
Atlanta
VA
Medical
Centre,
Atlanta,
GA
30033,
United
States
dDepartment
of
General
and
Geriatric
Medicine,
Emory
University
School
of
Medicine,
Atlanta,
GA
30322,
United
States
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
7
January
2015
Received
in
revised
form
19
January
2016
Accepted
10
June
2016
Available
online
24
June
2016
Keywords:
Auricular
Acupuncture
a
b
s
t
r
a
c
t
Objectives:
To
evaluate
clinical
effects
of
auricular
acupuncture
treatments
for
pain
based
on
a
revised
auricular
mapping
and
diagnostic
paradigm
(RAMP-uP).
Design:
Retrospective
chart
review.
Setting:
A
major
US
Veterans
Affairs
Medical
Centre
located
in
the
Southeaster
United
States.
Main
outcome
measures:
Pain
and
efficacy
rating
scores
based
on
visual
analogue
scales
during
each
clinical
visit.
Duration
of
acupuncture
treatment
effects
based
on
clinic
notes
documentation.
Results:
Patients’
average
pain
score
decreased
by
almost
60%
(p
<
0.0001).
The
treatment
effects
lasted
1–3
months
(47%).
The
overall
efficacy
reported
by
most
patients
was
helpful
(83.6%).
Conclusion:
The
observed
clinical
effects
of
auricular
acupuncture
based
on
RAMP-uP
are
promising.
Further
research
is
needed
to
assess
its
feasibility
to
generalize
and
generate
clinical
effects
in
randomized
controlled
clinical
trials.
©
2016
Published
by
Elsevier
Ltd.
1.
Introduction
The
complicated
link
between
ear
auricles
and
internal
organs
was
first
documented
in
the
ancient
Chinese
medical
classic,
Yel-
low
Emperor’s
Canon
of
Medicine.1This
text
indicated
that
many
physiological
or
pathological
changes
inside
the
body
may
reflect
on
the
auricles
through
“meridians”.
By
the
time
this
text
was
compiled
between
320
BCE
and
220
CE,
the
ancient
Chinese
med-
ical
practitioners
had
already
accumulated
a
wealth
of
knowledge
and
experience
in
treating
diseases
with
auricular
acupuncture.2
Auricular
treatments
also
were
widely
used
in
the
ancient
Egypt,
Rome,
Greece
and
the
greater
Mediterranean
area.3In
1957,
French
physician
and
acupuncturist
Dr.
Paul
Nogier
published
a
detailed
auricular
map
of
an
inverted
foetus.4This
publication
not
only
revived
this
ancient
treatment,
but
also
exerted
significant
influ-
ence
on
the
expansion
of
modern
ear
acupuncture
beyond
the
original
meridian
concept,
by
introducing
reflexology
into
the
development
of
his
auricular
map.3Reflexology
posits
that
access-
ing
surface
areas,
such
as
hands,
feet,
and
ear
auricles,
provides
∗Corresponding
author
at:
Extended
Care/Physical
Medicine
and
Rehabilitation,
Atlanta
VA
Medical
Centre,
1670
Clairmont
Road,
Decatur,
GA
30033,
United
States.
E-mail
address:
whuang4@emory.edu
(W.
Huang).
diagnostic
and
treatment
tools
for
conditions/diseases
inside
the
body.
It
is
speculated
that
reflexology
works
because
groups
of
embryonic
pluripotent
cells
contain
information
from
the
whole
organism;
when
they
migrate
during
foetal
development
they
carry
with
them
the
information
and
create
regional
representational
centres
for
the
entire
body.
Following
Dr.
Nogier’s
discovery,
many
auricular
maps
were
developed
throughout
the
world.
The
most
notable
ones
also
include
the
Chinese
map
developed
in
Beijing
led
by
Dr.
L.C.
Huang,5,6 and
the
UCLA
map
developed
by
Dr.
T.
Oleson.7Although
most
auricular
maps
take
into
considerations
individual
differences
in
auricular
shape5and
divide
the
auricle
into
anatomical
zones,
these
maps
are
not
uniform
or
consistent
regarding
auricular
acupoint
location.8Such
inconsistency
testifies
to
individual
variability
of
topographic
representations
that
these
maps
do
not
entail.
Inconsistencies
between
these
maps
have
created
potential
problems
for
practitioners.
First
of
all,
detection
of
acupoints
for
treatment
is
inconsistent.
Ear
auricles
are
very
small
relative
to
the
entire
body
that
it
represents;
when
auricular
maps
become
extremely
detailed
and
specific,
they
assume
that
each
individual
is
the
same
with
the
same
representative
points.
This
assumption
led
to
insufficient
agreement
between
detected
areas
and
ear
map
zones.9
http://dx.doi.org/10.1016/j.ctim.2016.06.002
0965-2299/©
2016
Published
by
Elsevier
Ltd.

W.
Huang
et
al.
/
Complementary
Therapies
in
Medicine
27
(2016)
130–136
131
Fig.
1.
Revised
Auricular
Mapping
for
low
back
pain,
neck
pain
and
headaches.
Green
lines
pointing
to
the
“master”
points
that
are
always
tested
in
chronic
or
acute
pain
presentation.
“Kidney”
and
“Liver”
corresponds
to
Traditional
Chinese
Medicine
notations
of
Vital
Energy
Source
and
Organ
for
Detoxication/Energy
Flow.
Abnormal
skin
sensitivities
are
tested
using
probe
in
the
areas
indicated.
Treatment
needles
or
magnets
are
placed
at
the
most
sensitive
points
in
the
areas.
Areas
without
increased
skin
sensitivities
are
not
treated.
(For
interpretation
of
the
references
to
colour
in
this
figure
legend,
the
reader
is
referred
to
the
web
version
of
this
article.)
Table
1
Demographic
characteristics
of
the
patients
who
received
RAMP-uP
guided
auricular
acupuncture
treatments
as
compared
to
other
patients
in
the
same
clinic.
The
significance
level
is
set
at
p
=
0.05.
Auricular
Acupuncture
(n
=
147)
Acupuncture
Clinic26 (n
=
136)
p-Valuea
Mean
Age
(range)
51
(26–83)
51
(23–93)
0.90
Sex:
n
Male:
99
Male:
97
0.47
Female:
48
Female:
39
Race:
n
White:
51
White:
58
0.36
Black:
90
Black:
74
Other:
6
Other:
4
Pain
areas
(%)
Mixed
pain:
85
87
0.51
Bodily
pain
only:
15
Bodily
pain
only:
12
Headache
only:
0
Headache
only:
1
aUnpooled
two
sample
t-tests
were
performed
for
age;
chi-square
tests
were
performed
for
sex,
race
and
pain
areas.
First
author,
WH,
has
practiced
auricular
acupuncture
as
part
of
an
acupuncture
regimen
for
chronic
pain
over
the
past
10
years.
To
address
some
of
the
challenges
identified
above,
she
developed
a
novel
approach
termed
as
the
Revise
Auricular
MapPing-diagnostic
Paradigm
(RAMP-uP),
and
expands
auricular
map
from
topograph-
ical
acupoints
to
regions.
These
regions
can
be
across
multiple
auricular
zones
defined
by
prior
maps.
They
are
used
for
detecting
the
best
representative
acupoint
for
any
said
problem
in
a
particular
individual.
Fig.
1
demonstrates
the
auricular
map
used
in
RAMP-uP
with
a
focus
on
common
pain
complaints,
such
as
neck
pain,
back
pain,
joint
arthritis,
headache.
For
instance,
detection
of
the
best
acupoint
to
treat
low
back
pain
in
a
particular
individual
is
not
lim-
ited
to
testing
at
the
antihelix
for
traditional
lumbar
and
sacral
spine
representation,
but
also
requires
testing
a
wider
region,
including
the
upper
portion
of
scaphoid
fossa
and
the
inferior
crus
of
antihe-
lix.
The
latter
areas
were
not
included
in
prior
maps
for
low
back
pain,
and
may
indicate
specific
or
individual
conditions,
i.e.
pain
in
hip,
thigh,
lateral
flank
or
sacroiliac
joint
(upper
portion
of
scaphoid
fossa),
sciatica
or
lumbar
radiculopathy
(inferior
crus
of
antihelix).
However,
they
may
represent
low
back
pain
in
some
individuals.
As
other
practitioners
also
have
realized
that
human
bodies
are
different,
with
much
variation
between
individuals,
multiple
differ-
ing
practices
develop
out
in
the
field.
We
conducted
a
small
sample
survey
of
10
acupuncture
practitioners
(2
in
China,
3
trained
in

132
W.
Huang
et
al.
/
Complementary
Therapies
in
Medicine
27
(2016)
130–136
Fig.
2.
Auricular
Acupuncture
tools
used
in
this
report:
(A)
Auricular
probe;
(B)
Auricular
magnets;
(C)
ASP
needles.
China
and
practicing
in
US,
1
in
Europe
and
4
trained
and
practic-
ing
in
US).
100%
used
only
one
particular
auricular
map
of
their
choice,
and
40%
were
not
using
any
additional
testing.
Among
the
practitioners
who
used
additional
testing
(30%
consistently
and
30%
not
consistently),
70%
of
them
used
electrical
skin
resistance
testing,
30%
used
skin
sensitivity
testing,
both
within
the
map-
designated
anatomical
zones.
Without
a
standardized
acupoint
detection
method,
potential
problems
can
arise.
The
survey
also
showed
that
many
practitioners
(especially
in
the
West)
measure
the
electrical
skin
resistance
as
a
method
of
acu-
point
detection:
acupoints
compared
to
non-acupoints
have
lower
skin
resistance.10–18 However,
in
practice,
one
has
to
calibrate
the
“normal”
skin
resistance
reading
by
manipulating
the
probe
sen-
sitivity
before
testing
for
acupoints.
This
step
is
unreliable
and
it
is
a
daunting
challenge
to
navigate
the
multiple
confounding
and
complicating
factors
when
measuring
electrical
conductance
of
the
acupoints.10 A
2012
Yale
study
demonstrated
that
the
pos-
itive
predictive
value
for
a
commercial
point
finder
was
0.25–0.76
in
detecting
low
skin
resistance
area,
corresponding
to
one
region
of
French
auricular
map.
This
value
dropped
to
only
0.29
in
patients
who
complained
of
more
than
two
musculoskeletal
pains,19 as
most
of
our
patients
are.
Historically,
surface
skin
sensitivity
has
also
been
used
for
detec-
tion
of
acupuncture
points.20–22 In
auricular
acupuncture,
using
a
tenderness
skin
test
or
pain-pressure
test
has
a
reported
accuracy
of
33–75%.23,24 By
using
a
simple
auricular
probe
(Fig.
2)
to
test
skin
pain
sensitivity
for
each
individual
within
suspected
auricu-
lar
regions,
the
provider
can
receive
instant
feedback
from
patients
and
use
that
information
to
more
accurately
target
locations
in
need
of
treatment.
Compared
with
measuring
electrical
skin
resistance,
this
procedure
is
also
easier
to
implement
during
busy
clinics.
By
using
such
patients’
feedback
and
later
treatment
effects
report,
this
revised
auricular
mapping
system
had
continued
to
be
modi-
fied
from
2008
till
2010,
before
they
were
shaped
into
the
current
reported
one.
The
RAMP-uP
acupoint
detection
method
has
been
well
received
by
patients
and
has
proven
feasible
to
use
in
a
busy
clinic.25 For
this
report,
we
conducted
a
retrospective
case
series
study
in
147
patients
who
were
treated
with
auricular
therapies
based
on
RAMP-
uP
at
a
major
US
veterans’
medical
centre.
Our
analysis
clearly
demonstrated
positive
clinical
effects.
2.
Methods
2.1.
Patient
population
The
US
military
veteran’s
healthcare
system
utilizes
electronic
medical
records
system
for
healthcare
management.
A
retrospec-
tive
chart
review
was
conducted
on
458
patients
who
sought
care
at
the
Atlanta
Veterans
Affairs
Medical
Centre
(VAMC)
Physical
Medicine
and
Rehabilitation
Acupuncture
Clinic
from
January
2008
to
August
2014.
One
hundred
and
forty-seven
patients
were
iden-
tified
as
receiving
auricular
acupuncture
treatments
for
common
pain
conditions.
Demographic
characteristics
and
acupuncture
clinic
visit
records
were
abstracted
for
this
report.
2.2.
Auricular
acupuncture
treatments
In
the
study
clinic,
two
types
of
auricular
acupuncture
treat-
ments
(Fig.
2)
were
applied
using
RAMP-uP.
1.
The
auricular
semi-permanent
needle
treatment
used
ASP
nee-
dles
that
are
gold-plated
and
taped
on
with
hypoallergenic
adhesive
plasters
for
added
protection.
Maximal
5
ASP
needles
are
used
for
each
ear,
and
they
can
be
left
in
for
up
to
10
days.
2.
The
auricular
magnet
therapy
used
magnets
that
are
700–800
G
of
magnetic
flux
density,
comparable
to
14–16
typical
refriger-
ator
magnets.
The
small
size
is
suitable
for
auricular
treatment,
about
0.06 ×
0.12 in
diameter
with
0.45 diameter
adhesive
plaster.
Maximal
6
magnets
were
used
for
each
ear,
and
they
can
be
left
for
up
to
2
weeks.
2.2.1.
Auricular
preparation
At
the
start
of
a
treatment,
antiseptic
alcohol
swabs
were
used
for
the
purposes
of
sterilization,
and
to
remove
oil
from
the
skin
to
prevent
probe
from
sliding
during
testing
and
easier
application
of
tapes
at
the
end.
For
ASP
needles,
three
alcohol
swabs
were
used
for
each
ear
to
maximize
sterilization
and
decrease
risk
of
infection.
For
magnets,
one
alcohol
swab
was
used
for
each
ear.
If
the
skin
presented
was
dirtier
than
usual,
more
alcohol
swabs
were
used
until
they
came
off
with
no
colour.
2.2.2.
Acupoint
detection
RAMP-up
auricular
map
was
used
for
acupoint
detection.
There-
fore,
a
wider
area
than
traditional
maps
was
tested
using
an
auricular
probe.
The
spring
on
the
probe
enabled
control
of
the
pressure
applied
at
each
spot
tested.
When
pressure
was
over
2oz
of
force
the
spring
was
activated.
Any
increase
of
force
will
tele-
scope
the
probe.
By
controlling
the
telescope
to
no
more
than
half
way
of
depression
(4–5oz
of
force),
equal
pressure
is
assured
across
all
points
tested.
The
point
with
highest
sensitivity
in
the
area
was
treated
with
either
ASP
needle
or
magnet.
2.3.
Follow-up
The
follow-up
intervals
of
auricular
acupuncture
treatments
averaged
between
3
and
6
months,
mainly
due
to
clinic
availability,
representing
minimal
acupuncture
interventions
as
compared
with
once
a
week
or
even
more
frequent
treatments
in
the
community
setting.
2.4.
Clinical
effects
assessment
To
monitor
the
quality
of
acupuncture
treatments
and
patients’
progress,
a
simple
10-item
self-report
Intake
Questionnaire
was
completed
by
each
patient
at
every
visit
during
check-in.26 For
these
patient-reported
measures,
ratio-level
scaling
was
made

W.
Huang
et
al.
/
Complementary
Therapies
in
Medicine
27
(2016)
130–136
133
available
with
a
VAS.
The
VAS
has
been
widely
adopted
to
measure
constructs
such
as
pain
and
functional
assessments.27 The
key
ben-
efits
of
a
VAS
are
the
increased
sensitivity
to
measured
change
as
well
as
the
decreased
reliance
on
verbal
skills
for
the
understanding
of
response
category
alternatives.
Using
a
VAS
rather
than
a
scoring
system
also
decreases
the
chance
of
patients
quoting
certain
cus-
tomary
numbers.
The
VAS
scale
we
used
was
an
unmarked
10-cm
line,
with
0
at
one
end
and
10
at
the
other.
All
questions
evaluated
by
the
VAS
were
scored
from
0
to
10,
based
on
the
distance
of
the
response
mark
to
0
on
the
10-cm
line.
–
Immediate
pain
relief
effect
of
acupuncture
was
assessed
by
com-
paring
pre-
and
post-treatment
VAS
pain
scores.
–
Clinically,
there
is
variability
in
the
onset
and
duration
of
treat-
ment
effects;
therefore,
patients
were
also
asked
to
rate
the
effectiveness
of
the
previous
session
acupuncture
treatment
at
the
subsequent
follow-up
visit
on
a
VAS
scale.
–
Besides
pain
and
efficacy
rating
scores,
patients’
reported
dura-
tions
of
treatment
effects
were
also
abstracted
from
clinical
notes
documented
during
subsequent
follow-up
visits.
2.5.
Ethics
review
This
retrospective
chart
review
study
was
approved
by
Emory
University
Institution
Review
Board
and
Atlanta
Veterans
Affairs
Medical
Centre
(VAMC)
Office
of
Research
and
Development.
3.
Results
3.1.
Demographics
From
January
2008
to
August
2014,
the
PM&R
acupuncture
clinic
at
Atlanta
VAMC
applied
524
auricular
acupuncture
treatments
(ASP
needles
or
auricular
magnets)
in
147
patients
for
various
refractory
pain
conditions,
including
bodily
pain
and
headaches.
The
majority
of
these
patients
were
unresponsive
to
prior
treat-
ments
and
thus
were
referred
for
a
trial
of
acupuncture.
The
mean
age
of
the
patients
was
51
(SD
11.2,
range
26–83)
at
their
first
visit.
Out
of
these
patients,
67.3%
were
men
(n
=
99);
34.7%
were
white
(n
=
51),
61.2%
African
Americans
(n
=
90),
3.4%
Hispanic
(n
=
5)
and
0.7%
mixed
race
(n
=
1).
Most
patients
(85%)
presented
with
multiple
areas
of
pain.
This
sample
population
that
received
auricular
acupuncture
treatments
was
comparable
to
the
patient
population
seen
in
the
clinic
(Table
1).
3.2.
Number
of
treatments
During
the
study
period,
most
veterans
received
less
than
3
treatments
(57.97%
from
ASP,
95.83%
from
magnet).
The
rest
(42.03%)
of
patients
who
received
ASP
needles
had
from
4
to
16
treatments,
with
33.33%
less
than
10
treatments
and
8.70%
more
than
10
treatments.
Because
magnetic
therapy
started
later
than
ASP
treatments,
the
rest
(4.17%)
of
patients
who
received
magnets
had
less
than
5
treatments.
3.3.
Treatment
interval
The
median
interval
between
treatments
was
91
days
(about
3
months),
and
the
mean
interval
was
147
days
(about
5
months).
3.4.
Treatment
effects
on
VAS
pain
scores
506
out
of
524
auricular
acupuncture
treatments
(96.6%)
had
pre-treatment
pain
scores
recorded
in
the
Intake
Questionnaire.
The
average
pre-treatment
pain
score
was
5.69
(SD
2.06).
Table
2
Patients’
reported
duration
of
effectiveness
of
RAMP-uP
guided
ASP
needle
treat-
ments
versus
auricular
magnets.
The
significance
level
is
set
at
p
=
0.05.
ASP
Needles
(n
=
255) Auricular
Magnets
(n
=
29)
p-Valuea
Less
than
1
day
7
0
0.86
1–7
days
15
3
7–14
days
38
5
2–4
weeks
65
6
1–3
months
119
13
More
than
3
months
11
2
aChi-square
test
was
performed
between
ASP
needles
and
Auricular
magnets.
Table
3
Patients’
reported
overall
efficacy
of
RAMP-uP
guided
ASP
needle
treatments
versus
auricular
magnets.
The
scale
is
from
0
to
10,
with
0
indicating
acupuncture
having
no
effects,
and
10
indicating
acupuncture
being
most
effective
in
treating
their
pain
conditions.
The
significance
level
is
set
at
p
=
0.05.
ASP
Needles
(n
=
101)
Auricular
Magnets
(n
=
33)
p-Valuea
0–2.4
9
0
0.09
2.5–4.9 12
1
5.0–7.4
37
14
7.5–10.0 43
18
aChi-square
test
was
performed
between
ASP
needles
and
Auricular
magnets.
Post-treatment
pain
scores
were
recorded
after
126
treatments
(24.0%);
the
average
post-treatment
pain
score
was
2.34
(SD
1.96).
In
addition,
verbally
reported
comments
such
as
“good”
“bet-
ter”
“much
better”
“significantly
better”
“whole
lot
better”
“pain
level
way
down”
“minimal
pain”
“pain
almost
gone”
“excellent
relief”
or
“more
relaxed”
were
documented
after
136
treatments
(25.9%).
Only
after
7
treatments
(1.3%),
“worse”
or
“more
pain”
was
reported.
Among
all
treatments,
125
treatments
had
recorded
both
pre-
treatment
and
post-treatment
pain
scores.
The
change
of
pain
scores
was
3.64
(SD
1.91)
and
statistically
significant
(p
<
0.0001).
3.5.
Duration
of
treatment
effects
Out
of
524
treatments,
284
had
recorded
the
duration
of
treat-
ment
effects
at
their
subsequent
follow-up
visit
(255
from
ASP
needle
treatments
and
29
from
auricular
magnet
treatments).
Six
duration
categories
were
used
for
this
case
series
(“less
than
1
day”,
“1–7
days”,
“7–14
days”,
“2–4
weeks”,
“1–3
months”,
and
“more
than
3
months”).
There
was
no
statistical
significant
difference
between
ASP
needles
and
auricular
magnets
(Table
2).
Therefore,
the
data
were
combined
to
show
the
patients’
reported
duration
of
effectiveness
of
auricular
acupuncture
in
Fig.
3.
3.6.
Reported
overall
treatment
efficacy
Of
138
patients
who
received
ASP
auricular
needle
treatments,
101
(73%)
had
recorded
effectiveness
rating
by
Intake
Question-
naires;
of
49
patients
who
received
auricular
magnet
treatments,
33
(67%)
had
recorded
effectiveness
rating.
The
effectiveness
rat-
ing
was
averaged
within
each
patient
to
reflect
each
individual’s
overall
effects
using
ASP
auricular
needles
or
auricular
magnets.
The
scale
is
from
0
to
10,
with
0
indicating
acupuncture
having
no
effects,
and
10
indicating
acupuncture
being
most
effective
in
treating
their
pain
conditions.
Four
effectiveness
categories
were
used
for
this
case
series
(“0–2.4”,
“2.5–4.9”,
“5.0–7.4”,
“7.5–10.0”),
in
consistent
with
prior
report.26 There
was
no
statistical
significant
difference
between
ASP
needles
and
auricular
magnets
(Table
3).
Therefore,
the
data
were
combined
to
show
the
patients’
reported
overall
effectiveness
of
auricular
acupuncture
in
Fig.
4.

134
W.
Huang
et
al.
/
Complementary
Therapies
in
Medicine
27
(2016)
130–136
Fig.
3.
Patients’
reported
duration
of
effectiveness
of
RAMP-uP
guided
auricular
acupuncture
treatments
(n
=
284).
Fig.
4.
Patients’
reported
effectiveness
of
RAMP-uP
guided
auricular
acupuncture
on
their
Intake
Questionnaires
(n
=
134).
The
scale
is
from
0
to
10,
with
0
indicating
acupuncture
having
no
effects,
and
10
indicating
acupuncture
being
most
effective
in
treating
their
pain
conditions.
The
categories
of
0–2.4,
2.5–4.9,
5.0–7.4,
7.5–10.0
roughly
correspond
to
“no
help
at
all”,
“a
little
help”,
“some
help”,
and
“a
great
deal
of
help”.

W.
Huang
et
al.
/
Complementary
Therapies
in
Medicine
27
(2016)
130–136
135
3.7.
Adverse
reactions
Adverse
reactions
to
treatment
were
minimal.
Two
patients
reported
dizziness
or
excess
sweat
following
ASP
needle
insertion;
both
concerns
were
resolved
after
resting
for
few
minutes.
Seven-
teen
patients
reported
one
or
more
ASP
needles
being
irritating
or
painful.
One
patient
reported
increased
care
needed
for
auricular
magnets
and
another
patient
complained
that
auricular
magnets
did
not
stick
for
long.
4.
Discussion
Based
on
prior
published
auricular
acupuncture
mapping
sys-
tems,
the
innovation
of
the
RAMP-uP
includes
enlarged
topographic
representation
body
areas
than
conventional
auricular
maps
to
reflect
individual
variability.
And,
as
the
mean
of
acupoint
detec-
tion,
skin
sensitivity
testing
was
standardized.
While
Andersson
pointed
out
that
all
tender
points
found
on
ears
should
be
treated,9
we
treated
the
most
sensitive
point
in
a
wider
topographic
rep-
resentative
region
using
the
reported
map,
enabling
individualized
acupoint
detection
and
treatment.
Our
use
of
skin
sensitivity
testing
in
diagnosis
is
easier
to
apply
in
clinical
setting
with
reasonable
sen-
sitivity
and
specificity.
RAMP-uP
has
been
tested
in
clinical
patients.
When
used
as
a
diagnostic
tool,
patients
were
surprised
at
its
accu-
racy
not
only
for
their
reported
symptoms
but
also
for
its
ability
to
detect
other
existing
but
not
yet
reported
conditions
(quanti-
tative
data
not
collected).
When
used
for
pain
treatment,
its
pain
relief
results
are
explored
in
this
case
series
study.
Observed
clinical
effects
are
promising.
In
our
retrospective
chart
review,
we
found
that
RAMP-uP
patient’s
average
pain
score
decreased
by
almost
60%
comparing
pre-
and
post-treatment.
This
change
was
significant
and
greater
than
effects
reported
in
the
literature.28,29 The
overall
effectiveness
of
the
treatments
was
considered
by
patients
of
mostly
beneficial:
83.6%
reported
effectiveness
of
over
5
on
a
0–10
scale
(indicating
“some
help”
or
“a
great
deal
of
help”
from
the
treatments).
The
duration
of
auricular
acupuncture
treatment
effects
varies
in
acupuncture
literature,
depending
on
the
number
of
treatments
within
one
month.29 Due
to
VAMC
clinic
availability,
we
had
an
opportunity
to
observe
duration
of
treatment
effects
with
long
intervals
(3–6
months)
between
sessions.
The
auricular
techniques
applied
by
first
author
(WH)
were
intended
for
longer
stimula-
tion
(ASP
needles
for
up
to
10
days,
magnets
for
up
to
2
weeks)
and
they
showed
longer
duration
of
effectiveness:
47%
of
treat-
ments
reported
to
have
pain
relief
effects
lasting
between
1
and
3
months.
This
is
longer
than
the
duration
of
effectiveness
in
general
body
acupuncture
(mostly
between
2
and
4
weeks).26 If
we
take
into
account
that
body
acupuncture
needles
generally
stay
in
for
about
30
min,
while
ASP
needles
or
magnets
stay
on
for
a
couple
of
weeks,
the
longer
duration
of
effectiveness
could
be
expected.
Such
prolonged
duration
of
treatment
(and
effects)
is
the
advantage
of
auricular
treatments
over
body
treatments,
where
indwelling
nee-
dles
are
generally
unsuitable.30 On
the
other
hand,
body
needle
acupuncture
has
its
indication,
as
well
as
individual
differences
in
treatment
responses
to
body
needle
acupuncture
versus
auricular
treatments,25 further
discussion
is
beyond
the
scope
of
this
report.
4.1.
Limitation
and
future
studies
The
purpose
of
this
case
series
is
to
illustrate
the
clinical
effects
of
auricular
acupuncture
treatments
for
pain,
using
a
Revised
Auric-
ular
MapPing-diagnostic
Paradigm
(RAMP-uP).
All
data
were
based
on
patients’
reports
to
the
provider
during
clinical
visits
and
thus
could
be
subject
to
reporting
bias,
giving
rise
to
larger
effective
size
that
otherwise
would
be
in
clinical
trials.
In
this
report,
only
one
provider’s
clinic
was
reviewed,
also
limiting
the
power
for
gener-
alization.
To
address
these
limitations,
future
work
using
RAMP-uP
will
involve
more
than
one
provider
and
its
feasibility
to
be
practiced
in
a
wider
range
will
be
assessed.
Clinical
outcomes
will
be
further
evaluated
using
randomized
controlled
clinical
trials.
The
under-
lying
mechanisms
of
auricular
acupuncture
treatments
based
on
RAMP-uP
also
will
be
explored,
examining
possible
neural
and/or
vascular
influences.31–33
Conflict
of
interest
The
authors
confirm
that
there
are
no
known
conflicts
of
inter-
est.
Acknowledgements
This
study
used
resources
of
the
Atlanta
Department
of
Veterans
Affairs
Medical
Centre
and
was
supported
in
part
by
US
Depart-
ment
of
Veterans
Affairs
Rehabilitation
Research
and
Development
Career
Development
Award
Level
II
(WH)
(B6924W).
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