The Effect of Auriculotherapy on Stress, Anxiety, and Depression in MS Patients:
A Double Blind Randomized Clinical Control Trial (Parallel Design)
Mahboubeh Valiani1, Fereshteh Ashtari1*, Marjan Mansourian2,
1-Isfahan Neurosciences Research Center, Alzahra research Institute, Isfahan University of Medical Sciences,
2- Department of Biostatistics, Health School, Isfahan University of Medical Sciences, Isfahan, Iran.
*Corresponding author: Fereshteh Ashtari
Isfahan Neurosciences Research Center, Alzahra research Institute, Isfahan University of Medical Sciences, Isfahan,
Iran. Email: firstname.lastname@example.org
Background: MS is one of the central nervous system diseases, which is of relatively high
prevalence among neurological diseases. Multiple studies have shown that stressful life is
associated with an increased risk of MS. The aim of this study is to investigate the impact of
using the auriculotherapy technique on stress, anxiety, and depression in MS patients.
Materials and Methods: This study was a double blind randomized clinical trial in two groups.
The sample size was estimated to be 64 subjects in each group. The Center for MS at Kashani
hospital in the Province of Isfahan was the location of research. DASS-21 questionnaire were
completed before, after and one month after intervention. The auriculotherapy technique began
in the intervention group and at the end of each session, herbal vaccaria seeds were fixed at three
main points on the ear, for at least 3 days. All the tests were carried out using the SPSS19
software at an error level of 5%.
Results: The results showed that the mean score of stress, anxiety and depression decreased in
the auriculotherapy group compared with that in the placebo group. The analysis of variance
showed significant differences between the two groups after intervention and one month later (P
<0.05). Whereas the stress, anxiety and depression score had not undergone any significant
changes before intervention in two groups (P>0.05).
Conclusion: Auriculotherapy reduced stress, anxiety, and depression in MS patients. The mean
scores of stress, anxiety and depression were significantly different in two groups.
Key Words: multiple sclerosis, auriculotherapy, stress, anxiety, depression, Iran.
Multiple Sclerosis or MS is one of the central nervous system diseases, which is of relatively high
prevalence among neurological diseases. (1) The disease is associated with the incidence of a wide range of
signs and symptoms, including: physical, mental (2), and sometimes psychological (3) changes. The
occurrence of MS is rare in childhood, but its prevalence increases quickly in the following years (2). It is
also twice to 3 times more common in women than in men. And life expectancy is 5 to 10 years lower in an
affected population than in an unaffected population. (1) Although it is not clear what the cause of the
disease is, in the study of the disease mechanism, it seems that it is associated with the immune system
disorder and/or damage to myelin-producing cells. (4) The body's immune system attacks the central
nervous system, and destroys the myelin sheath in the central nervous system. (1) With the myelin sheath
destroyed, axons do not conduct neurons appropriately. But, the damaged myelin can regenerate, and with
its regeneration, the symptoms of the disease will subside, and the patient will return to their normal
condition. If the disease progresses, and demyelination is exacerbated, axons will be damaged, and
neurological symptoms usually become irreversible at this stage. (5)
MS is divided into four different types: relapsing-remitting (RRMS), secondary progressive (SPMS),
primary progressive (PPMS), and progressive relapsing (PRMS) In 85 to 90% of the patients, the clinical
course is such that the relapsing-remitting type is seen at the beginning of the disease, which is sometimes
called benign MS as well. (64) The most common symptoms of MS are as follows: weakness, fatigue,
dizziness, numbness, tingling, neuromuscular disorders in multiple systems including: ataxia and gait
abnormalities, paralysis, tremors, pain, spasm, muscle stiffness, visual disturbances (nystagmus, double
vision, decreased vision, etc.), speech problems, bladder dysfunction (bladder hypotonia and hypertonia),
bowel dysfunction (constipation and diarrhea), memory disorders, sexual problems, unstable mood,
isolation, etc. (1,2,6)
Pain, which is one of the symptoms of MS disease, causes emotional arousal. And anxiety, depression,
anger, and fear are emotions which affect the pain. On the other hand, anxiety reduces the pain threshold in
a way that the patient attributes any feeling to the pain. (6, 7) Excitement, anxiety, and fear are three
important factors, which affect the individual’s perception of pain. (7) Studies have shown that
psychological factors affect physiological factors associated with pain. Fear and anxiety intensify the
patient’s pain and discomfort. (8) The hormones which are released in response to stress and anxiety,
include: catecholamines, cortisol, epinephrine, and norepinephrine. (7) In this regard, Otajärvi states that
neuropsychological rehabilitation reduces the cognitive symptoms of the disease. And cognitive exercises,
in combination with other methods of neuro-cognitive rehabilitation, can reduce anxiety, and boost
accuracy and memory. (9)
Pain also causes stress and affects blood flow. It is important to control anxiety and stress in MS patients.
Because if stress is not controlled and directed, it will become the source of many mental and physical
diseases (10). Multiple studies have shown that stressful life is associated with an increased risk of MS. In
their study titled “Stress and the Risk of Multiple Sclerosis” which was conducted on 77 subjects in 2011,
Riise et al. show that repeated stress and a greater focus on stressors can be a potential risk factor for MS
disease. (11) In this regard, another piece of research was conducted by Artemiadis in 2011, with the aim of
synthesizing studies related to psychological stress and the onset and relapse of MS disease, and the results
of seven studies in this piece of research showed that, in five studies, stress played a significant role in the
incidence and relapse of MS disease. (12)
Researchers investigated the effect of stress on the components of the immune system, such as: antibodies
and natural killer cells (NK cells). They believe that if negative emotions and stress in an individual, last
more than a certain period of time, it will suppress the immune system, and will reduce their resistance to
diseases. (13) Therefore, it is very important to reduce and manage stress when taking care and controlling
the disease in this group of people. Stress can be controlled by employing appropriate and low-risk
methods. In many cases, patients take refuge in drugs to control pain. But although they reduce the feeling
of pain in physical terms, they hurt the patient’s psychological and emotional condition. (14) Hence, with
the aid of techniques, which are not associated with adverse drug reactions, maybe these patients can be
somewhat alleviated psychologically, and the complications and symptoms in this disease, which are
caused by stress, can be controlled.
In this regard, Abolfazli declares that it has been shown in a number of studies conducted, that Interferon-B
(INFB), has a negative impact on quality of life, especially in terms of fatigue and depression. He quotes
from Simon that this drug leaves its mentally negative impact on quality of life after two years of
consumption. (15) Many of these patients also use different types of painkillers to treat the pain caused by
anti-MS drugs, among which we can refer to acetaminophen as an example. The side effects of long-term
use of this drug include: liver damages, skin rashes, allergic dermatitis, blood disorders, and acute
pancreatitis. (16) Therefore, to reduce the side effects of anti-MS drugs and painkillers, it is better to
investigate the usage of non-drug techniques, and substitute them for drugs if appropriate.
NICE solutions for MS include reflexology, massage, etc., which are considered as complementary
therapies, and can be helpful. (17) Complementary and alternative medicine (CAM) encompasses a wide
range of philosophies, approaches and remedies, and acupuncture falls under this category too. Although
some of these treatments can reduce the symptoms of the disease, little scientific evidence is available about
the efficiency of most complementary therapies (18). It was reported in a national descriptive study in the
United States that more than 42% of American adults have at least tried one of the 16 types of
complementary and alternative therapies (19). Acupuncture forms a large and important part of traditional
Chinese medicine. According to the TCM principles, there are energy channels inside the body, and the
energy flowing inside these channels is essential for health (20). This energy which is known as “life
energy” or Qi, is a primary and internal force consisting of two complementary forces: yin and yang.
Imbalances and failure of energy flow can result in the incidence of diseases in humans. According to the
principles of traditional Chinese medicine, diseases are placed in a specific pattern based on the symptoms,
pulse, and tongue, and are treated according to this pattern. For instance, MS disease encompasses 15
patterns (21), out of which the three most common have been investigated in this study.
Auriculotherapy is introduced as a branch of reflexology and acupuncture. Traditional Chinese Medicine
emphasizes the presence of a reflective relationship between the outer ear and different parts of the body
(22). This technique was recognized by the World Health Organization (WHO) in 1990 (21). The
fundamental of this method of therapy is based on an anatomical map of the body on the outer ear (22). By
stimulating the desired points on the ear through non-invasive stimulation, this method causes some signals
to be sent to the brain and specific organs, thus adjusting and balancing the physiological function. (23)
This technique works with the aid of a set of polyvalent cells. Such that these cells contain data from all
organs of the body, and form regional centers (land marks), which represent different parts of the body on
the ear (24). In fact, the ear has a microsystem, which supports a direct reflective relationship with the
whole body. Stimulating a point on the ear, can affect the anatomical organ related to that point. Ear
stimulation methods include: stimulation by needles (ear acupuncture), vaccaria seeds, probes and fingers
(ear acupressure), electrodes attached to the needles, direct electrical stimulation of points on the ears,
and/or use of lasers. (22) Considering the release of beta-endorphins in this method, it seems that
acupuncture can provide alternative conditions to reduce stress and depression through sympathetic
inhibitory activities, as well as avoiding the incidence of side effects caused by the consumption of anti-
anxiety and anti-depression drugs. (25)
A study titled “Auricular Acupressure to Improve Pain, Stress, and Heart Rate Variability in Young Girls
with Primary Dysmenorrhea and Stress" was conducted by Yu-Jen Wang et al. in Taiwan in 2013. Its aim
was to use objective tools to measure the effectiveness of ear acupressure in menstrual distress and pain in
adolescent girls with primary dysmenorrhea. And its results showed that ear acupressure increased
parasympathetic activities, and could somewhat be effective in reducing menstrual pain and distress in
individuals who experience stressful living conditions (26).
Also multiple studies on MS disease indicate the applicability of complementary methods. In a study titled
“Acupuncture and Multiple Sclerosis: A Review Study” conducted in 2014, Karpatkin et al. write that it is
common to use acupuncture in the treatment of multiple sclerosis, but few studies have been conducted on
its effectiveness. Hence, in this study, we have reviewed 12 research papers, which had investigated the
effectiveness of acupuncture in the treatment of MS and its relationship with quality of life and fatigue”.
Many of these papers have had poor research designs, without a control group, random selection, and/or
blinding. In another study conducted by Cabanillas (2012) titled "The impact of electro-acupuncture on
quality of life in patients with the relapsing-remitting MS under treatment with regulators of the immune
system, the results showed that quality of life improved with the reduced pain and depression in the
experimental group (27).Although many studies have proved the effectiveness of acupuncture in improving
MS symptoms, but due to their poor designs, these studies could not statistically prove its effectiveness in a
proper way. (28)
What can be inferred from the study and review of the above-mentioned investigations and other studies on
auriculotherapy in other areas, indicates that all forms of auriculotherapy have had appropriate and
considerable effectiveness in the trials carried out. And none of these studies have mentioned any side
effects, which can be attributed to auriculotherapy. Of course, some of these studies do not have a proper
research structure such as: the sample size, categorization of patients, and control, intervention, and/or
placebo groups, and no appropriate method of sampling has been done in them. And maybe carrying out a
study with the aforesaid specifications shows different results.
Achieving ways of coping with stress, and evaluating the effectiveness of non-pharmacological methods
such as: auriculotherapy which is known as a cheap method without any complications, perhaps can not
only help improve these patients’ individual lives, but also play a major role in the health economics. It
seems that designing a perfect research can provide more comprehensive results, and open a way for future
studies to prepare an appropriate instruction to reduce some of the symptoms and complications of MS
disease. Hence, the aim of this study is to investigate the impact of using the auriculotherapy technique on
stress, anxiety, and depression in MS patients.
Materials and Methods
This study was designed in the form of a double blind randomized clinical trial in two groups, to assess the
effect of auriculotherapy on stress, anxiety, and depression in patients with multiple sclerosis in a
specialized clinic in the Center for MS at Kashani hospital in the Province of Isfahan (2015-16). Sampling
was done randomly, and given that there were multiple parameters in this study, randomization was done
using the Qminim software. The sample size was estimated to be 64 subjects in each group, based on the
highest stress variance in the MS patients. The DASS-21 standard questionnaire was used to determine the
level of stress, anxiety, and depression, in which seven questions was designed to measure each of the
symptoms: anxiety, stress, and depression. This questionnaire was first introduced by Lovibond in 1995,
and was tested in a large human sample. The validity and reliability of this questionnaire was approved
through conducting a study in England. (29) The validity and reliability of this questionnaire was also
evaluated in Iran by Iranian psychologists, and its Cronbach's alpha coefficient was reported to be 0.82. (30,
31) The inclusion criteria of the study included: confirmation of the diagnosis of MS, passing at least one
year from the onset of the disease, not suffering from any underlying diseases such as acute infectious
diseases, not being pregnant, being of Iranian race, not using this technique over the past two months. The
exclusion criteria of the study included: unwillingness to continue the technique, unwillingness to complete
the questionnaire, migration, and death.
After obtaining written consent from the subjects, and explaining the research goals, and before the
intervention, the data collection form and the DASS-21 questionnaire were completed, and the
auriculotherapy technique began in the intervention group. After the completion of the intervention period,
the questions were asked again, and then this questioning was repeated a month later.
This study was designed in a double blind form. Such that, in the placebo group, auriculotherapy was done
while the device was off, and without any pressure and without any vaccaria seeds (only glue was applied).
Also, questionnaires were administered at three times by someone other than the researcher
Two sessions per week, and a total of 10 sessions of auriculotherapy were held in the intervention group. In
each session, after using cotton and alcohol to clean the outer ear, and positioning the patient in an
appropriate state (preferably in a supine position), each of the following points: Shen Men, Relaxation, Zero
point, Thalamic Point, Master Shoulder, Tranquilizer, Heart, Thymus, Endocrine, Adrenal, and Brain, was
stimulated for 15 seconds, using a Pointer Plus Excel II device. (32, 33) At the end of each session, herbal
vaccaria seeds were fixed at three main points on the ear, and the subjects were told to keep the seeds at
their places for at least 3 days. (32,34)
After the completion of the intervention and questioning at three stages (before, immediately after, and one
month after the intervention), which totally lasted for one year, the information was entered and a statistical
analysis was performed. All the tests were carried out using the SPSS19 software at an error level of 5%.
The results showed that the mean age of the patients was 36.02 ± 9.33 years, in which there was no
significant difference between the two groups (P> 0.05). And the mean age for the onset of the disease was
26.93 ± 7.79 years. The mean duration for the disease was 9.08 ± 6.04 years, and the two groups were not
significantly different in it (P> 0.05). An investigation on the gender of the patients, showed that there were
22.7% of men and 77.3% of women. Out of 128 subjects participating in the study, 70.3% were married,
and 29.7% were single, divorced, and/or separated people, in total. An investigation on the patients’ level of
education showed that 71.1% of them had high school diplomas or academic degrees, and 28.9% had
degrees under a high school diploma. Since women formed the greatest number of subjects in the sample,
the housekeeping job allocated to itself the highest frequency at 59.4%. With regard to housing, 68.8% of
the patients were home owners.
With regard to stress, the results showed that 12.5% of the MS patients had normal stress, 7.8% mild stress,
13.3% moderate, 35.9% severe, and 30.5% very severe stress in both groups before the intervention. The
results indicate that these percentages changed into 28.8% normal, 15.2% mild, 18.4% moderate, 20.8%
severe, and 16.8% very severe, respectively, after the intervention. And these results changed into 28.8%,
19.2%, 21.6%, and 23.2%, respectively, one month after the intervention.
The study results also showed that the mean score of stress decreased in the auriculotherapy group
compared with that in the placebo group. The analysis of variance did not show any significant differences
between the two groups before intervention (P >0.05). The test showed that the mean stress score indicated
a significant difference in the auriculotherapy group immediately after (P<0.05) and one month after the
intervention (P<0.05), compared with that before the intervention (P >0.05). (Table 1) An investigation on
the patient's anxiety score showed that anxiety had significantly decreased in the auriculotherapy group
(P<0.05), and this change continued even one month after the intervention (P<0.05). (Table 1)
In addition, the patient's depression score showed a significant difference between the two groups, and
reached almost half its value before the intervention in the intervention group. Whereas in the placebo
group, the depression score had not undergone any significant changes, and even showed a slight increase.
Generally, the ANOVA test with repeated observations showed that the effect of time on the scores of
anxiety, stress, and depression was significant (P < 0.001). The effect of the intervention was also
significant (P <0.001). Furthermore, the interactive effect between time and the intervention was also
significant (P <0.001). In the sense that the differences between the two groups were not identical at all
times. And as it is clear in Table 1, the two groups were nearly identical before the intervention. But
immediately after, and one month after the intervention, the mean scores of anxiety, stress, and depression
were different between the two groups.
Table 1: The mean scores of anxiety, stress, and depression in the two groups at different times
Before the intervention
Immediately after the
One month after the
Before the intervention
Immediately after the
One month after the
Before the intervention
Immediately after the
One month after the
The results about the MS patients’ sleep, showed that the patients’ sleep improved after the
intervention, and this difference was statistically significant (P <0.05). Such that, in the
auriculotherapy group, all the patients experienced better sleep conditions compared with those
before the intervention, and the good sleep condition reached 85.9% one month after the
intervention. (Table 2)
Fisher's exact test showed that before the intervention, there was no significant difference
between the two groups in the frequency distribution of sleep quality (P > 0.05) But Chi-square
test showed that the frequency of good sleep quality was significantly higher in the
auriculotherapy group than in the control group immediately after and one month after the
intervention (P < 0.05). The Cochran test showed that in both groups, the sleep quality was
significantly different between the three times (P < 0.001). McNemar's test showed that in both
groups, the quality of sleep improved immediately after the intervention relative to that before
the intervention (P < 0.05), even though this improvement was much more evident in the
auriculotherapy group. The quality of sleep decreased in both groups one month after the
intervention compared with that immediately after the intervention (P < 0.05). In other words,
both time and the intervention had a significant impact on the quality of sleep. (Table 2)
Table 2: The frequency distribution of sleep quality in the patients at different times in both
Before the intervention
Immediately after the
One month after the
The present study was conducted with the aim of determining the effect of auriculotherapy on stress,
anxiety, and depression in patients affected by multiple sclerosis. The results obtained from the
statistical analysis of findings in this study, showed that auriculotherapy reduced stress, anxiety, and
depression in MS patients. And the mean scores of stress, anxiety and depression were significantly
different in both groups between the two times after the intervention.
According to the EDSS-21 questionnaire, the mean score of stress in the auriculotherapy group,
showed a significant difference between the three times. Also, the mean score of anxiety decreased
after the intervention. This indicator also showed a decrease one month after the intervention, and
was significantly different from that in the pre-intervention stage. The results showed that the mean
score of depression in the intervention group immediately after and one month after the intervention,
was significantly different from that before the intervention. In general, the mean total score of
stress, anxiety, and depression showed a significant decrease in the auriculotherapy group compared
with that in the placebo group. These differences indicate the effectiveness of auriculotherapy in
reducing psychological and mood symptoms in MS patients.
When someone faces stressful conditions, their sympathetic nervous system was stimulated, and
causes the secretion of adrenaline (or epinephrine), noradrenaline, and cortisol hormones, through
affecting the hypothalamus, pituitary, and adrenal glands (11). As a result of the secretion of these
hormones in blood, a larger amount of glucose is released from the liver for muscle activities,
resulting in the increased cardiovascular activity along with the increased heart rate and blood
pressure, increased blood viscosity, blood transfer from digestive organs and skin to the brain and
muscles, cold skin, dry mouth, restlessness, increased respiratory rate and depth, and pupillary
Therefore, stress and pain in humans, are two phenomena, each of which strengthens the other. And
everybody’s behavior depends on the concentration of nerve mediators (neurotransmitters) in their
brain. Some of these mediators include: endorphins, adrenaline, and serotonin. The balance of these
neurotransmitters makes it possible for the brain to analyze better, and their imbalance results in the
feeling of anger and annoyance. Maintaining a high level of endorphins can play a major role in
reducing pain, stress, and anxiety. Therefore, the production of the endorphin hormone is helpful in
reducing fear and stress when facing stressors (10). This hormone also plays its positive role in
controlling stress and anxiety through enhancing the focus, self-awareness, and self-confidence. If
the level of adrenaline hormone increases for whatever reason, the endorphin level will decrease, and
the symptoms of anxiety will appear. (10) Therefore, the effectiveness of the auriculotherapy
technique through the stimulation of points on the ear, is associated with the release of endorphin
hormone and increase in its level and a decrease in adrenaline neurotransmitters. And according to
the results obtained, it has been able to reduce stress and anxiety using this mechanism. The Beta-
endorphin, which is released during acupuncture, is derived from pro-opiomelanocortin (POMC),
which is present in the hypothalamus, pituitary gland, and central and peripheral tissues. (32)
On the other hand, in acupuncture and all sorts of complementary and alternative medicine methods,
imbalances in the life energy in the two forms: yin and yang, can cause diseases, and creating a
balance in these forces can lead to the patient's health. Therefore, using auriculotherapy, symptoms
such as: unstable moods due to MS disease including: stress, anxiety, and depression can be
improved by creating energy balances through the stimulation of specific points on the ear (e.g.
exerting pressure on the points using a Pointer Plus device or vaccaria seeds as described in this
In his qualitative research, Douglas considers one of the themes derived from analyzing the content
of the interviews, to be this theme “Nobody understands my pain”, and notes that people suffering
from MS usually seek accreditation for their pain through their families, friends, and specialized
caregivers, and this issue is treated emotionally (35). It can reduce the patient’s exhilaration, vitality,
and emotional flow, thus increasing stress and anxiety in MS patients. As the results of studies by
researchers show, a number of diseases are caused by stress. These diseases include: coronary heart
disease, angina pectoris, irritable bowel syndrome, gastritis, diabetes, migraine headaches,
rheumatoid arthritis, systemic lupus erythematosus, disabilities, multiple sclerosis, etc. (11).
As described previously, a study was conducted by Wang on 32 adolescent girls suffering from
primary dysmenorrhea in Taiwan in 2013, with the aim of investigating the effect of ear acupressure
on menstrual pain and distress. The study results showed that ear acupressure increased
parasympathetic activities, and could be effective in reducing menstrual pain and distress in
individuals experiencing stressful living conditions, through maintaining and regulating autonomic
homeostasis (26). Also, in another study, Valiani et al. investigated the effects of auriculotherapy on
reducing the symptoms of polycystic ovarian syndrome. And the results of this study which was
conducted in Isfahan on 45 single girls suffering from this syndrome, showed that hormonal changes
were in favor of reducing stress and improving the syndrome (36). In 2017, Zhang et al. published
their paper about the impact of acupuncture on stress in 35 infertile patients in the intervention
group, who were ready to undergo IVF. And they concluded that acupuncture significantly reduces
the patient’s stress at the stages of preparing her to transplant the embryo, compared with the control
group (37), which is consistent with the results of our study.
In his article, Karpatkin refers to a case report from McGuire, under the title "Use of acupuncture to
treat fatigue in an MS patient". In this study, acupuncture had been carried out on a patient on ten
points for 20 minutes, on a weekly basis, and for seven weeks. According to the principles of
traditional Chinese medicine, the balance of heat and cold had been disturbed in this patient, and
after completing the treatment, the patient had more energy, and was fully alert and in good spirits.
Karpatkin states that this kind of studies cannot be generalized to any group of patients, and
indicates the need to design a comprehensive study. (38) Hence, the present study was conducted to
design a thorough and desirable investigation, and its results are citable. And although McGuire’s
research is consistent with the results of the present study, his research design does not cover
In his study on depression and its relationship with other MS symptoms, Siegert showed that
although depression was highly common in MS patients, it had no significant relationship with
fatigue. He recommends pharmacologic therapy methods to control this depression, and reports the
level of depression and anxiety to be 34% and depression alone 47% in MS patients. But he does not
assume that it is associated with Betaferon medicine. (39) In her study on the combined effect of
acupuncture and fluoxetine on depression in 46 patients who were treated in two groups:
intervention and sham, for eight weeks, Zengjian writes that acupuncture has been able to
significantly increase the resting-state functional connectivity (rsFC) in the posterior ventricle and
frontal cortex, and caused corticostriatal balance, and this way depression was controlled. The
above-mentioned research confirms the results of the present study. (40)
With regard to sleep in MS patients, Nociti et al. (2017) report that sleep disturbances are highly
common in MS patients, and include poor quality of sleep and drowsiness during the day. She states
that poor quality of sleep is associated with greater fatigue in these patients, and the two variables
show a significant difference (P <0.05) (41). Accordingly, in their case-control study titled “Sleep
Disorder as a Triggering Factor in MS Relapse” which was conducted on 80 patients, Sahraeian et
al. (2017) write that 87.5% of patients who experience intensified acute symptoms and 50% of those
with no acute symptoms report poor quality of sleep, and these two variables show a significant
difference (P <0.05). The results of the two above-mentioned studies indicate the high prevalence of
poor quality of sleep in MS patients, which is consistent with the results of the present study. But no
mechanisms were provided in the above-mentioned studies to treat the poor quality of sleep in the
patient (42). In their study on the effect of tai chi or acupressure on sleep in MS patients, Xiang et al.
showed that this complementary and alternative medicine (CAM) technique, which was called tai
chi, had a positive impact on reducing dyssomnias, stress, and depression, but did not improve the
sleep quality. (43) The result of their study is consistent with the results of the present study.
According to the findings of this study, it can be concluded that auriculotherapy, as a CAM
technique and a subcategory of acupuncture and reflexotherapy, can be used to reduce stress in MS
patients. This technique is easy and safe, and is recommended as a harmless non-drug method to
control stress and anxiety in MS patients.
This paper is the result of a part of a doctoral thesis titled "An investigation on the effect of
auriculotherapy on pain and stress in patients suffering from multiple sclerosis", which is sponsored
by the deputy of research at Isfahan University of Medical Sciences and the Neuroscience Research
Center of this University. And no doubt, it was not possible to conduct this study without
coordination from the management at Ayatollah Kashani Hospital and cooperation of the respectable
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