8/9/17 pain management with auricular therapy/auricular ... · • auricular therapy • auricular...

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PainManagementwithAuricularTherapy/AuricularAcupuncture

KarenWilliams,MSN,RN,FNP-BC(K1)KDWHealthManagement

KarenSova,MSN,RN,ANP-BC,COHN-S(K2)NationalInstitutesofHealth

TNP2017BFAWorkshop

Objectives

• Overviewofhistoryofacupuncture

• Reviewoftypesofacupuncture

• DiscusshistoryandsignificanceofAuricularAcupuncture/Auriculotherapy

• ReviewparticularsofAuricularAcupuncture/Auriculotherapy

• DemonstrateBattlefieldAcupunctureProtocol

• Casepresentations

Disclosures

• TheviewsexpressedinthispresentationarethoseoftheauthoranddonotreflecttheofficialpolicyoftheDepartmentoftheVeteransAffairs,DepartmentofDefense,orU.S.Government

• Thiscourseisforanintroductiontoauricularacupunctureonlyandisnotforcredentialingpurposes.Thiscoursedoesnotcredentialtheparticipanttoperformauricularacupuncture

WhichOneAmITalkingAbout?!

• Auriculotherapy

• AuricularTherapy

• AuricularAcupuncture

Auriculotherapy/AuricularAcupunctureEvolveswithChineseAcupuncture

• Meridianbasedmedicine- Seekstorestoreharmonyandbalance:Qi- lifeforceenergy- travelsalong12mainpathwaysormeridianswithinthebody

• Qiisprofoundlydisturbedbytraumaticstress

• HistoricallyevolvedinChinaover5000yearsago

• YellowEmperor’sInnerClassic- earliestmajormedicalsourcedatingbackto206BC- 220AD1

History(continued)

• China– isolatedfromrestofworldbecauseofinternalfeudingforpower.

• 1800’s- OutsidetradeandinfluxofChristianityandWesternmedicine

• 1822- QingEmperorordersteachingofacupuncturetostopatImperialMedicalcollege

• RestrictionsonacupuncturecontinuedresultinginthedeclineoftraditionalChinesemedicine.

• 1949- RiseofMaoZedong- poorruralhealthcarecreatedneedfor‘BarefootDoctors’1

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InterestinAcupunctureBeginsintheUnitedStates

• OnatriptoChinawithPresidentRichardNixon,NYTimesreporter,JamesReston,sufferedappendicitis

• 1971- FrontpageofNYTimes,JamesRestonreportedonhisemergencyappendectomyinChina- postoppainrelievedby3needles2

• 3monthslaterareportinJournalofAmericanMedicalAssociation3

• NationalInstitutesofHealthsponsoredphysicianstostudyChinesehealthcareandresearchacupuncture4 (NICAM)

DifferentTypesofAcupuncture

• TraditionalChineseAcupuncture(TCM)

• MedicalAcupuncture

• Japanese Acupuncture

• Korean Hand Acupuncture

• Scalp Acupuncture

• AuricularAcupunctureandAuriculotherapy

• VeterinaryAcupuncture

DescriptionofTypesofAcupuncture• JapaneseAcupuncture:usesthinner,fewerneedlessometimesonly

touchingneedletoskinsurfaceand/oronlyusingoneneedle

• KoreanHandAcupuncture:utilizesthehandasahomunculus/microcosmrepresentationoftheentirebody.Usesneedlesortapingofspecificpoints

• ChineseScalpAcupuncture(CSA):usesthescalpasthemicrocosm–especiallyeffectiveformotorandspinalimpairment

• VeterinaryAcupuncture:usedonanimalsofallkinds– requiresspecialtraining,veryeffective

• FiveElementAcupuncture:Meridianbased– emphasizingconnectednesstotheuniverseandtheeverchangingseasons

TraditionalChineseMedicine(TCM)

• TCMMostcommonformofacupunctureintheUS– usesthe12meridiansplusseveral‘curious’meridiansthattransversethebody

• All12meridiansatsomepointpassthroughtheear

• Herbsaswellasacupuncturecanbeused

• Diagnosisbasedon8principles:YIN YANG

InteriorExterior,DeficiencyExcess,ColdHeat

MedicalAcupuncture

• SimplifiedversionofTCMfrequentlyaddressesmoreacuteissues.

• 300-500hoursoftraining.

• Physician,NursePractitionersandPhysicianAssistantsusingthismodality.

• AddedtreatmentmodalityinWesternmedicine– gainingmomentuminmilitaryandVAfacilitiesforpaintreatment,PTSD/mooddisorders,headinjury

• NationalInstitutesofHealth– usedasawellnessinitiativeforemployeesaswellaspainmanagementinoccupationalinjury,stressmanagementforworkinhighlevelcontainmentlabsandafterdeploymenttoworkinemerginginfectiousdiseaseareas.

Auriculotherapy/AuricularAcupunctureTheory

• Utilizestheearasahomunculus/microcosmrepresentationofhumanbodywithspecificcorrespondingacupuncturepointsonear

• 12Meridianspassthroughears

• Embryologicaldevelopmentoftheearallowsaccesstobrainandsubsequentlythebodyorgans

• Stimulationofnerveendingssendssignalstothebrainandthentothebody

• Byobservingtheearonecanidentifyspecificissues/diseaseprocesses5

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HistoryofAuriculotherapy

WithpermissionfromTerryOleson,Ph.D

EmbryologicalAuricularDevelopmentandAreasofInfluence

WithpermissionfromTerryOleson,Ph.D

EarlyDocumentedUseofAuriculotherapy

• Egypt,GreeceandRome500BCto100AD- HippocratesandGalenusedearringsandotherformsofearstimulation

• Persiansin200ADafterthefallofRome,recordedcauterizationforsciaticapain

• 1500to1700theDutchEastIndiaCompany

• 1957Dr.PaulNogier(French)noticedscarringonpatientsears,whichwasusedforthetreatmentofsciatica5

EarlyDocumentedUse(continued)

• 1958theChineselearnedofDr.Nogier’schartsandverifiedtheaccuracyofthepoints5

• 1980– Dr.TerryOlesonfromUCLAverifiedthescientificaccuracyoftheauriculardiagnosis6

• 1990WHOstandardizedtheterminology 5

• 2001Col.RichardNiemtzow,MD,PhDdevelops‘BattlefieldAcupuncture”

Auriculotherapy/AuricularAcupuncture

WithpermissionfromTerryOleson,Ph.D

AnatomyofAnEar-AGuidetoFindingthePoints

Posterior Periphery PP Back of Scaphoid Fossa and Helix

Anatomical Regions of the Ear

Auricular Landmarks

WithpermissionfromTerryOleson,Ph.D

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AuricularZones– MoreSpecificPointLocations

WithpermissionfromTerryOleson,Ph.D

Auriculotherapy/AuricularAcupunctureuse

• Treatmentforsubstanceabuse(NADAprotocol)andmorerecentlyforPTSD,TBI,andbattlefielduse

• Widerangeofdisorderstoincludeheadache,chronicbackpain,asthma,allergicrhinitis,dentalpain,anxiety,insomnia

• Pointscanbeneedled,seeded,electricallystimulated

• Allowsquickandeasyaccessfortreatment

• Treatmentstakeaslittleas20minutes,providerelieffordaystoweeks

• Easytolearn5

EasyAuricularAcupunctureProtocols

• NationalAcupunctureDetoxificationAssociation(NADA)– Lung,Liver,Kidney,ShenMen,AutonomicPoint

• BattlefieldAcupuncture(BFA)– Cingulategyrus,Thalamus,Omega2,PointZero,ShenMen

• AuricularTraumaProtocol(ATP)– MasterCerebral,Amygdala,Hypothalamus,Hippocampus,Insula,Vagus,PointZero,

ShenMen12

Howbigaretheneedles?

DoesItWork?- Research-

• Efficacyinpainmanagement:Meta–analysisof13studiesonAuricularTherapy(Acupressure,AcupunctureandElectro-acupuncture)showedagreaterdecreaseinpainscorethanshamorcontrolgroup7

• Pilotstudyof87activedutymilitarypersonnelwithacutepain- theacupuncturegroupshoweda23%reductioninpainversesthestandardmedicalcaregroup8

• Postconcussiveheadachesinactivedutyservicemembers.Randomizedexploratorystudyevaluated:usualcare,TCMandAuricularAcupuncture.Acupunctureimprovedheadacherelatedqualityoflifemorethanusualcare9

Research(continued)

• Ratswerestressedinordertoinducedepression- dividedintoacupuncture,antidepressant,notreatment.Theacupuncturegroupandantidepressantgroupsshowedreducedglutamateinthehippocampus,preventeddamagetohippocampalneuronsandimprovedbehavior10

• ClinicalobservationintheTempleVAheadacheclinic- acupunctureuseddailytostoptheheadacheandgeneralpainreduction,improvemoodandhelpwithsleep.Nouseofnarcotics.

• ClinicalanecdotalobservationatNIH– acrossthespectrumofdiverseproblems– successwithpainreduction,musclerelaxation,lesseningofacutepresentationsandimprovementinsleepandstressreduction– nouseofnarcotics

• Furtherresearchisdefinitelyneeded,someofthedifficultyishavingacontrolgroup.

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AcupunctureSystemicReviews

• NIHsystemicreview2012– Acupunctureiseffectivefor

chronicpaintreatmentandcanbeconsideredareasonableoption

– Chronicpaintoincludebackandneckpain,osteoarthritis,chronicheadacheandshoulderpain13

• Cochranesystemicreview2016– Acupunctureshouldbe

consideredformigrainepatientsforprevention,particularlyifhavingadverseeffectsfrommedications

– Acupunctureeffectsizewasstaticallysignificantlylargerinrealacupunctureversesshamacupunctureforchronicheadaches

– Acupunctureshouldbeconsideredfortreatingepisodicorchronictensionheadaches14

"WithPermissionfromDr RichardC.Niemtzow"

BFAScience

AnteriorCingulateCortexandThalamicNuclei

Painstimulation Painstimulation w/acupuncture

BattlefieldAcupunctureprotocol

• Cingulategyrus• Thalamus• Omega2• Pointzero• ShenMen

BFAPointLocations- CTOPS

ShenMen

PointZero

Thalamus

CingulateGyrus

Omega2

KDWHealthManagementLLC

SignificanceofPoints/BFA

• Cingulategyrus-memoryandemotionwithpain

• Thalamus- Communicationofnervoussystemtocerebralcortex(GrandCentralstation),reducingshock,restoringtranquility

• Omega2 Psychosomaticd/o&paininlimbs

• Pointzero- Generalbodyhomeostasis/autonomicbraincontrollingvisceralorgans

• ShenMen- Parasympatheticswitch,alleviatesexcessivesensitivity,calming,painreduction,insomnia– supportsotherauricularreflexpoints

KDWHealthManagementLLC

Precautions

• Knowwhatyouaretreating

• Donotrelievepainifitisneededtolimitthepatientsactivity

• Donotuseduringpregnancy

• Needlecautiouslywithbleedingdisorders

• Donotuseelectriccurrentwithacardiacpacemaker

• NoETOH,drugsbeforetreatment

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Precautions(continued)

• Avoidtreatingthosethatareextremelyweak,anemic,tired,hungryorhaveeatenabigmeal- treatmentwillnotbeeffective

• Thosethatareweakafter,needtorestbeforeleaving

• Needleshock- vasovagalreaction(uncommon,butcanhappen)

• Treatwithantibioticsifinfectiondevelops(veryrare)

• Mostcommonsideeffectisredortenderear

Procedure

• Consent(goodfor1year)

• Washhandsorusehandsanitizer

• Wipeearswithalcoholswap

• Accesspainlevelpriortoplacementofneedle

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Needlepractice

KDWHealthManagementLLC

AnatomyDifferences

KDWHealthManagementLLC

BFACingulategyrus

CingulateGyrus

KDWHealthManagementLLC

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PointPracticeCingulateGyrus

KDWHealthManagementLLC

BFAThalamus

Thalamus

KDWHealthManagementLLC

PointPracticeThalamus

KDWHealthManagementLLC

BFAOmega2

Omega2

KDWHealthManagementLLC

PointPracticeOmega2

KDWHealthManagementLLC

BFAPointZero

PointZero

KDWHealthManagementLLC

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PointPracticePointZero

KDWHealthManagementLLC

BFAShenMen

ShenMen

KDWHealthManagementLLC

PointPracticeShenMen

KDWHealthManagementLLC

BFACTOPS

ShenMen

PointZero

Thalamus

CingulateGyrus

Omega2

KDWHealthManagementLLC

Reasonstostopthetreatment

• Patientasks

• Painisat0– 1/10

• LightheadednessSTOP

PatientDischargeInstructions

• Drinkplentyofwater

• Avoidstrenuousactivitiesforrestofday

• Avoidheavymeals

• Avoidalcoholandsexfor6hours

• Continuemedicationsasdirected

• Monitorresponsetothetreatment

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CostofAcupuncture

• Thecostactuallyvariesbythetypeofprovider(physicianvs"other"(NP))andthetypeofPatient.ThePriceQuote:asofJan17th 2013.Theratetablesarechanged1-2timeseachyearandratesdogoupanddown,usuallyonlyslightly.

• Pricequoteforacupuncturewithoutstimulation

• 97810- $35.74(Physician)$30.38(ExtraMedical/NP)-first15minutes

• 97811- $26.89(Physician)$22.86(ExtraMedical/NP)-additional15minutes

• Pricequoteforacupuncturewithstimulation

• 97813- $38.12(Physician)$32.40(ExtraMedical/NP)-first15minutes

• 97814- $30.63(Physician)$26.04(ExtraMedical/NP)-additional15minutes

RelativeValueUnit(RVU)foracupuncture

Acupuncturewithoutelectricstimulation• 97810- 0.6RVU’s- first15minutes

• 97811- 0.5RVU’s-additional15minutes

• Acupuncturewithelectricstimulation

• 97813– 0.65RVU’s- first15minutes

• 97814– 0.5RVU’s– additional15minutes

GreatNews!

• TheTexasBoardofNursinghasgrantedapprovalforuseofAuricularacupuncture,ifyouhavetakentheappropriatecourses.TheuseofauricularacupuncturedoesnotoverlapintotheterritoryoftheLicensedAcupuncturist,accordingtoTexasMedicalBoarddefinitionofacupuncturist.

• PossibilityforlearningthisvaluableskillTheAuriculotherapy CertificationInstitutewww.auriculotherapy.org*Thiscertificatedoesnotreplacetheneedforstatelicensureinaspecifichealthcarefield,butitdoesacknowledgespecialtyoftraininginthisparticularhealthcaremodality.

CasePresentations

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RefractoryMigraine

FailedtreatmentinER

HistoryandTreatment

• 38yr.oldfemalewitha2weekshistoryofmigraine

• FailedallabortivetreatmentsoftriptansandIVmedicationintheER

• PlacedBFAprotocolbilaterally,for20minutes

• Resolutionofthemigraine

Occipitalneuralgiaandneckpain

Chronicpain

History

• 40yearoldmalewithahistoryofmultipleconcussions,neckandlowbackpainrelatedtomultipledeployments:toincludehardlandingswithparachutejumps,headstrikesonvehiclesandmultipleblastsfromIdentifiedexplosivedevices(IED)

• Chronicposterioroccipitalpainwithjabandjoltforwardbehindtheeyes.Occurring2-3timesperweeklasting2hours,ratedas7/10.Headacheshavebeenoccurringsince2006(10years)

• Priortreatmentswithacupunctureandmassagetobackhelpful,nottolerantofTopamax,Robaxin- wouldprefertostayawayfrommedications

• Pastmedicalhistory- Migraines,PTSD,SleepApnea,Insomnia,Lowbackpain,Neckpain,Tinnitus,GERD

AuricularAcupuncturetreatment

• Placementofneedlesatthefollowingpoints:• Shenmen,Amygdala,MasterCerebral,Vagus,Hypothalamus,

Hippocampus,Thalamus,Cingulategyrus,pointzero,Cervical(Sensory&Motor),Lumbar(Motor)

• Painpriortotreatment:7/10neckandshoulders,mildoccipitalpain• Anxietypriortotreatment:6/10

• Needlesleftinfor20minutes

• Painaftertreatment:4/10neckandshoulders,occipitalpainresolved• Anxietyaftertreatment:3/10

Occipitalneuralgiaandanxiety

Pre-procedurepain

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History

• 38yr.oldfemalewithaHx ofoccipitalneuralgia/tensionheadachesoccurringsince1998- unsureoftriggerotherthanwasonactivedutyasamedicattimeofonset.Inadditionhadamedicationoverusecomponenttohercurrentheadaches(takingdailyExcedrin/Imitrexfor3weeks)

• failedmultiplemedicationstoincludePaxil,Celexa,nortriptyline,Topamax,Depakote,Motrin

• Medicalhistory- PTSD,Sexualassaultinadolescence/MST,Anxiety,Insomnia,Constipation,Allergicrhinitis,Asthma,GERD,Lowbackpain,Dizziness,Polyarthralgia

• SeeninclinicfortrialofBotox- attimeofappthada5/10headachelocatedintheleftoccipitalarearadiatingtobehindherlefteye.InadditionshewasextremelyanxiousabouttheadministrationofBotox.Ratedanxietyas10/10

Treatment

• Auricularacupunctureadministeredatthefollowingsites:Tranquilizer,Shenmen,Pointzero,Amygdala,Hypothalamus,Hippocampus,MasterCerebral,Insula,Lesseroccipital– needlesleftinfor20minutes

• Alpha-stimAID(micro-currentappliedbywayofeartabs)wasappliedtohelpwithanxiety

• Herheadacheresolvedafter10minutesandanxietywasreducedto3/10

• ShewasabletocompletetheadministrationofBotoxwithoutissue,herheadachedidnotreturnthatdayandheranxietyremainedlow

Dentalpain

Acutepain

HistoryandTreatment

• 51yr.oldmalewith3dayhistoryofrightsidedjawpainfollowingrootcanal.Ratespainas8/10,constantthrobbinganddistractinghimfromworking

• AcupunctureneedleplacedatDentalanalgesiapoint• Painresolvedbeforemyhandwasawayfromhisear- paindidnotreturn

• 75yr.oldmalewith2dayhistoryleftjawpainfollowingtoothextraction,“drysocket”.Ratedpainas9/10,unabletoeatorevenbrushhisteeth

• AcupunctureneedleplacedatDentalAnalgesiapointx2,Thalamus,ShenMen

• Painresolvedover5minutes- paindidnotreturn

DentalPain(continued)

• 35yr.oldfemalewith10daysofleftfacialpain.Foundtohaveinfectionintooth,nowneedingdentalsurgeryastheinfectionhadsurpassedtheabilitytodoarootcanal.Inadditionshewasdxwithsinusinfectionastoothrootwasintothesinuscavity.TakingT&C#3every4hours- reducedherpainto5/10

• PlacedauricularneedlesatDentalAnalgesia,JawandThalamus- painresolvedover3minutes.Needlesremovedandgoldstudsplaced.

• Patientleftpainfreeandhappy,afterbeingintheofficeatotalof10minutes.Pain0-2/10for3days,noneedtotakeT&C#3.Paincamebackwhengoldstudsfellout,neededtogobackonT&C#3untilsurgeryasshecouldnotgetbackintotheoffice.

OccupationalInjury– BackStrainHistory

• 44yr.oldmalehelpingtotransporta300lb.anesthetizedpigbacktopenwhenpigsuddenlyawokeandinthestrugglethatensuedtheemployeeinjuredhisback.

• Presentsinacutepain,unabletofindapositionofcomfort,unabletostandorsit,lyingonsidewithoutrelief.

• Healthy,alertmale:Nomeds,NKA,PMH:NC

• Pain:10/10P:96BP:156/84

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BackStrain- Treatment

• NPandPTunabletoexamemployeeincurrentstateofpain– restlessinfetalposition

• NeedledpointsBFAplusmusclerelaxation,sacralandlumbarspineinonlyoneear– encouragedtodeepbreathe– coldpacktoback

• Inlessthan5minutes,suddenlypulledhimselftothesideofthebed,stoodupstillbendingslightlyforwardandsaid(smiling)‘you’reawitch’hispainhadgoneto5/10withincreasedmobilityandabilitytowithstandfurtherevaluationP:76BP:132/74

• WasabletotreatwithNSAIDsandPhysicaltherapywithAuriculotherapyforaddedpainmanagement.Onlightdutyreturnedtofulldutyin2weeks.

OccupationalExposure– AllergyHistory

• 36yr.oldfemalepresentswithmildresp.distressaftersustainingamousebitewhilemovingthemousetoadifferentcage

• EmployeewasworkingwithHPAI(HighPathAvianInfluenza)mousehadnotbeeninfected

• PMHxofseasonalandcatdanderallergies.Meds:prnLoratadine– nonetakeninpast7days

• P=104R=28audiblewheezing,BP=146/82

Allergy- Treatment

• Alertfemalebegins15min.scrubofbitemarkonrightindexfinger

• Whilescrubbing,needlesquicklyplacedinBFAinbothearsandwithallergyandantihistaminepointsbilaterally

• R=20(nowheezingeitheraudibleoronauscultation)P=76BP=128/76after15min.scrubwithneedlesinplace

• Oralantihistaminegiven.Employeeabletoreturntoworkinanhour.Work-upformouseallergies

PostDeploymentInsomniaHistory

• 52yr.oldmaleintheU.S.PublicHealthServicerecentlyreturnedfromdeploymentinAfricaduringEbolaepidemicfor3months.Heisunabletosleepthroughthenightwaking5-6times

• PMHx:Hypertension,hyperlipidemia

• Meds:Losartan50mgqd,Rosuvastatin10mgqd

Insomnia- Treatment

• Firsttreatment:BFAinoneearandATP(auriculartraumaprotocol)inotherearwithInsomnia1,Insomnia2,inboth.Leftneedlesinfor45minutes.Hefellasleepandreportedhe‘feltasifIhaven’tsleptthiswellinmonths’

• Continuedtohavesleepdisruptionbutonly3-4timesanight.After2similartreatmentshewaswaking0-2timesanightandstatedfelt‘lessanxious’

WordsofWisdom

"Anyonewhoistrainedandlicensedtogiveinjectionsordosuturescouldlearntouseafewsimpleacupunctureprotocolsinamatterofweeks,andcouldrelieveanenormousamountofsuffering." 11

‘AcupunctureislikeChinesenoodles’:communitybasedacupunctureconcept

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KarenWilliams,MSNRNFNP-BCKDWHealthManagement@gmail.com

704-706-5519

KarenSova,MSN,RN,ANP-BC,COHN-Skmsova2@gmail.com

301-980-8062

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References

1. HelmsJ.AcupunctureEnergeticsAclinicalApproachforPhysicians.NewYork:Thieme publishers,2007:3-17.

2. RestonJ.NowaboutmyoperationinPiking.TheNewYorkTimes,July26,1991:1,6.

3. DiamondEG.AcupunctureAnesthesia:westernmedicineandChinesetraditionalmedicine.JournaloftheAmericanMedicalAssociation,2181971:1558-1563.

4. ChenJYP.Acupuncture.InMedicineandPublicHealthinthePeople’sRepublicofChina.EditedbyJ.R.Quinn.U.S.Dept.ofHealth,EducationandWelfare:NationalInstitutesofHealth,JohnS.FogartyInternationalCenter.1972:65-90.

5. Oleson T.Auriculotherapy Manual:ChineseandWesternSystemsofEarAcupuncture,3rd edition.NewYork:ChurchillLivingston,2003:2-19.

References

6. Oleson T,Kroening R,Bresler D.Anexperimentalevaluationofauriculardiagnosis:thesomatotpic mappingofthemusculoskeletalpainatearacupuncturepoints.Pain1980;8:217-229

7. Yeh CH,etal.EfficacyofAuricularTherapyforPainManagement:ASystematicReviewandMeta- Analysis.Evidence-BasedComplimentaryandAlternativeMedicine2014;20141-14.

8. GoertzCM,NiemtzowR,BurnsSM,Fritts MJ,CrawfordCC,JonasWB.Auricularacupunctureinthetreatmentofacutepainsyndromes:Apilotstudy.MilMed2006Oct171(10):1010-4.

9. JonasWB,etal.ARandomizedExploratoryStudytoevaluateTwoAcupunctureMethodsforthetreatmentofHeadachesAssociatedwithtraumaticBrainInjury.MedicalAcupuncture2016;28:113-130.

References

10. FanL,etal.GlutamateofHippocampusInvolvedinRemissionofDepressionbyAcupunctureinRats.MedicalAcupuncture2016;28:71-78.

11. Rohleder L,EtAl. Acupunctureislikenoodles.Oregon:WorkingClassAcupuncture,2009:122.

12. RobertL.Koffman,&JosephM.Helms.(2013).AcupunctureandPTSD:‘Comefortheneedles,stayforthetherapy’. PsychiatricAnnals,43(5),236.doi:10.3928/00485713-20130503-09.

13. Vickers,A.J.,Cronin,A.M.,Maschino,A.C.,Lewith,G.,MacPherson,H.,Foster,N.E.,...AcupunctureTrialists'Collaboration.(2012).Acupunctureforchronicpain:Individualpatientdatameta-analysis. ArchivesofInternalMedicine,172(19),1444-1453.doi:10.1001/archinternmed.2012.3654.

14. Coeytaux,R.R.,&Befus,D.(2016).Roleofacupunctureinthetreatmentorpreventionofmigraine,tension-typeheadache,orchronicheadachedisorders. Headache:TheJournalofHeadandFacePain,56(7),1238-1240.doi:10.1111/head.12857.