Lowering anxiety of university students prior to the exams by auricular acupuncture Preliminary study

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1 Short Communication Experimental Pathology and Health Sciences 2016;8 (2): Lowering anxiety of university students prior to the exams by auricular acupuncture Preliminary study Andreia Vieira1,7, Karine Silva3, Mariana Hinzmann1,3,Jürgen Stürmer1,8, Maria João Santos1, Nuno Correia,4,5,6, Henry J. Greten1,2 and Jorge Machado1,3,9 (1) TCM Master Programme, Abel Salazar Institute for Biomedical Sciences, University of Porto, Porto, Portugal; (2) Heidelberg School of Chinese Medicine, Heidelberg, Germany; (3) ICBAS- Abel Salazar Institute for Biomedical Sciences, University of Porto, Porto, Portugal; (4) Internal Medicine, Emergency Department, University Hospital of São João, Porto, Portugal; (5) Nursing School of Oporto, University of Porto; Porto, Portugal; (6) Acupuncture Clinic, Alfena Private Hospital, Porto, Portugal; (7) Physiotherapist Department, Hospital Santa Maria, Porto, Portugal (8) Deutsche Gesellschaft für Traditionelle Chinesische Medizin. (9) Labiomep- Laboratório de Biomecânica do Porto, Faculdade de Desporto, University of Porto, Abstract High-level students are exposed to various challenges that trigger high anxiety levels in relation to their academic requirements. Few studies suggest that auricular acupuncture (AA), may improve anxiety. In this study, we evaluate the potential effect of AA on the anxiety-levels of university students and also try to assess if the improvement of anxiety status is correlated with some alterations of vital signs, as blood pressure (BP), heart beat per minutes (HC), oxygen saturation (OS) and temperature (T). This study suggests that AA is effective in reducing exam-related anxiety in university-level students. Our results show that the experimental group had a reduced in the level of anxiety of just after 30 minutes, being even greater after 48 hour, with only a single auricular acupuncture treatment, when compared with control (waiting list) and placebo groups. The selected points showed to be the adequate for the treatment, since the placebo group, where unspecific points were used did not manifest any improvement; the results were even very similar to the starting point and similar to the control group. So, potentially, AA may be used as a complementary or alternative treatment for anxiety prior exams on high level students. However, this effect needs more deep scientific studies on larger samples. An additional long-term double-blinded with AA may confirm this results. Keywords: Anxiety, Acupuncture; Auriculotherapy; Traditional Chinese Medicine; Exames. Andreia Vieira andreiarsv@gmail.com Introduction Anxiety is one of the most frequent clinical behavioral disorders, affecting both the physical and emotional state, inducing changes in behavior and cognition of individuals [1-4]. Regarding the emotional state, the individual can express feelings of fear, insecurity, apprehensive anticipation, catastrophic thinking and increased time of alert [1, 2, 5]. From the physiological point of view, anxiety is characterized by activation of the hypothalamicpituitary-adrenal (HPA) axis, presenting symptoms such as insomnia, tachycardia, pallor, sweating, muscle tension, tremor, dizziness, nervousness, difficulty with concentration, intestinal disorders and epigastric discomfort [1, 2, 5, 6]. According to the diagnostic and statistical manual of mental disorders (DSM-IV), anxiety is a natural response, resulting in a sign of fundamental alert in humans, the given threat. However, anxiety can become pathologic when excessive and uncontrollable. In this sense, physical health is also compromised due to hormonal changes and consequent decrease of the immune system, which aggravates the development of various other conditions such as chronic musculoskeletal pain, respiratory diseases, cardiovascular problems, infectious and even cancer [7]. In a survey conducted by Rodrigues and Pelisolo in 2008, which included students in preparation for the final examination, it was found that 23% of the

2 Experimental Pathology and Health Sciences students reported anxiety in moderate to severe degree [8]. The same authors also concluded that students attending health courses showed even higher levels of anxiety. Concomitantly, Cruz and Pinto (2010) found that 52.3% of nursing students at Viseu showed moderate anxiety, and 27.1% lowgrade rated by STAY Cruz and Pinto (2010) also observed the existence of a relationship between anxiety and academic demands related to oral presentation of papers, prior the attendance or exam days, the day of examination or frequency and duration of clinical trials [9]. As Andrade and Gorenstein (1998) stated, there are several instruments formulated to assess anxiety, each of which emphasize different aspects such as mood, cognition, behavior, state of hyperalertness and somatic symptoms [3]. According to the literature, Spielberger (1970), has presented a greater emphasis on the study of anxiety in all individuals[10]. Of particular importance to determine whether an instrument will measure the trait anxiety as a characteristic condition of the individual; or the assessment of state anxiety will be in a given moment, before a given situation (e.g., school ratings) [3, 11-13]. As a means to treat anxiety, conventional medicine makes use of several drugs, such as benzodiazepines, antidepressants, barbiturates and antihistamines [14]. However, several authors (Durham & Higgins, 2012) have emphasized that Western medicine can t solve all cases of anxiety[15]. Besides the risk of side effects, resistance to pharmacological treatment affects approximately one in three patients with anxiety disorders[16, 17]. Auricular acupuncture is a therapeutic method often used in anxiety treatments, acting directly on the nervous system, promoting the release of endorphins in the brain and melatonin s related to relaxation, supporting the balance of the autonomic nervous system[18-22], with already very promissory results, needing only the support of more scientific data to complement and validate this therapy [23]. Thus, in this context, a small student sample from an university population will be exposed to the auricular acupuncture (AA), in order to improve from their anxiety symptoms. The criteria for participation and psychopathological symptoms were previously evaluated based on specific and validated questionnaires. Few physiological parameters were also accomplished [13]. This assay should be a prospective, randomized, controlled, singleblinded study. cation, and with no known psychiatric or thyroid disorders. Study Design. Individuals were randomly allocated to the Experimental group (EG, n=8): verum AA in points (Figure2): 1. joy, 2. lung parenchyma, 3. anxiety, 4. psychosomatic and 5. diazepam; the Placebo group (PG, n=5): sham AA on points in neurological segments distinct from the verum AA (Figure 3): 1. articulation of the right hand, 2. foot joint right, 3. left hand joint, Methodology Selection of Students. This study was approved by the Ethics Committee of Piaget University from Vila Nova de Gaia, Portugal. Written informed consents were obtained from all students before study enrollment. An experimental, prospective, randomized, controlled and single-blinded study was conducted. The sample included university students (n=18), naive to acupuncture, under no psychotropic medi- 148

3 4. joint of the left foot and 5. shoulder joint, and the control waiting list group (WL, n=5): without any AA treatment. One week prior to the examination series at the University, subjects were treated with AA using semi-permanent needles in place for 48 hours. Initially, the following documents were delivered to all those interested in participating in this study: informed consent, questionnaire evaluation of the criteria for participation, inventory psychopathological symptoms (BSI) [25]; Inventory trait-state anxiety (STAI) [11, 12]. 2016:8 (2) data, variance was held for each assessed physiological parameters (blood pressure, cardiac and respiratory rate), an ANOVA for repeated measures, dependent variables: values related to physiological parameter observed before the experimental session and 30 minutes after the experimental session, the independent variable: experimental condition (study group, placebo group and control group). Any significant result was not observed. That is, there were no statistic significant changes in the values of physiological parameters HB, HC, OS and T collected. Possibly need other accuracy in a larger population samples and more adequate conditions and specific equipment to obtain consistent and clear physiological results. As for the level of anxiety data after verification of normality and homogeneity of data variance, held a repeated measures ANOVA (dependent variables: state anxiety values recorded before the experimental session, 30 minutes after the experimental session and 48 hours after the trial session). The results (Figure 5) were that after 48 hours, a big decrease in anxiety-state values in the study group (EG experimental group). None of the other experimental conditions produced significant changes in levels of anxiety (either 30 minutes or 48 hours after experimental session). Prior to the formation of experimental groups, and to ensure greater uniformity in the same, students selected for the study were divided into four groups according to the level of trait anxiety achieved by one of STAI (Y2 form) : group of students nothing anxious, a little anxious, a group of moderately anxious students, and a group a very anxious students. Assessments were made 5 minutes before (T0), 30 minutes (T1) and 48 hours after (T2) the needling (Figure 4). Main Parameters: Level of anxiety were assessed according to the state anxiety inventory STAI (form Y1) and a Visual Analogue Scale (VAS) for anxiety. Physiological parameters, as blood pressure (BP), heart beat per minutes (HC) and oxygen saturation (OS) and temperature (T) were taken at each study time (0, 30 min and 48 hours) using a monitor Goldway UT6000A. Results Total of 18 students (13 women; 5 men) were included, with age= 21,4±1,85 years, weight= 63,9±8,43kg, height= 1,70±0,07m and body mass index= 22,17±4,17kg/m2, from which 16,8% showed moderate to severe states of anxiety and 14,3% trace of anxiety. After verification of normality and homogeneity of The placebo group revealed slightly higher values of anxiety than the control group, thought the study, but the standard deviation is too high, to separate these two groups (WL and PG). Discussion This study appears in a context, firstly, the sharp interest and growing activity in the preparation of standards that will regulate the practice of tradicional chinese medicine (TCM) and on the other hand, a marked anxiety installed for socio-economic reasons, the current flow will be the increased due to emotional instability of many students in exams season. However, only few studies indicate that acupuncture, including auricular acupuncture, can improve anxiety. The results showed a statistically significant de- 149

4 Experimental Pathology and Health Sciences crease in mean anxiety levels via the STAI Y1 medium to anxiety in the real auricular acupuncture group, compared to control and placebo between 5 minutes before the session and 48 hours after experimental session. Similarly, the average of anxiety levels in real auricular acupuncture group, were lower than control and placebo groups, between 30 minutes and 48 hours after the session. However, although it is noted a decrease in mean levels of anxiety true auricular acupuncture group, 5 minutes before the session and 30 min after the session were not statistically significant. This means that although there is a tendency for a reduction of anxiety levels after 30 minutes, the auricular acupuncture effect were more effective after 48 hours. These results are in agreement with the study of Wang and Kain (2001), on the effectiveness of STAI-Y1 way past 48 hours after the headset session[19, 20]. However, the tendency to decrease the anxiety levels after 30 minutes of the session, even not being statistically significant contradict with the study of Wang and Kain (2001). On the other hand, the study by Prado and Silva (2012), as the only study evaluating auricular acupuncture anxiety in students found significant differences in the real auricular acupuncture group, compared to other groups, only 8th session, 12th session and 15 days after the end of the sessions, so is normal to have different results, in different studies since the study population are a very heterogeneous group, only with bigger study groups and repeating the same treatment the result can be comparable [26]. Note that these researchers conducted 12 auricular acupuncture sessions with mustard seeds, 1 time per week. However, the authors did not take into account the students phase related to the academic requirements in the studies conducted by Cruz and Pinto (2010) and Pilkington (2010) in order to increase levels of anxiety-state [9, 27, 28]. Relatively to the physiological data BP, HB and OS there was not statistically significant differences between the five minutes before the session and 30 minutes after the session, as well as between the five minutes before the session and 48 hours the session. It notes that the semi-permanent needles were maintained for 48 hours. These results go against those obtained by Wang and Kain (2001) stating that the increase in level of anxiety is associated with an increase of physiologic response, the correlation is still not well defined (SM Wang and Kain, 2001). Wang and Kain (2001) analyzed individuals with anxiety levels of day-to-day, relating the absence of differences in HR and BP in the absence of any experimental factor of anxietystate. In fact, in our study, we were careful to include a homogeneous sample; there was a predictor of state anxiety (eg, school exams). But even with a week in advance, it was not possible, due to ethical issues; make our nearest evaluation of school exams. However, these results show us that the auricular acupuncture method presented can be a safe therapeutic relating to the non variation of physiological and effective when data related to the decrease in anxiety levels. With regard to methodological procedures, some aspects deserve our analysis, the use of semi-permanent needles, rather than regular acupuncture needles, since the effects of the puncture can be maintained for several days of stimulation, prolonging the treatment effect. According Landgren (2008) and Umeh (1988) the semi-permanent needles are more efficient than regular acupuncture needles as they continue to stimulate the point for a longer period. On the other hand, semi-permanent needles have a lower depth level of the standard stimulus [29, 30]. However, when comparing semi-permanent needles mustard seed used by Prado and Silva (2012) at the university level of anxiety the first show better effects [26]. Regard to the placebo group, we were careful in selecting the points according to some criteria: puncture 5 auricular points in total, as in the study group; put points without any influence on anxiety, according to TCM; two points located on the nondominant auricular and 3 points in the dominant ear, to cover nerve trigeminal irrigation zone, i.e., outside the dermatomes of auricular points of the study group. The group of auricular points selected in the study: "Diazepam" "anxiety," "psychosomatic" and "joy" are located in the pinna at the cervical plexus irrigation zone; on the other hand the point "pulmonary parenchyma" is in the dermatome of the vagus nerve of the ear. Thus, we follow international recommendations for selecting skipped stitches (White, Filshie, & Cummings, 2001). White (2001) suggests that based on acupuncture school in the nerve endings (medical acupuncture), be defined checks based on skin spots that are not traditional acupuncture points and located in different nerve segments of acupuncture points to be tested. With these criteria we intended to, on the one hand, not give any suggestion to the participant of the type of treatment to which were being subjected, on the other hand, to prevent puncture dermatomes covered by true acupuncture points[31, 32]. Conclusions In this study, although there is a tendency for a reduction of anxiety levels after 30 minutes, the auricular acupuncture effect was more effective and significantly after 48 hours of the experimental session. These results are in agreement other studies regarding the effectiveness of STAI Y1 way past 48 hours atrial session. However, despite a tendency to anxiety levels decrease after the 30-minute session in the preliminary study, this was not statistically significant, contradicting the study of Wang and Kain (2001). In this sense, we propose a new collection with a larger sample and introducing new variables such as heart rate variability, respiratory frequency and the salivary cortisol and dermal electro-conductance. Potentially, AA may be used as a complementary or alternative treatment for anxiety prior exams, and benefit greatly the ones that suffer the most with this disorder. Study limitations The study evaluated the effect in the short and me- 150

5 dium term auricular acupuncture, so it is important to assess larger samples and the long-term effect in the treatment of anxiety before exams, as well as others evaluations approaches according with TCM diagnosis, variable, it would be interesting target for future studies. Knowledgments This work was accomplished under the master program of Traditional Chinese Medicine in biomedical Science Institute ICBAS-UP. I would like to thanks all staff of Applied Physiology Laboratory and to the participant students of Piaget University from Vila Nova de Gaia. References 1. Association, A.P., Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (4 ed.). Artmed, Mackenzie, J.W., Daycase anaesthesia and anxiety. A study of anxiety profiles amongst patients attending a day bed unit. Anaesthesia, (5): p Andrade, L.G., & Gorenstein, C., Aspectos gerais das escalas de avaliação de ansiedade. Rev Psiq Clin, (6): p Alcantara, P., Ansiedade e inteligência. Pediatria (São Paulo) (3): p Almondes, K.M., & Araújo, J. F., Padrão do ciclo sono-vigília e sua relação com a ansiedade em estudantes universitários.. Estudos de Psicologia, (1): p Ferreira, C.L., Almondes, K. M., Braga, L. P., Mata, A. N., Lemos, C. A., & Maia, E. M, Universidade, contexto ansiogênico? Avaliação de traço e estado de ansiedade em estudantes do ciclo básico. Ciências e Saúde coletiva-rio de Janeiro, (3): p Kolesnikov, O.L., et al., Dependence of immune system function and metabolism on reactive anxiety. Bull Exp Biol Med, (2): p Rodrigues, D.G., & Pelisolo, C, Ansiedade em vestibulandos: um estudo exploratório Revista Psiquiátrica Clínica, (5): p Cruz, C.M., Pinto, J. R., Almeida, M., & Aleluia, S., Ansiedade nos estudantes do ensino superior. Um Estudo com Estudantes do 4º Ano do Curso de Licenciatura em Enfermagem da Escola Superior de Saúde de Viseu.. Centro de Estudos em Educação, Tecnologias e Saúde, 2010: p Gaudry, E. and C.D. Spielberger, Anxiety and intelligence in paired-associate learning. J Educ Psychol, (5): p Silva, D., & Correia, S., O inventário de estado-traço de ansiedade - S.T.A.I. In M. Gonçalves, M. Simões, L. Almeida & C. Machado (Coords.). Avaliação Psicológica Instrumentos validados para a população portuguesa 2006: p Spielberger, C.D., Gorsuch, R. C., & Lushene, R. E., Manual for the State-Trait Anxiety Inventory Psychologists. Palo Alto: CA. Consulting., :8 (2) 13. Zhang, Z., Su, H., Peng, Q., Yang, Q., & Cheng, X., Exam anxiety induces significant blood pressure and heart rate increase in college students. Clin Exp Hypertens, (5): p Barbosa, L.C., Alvarenga, E. S., Demuner, A. J., Virtuoso, L. S., & Silva, A. A., Synthesis of new phytogrowth-inhibitory substituted arylp-benzoquinones. Chem Biodivers, (5): p Durham, R.C., Higgins, C., Chambers, J. A., Swan, J. S., & Dow, M. G., Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups. J Affect Disord, (3): p Menezes, G.B., Fontenelle, L. F., Mululo, S., & Versiani, M., Treatment-resistant anxiety disorders: social phobia, generalized anxiety disorder and panic disorder. Rev Bras Psiquiatr, (2): p Davidoff, L.L., Emoção e Ajustamento São Paulo: Makron Books., ed. 18. Wu, S., et al., Comparing the treatment effectiveness of body acupuncture and auricular acupuncture in preoperative anxiety treatment. J Res Med Sci, (1): p Wang, S.M. and Z.N. Kain, Auricular acupuncture: a potential treatment for anxiety. Anesth Analg, (2): p Wang, S.M., C. Peloquin, and Z.N. Kain, The use of auricular acupuncture to reduce preoperative anxiety. Anesth Analg, (5): p , table of contents. 21. Wang, S.M., et al., Acupuncture as an adjunct for sedation during lithotripsy. J Altern Complement Med, (2): p Pilkington, K., Kirkwood, G., Rampes, H., Cummings, M., & Richardson, J., Acupuncture for anxiety and anxiety disorders--a systematic literature review. Acupunct Med, (1-2): p Cabyoglu, M.T., Ergene, N., & Tan, U., The mechanism of acupuncture and clinical applications. Int J Neurosci, (2): p Bahr, F., & Strittmatter, B., Bahr, F., & Strittmatter, B. (2010). Das große Buch der Ohrakupunktur.2010, Germany: Hippokrates. 25. Canavarro, M.C., Inventário de Sintomas Psicopatológicos: BSI. In M. R. Simões, M. Gonçalves, L. S. Almeida (Eds.). Testes e Provas Psicológicas em Portugal, II: p Prado, J.M., Kurebayashi, L. F., & da Silva, M. J., Auriculotherapy effectiveness in the reduction of anxiety in nursing students. Rev Esc Enferm USP, (5): p Cruz, C.M., Pinto, J. R., Almeida, M., & Aleluia, S., Ansiedade nos estudantes do ensino superior. Um Estudo com Estudantes do 4º Ano do Curso de Licenciatura em Enfermagem da Escola Superior de Saúde de Viseu. Centro de Estudos em Educação, Tecnologias e Saúde, 2010: p Pilkington, K., Anxiety, depression and acupuncture: A review of the clinical research.. Auton Neurosci, (1-2): p

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