Auriculotherapy to reduce anxiety and pain in nursing professionals: a randomized clinical trial

RESUMEN Objectives: to evaluate the effectiveness of the auricular protocol (APPA) in reducing pain and anxiety and improving the quality of life of the nursing staff of a hospital. Method: randomized clinical trial with an initial sample of 180 professionals divided into 4 groups Control (G1), Seed (G2), Needle (G3) and Tape (G4). The evaluation instruments were the State-Trait Anxiety Inventory, Pain Visual Analog Scale and Quality of Life instrument, applied at the start and after five and 10 sessions (five weeks). Descriptive statistics, analysis of variance (ANOVA) and Cohen's d Index were used in the analysis. Results: there was a statistical difference (p < 0.05) for anxiety according to the repeated measures ANOVA, with better results for the G3 in the final assessment (Cohen's d index 1.08/17% reduction). There was a reduction of pain of 36% in G3 and 24% in G2 and a 13% increase in the mental aspect of quality of life for the G3, although without statistical significance. Conclusion: the APPA protocol reduced the anxiety levels of nursing staff after 10 sessions. Further studies are, however, suggested with new populations and in different contexts so that the results can be confirmed. RBR-5pc43m.


Introduction
Mental health is one of the great challenges of the twenty-first century. Considering this, a study revealed that 30% of the population of the metropolitan area of São Paulo suffered from some kind of mental disorder.
Among the most common problems identified in the study were anxiety, behavioral changes and substance abuse. Anxiety was present in 20% of the respondents. The study confirmed a greater prevalence of mental disorders in adults in São Paulo than those of similar study conduct in other area of the world (1) .
Although the individual clinical and sociocultural factors need to be considered, contextual factors inevitably have a heavy impact on the development of mental problems. Among these, the economic crisis and rising unemployment levels can certainly contribute to a sense of general and collective insecurity (2) . Brazil is experiencing a chaotic historical moment regarding political, economic, ethical and social aspects, with a tragic legacy of a driving motion of the economy that has acquired an astonishing rhythm of unbalance and overload over the past four years. The result of government intervention in the economy associated with corruption has caused increased inflation, credit restriction, closure of businesses and rising unemployment, coupled with a lack of faith of the population in relation to the government (3) .
The city of São Paulo had a population of 11,581,798 inhabitants in 2015 and is considered the largest city in the country and in South America (4) . In addition to the current economic and political developments, the process of rapid expansion and urbanization is an aggravating factor for the welfare of the residents, contributing to increased social insecurity, creating urban environmental problems and irregular settlements and prejudicing the quality of life (5) . This climate of dissatisfaction and personal and collective insecurity is the background of this study, which was carried out with the nursing staff of a large general hospital in São Paulo, with an average of 3,500 Nursing professionals, many of whom lived in neighborhoods a long distance from the workplace.
Nursing workers represent one of the groups of professionals most susceptible to present health problems at work, as they perform complex tasks involving a high physical and mental workload (6) . Other factors potentiate damage to their physical and mental integrity, causing pain and anxiety, such as: lack of personal protective equipment, dissatisfaction related to working conditions, low wages, difficult interpersonal relationships, lack of trust between professionals and management, and physical and emotional exhaustion due to caring for patients with pain and suffering. All this generates increased rates of absenteeism (7) .
In anticipation of proposing a preventive treatment to reduce levels of anxiety and pain in the nursing staff, the use of auriculotherapy has been proposed as a complementary and preventive practice. with a Nursing team. The protocol was previously created for people living in situations of danger, conflict, disaster and poverty (8) .
While it was recognized that the scope of auricular technique can be greater when performed in an individualized way that does not follow a protocol and by professionals with theoretical and practical knowledge of diagnoses (9) , the possibility of using a protocol assists in the dissemination and popularization of the art, with the aim of benefiting more people. It should also be noted that auriculotherapy has important advantages, being easily administered, very rapid, relatively inexpensive, achievable with non-invasive materials and presenting minimal adverse side effects (10) . The aim of the study was to evaluate the effectiveness of the auricular protocol for pain and anxiety (APPA) and improving the quality of life of nursing staff of a hospital.

Method
This was a parallel-group randomized controlled trial conducted in the Beneficência Portuguese Hospital   All participants completed a biosociodemographic questionnaire and the instruments: Spielberger's State-Trait Anxiety Inventory (STAI) (11) , Visual analogue scale (VAS) of pain and SF-12v2 Quality of life (12) , applied at the beginning, after five sessions and at the end of ten sessions.
The study fulfilled the requirements of resolution
Only one person withdrew from the study due to pain with the needles. Other people who felt pain continued in the trial. The adhesive tape group did not function as a placebo, as the participants were not blinded and it also did not produce any effects.
www.eerp.usp.br/rlae needles do not need to be stimulated, however, may produce local pain and run a risk of infection. Even with lower results, there is an advantage in the use of seeds as they produce less discomfort (13) and can be applied by people only trained for the protocols. In this regard, the first test of the APPA protocol in Nepal obtained positive results after the earthquake that devastated the country in 2015 (14) . Cerebral, Heart, Valium or Tranquilizer, Sympathetic and Endocrine (18) . Auriculotherapy has also been studied as a actions (20) .
The APPA produced a reduction in the level of pain of 36% with needles and 24% with seeds. Specific points for musculoskeletal or visceral pain were not used, opting for the use of general points, such as the Shenmen, Thalamus, which are indicated for pain. It is in the thalamus that painful information is located and projected to the structures of the limbic, motor and cortical systems. Thus, the painful impulse reaches the limbic system, carrying the experience as something unpleasant and emotional, resulting in the interpretation of pain (21) . Other studies with the APPA protocol have is recognized and accepted. There is a significant correlation between pain and symptoms of anxiety and depression, especially chronic pain (22) .
Considering the limitations of the study, it was not possible to ensure the proper participation of the subjects who were treated with seeds, as the seeds need to be pressed to achieve better results. As it is important for the APPA Protocol that the auriculotherapy is made

Conclusion
The APPA protocol, when applied with the nursing staff of a hospital in São Paulo, achieved significant positive differences in the reduction of anxiety, according to the repeated measures ANOVA, after 10 sessions.
The group with semi-permanent needles presented a Cohen's d index of 1.08 (large effect) and 17% reduction.
There was a reduction in pain levels by 34% for the needle group and 24% for the seed group and a 13%