Auriculotherapy

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NeuroRehabilitation 17 (2002) 49–62 IOS Press

Auriculotherapy stimulation for neuro-rehabilitation Terry Oleson Auriculotherapy Certification Institute, 8033 Sunset Blvd., PMB #270, Los Angeles, CA 90046-2427, USA Tel.: +1 323 656 2084; Fax: +1 323 656 2085; E-mail: t [email protected]

Abstract: The capability of reflex points on the external ear to alter neuromuscular and neuropathic disorders has been attributed to the descending pain inhibitory pathways of the central nervous system. The inverted fetus perspective of the somatotopic arrangement of auricular acupuncture points was first described in the 1950’s by Dr. Paul Nogier of France, and has received scientific support from double blind studies examining auricular diagnosis of musculoskeletal and of coronary disorders. Acupuncture points on the ear and on the body have lower levels of electrical skin resistance than surrounding tissue. These electrodermal differences are apparently related to autonomic control of blood vessels rather than increased sweat gland activity. The heightened tenderness of reactive acupuncture points may be explained by the accumulation of noxious, subdermal substances. Electrical stimulation of specific points on the external ear leads to site specific neural responses in different regions of the brain. Behavioral analgesia produced by auricular acupuncture can be blocked by the opiate antagonist naloxone, indicating the role of endorphinergic systems in understanding the underlying mechanisms of auriculotherapy. The anatomical structures and electrical application of the auricle are described as they relate to the localization of master points, musculoskeletal points, internal organ points, and neuroendocrine points. Keywords: Auriculotherapy, ear acupuncture, microsystems, neuromuscular disorders, electrical skin resistance, descending pain inhibitory system

1. Introduction Since the discovery of stimulation produced analgesia by Liebeskind et al. [1], electrophysiological perspectives of the modulatory role of neurological reflex pathways have been increasingly explored. In addition to the specific nerve tracts which carry ascending, nociceptive signals to specific brain regions, there is a separate set of descending pathways from the brain which have the ability to inhibit the nociceptive impulses, and thus suppress the perception of pain [2]. Because the opiate antagonist naloxone blocks both stimulation-produced analgesia from brain stimulation [3] and blocks analgesia from stimulation of acupuncture points [4], the descending pain inhibitory system has been strongly associated with endorphinergic pathways in the brain and spinal cord [5,6]. Analgesia from the electrical stimulation of auricular acupoints is also reversed by naloxone [7] and distinct elISSN 1053-8135/02/$8.00  2002 – IOS Press. All rights reserved

evations of endorphins immediately follow auricular stimulation [8,9]. Subsequent research has also suggested that cortisol, serotonin and norepinephrine also play a significant role in these neural pathways which regulate pain [10]. The essence of these neurophysiological theories is that the nociceptive signals from peripheral nerves ascending to the higher brain can be blocked by descending impulses from the brain itself. Auriculotherapy and classical acupuncture are viewed as clinical procedures for stimulating the peripheral reflexes, which activate these central brain pathways, thus inhibiting the maladaptive reflexes that contribute to neuromuscular disorders. While the stimulation of acupuncture points near a region of body pathology has received moderate acceptance by Western trained scientists [11], the use of remote acupuncture points to treat pathological organs that are distant from the site of stimulation arouses considerable skepticism. It seems plausible that activa-

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T. Oleson / Auriculotherapy stimulation for neuro-rehabilitation

tion of tissues immediately surrounding a stimulating electrode could directly alter the bioelectric fields and the biochemical environment of nearby cells. The underlying mechanisms for remote acupuncture points, however, seems less apparent. At the very least, there would be significant decay of the electrical signal as it traveled over the body from the ear to the hand or to the foot. Nonetheless, electrical stimulation of specific regions of the external ear has been shown to alleviate pathological conditions throughout the body [12]. What is often misunderstood is that the electrical signals from the external ear do not directly flow to distal regions of the body. The actual pathway is more circuitous, traveling along neuron fibers from the auricle to the brain, from the brain down the spinal cord, and from spinal nerves to the correspondent region of the body. These circuitous communication pathways along the nervous system allow the activation of auricular acupoints to alleviate disorders in widespread parts of the body. The arrangement of auricular acupoints can be viewed as an inverted somatotopic map of the body. According to this view, upper regions of the external ear are used to alleviate conditions in the legs and feet, middle regions of the auricle represent the chest and back, and lower regions of the auricle can relieve headaches and brain disorders. The purpose of this presentation is to review the history, theories, clinical studies, and neurophysiological research which has examined the field of auriculotherapy and its relationship to neuro-rehabilitation.

2. Somatotopic organization of auricular acupuncture points In traditional acupuncture theory, chronic pain and pathological diseases are due to the blockage of energy flow along acupuncture meridians, invisible lines of force extending over the surface of the body. Ancient Oriental medical texts described direct energy connections between the yang acupuncture meridians which connect to the head and acupuncture points found on the external ear [13]. In 1958, the Chinese revised their charts of auricular acupuncture points after they learned of the inverted fetus map discovered by Dr. Paul Nogier, of Lyon, France [14]. This inverted fetus image is shown in Fig. 1. Nogier was familiar with an energy perspective of the human body from his studies of the French acupuncturist Georges Soulie de Morant [15]. The somatotopic pattern on the external ear was compared to the neurological homunculus demonstrated by

Inverted Fetus on Ear

Fig. 1. Inverted fetus map represented on the external ear.

Penfield and Rasmussen for the human cerebral cortex [16]. Neurophysiological research revealing a connection between this Nogier auricular map and the somatotopically organized neurons in the brain is in only the initial stages of scientific investigations. Nogier [17] suggested that there are three different zones on the external ear which are related to different types of neural innervation and different categories of embryological tissue. A picture of the external ear identifying the nomenclature for different anatomical regions of the auricle are shown in Fig. 2, whereas the specific functional zones of the ear are represented in Fig. 3. The central concha of the ear is innervated by the vagus nerve and serves as the region for autonomic regulation of pain and pathology originating from internal organs [18]. The surrounding antihelix and antitragus ridges of the ear represent somatic nerve processing of myofascial pain, backaches, and headaches [19]. The outer helix tail and the lobe represent the spinal cord and brain regions which affect neuropathic pain,such as peripheral neuropathies and trigeminal neuralgia. The body organs represented on the external ear can also be viewed as three concentric rings. The embryologically based endodermal organs are found at the center of the ear, the mesodermal tissue that become the somatic

T. Oleson / Auriculotherapy stimulation for neuro-rehabilitation Auricular Anatomy

3. Neurophysiological theories of acupuncture and micro-acupuncture systems

❍ Helix

Superior Crus

Triangular Fossa ❍

●

Inferior Crus ❍ ●

Superior Concha

●

❍

●

Inferior Concha

Scaphoid Fossa

❍

Antihelix Body

●

Tragus

❍

❍

Concha Ridge Antihelix Tail

❍

Intertragic Notch

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Antitragus ❍ Lobe

Fig. 2. Identification of specific anatomical regions of the auricle.

Mesodermal Area Somatic Nerves Myofascial Tension

Endodermal Area Autonomic Nerves Visceral Disorders

Ectodermal Area Brain and Spinal Cord Neuropathic Disorders

Fig. 3. Identification of three functional regions of the auricle.

musculature is represented on the middle ridges of the auricle, and the ectodermal skin and nervous system tissue are found on the outer ridges of the ear. Each of these three auricular regions depicts body orientation in an inverted somatotopic pattern. Organs higher in the body, such as the endodermal lungs, the mesodermal, shoulder or the ectodermal cerebral cortex, are represented on lower areas of the auricle, whereas organs lower in the body, such as the intestines, the leg, or the lumbar spinal cord, are represented on higher areas of the auricle.

According to Ralph Alan Dale [20], the homunculus pattern shown on the external ear is one of several micro-acupuncture systems that connect peripheral regions of the body to the central nervous system. Dale suggested that these microsystem points have remote reflex connections to other parts of the body through neuronal pathways in the central nervous system. Dale has proposed that there are both organocutaneous reflexes which allow the microsystem to reveal underlying body pathology and cutaneo-organic reflexes which enable micro-acupuncture stimulation to alleviate the pathological condition. Foot reflexology, hand acupuncture, and scalp acupuncture are other examples of such micro-acupuncture systems, each serving as peripheral terminals to a central regulating system. Tsun-nin Lee [21] has hypothesized a thalamic neuron theory to account for reflex connections between acupuncture points and the brain. According to this view, pathological changes in peripheral tissue will eventually lead to dysfunctional neural firing patterns in the correspondent neural microcircuits in the brain and spinal cord. The organization of the connections between peripheral nerves and the CNS is controlled by sites in the sensory thalamus that are arranged like the overall body, but inverted. The CNS institutes corrective measures intended to normalize the disordered neural circuits, but strong environmental stressors or intense emotions may cause the CNS circuitry to malfunction. If the neurophysiological programs in the neural circuits are impaired, the peripheral disease may remain chronic. Pain and disease are thus attributed to learned, maladaptive programming of these central neural circuits. Stimulation of acupuncture points on the body or on the ear can serve to induce a reorganization of these pathological brain pathways. The spatial arrangement of these neuronal chains within the thalamic homunculus is said to account for the arrangement of acupuncture meridians in the periphery. Nogier [15] had suggested a similar theory to explain auriculotherapy. The auricular acupuncture system is said to be arranged in a somatotopic pattern on the auricular skin surface that connects to the somatotopic circuits to the brain. 4. Electrodermal determination of acupuncture points Double blind assessment of the somatotopic pattern of musculoskeletal reflex points on the auricle was first

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conducted by Oleson et al. in 1980 [22]. Forty patients with specific musculoskeletal pain problems were evaluated by a UCLA doctor or nurse to determine the exact body location of their physical pain. These patients were then draped with a sheet to cover their body so that only their external ear was exposed to view. Crutches and braces were removed from the room in order to prevent any clues as to the nature of their condition. A second medical doctor, who had extensive training in auricular acupuncture procedures, then examined each patient’s ear. This second doctor had no prior knowledge of the subject’s previously established medical diagnosis and was not allowed to verbally interact with the patient. Auricular diagnosis was determined by numerically rated levels of tenderness to a palpating probe and by the quantified electrical conductivity of the skin. Specific areas of the auricle were examined which were associated with different musculoskeletal regions of the body. There was a positive correspondence between auricular points identified as reactive, both tender to palpation and exhibiting at least 50 microamps of electrical conductivity, and the parts of the body where there was musculoskeletal pain. Non-reactive ear points corresponded to parts of the body from which there was no reported pain. The statistically significant, overall correct detection rate was 75.2%. When the pain was located on only one side of the body, electrical conductivity was significantly greater at the somatotopic ear point on the ipsilateral ear than at the corresponding area of the contralateral ear. These results supported the concept that specific areas of the ear are related to specific areas of the body. Auricular points related to coronary disorders were examined by Saku et al. [23] in Japan. Reactive electropermeable points on the ear were defined as auricular skin areas that had conductance of electrical current greater than 50 microamps, indicating relatively low skin resistance. There was a significantly higher frequency of reactive ear points at the Chinese heart points in the inferior concha (84%) and on the tragus (59%) for patients with myocardial infarctions and angina pain than for a control group of healthy subjects (11%). There was no difference between the coronary heart disease group and the control group in the electrical reactivity of auricular points that did not represent the heart. The frequency of electropermeable auricular points for the kidney (5%), stomach (6%), liver (10%), elbow (11%), or eye (3%), was the same for coronary patients as for individuals without coronary problems. Quantified examinations of the electrical properties of the skin have provided the most objective demonstra-

tion of the scientific validity of acupuncture points [24, 25]. Observations that acupuncture points exhibit higher levels of skin conductance than surrounding skin surface areas, or lower levels of skin resistance, were first reported in the 1950’s by Nakatani in Japan and by Niboyet in France [26]. In the 1970’s, Matsumoto found that 80% of acupuncture points could be detected as low resistance points. The electrical resistance of acupuncture points was found to range from 100 to 900 kilohms, whereas the electrical resistance of nonacupuncture points ranged from 1,100 to 11,700 kilohms. Taking great care to control for electrical resistance variance due to pressure on the skin by the detecting probe, Reichmanis, Marino, and Becker [27, 28] systematically verified that the electrodermal resistance at acupuncture points is significantly lower than surrounding tissue. In addition, meridian acupuncture points exhibit even lower electrical resistance when there is pathology in the organ they represent. The normal, bilateral symmetry of the electrical resistance of acupuncture points is disturbed when there is unilateral pathology in the body. Xianglong et al. [29] of China examined 68 healthy adults for computerized plotting of low skin resistance points. A silver electrode was continuously moved over a whole area of body surface, while a reference electrode was fastened to the hand. Starting from the distal ends of the four limbs, investigators moved the electrode along the known meridians. The resistance of low skin impedance points (LSIP) was approximately 50 kilohms, whereas the impedance at non-LSIP was typically 500 kilohms. LSIP’s were distributed over the body predominantly along the 14 classical acupuncture meridian channels. A total of 64% of LSIP’s were located exactly on a meridian and 83.3% were located within 3 mm of an acupuncture channel. Individual LSIP’s could be found in non-meridian areas in only a few cases. There was not an uninterrupted, continuous line of low skin impedance, but a series of electroactive points distributed along the meridian channel. There was no marked natural fluctuation of skin impedance and the distribution of LSIP’s was considerably stable and repeatable from one day to the next. Chiou et al. [30] examined the topography of low skin resistance points (LSRP) in rats. The moveable search electrode was a polished acupuncture needle applied with uniform pressure which did not pierce the skin, while the reference electrode was a needle subdermally inserted into the tail. Specific LSRP loci were distributed symmetrically and bilaterally over the shaved skin of the animal’s ventral, dorsal, and lateral


surface. The arrangement of LSRP corresponded to the acupuncture meridians found in humans. The LSRP’s were hypothesized to represent zones of autonomic concentration, the higher electrical conductivity due to higher concentration of neural and vascular elements beneath the points. The LSRP’s gradually disappeared 30 minutes after the animal’s death. Skin and muscle tissue samples were obtained by Chan et al. [31] from four anesthetized dogs. Acupuncture points, defined by regions of low skin resistance, were compared to control points exhibiting less conductivity. The points were marked for later histological examination. Concentration of substance P was significantly higher at skin acupuncture points (3.33 ng/g) than at control skin points (2.63 ng/g) that did not exhibit low skin resistance. Concentration of substance P was also significantly higher in skin tissue samples (3.33 ng/g) than in the deeper, muscle tissue samples (1.81 ng/g). Substance P is known to be a spinal neurotransmitter found in nociceptive, afferent C-fibers. It plays a role in pain transmission, stimulates contractility of autonomic smooth muscle, induces subcutaneous liberation of histamine, causes peripheral vasodilation, and leads to hypersensitivity of sensory neurons. This neurotransmitter seems to activate a somato-autonomic reflex that could account for the clinical observations of specific acupuncture points that are both electrically active and tender to palpation [32]. Experimentally induced changes in auricular reflex points in rats were examined by Kawakita et al. [33]. The submucosal tissue of the stomach of anesthetized rats was exposed, then acetic acid or saline was injected into the stomach tissue. Skin impedance of the auricular skin was measured by constant voltage, square wave pulses. A silver metal ball, the search electrode, was moved over the surface of the rat’s ear and a needle was inserted into subcutaneous tissue to serve as the reference electrode. Injection of acetic acid led to the gradual development of lowered skin resistance points on central regions of the rats’ ears, auricular areas which correspond to the gastro-intestinal region of human ears. In normal rats and in experimental rats before the surgical operation, low impedance points were rarely detected on the auricular skin. After experimentally induced peritonitis, there was a significant increase in low impedance points (0–100 kilohms) and moderate impedance points (100–500 kilohms), but a decrease in high impedance points (greater than 500 kilohms). These results demonstrated a reduction in the electrodermal resistance response to experimentally induced irritation of the internal organ related to that auricular

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point. Histological investigation could not prove the existence of sweat glands in the rat auricular skin. The authors suggested that the low impedance points are in fact related to sympathetic control of blood vessels.

5. Changes in brain responses related to auricular reflexes Further evidence of the neurophysiological connection between the external ear and the brain has been provided by animal research. Kalyuzhnyi [34] applied 15 Hz electrical stimulation to the auricular lobe of rabbits, an area corresponding to the jaw and teeth in humans. They measured behavioral reflexes and cortical somatosensory evoked potentials in response to tooth pulp stimulation. Auricular electroacupuncture produced a significant decrease in behavioral reflexes and in cortical potentials evoked by electrical stimulation of the teeth. For most animals, the suppression of the behavioral and neurophysiological nociceptive responses was abolished by injection of the opiate antagonist naloxone, suggesting endorphinergic mechanisms. Fedoseeva et al. [35] also examined electrical stimulation of auricular acupuncture at ear lobe points of rabbits, in the auricular area representing the trigeminal nerve. Auricular electroacupuncture led to a reduction of the amplitude of cortical somatosensory potentials evoked by tooth pulp stimulation. Intravenous injection of the opiate antagonist naloxone diminished the analgesic effect of auricular electroacupuncture at 15 Hz stimulation frequencies, but not at 100 Hz stimulation. Conversely, injection of saralasin, an antagonist of angiotensin II, blocked the analgesic effect of 100 Hz auricular acupuncture, but not 15 Hz stimulation. Asamoto and Takeshige [36] studied selective activation of the hypothalamic satiety center by auricular acupuncture in rats. Electrical stimulation of inner regions of the rat ear, which corresponds to auricular representation of the gastro-intestinal and thoracic organs, led to evoked potentials in the ventromedial hypothalamus (VMH) satiety center, but not in the lateral hypothalamic (LH) feeding center. Stimulation of more peripheral regions of the auricle did not activate hypothalamic evoked potentials, indicating the selectivity of auricular acupoint stimulation. Acupuncture needles were subsequently placed into the same auricular sites as those that led to VMH evoked potentials in the first set of rats. After 16 days, the body weights of rats in the auricular acupuncture group was significantly lower than in a control group of rats that were not treated.

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Auricular acupuncture had no effect in rats who had received bilateral lesions of the VMH, thus indicating that the integrity of the hypothalamus was essential for achieving this weight loss effect. Shiraishi et al. [37] also recorded hypothalamic neurophysiological activity in the VMH and LH of rats in a different manner. Single unit neuronal discharge rates were recorded in the hypothalamus following electrical stimulation of low resistance regions of the inferior concha of the rat, areas of the ear innervated by the vagus nerve. Auricular stimulation tended to facilitate neuronal discharges in the VMH and inhibit neural responses in the LH. Responses of 162 VMH neurons showed that 44.4% exhibited increased neuronal discharge to auricular stimulation, 3.7% exhibited decreased activity, and 51.9% showed no change. Of 224 LH neurons in these rats, 22.8% were inhibited by auricular stimulation, 7.1% were excited, and 70.1% were unaffected. When the analysis was limited to 12 rats classified as responding to auricular acupuncture stimulation with weight loss, 49.5% of LH units were inhibited, 15.5% were excited, and 35.0% were not affected by auricular stimulation. A different set of rats were given lesions of the VMH, which led to significant weight gain. In these hypothalamic obese rats, 53.2% of 111 LH neurons were inhibited by auricular stimulation, 1.8% showed increased activity, and 45% were unchanged. These neurophysiological findings in animals suggest that auricular acupuncture selectively activates one area of the hypothalamus while it inhibits another. Other studies have demonstrated the ability of stimulation of the specific auricular points to alter electrophysiological measures of gastro-intestinal activity in humans [38,39]. Auricular acupuncture has also been shown to suppress autonomic electrodermal activity associated with the startle reflex to arousing stimuli. Young and McCarthy [40] conducted a controlled clinical trial on 38 healthy human volunteers. Forearm electrodermal recordings (EDR) to different stimuli were obtained when a needle was inserted into the auricular sympathetic point. In another set of subjects, EDR levels were recorded when a needle was inserted into a placebo auricular point not associated with autonomic regulation. Electrodermal responses were consistently lower following stimulation of the auricular sympathetic point than when needles were placed in the placebo point, suggesting that the auriculotherapy attenuated the autonomic startle reflex. The most conclusive evidence that needle stimulation of acupuncture points can selectively activate dif-

ferent areas of the brain has been provided by brain imaging research conducted by Cho et al. [41]. Baseline recordings of functional magnetic resonance images (fMRI) activity were obtained and changes in fMRI activity were recorded following visual stimulation versus auditory stimulation. Needles were then inserted into different acupuncture points of the human volunteers. Acupuncture points that are typically used for visual disorders led to changes of fMRI typically in the visual cortex, whereas needles inserted into another set of acupoints that are typically used to affect hearing disorders selectively activated fMRI activity in the auditory cortex. The first demonstrations of fMRI of brain activity following ear acupuncture was reported by Alimi [42] at the Third International Symposium of Auriculotherapy and Auricular Medicine in Lyon, France; 2000. Manipulation of gold needles inserted into the thumb region of the auricle activated the same areas of the brain as tactile stimulation of the actual thumb.

6. Mechanisms for withdrawal from opiate drugs by auricular acupuncture The discovery by H.L. Wen [43] that auricular acupuncture facilitates withdrawal from narcotic drugs has led to a plethora of studies demonstrating the application of this technique for substance abuse [44,45]. Auricular electroacupuncture has been shown to raise levels of met-enkephalin levels in human narcotic addicts [46] and beta-endorphin levels in mice withdrawn from morphine [47–49]. Pert et al. [50] showed that 7 Hz electrical stimulation through needles inserted into the concha of the rat produced an elevation of hot plate threshold which was reversed by the opiate antagonist naloxone. The behavioral analgesia to auricular electroacupuncture was accompanied by a 60% increase in radioreceptor activity in cerebrospinal fluid levels of endorphins, which was significantly greater than the endorphin changes observed in a group of control rats. Concomitant with these CSF changes, auricular electroacupuncture produced depletion in beta-endorphin radioreceptor activity in the ventromedial hypothalamus and the medial thalamus. Supportive findings from human patients suffering from back pain was demonstrated by Clement-Jones et al. [51]. Low frequency electrical stimulation of the concha region of the ear led to relief of back pain within 20 minutes of the onset of electroacupuncture and an accompanying elevation of radioassays for CSF beta-endorphin activity in all 10


back pain patients. Abbate et al. [52] examined endorphin levels in 65 patients who were undergoing thoracic surgery with 50% nitrous oxide and 50 Hz auricular electroacupuncture. These patients were compared to six control patients who underwent surgery with 70% nitrous oxide, but no acupuncture stimulation. The auricular acupuncture patients showed a significantly greater increase in beta-endorphin immunoreactivity. Simmons and Oleson [53] examined naloxone reversibility of auricular acupuncture analgesia to acute induced pain. All 40 volunteers were assessed for tooth pain threshold by a dental pulp tester. Dental pain levels were determined before and after auriculotherapy and then again after double blind injection of naloxone or placebo. Subjects were assigned to one of four groups: true auricular electrical stimulation (AES) followed by an intravenous injection of naloxone; true AES followed by an injection of saline; placebo stimulation of the auricle followed by an injection of naloxone; or placebo stimulation of the auricle followed by an injection of saline. Dental pain thresholds were significantly increased by AES conducted at appropriate auricular points for dental pain. Pain thresholds were not altered by sham stimulation at inappropriate auricular points. Naloxone produced a slight reduction in dental pain threshold in the subjects given true AES, whereas the true AES subjects who were then given saline showed a further increase in pain threshold. The minimal changes in dental pain threshold shown by the sham auriculotherapy group were not significantly affected by saline or by naloxone. Pain threshold levels did not completely return to baseline after naloxone, suggesting non-opioid as well as endorphinergic brain mechanisms. Kroening and Oleson [54] examined 14 chronic pain patients who were switched from their original analgesic medication to an equivalent dose of oral methadone, typically 80 mg per day. An electrodermal point finder was used to determine areas of low skin resistance for the lung point and the shen men point. Needles were bilaterally inserted into these two ear points and electrical stimulation was initiated between two pairs of needles. After 45 minutes of electroacupuncture, these hospitalized pain patients were given periodic injections of small doses of naloxone (0.04 mg every 15 minutes). The daily dose of methadone was cut in half each day, presuming there were no aversive withdrawal effects. All 14 patients were withdrawn from methadone within 2 to 7 days, for a mean of 4.5 days. Only a few patients reported any side effects, such as mild nausea or agitation. The authors proposed

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that the occupation of opiate receptor sites by narcotic drugs leads to the inhibition of the activity of natural endorphins, whereas auricular acupuncture facilitates withdrawal from these drugs by activating the release of previously suppressed endorphins. By giving small, incremental doses of naloxone administration after auricular acupuncture, it was theorized that opiate receptor sites can be allowed to more readily return to their normal state. Other biochemical changes also accompany auricular acupuncture. Jaung-Geng et al. [55] evaluated lactic acid levels from pressure applied to ear vaccarie seeds positioned over the liver, lung, san jiao, endocrine, and thalamus (subcortex) points. Pressure applied to ear points produced significantly lower levels of lactic acid obtained after physical exercise on a treadmill test than when ear seeds were placed over the same auricular points but not pressed. Actual stimulation of these auricular acupressure points seemed to reduce the toxic elevations of lactic acid build-up to a greater extent than did the control condition, perhaps due to improved peripheral blood circulation. Debrecini [56] examined changes in plasma ACTH and GH levels after 20 Hz electrical stimulation through needles inserted into the adrenal point on the tragus of the ears of 20 healthy females. While GH secretions increased after electroacupuncture, ACTH levels remained the same.

7. Auricular anatomical regions The practice of auricular acupuncture begins with an in depth appreciation of the complex curvatures that compose the anatomy of the external ear. In accordance with its purpose as the most distal component of the auditory system, the auricle of the ear is shaped to conform to the undulating waves of sound that arrive at the ear. International standardized nomenclature for these anatomical areas was agreed upon at a 1990 meeting of the World Health Organization [57]. The auricle consists of a series of circular ridges and valleys that finally focus sound input into the auditory canal at the center of the external ear. The most outer ridge of the auricle is referred to as the helix, which is a Latin term for a spiral pattern. An inner ridge within this outer rim is called the antihelix, indicating a spiral structure opposite to another spiral configuration. These two regions of the ear are illustrated in Fig. 3. The helix is further subdivided into a central helix root, an arching superior helix, and the outermost helix tail. The subsections of the antihelix include an antihelix tail at the bottom, an

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Master Points

8. Auricular master points

Allergy Point Autonomic Sympathetic Point

Shen Men

Point Zero Master Oscillation Point Tranquilizer Point Endocrine Point Master Cerebral

Thalamus Subcortex Point Master Sensorial

Fig. 4. Location of master points on the auricle.

antihelix body in the middle, and two branches from the antihelix body, the superior crus and the inferior crus. Between these two arms of the upper antihelix lies a deeper region, the triangular fossa, whereas the valley of the scaphoid fossa separates the antihelix from the helix tail. Covering the auditory canal is a flat section of the ear known as the tragus. Opposite to the tragus is a ridge that is labeled the antitragus. It is a curving, descending continuation of the antihelix. Below the antitragus is the soft, fleshy ear lobe and between the antitragus and the tragus is an area known as the intertragic notch. The deepest region of the ear is called the concha, indicating it is shell shaped in its structure. The concha is further divided into an inferior concha below, a superior concha above, a concha ridge in between, and a concha wall which surrounds the whole concha floor. Two hidden areas of the ear include the subtragus underneath the tragus and the internal helix underneath the helix. On the back side of the ear is a whole surface referred to as the posterior auricle. This hind portion of the ear is subdivided into a posterior groove behind the antihelix, a posterior lobe behind the lobe, a posterior concha behind the concha, a posterior triangle behind the triangular fossa, and the posterior periphery behind the scaphoid fossa and helix tail. Taking the time to visually recognize and tactilely feel the different contours of the ear will greatly assist one in applying the auricular somatotopic correspondences to specific anatomical structures.

The relationship of each anatomical region of the auricle to clinical applications has been described in previous publications by Oleson et al. [58] and in various clinical texts on auricular acupuncture [13,14,59]. The first set of ear acupoints to be considered are referred to as master points or tune-up points, shown in Fig. 4. These auricular points do not correspond to one specific body organ, but affect many different medical conditions. They thus have a “mastery” over the general health of the body. Stimulation of these master points is said to “tune-up” or correct metabolic malfunctions. The master points identified as point zero and shen men are utilized in almost all auriculotherapy treatment plans and seem to facilitate the improvement of most health disorders. Point zero was first described by Nogier and is found in a notch on the helix root as it rises from the concha ridge. Besides serving as an anatomical landmark that indicates the central most position of the auricle, point zero is thought to function as a homeostatic point which balances dysfunctional conditions. The shen men point is similar in function to point zero, purportedly producing a general balance of physiological activity. It is clinically used to alleviate stress, pain, tension, anxiety, depression, and substance abuse disorders. The English translation of shen men is “spirit gate”, suggesting that activation of this Chinese ear point connects an individual to one’s spiritual essence, enhancing the vital forces of life. The physical location of shen men is found toward the tip of the triangular fossa. The next master point is referred to as the autonomic or sympathetic point, referring to its use in regulating the autonomic nervous system. While there are many physiological disorders that involve hyperactive or hypoactive autonomic reflexes, the autonomic point is particularly prescribed for treating vasoconstrictive problems associated with hypertension and cardiovascular disorders. This point is also one of the principal auricular points used for drug detoxification and substance abuse treatment. The autonomic sympathetic point is found on the underside of the internal helix, where it meets the antihelix inferior crus. Such hidden points are represented by a black square, indicating that these auricular points are not normally visible because they are covered by another region of the ear, in this case the helix root. The next two master points, the thalamus point and the endocrine point, are also represented by filled squares. These two points are also not visible without pulling the auricle outwards with


retractors. The thalamus point is found on the base of the concha wall, behind the antitragus, whereas the endocrine point is located nearby, on the vertical surface of the intertragic notch. The thalamus point is thought to connect to subcortical structures in the brain that are involved in neurological dysfunctions and the reduction of pain sensations. The endocrine point represents the pituitary gland, the master control gland for all other endocrine glands and the target hormones which they release into the general blood supply of the body. Superior to the endocrine point, and underneath the lower knob on the peripheral edge of the tragus, is the master oscillation point. This auricular point is used by European practitioners of auricular medicine to facilitate interactions between the left brain and right brain. Oscillators are said to have a problem with laterality, the inappropriate control of cortical functions by the opposite cerebral hemisphere. On the underside of the apex of the ear is the allergy point, named for its ability to alleviate allergies, arthritis, and inflammatory reactions. Toward the bottom of the tragus is the tranquilizer point, an ear acupuncture point used for sedating the mind and calming the body. The final two master points are located on the ear lobe. At the center of the lobe, vertically below point zero, is the master sensorial point, used to alleviate any disturbing sensations. Below the intertragic notch is the master cerebral point, also referred to as the neurasthenia, nervousness, or worry point. It is stimulated in order to reduce obsessive, worry thoughts and to alleviate the symptoms of generalized anxiety.

9. Somatotopic musculoskeletal auricular points In his original text, The Treatise of Auriculotherapy, Paul Nogier [14] focused on auricular representation of the musculoskeletal body because a distinctive correspondence could be confirmed between anatomical areas of myofascial tension and specific regions of tenderness on the external ear. The somatotopic relationship of specific points on the auricle to specific areas of the musculoskeletal body is depicted in Fig. 5. The cervical vertebrae are represented on the central side of the antihelix tail, the thoracic vertebrae are represented on the central side of the antihelix body, and the lumbo-sacral vertebrae are represented on the top of the inferior crus of the antihelix. This particular pattern first reported by Nogier in 1957 is a slightly different configuration than the vertebral arrangement shown in many Chinese ear acupuncture charts [14]. With re-

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Inverted Somatotopic Pattern Foot Leg Hand Arm Lower Back Upper Back Neck Head Face Fig. 5. Location of musculoskeletal points on the auricle.

gard to auriculotherapy of the musculoskeletal system, the European system seems to be more accurate for the alleviation of neck tension, back pain, and muscle tension. The posterior groove behind each level of the antihelix is stimulated to reduce myofascial pain from localized muscle spasms. Osteopathic physicians, chiropractic doctors, and physical therapists have reported that auriculotherapy stimulation applied before or after spinal adjustments can significantly improve the clinical effectiveness of their treatments by reducing muscles spasms [19]. Auricular representation of the head and face is located toward the bottom of the ear, on the antitragus and the lobe. The occiput is appropriately represented on the antitragus region adjacent to the lowest portion of the antihelix tail that corresponds to the upper cervical spine. Toward the middle of the antitragus is found the auricular microsystem point for the temples, whereas toward the base of the antitragus, near the intertragic notch, is the forehead point. The most reactive of these antitragus auricular points is utilized to treat both tension headaches and migraines. At the junction of the upper regions of the ear lobe and the lower sections of the scaphoid fossa is found the TMJ point, for relief of tight and tense muscles of the lower jaw and upper jaw. Figure 5 also shows the similarities and differences between the Chinese and the European systems of ear acupuncture for auricular representation of the lower extremities. In Chinese auricular charts, the hip, knee,

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ankle and foot are represented in an upside down perspective on the superior crus of the antihelix. The somatotopic presentation of these same leg points in the Nogier system are also found in an inverted orientation, but they are located in the triangular fossa. For some people, the Chinese leg points most accurately correspond to auricular representation of their hip, knee, or foot problems, while for other patients with lower extremity problems, greater tenderness and electrical activity is found on auricular points in the triangular fossa. As with vertebral points, stimulation of the posterior side of the triangular fossa and the superior crus also serves to enhance the relief of myofascial pain in the legs or feet. There is no discrepancy between European and Chinese ear charts which indicate auricular representation of the upper extremities. Treatment of shoulder problems is achieved by stimulation of a point in the scaphoid fossa peripheral to point zero. The shoulder point is logically located next to the junction of auricular representation of the cervical spine and the thoracic spine. Since the somatotopic system on the ear is an inverted orientation, the elbow point is found in the region of the scaphoid fossa above the shoulder point, and as one ascends higher in the scaphoid fossa, one arrives at the wrist point and above that are several points for the fingers. Both the front and the back side of the ear are stimulated to relieve tennis elbow, carpal tunnel syndrome, and arthritic pain in the fingers. In addition to auricular points for the arms and legs, Fig. 5 indicates areas on the external ear which are utilized to treat sensory dysfunctions related to the eyes, nose, and inner ears.

10. Auricular representation of internal organs Visceral organs derived from endodermal embryological tissue are found in the central valley of the auricle, the concha. Intriguingly, the autonomic vagus nerve which regulates internal organs only reaches the superficial skin in the region of the concha of the ear. All of the digestive and thoracic internal organs are illustrated in figure 6. Near the opening to the actual auditory canal is the opening to the digestive system, the mouth. It is found in the inferior concha, below the helix root. The esophagus point extends peripherally from the auditory canal, and is used in the treatment of esophageal spasms. Of all the gastro-intestinal auricular points, the point for the stomach is the most frequently used in auricular treatment plans. Located

on the concha ridge, just peripheral to point zero, the stomach point is used to alleviate stomach aches, nausea, vomiting, ulcers, and weight control problems. As noted before, Shiraishi et al. [37] demonstrated that stimulation of the auricular stomach point in animals affects neuronal firing rates in the neuro-vegetative hypothalamus. In the superior concha is found auricular representation of the duodenum, the small intestines, and the large intestines. In Chinese auricular acupuncture, the ear points for the stomach, small intestines, and large intestines are also said to connect to the energetic meridians of the same name. Stimulation of these points could thus relieve physiological dysfunctions of each organ, such as diarrhea or constipation, or they could alter the energetic function of the corresponding yang meridian. The auricular point for the rectum is found on the helix root and is used for problems of rectal pain. The five element theory of traditional Oriental medicine suggests that five yin organs affect problems of energetic constitution other than the known physiological function of that organ. The kidney auricular point is related to bone problems, hearing disorders, and urinary dysfunctions, the liver point can affect tendon and ligament sprains as well as hepatitis, the spleen point can reduce muscle spasms as well as lymphatic disorders. The lung point is said to affect respiratory problems, yet it also is used to treat skin disorders and drug detoxification. The auricular point for the heart in Chinese charts is found at the very center of the inferior concha, in the deepest region of the concha floor. This point is used to treat angina pain, hypertension, heart palpitations, and anxiety. Surrounding the heart point are the auricular points for the lungs, which the Chinese further differentiated into lung 1, lung 2, and bronchi ear points. All these lung points are utilized to alleviate respiratory problems, but lung 1 and lung 2 are also the principal ear points included in auricular acupuncture treatment of substance abuse. On Fig. 6 is indicated the ear acupoint representing the liver. It is located on the concha ridge, peripheral to the stomach point. Below the liver point, in the inferior concha of the left ear, is the Chinese location for the spleen point, whereas the European location for the spleen is on the left superior concha, but above the liver point. In the superior concha of the right ear is auricular representation of the gall bladder. Nearby, the pancreas is represented in the superior concha. Urogential organs are found on the external ear in either the superior concha below the inferior crus of the antihelix, or in the internal helix on the underside of the


Internal Digestive and Thoracic Organs Uterus .C

59

Auricular Neuro - Endocrine Points Sciatic Nerve

Bladder Kidney .C

Kidney .E Heart .E Large Intestines Small Intestines Rectum Stomach

Spleen .E

Mouth

Liver Spleen .C Lung 1

.E = European Point

Lumbo Sacral Spinal Cord

Pancreas

Esophagus Bronchi .C = Chinese Point

Adrenal Gland .E

Heart .C Lung 2

Ovaries & Testes Vagus Nerve Adrenal Gland .C Pineal Gland Pituitary Gland Frontal Cortex

Fig. 6. Location of internal organ points on the auricle.

helix root. The Chinese auricular points representing the kidneys are found in the upper regions of the peripheral superior concha. This ear point is frequently used to alleviate bone fractures, back pain, and hearing disorders as well as kidney dysfunctions. Nogier, however, depicted the kidney on the internal helix region of the auricle that is near the triangular fossa. Both Chinese and French practitioners localize the auricular bladder point to that region of the superior crus below the midpoint of the inferior crus of the antihelix. One of the most frequently used points for female related disorders is the Chinese location for the uterus. This rather amazing point has been successfully used for alleviating pre-menstrual syndrome, menopausal problems, and even infertility. In ancient China, this region of the ear was alluded to as the forbidden zone, since it purportedly lead to abortions in pregnant women. The European representation of the uterus is on the internal helix, below the region of the ear which represents the kidney. The helix root, which is on the external surface of the auricle, is said to be the location where the genitals are stimulated, whereas the underlying internal helix crus corresponds to the internal genitals. All of these genital points have been reported to alleviate impotency and genital pain. 11. Neuro-endocrine points on the ear The master endocrine point in the wall of the intertragic notch has already been described as the region of

Thymus Gland Thoracic Spinal Cord Thyroid Gland Cervical Spinal Cord Brain Stem Occipital Cortex Temporal Cortex Trigeminal Nerve Parietal Cortex

Fig. 7. Location of neuro-endocrine points on the auricle.

the external ear used to treat hormonal imbalances. On auricular areas nearby the intertragic notch are found points which represent pituitary control of the adrenal gland, the thyroid gland, and the gonads. At the bottom of the tragus is represented the pineal gland, which affects melatonin release and daily circadian rhythms. These auricular points are shown in Fig. 7. The rest of the endocrine glands are represented on the concha wall, adjacent to the antihelix areas which represent the vertebral regions of the body where those glands are found. The thyroid gland in the neck is represented on the ear near the antihelix tail that represents the neck. The thymus gland in the chest is represented on the antihelix body, that represents the thoracic vertebra. Finally, the adrenal gland is represented near the inferior crus, the auricular region that corresponds to the lumbar vertebra. The ovaries and testes are represented on the internal helix underneath the helix root region that represents the external genitals. Stimulation of each endocrine point would lead to a balance of hyperactive or hypoactive hormone release by the corresponding endocrine gland. Ear acupuncture points corresponding to the peripheral nervous system are found on loci all over the external ear, while the ectodermal central nervous system points are found on the outer rim of the auricle. The most commonly utilized auricular points for peripheral nerves are points for the sciatic nerve on the inferior crus, the vagus nerve on the inferior concha, and

60


the trigeminal nerve on the peripheral ear lobe. These points are respectively used for alleviating pain problems associated with sciatic neuralgia, autonomic dysfunctions, and trigeminal neuralgia. Peripheral neuropathies are treated by stimulating the corresponding auricular area where that body area is represented, and by stimulating the origin of the spinal nerves projecting to that body area, represented on the helix tail. The lumbo-sacral spinal cord is represented on the upper helix tail, the cervical spinal cord is represented on the lower helix tail, and the thoracic spinal cord is found in between. The ear lobe corresponds to the different lobes of the cerebral cortex, again in an inverted orientation. The motor frontal lobe is represented on the central part of the lobe, near the head, while the somatosensory parietal cortex, auditory temporal cortex, and visual occipital cortex are represented on more peripheral regions of the lobe. These cortical points are used to treat neurological disorders related to each respective cortex.

12. Auriculotherapy treatment applications Traditional acupuncturists activate body and ear acupoints through the insertion of needles into specific areas of the skin. With auriculotherapy, transcutaneous electrical stimulation as well as needle insertion are both effective in achieving beneficial clinical results [59]. Various electrical stimulation devices have been developed which first detect the precise location of a reactive reflex point on the skin of the external ear. A button on these same detecting probes is then used to electrically stimulate that auricular point. Because ear acupuncture points are found in the thin layer of skin that overlies the cartilaginous curves of the auricle, shallow penetration of the microcurrent stimulation is sufficient to activate the nervous receptors at that ear point. This auricular stimulation is believed to send impulses to the brain, which then has the capacity to correct neural function of the corresponding body area where there is pathology. Brief electrical stimulation of the appropriate ear reflex point can yield alleviation of pain and an increase in physical range of motion within a few minutes of the treatment. It is important to first identify the most electrically conductive ear reflex point with an electrical point finder, and then apply stimulation to both the anterior and the posterior surfaces of the reactive ear point. Somatotopic auricular charts indicate the specific areas of the auricle that have been found to correspond

to specific areas of the body. These auricular points are identified in individual patients by their electrical conductivity, by their tenderness to applied palpation, and by changes in the coloration and morphology of the skin at that region. Although some electrical stimulators apply a uniform stimulation frequency for all areas of the auricle, other stimulators utilize the frequency system first proposed by Dr. Nogier [14]. A frequency of 5 Hz is applied to the stimulation of concha points that represent internal organs and 10 Hz is applied to areas of the auricle corresponding to musculoskeletal disorders that are represented along the antihelix, antitragus, scaphoid fossa, and triangular fossa [59]. Higher frequencies of stimulation are used for areas of the auricle that represent neurological tissue. Spinal cord neuralgias represented on the helix tail are stimulated with 40 Hz, subcortical brain areas on the antitragus region are stimulated with 80 Hz, and cerebral cortex areas on the ear lobe are stimulated with 160 Hz. The treatment of the oscillation point on the subtragus is used to alleviate imbalances in the activity of the left and right cerebral hemispheres. Selective stimulation of specific regions of the auricle can facilitate neuromuscular regulation of overly excited spinal reflexes that cause pain and muscle spasms and rehabilitation of deficient neural reflexes that produce tremors.

13. Conclusions There is not yet the sufficient scientific evidence that would allow one to readily accept the validity of the neurological explanations of the auricular acupuncture system which has been described. It may seem too implausible that such a simple concept as the inverted fetus perspective represented on the external ear could selectively alter the brain activity in order to alleviate pain in different parts of the body. Nonetheless, practitioners of this approach have repeatedly observed that specific areas of the auricle are more sensitive to pressure and more electrically active in a predictable, somatotopic pattern that was first described by Paul Nogier in the 1950’s. Activation of these reactive ear points with either inserted needles or with transcutaneous electrical stimulation has been repeatedly found to alleviate physical symptoms of pain and tension in the corresponding part of the body. The clinical use of auricular acupuncture for the relief of chronic pain and the treatment of substance abuse is expanding in Europe, China, and the United States. The observations that neurological reflexes could connect distant regions


of the body to a somatotopic microsystem on the ear suggest that a whole new type of neuronal organization is available that has not yet been fully understood, nor fully utilized, by the health care profession.

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