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This review on auricular acupuncture (AA) represents something of a personal exploration for me. I was reasonably open minded when I attended Paul Nogier's historic course on AA for the BMAS in 1983, summarised by a fine cartoon portrait of the ‘great man’.1 Scepticism grew as this wonderfully charismatic person, his bald pate and long, impressive visage hanging forward over the lecture stand, recounted the birth of auriculotherapy. One day, he was examining an ear at the antihelix where it had been cauterised to treat low back pain; the sun slanted across it, casting into relief the segments of antihelix cartilage at that very spot: Nogier suddenly recognised its similarity to the segments of the lumbar spine—and AA was born. This story of serendipity did not have quite the same ring as Florey's Penicillium mould landing on a bacterial culture on a Petri dish.
Nogier then related how he worked out the correspondence between ear points and body sites (somatotopic representation), in the form of an upside-down fetus, based on patient examination, and one particular interpretation of the ear's innervation. An audience member politely enquired whether he had done any objective testing to confirm the correspondence, such as thyroid blood tests for thyroid points. Regretfully not. Credibility fell further the following day when we learnt that, apparently, the inverted image sometimes did not fit the patient. In which case the body could be upright, ‘phase II’. Or, then again, sometimes it is reversed from left to right, ‘phase III’. But there was no way of telling which one to apply when.
Over the years since that event, I gradually came to believe that the AA story is half right: there is not much evidence (from anatomy, or from clinical studies) in support of any correspondence between ear points and parts of the body; but the ear is richly innervated, so stimulating it produces a strong impact on the brain which could be clinically useful, for example for analgesia and relaxation. The evidence from clinical trials is far from conclusive—but then, they are generally designed using the concept of the correspondence idea, and the control points are supposed to be ‘incorrect’ for the condition. They might be expected to fail, unless the correspondence idea is correct after all.
Having recently been accused of being biased against AA, I took the opportunity to look more closely at four textbooks of AA that I had recently been sent (or in one case, paid good money for), particularly looking for arguments and evidence for the correspondence idea.
Ear Acupuncture – A Practical Guide
By Kajsa Landgren. Published by Churchill Livingstone/Elsevier. English edition 2008. Hardback, 232 pages. ISBN 9780443068997.
The great strength of Kajsa Landgren's book is her beautifully clear writing style, a fine example for all medical textbooks. Her book is exactly what it says—a practical guide—and makes no attempt to present or discuss the evidence, but simply describes the state of the art. If you want to know how to start treating patients, everything you might ever need is clearly laid out and readily accessible, with helpful chapter titles, perfect subheadings and lovely pictures and legends. She emphasises the concept of the ‘reflex’ response, emphasising the importance of examination by the three methods of inspection, palpation and electrical detection to find the point rather than relying solely on maps of correspondences. It is somewhat ironic that the most widespread use of AA in the world—namely, the National Acupuncture Detoxification Association (NADA) technique for drug dependence, contradicts this principle.
If you want a practical book that you can easily read in bed at night and use as a source of reference, this could hardly be bettered. It will not provide you with the references to introduce the scientific literature and there may be better sources for understanding acupuncture neurophysiology or research methodology. You may want to reserve a little scepticism for the advice to use points on the outer surface of the pinna for a patient's pain and those at the back of the pinna for their tension. But the beauty of this book is that it will start you off and see you through treating a wide range of conditions, if you are happy to follow the instructions without question.
Auricular Acupuncture Diagnosis
By Marco Romoli. Published by Churchill Livingstone/Elsevier. 2010. Hardback, 301 pages. ISBN 9780443068669
Marco Romoli's book is for the serious student and devotee. This is an erudite, detailed and well-referenced text that gives the author's own fresh view on the conventional French and Chinese approaches, a view based on his unique personal voyage of exploration over more than 20 years of clinical practice using AA alongside conventional medicine. He includes many clear and remarkable case histories, and this richly illustrated book is the product of a happy combination of devotion, enquiry and authority.
Each of these books offers its own particular novel facts about the story of ear treatment. Romoli's contributions are that the ear was cauterised as treatment as far back as the 17th century, including by Valsalva—he of the manoeuvre; that Nogier would never accept the logic for the point Shenmen; and that anthroposophic doctors still use the auricle as a form of physiognomy to identify health problems. Romoli is an original thinker. He criticises the manufacturers of electrical diagnostic devices for not releasing their technical details, and then works hard to optimise the method for using them reliably.
Romoli developed a systematic way of recording points by overlaying a transparent, compass-like ‘sectogram’ over the auricle. He has conducted countless observational studies with it, few previously published. For example, he recorded the correlation between age and the number of skin changes in 711 patients; recorded the distribution of active points in 102 patients with headache, 175 patients awaiting gastroscopy (82% accurate) and skin changes in 311 patients with various forms of scoliosis (p<0.05); he showed that the number of active points correlates with anxiety scores; and he reviews the surprisingly extensive literature on the association of the oblique ear lobe crease with coronary heart disease—which is positive.
One chapter by a guest author is devoted to the anatomy, embryology and neurophysiology, so I scrutinised it for evidence of a neurological basis for the correspondences. Only at the very end did I find his sad conclusion: ‘no scientific arguments can be found for the cartography proposed …’
So what is Romoli's ‘bottom line’? The proper application of AA involves learning how to find the points for each patient by examination—note his title is all about diagnosis. This is the only one of these four books that does not give a long list of conditions with the points used to treat them. He believes that the correspondences between points and organs are variable and unreliable. He recommends his needle contact test, in which the needle is placed on each point in turn to find the location that best relieves the pain. He admits there is still much work to be done on AA, but in his long experience he believes it can benefit patients with pain or psychosomatic disorders, and those undergoing rehabilitation.
Principles of Ear Acupuncture – Microsystem of the Auricle
By Axel Rubach. Published by Thieme. English Translation 2001. Hardback, 2678 pages plus CD ROM. ISBN 0865779376.
Axel Rubach's book developed from the lecture notes of the standard course of German Society of Physicians for Acupuncture, and is therefore presented in a systematic and progressive sequence of introduction, anatomy, description of the points (60 pages), followed by ‘Practical tutorials’ illustrating the method. The tutorials finish with a 60-page reference list of conditions and their standard treatment. So this book teaches the conventional approach, and one that is largely based on a traditional Chinese medicine diagnosis.
Rubach's particular contribution to the story of AA is that the correspondences are clearly shown in an ear depicted in The Garden of Lust, a painting by Hieronymus Bosch (1450–1516)!
This book is commonsense and safe. It is mostly, but not entirely, conventional. It differs from the other three books with one very clear statement: ‘Do not in any circumstances needle areas of altered skin’. Rubach does not discuss the reason for this, though presumably he has seen some adverse events such as bleeding or infection. He gives clear descriptions of the Chinese and French systems of point notation and the current method of Oleson. He also describes the ‘Very Point’ technique in which the skin in stroked and tapped delicately to locate the most sensitive point precisely. He presents a useful, if brief, decision path for choosing AA treatment, including the fact that it is more useful for acute than chronic conditions. And he is (uniquely) very clear indeed that the NADA technique for alcohol and drug dependence should be used only as support for other interventions.
Auriculotherapy Manual – Chinese and Western Systems of Ear Acupuncture
By Terry Oleson. Published by Churchill Livingstone/Elsevier. 3rd Edition 2003. Hardback 359 pages. ISBN 0443071624.
Terry Oleson's classic text is a manual, encyclopaedia and reference volume rolled into one. Oleson trained as a psychologist and became involved in acupuncture by a chance meeting at his university. Being of an enquiring mind, he set up the blinded test of correlations of musculoskeletal problems which was published in 1980 and is now a classic. He himself was surprised by the positive result.2
Oleson has an enquiring mind that constantly challenges accepted dogma—highly respectful of Nogier, but not afraid to contradict him where he thinks it necessary. After an introductory chapter, there follows a wide overview setting the context of microsystems and traditional and ayurvedic medicine. He then moves on to the neurophysiology of pain and a useful summary of research into the analgesic effects of AA. The chapter ends with an important section on the innervation of the auricle and its supposed relationship to embryological development. I read and re-read this carefully looking for an explanation of the correspondences—but we are asked to accept much of the explanation on trust, rather than being given supporting references. This is in marked contrast to the remainder of the book which is extremely well supported by references.
Oleson spends another couple of chapters explaining how to identify points by their relation to ‘landmarks’ or the ‘zones’ used in WHO charts and his own. The detail is fantastic, but I wonder whether many students will learn the precise locations that are suppose to correlate, for example, with the red nucleus, the substantia nigra and the striatum?
Chapters 5 and 6 are the meat of the book for the practitioner, describing clearly first how to diagnose patients using appearance, tenderness and electrical resistance, as well as Nogier's vascular autonomic signal, and then how to treat these points with various techniques. Chapter 7—almost a hundred pages on its own—is a reference text for all points and their corresponding parts of the body, once again in great detail. There follows a chapter on fascinating case histories and admirably he includes some cases where treatment failed, giving him the opportunity to discuss the reasons—mainly because chronic pathology is present, emphasising that AA is mainly useful for functional disorders. The final chapter lists a recommended treatment for almost every conceivable medical disorder—from ascites to ‘weather changes’ by way of sunburn! These need to be taken with a grain of salt—ascites seems much more likely to be chronic pathology than a functional disorder. This book is clearly the standard reference text against which all others should be measured. It is hard to beat it for richness of anecdote, science, detailed rationality and lists of references, though it might be over the top for some readers.
Throughout my reading of these books, I have reconsidered my own views, but I admit they have not shifted much. None has provided evidence or argument to convince me of the correspondences: in the absence of a known neurological basis they are an exceptional claim, and so need exceptional evidence, which is not there yet. There are plenty of consistent clinical anecdotes that combine to suggest strongly that analgesia and relaxation are worth exploring further. It is clear that basic research is needed to replicate and extend Romoli's studies in exploring tender points: Are they consistent over time and between individuals? Do they have an anatomical basis? Do they relate to the patient's status? Is the clinical response better from treating tender points than non-tender ones? The big hurdle, as ever with acupuncture research, is convincing the funding bodies that AA is a serious topic for research.
Provenance and peer review Not commissioned; not externally peer reviewed.
Competing interests none
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