Case Study

The second case was a male patient aged 57 who drove on average 4-5000 km a month, smoked cigarettes and had a persistently disorderly lifestyle. One month before I saw him he started to suffer from moderate neck pain with some radiation to both arms. A first ECG was negative and the patient's family doctor prescribed nimesulide and benzodiazepines. With the analgesic medication the remission of pain lasted only 6 hours. Examining the patient's neck I found a stiffness which he also associated with a whiplash he had suffered a few years before. On inspection of the left ear I noticed an incisure of the anthelix and with PPT I found three tender points which could be associated with a cervical-brachial syndrome (Fig. 5.41, red points); however, ear acupuncture and manipulation of the cervical-thoracic tract of the spine did not yield satisfactory

Fig. 5.41 Tender points detected with PPT in a male patient aged 57, associated at first with a cervical-brachial syndrome (red), afterwards with myocardial ischemia (gray).

sensitization in subjects with hypertension and on medication for lowering blood pressure. The set of areas proposed by Chinese authors for treating hypertension represents another puzzle of difficult interpretation (see Fig. A1.8). Beyond the obvious heart area of the medial surface and the nearby groove for lowering blood pressure, we may also find related to hypertension the liver (CO12 gan): the expert in TCM will probably cite on this subject some typical syndromes such as 'Liver raising Yang' or 'Liver fire'.

A further area associated with this kind of dysfunction to remember is 'Liver Yang' of the early Chinese ear acupuncture authors, carrying the indications hypertension, headache and dizziness, which was located on Darwin's tubercle. These indications were left unchanged in the standardized version but the area was renamed node (HX8 jiejie). Moreover, the indication for high blood pressure was also summed to tonsillitis for the whole portion of the helix including areas

1-4. The other areas to mention are the superior triangular fossa (TF1 jiaowoshang), the ear apex and the antitragus apex; another point which has been left out of the standardized version is the point for lowering blood pressure gaoxueyadian, within area TG2, which is curiously very near to the adrenal gland shenshangxian carrying the opposite indication for increasing blood pressure (see Fig. A1.6). These apparently discordant indications, already cited in Chapter 4, may perhaps indicate one of the important sites related to the complex mechanisms regulating blood pressure.

I tried to make my contribution to the identification of some recurrent areas associated with hypertension by examining a group of 26 patients (17 females and 9 males, average age 53.2 years) in whom a hypertensive condition was found incidentally: none were taking drugs for lowering blood pressure or other medications such as analgesics or benzodiazepines which could affect correct identification of the points (see Ch. 9). I made two measurements at least 5 minutes apart and if there was a discrepancy of more than 10 mmHg I performed a third reading: systolic pressure averaged 182 mmHg and diastolic 99 mmHg. An ECG and blood tests including creatinine, electrolytes, glucose and cholesterol were then carried out on each patient, as well as PPT: four subjects did not show any tender point whereas the others showed an average of 5.9 points which were mainly concentrated on sectors 1, 2, 39 and 40. Indeed, 60% of the tender points were concentrated on the rim of the lower part of the tragus and on the hidden part of the intertragic notch, at the junction with the floor of the external auditory canal (Fig. 5.42). Other minor areas were the heart area, especially in those patients who showed an initial cardiac overload, and a further area, of uncertain significance, aligned with the former on the ear lobe. I found a minor concentration of points (only 8.5% of the total) on the Chinese groove for lowering blood pressure, therefore I am not able to confirm the importance of this area. I made a regression line for each patient between the number of tender points and the respective level of systolic and diastolic pressure. I was surprised to obtain quite different results as the coefficient R was very low in the case of systolic pressure and P was not significant; instead, in the case of diastolic pressure I obtained an R = 0.582 and a P<0.005. These findings have in my opinion a double value for the practitioner: first that especially higher levels of diastolic pressure tend

Fig. 5.42 Sensitized areas in 26 new, still untreated, hypertensive patients. Red areas = lateral surface; blank area = medial surface.

to sensitize the auricles; second that the persistent tenderness of some auricular points, despite the intake of antihypertensive drugs, is a possible sign of a non-optimal strategy for lowering blood pressure.

Convergent results have been obtained in a pilot study still in progress conducted by general practitioners Rosaria Di Noia and Giuseppina Facendola, examining the auricles of two groups of 20 subjects each: one with hypertension already in treatment with various classes of drugs; the other without hypertension representing the control group. The first physician records heart rate and blood pressure three times 5 minutes apart in all subjects; the second physician blindly identifies their active points with ESRT and PPT. The first results show that systolic and diastolic pressure do not present significant differences between the two groups (average 131 and 76.1 mmHg in the hypertension group vs. 123 and 72.6 in the control group). This is of course a good result for the general practitioner, indicating an effective control of the patient's hypertension with the medication prescribed. The groups, however, are not homogeneous with regard to the number of points identified with ESRT and PPT: there are no differences between them in the total number of tender points; with ESRT, however, sectors 1, 2 and 40 show a significantly higher number of points with a relative low electrical skin resistance (ESR) (P<0.05) in the hypertension group (on the left of Fig. 5.43) than in the control group (on the right of Fig. 5.43).

In addition, sector 23, which apparently seems correlated with the colon, bladder and sciatic nerve, shows a higher number of points. However, if we check the Chinese standardized map we find, within this sector, the area TF1 jiaowoshang on the superior triangular fossa, with the main indication for hypertension.

The convergent results of these observations may point to the importance of the tragus and the intertragic notch representing at least one of the possible mechanisms of primary/essential hypertension which in 90-95% of adults does not show an identifiable cause according to the American Heart Association. It has been estimated that as many as 30% of essential hypertensive patients have a primary neurogenic stimulus contributing to their hypertension.66 In particular, the role of sympathetic neural mechanisms in the pathogenesis of hypertension has been an issue of enduring interest and productive investigation for several years.

Recent studies on humans evaluating sympathetic activity with sophisticated techniques such as the radiolabeled noradrenaline (norepinephrine) technique and the microneurographic quantification of sympathetic nerve traffic have demonstrated the participation of adrenergic mechanisms in the early and late phases of the hypertensive process. Evidence has been provided also that the activation of the sympathetic nervous system is peculiar to the essential hypertensive state, parallels the degree of blood pressure elevation, is triggered by reflex and humoral mechanisms, and may exert deleterious metabolic and cardiovascular effects, accelerating the progression of the end organ damage accompanying hypertension. According to Grassi:67

these findings explain why non-pharmacological and pharmacological approaches to the treatment of hypertension should be aimed not only at lowering elevated blood pressure values but also at exerting sympathetic-inhibitory effects.

Auricular Point Chart

Fig. 5.43 Sectors with significantly higher concentration of points with lower ESR in a group of 20 hypertensive patients under treatment (on the left) compared to a control group of subjects with normal blood pressure (on the right) (unpublished data, with permission of Facendola and Di Noia).

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Fig. 5.43 Sectors with significantly higher concentration of points with lower ESR in a group of 20 hypertensive patients under treatment (on the left) compared to a control group of subjects with normal blood pressure (on the right) (unpublished data, with permission of Facendola and Di Noia).

It is possible, therefore, that the repeated/lasting stimulation of the tragus-intertragic area could have such a regulating effect, provided that the patient is sufficiently motivated to change his lifestyle in terms of losing weight, restricting salt intake and exercising.

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