The pressure pain test

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Introduction 110

The palpation of the auricle 112

What is the significance of a painful point on the ear? 114

What is the average pain threshold for pressure on the auricular points? 114

Are there other techniques for exploring the pinna with the pressure-probe? 115

What is the general distribution of tender points on the outer ear? 115

The role of PPT in identifying areas related to symptoms commonly met in practice: the musculoskeletal system 116

The representation of the lower limb 117 The representation of the thoracolumbar spine 117

The representation of the cervical spine 120 The etiological puzzle of fibromyalgia 122

Psychological/psychiatric areas detected by PPT 124

Introduction 124

Stress response areas 125

Sleep disorder areas 128

Phobic anxiety on the auricle 128

The co-morbidity of anxiety and depression on the auricle 130

Conclusions 134

Headaches and trigeminal neuralgia on the auricle 134

Migraine and tension-type headache (TTH) 134

Trigeminal neuralgia on the ear 136

Allergic conditions on the auricle 138

The puzzle of the representation of ear, nose, eye and teeth on the ear lobe 140

The representation of the ear on the ear 141 The representation of tinnitus on the auricle 143

The representation of the symptom of dizziness on the auricle 143

The representation of the nose on the ear 145 The representation of the eye on the ear 146 The representation of the teeth and the temporomandibular joint 148

The major divergences between Nogier's and the Chinese auricular representation of internal organs 149

The cardiovascular system 149 The representation of the urinary system 155 The representation of the genital system on the ear 156


In his tireless work on the nature of the auricular representation of the body Paul Nogier used a variety of methods to obtain what he called the 'reactional information' of every subject. Both evoked pain in the pinna at palpation and the application of cold and heat were repeatedly used for diagnostic purposes. For example he used the cold test, applying a rod of cold copper on the ant-helix to localize any vertebral blockage. In this case he often found a reduced cold sensation on the representation of the vertebrae concerned which disappeared as soon as the blockage had been corrected with manipulation.

Nogier nevertheless realized that the most readily available technique for determining the reactivity of auricular reflex points was palpation and pressure pain test (PPT) applied to specific areas of the auricle. He wished, however, to approach this topic scientifically, so with his collaborator Bourdiol set up an experiment which is easy to realize and reproduce and which is now part of the history of ear acupuncture1 (Fig. 5.1). The procedure was as follows:

1. The auricular area representing the thumb was first repeatedly tested with the pressure-probe to ensure it was not sensitive.

2. A clamp was placed on the tip of the thumb so that the subject experienced a local sensation of pinching. During the next few minutes the somatotopic area of the thumb became sensitized and one point was hyperalgesic at palpation, while the other areas remained neutral.

3. In the minutes following removal of the clamp, the auricular point lost its tenderness and repeated application of the pressure-probe no longer evoked any pain.

This experiment by Nogier and Bourdiol was repeated by Alimi2 applying functional magnetic resonance imaging (fMRI). The aim of the study was to examine the hypothesis that there are specific neurophysiological connections between ear acupoints and the central nervous system (CNS). A dynamometric clamp was calibrated at 2 kg/ cm2 to induce a nociceptive stimulation of the thumb. To identify the auricular reflex points, instead of the pressure-probe an electronic microvoltmeter (Pointoselect DT+, manufactured by Schwa-medico) was used, selecting the points

Fig. 5.1 Nogier-Bourdiol's historic experiment on evoked pain on the pinna (with permission).

which had a variation of more than 3 SDs from the basic value of the auricular potential for every subject. Five paradigm stimulations were performed and real time fMRI brain signals were recorded in 10 healthy volunteers:

1. at rest

2. during tactile stimulation of the right thumb at a frequency of 2 Hz

3. during tactile stimulation of the right auricular thumb representation identified previously by electrical detection

4. after the insertion of three gold needles to a depth of 3 mm into the right thumb auricular site, without stimulation

5. during mechanical stimulation of the needles at 2 Hz frequency.

The recordings lasted 5 minutes, with alternating periods of stimulation and rest, for 30 seconds each. To avoid any interference between the different signals, there was a 10-minute rest period between every sequence.

The results of Alimi's experiment were that for 9 out of 10 subjects the stimulation of the needles produced a significant MRI signal, superimposed on that obtained by tactile stimulation of the thumb, on the presumed somatotopic projection of the thumb in the S1 somesthesic area. In three subjects recordings were obtained bilaterally; two of them showed the same phenomenon during tactile stimulation of the thumb.

We tried to repeat Alimi's work reintroducing Bourdiol's procedure: the auricular area representing the thumb was tested repeatedly 2 hours before fMRI with the pressure-probe to ensure its insen-sitivity.3 By immediately afterwards applying a dynamometric clamp calibrated at 2 kg/cm2, we identified the most tender point in the thumb area and marked it with ink. The subjects were right-handed healthy volunteers and we chose the left non-dominant thumb for the experiment. The following six recording sequences were carried out:

1. at rest

2. during active movement of the left thumb (Fig. 5.2A)

3. during tactile stimulation of the left thumb at a frequency of 2 Hz (Fig. 5.2B)

4. during the pressure stimulation of the left auricular thumb point with a blunt probe of 1 mm2 (Fig. 5.2C)

5. after the insertion of a titanium semi-permanent ASP needle, without stimulation

6. during the mechanical stimulation of the needle at a frequency of 2 Hz (Fig. 5.2D).

Figure 5.2A shows the activation of motor region

M1 on the contralateral (right) side during sequence

2; Figure 5.2B shows the activation of the primary

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