Z

Fig. 5.2 Cerebral activity recorded with fMRI in a 30-year-old female: (A) during active movement of the left thumb; (B) during tactile stimulation of the left thumb; (C) during the pressure stimulation of the left auricular thumb point; (D) during the mechanical stimulation of the needle placed on it. (Courtesy of William Liboni, Gradenigo Hospital, Turin, Italy.)

Fig. 5.2 Cerebral activity recorded with fMRI in a 30-year-old female: (A) during active movement of the left thumb; (B) during tactile stimulation of the left thumb; (C) during the pressure stimulation of the left auricular thumb point; (D) during the mechanical stimulation of the needle placed on it. (Courtesy of William Liboni, Gradenigo Hospital, Turin, Italy.)

somatosensory cortex S1, during sequence 3, on the contralateral but also on the ipsilateral (left) side. The acupressure stimulation of the left auricular thumb point in sequence 4 as well as the mechanical stimulation of the inserted needle in sequence 6 demonstrate that the information is processed in several areas: the right somatosensory S1-S2 and frontal-prefrontal supplementary motor area cortices are activated during acupressure, whereas the ipsilateral primary somatosensory and motor areas are more focally activated during sequence 6.

In our first cases we found that the stimulation of the auricular thumb point produces a more diffused activation than the tactile stimulus or the motion of the thumb. At the present time we find that the insertion of the needle in our cases demonstrates that the information is processed overall on somatosensory areas ipsilaterally or in both hemispheres. Our research is still ongoing and we do not know yet how far our findings will overlap with those of Alimi. Functional MRI does indeed appear to be an interesting method for deeper acquaintance with the reflex activity on the CNS induced by auricular stimulation, but of course the observation of a higher number of cases is necessary.

Palpation of the outer ear can be carried out by anyone. Even the patient can learn to find the sensitive points of his auricle easily and massage them for relieving, for example, musculoskeletal pain.

Palpation can be carried out with the patient lying down, which is the ideal position for inducing maximum relaxation; it can also be done with the patient in the sitting or standing position. For all these positions it is best if the therapist places himself behind the patient and presses both ears simultaneously and symmetrically between the thumb and the index finger. The therapist should regulate the pressure according to the patient's sensitivity: certain people react only to strong pinching, whereas others react to the slightest compression. The whole pinna should be explored, taking care to follow all of the cartilaginous irregularities. When such investigation is rendered impossible through the anatomy, for example at the level of the concha, one may press bilaterally with the index fingers, being careful to do this in an identical fashion.

Identifying a painful point at palpation is a good start in the examination of a patient but there are several aspects to be considered before proposing a diagnostic hypothesis. The first issue to clarify is the exact meaning of the identified area: for example we do not know if the area is the expression of an acute problem or of a chronic, recurrent disorder. Another possibility is that the painful point could represent a symptom hitherto not manifested.

Sometimes a persistent sensitivity of the auricle may indicate a functional disorder: in this case it is important to verify possible tenderness of the auricular zones such as the concha, the incisura intertragica, the ear lobe, etc. which are more often related to visceral, endocrinal and psychosomatic disorders. It is obvious that Chinese acupuncturists give a lot of importance to these areas since traditional Chinese medicine (TCM) is able to reveal dysfunctions before they manifest.

Another important aspect is the variability in the number of detected areas and their relation to the tender points of the auricle to which to apply therapy. The number of painful points identified by thumb and index finger palpation is very variable and depends on several factors such as the general sensitivity of the subject, the number of symptoms and districts involved, the intake of drugs, etc. I examined 92 consecutive patients from my general practice and randomly alternated palpation and the PPT with a commercially available pressure-probe of 250 g maximal pressure (Sedate-lec). The reason for the random application was to exclude any possible mutual interference between the two methods. The number of painful areas, however, ranged from 0 to 21 (average 5.1) but was not significantly different from the average of tender points (average 5.7). Each area could contain from 1 to 4 sensitive points, but what is interesting in my research is that only in 55.7% of the identified areas could I isolate at least 1 tender point.

The meaning of this observation is that for every case the therapist should try to localize the points hidden in each tender area at palpation; however, in about half of the cases he will not detect any point at all. It is possible, however, that a repeated examination of the area with the pressure-probe or the application of an instrument with higher maximal pressure (for example 400 g) may finally detect one or more tender points.

THE PALPATION OF THE AURICLE

CASE STUDY

A 37-year-old female patient came for examination because she had been suffering with persistent headache of the frontal and nuchal region for a week. She was in her 20th week of pregnancy and did not wish to take any painkillers. She had never suffered from migraine before nor had any member of her family. The palpation of her auricles evidenced in total nine tender areas, three on the right (A) and six on the left (B) (Fig. 5.3). Four of these areas hid a tender point: three of them were directly related to her pain syndrome; the fourth, on the left stomach area, was included into treatment because she had suffered frequently with dyspepsia, both before and during pregnancy. Her pain score was 7 on the verbal numeric scale (VNS) at the beginning, and dropped to 4 after treatment, but a further point was needed (see arrow) for the pain to disappear.

As regards the areas which did not hide any tender point, I interpreted these as important, but less important with respect to the current pain syndrome. The two left areas of the right ear were correlated with the period of anxiety and worry experienced by the patient in relation to problems at work and especially with her husband's health problems: he had undergone a heart operation some months before. The spleen area (or alternatively the area of Nogier's sympathetic cervical ganglia) was also correlated with the patient's emotional problems: indeed her pulse frequency was 95-100/m. The last areas to interpret were those of the large intestine and hemorrhoids on the left helix which I correlated with her current constipation and a tendency to piles which was undemonstrated but possibly associated with pregnancy.

Fig. 5.3 Tender areas and points identified in a 37-year-old female, with, respectively, the thumb-index finger technique (circles) and pressure-probe of 250 g maximal pressure (dots). The arrow indicates a tender point on the internal (hidden) border of the antitragus.

WHAT IS THE SIGNIFICANCE OF A PAINFUL POINT ON THE EAR?

This question is not easy to answer since there are several confounding factors which may influence the tenderness of the auricle. Nevertheless we can assume that a healthy person, well balanced from the psychophysical point of view, shows a reduced number of tender points at PPT. We cannot, on the other hand, accept the reverse statement, since there are people who in certain circumstances, or for particular diseases, demonstrate a negative auricle.

Another confounding factor may be related to the normal functions of the body. Portnov, for example, observed that in 90% of healthy subjects the bladder point was sensitive. It was, however, sufficient to invite these people to empty their bladders to see an evident reduction of this tenderness.4

A further example is Bourdiol's1 observation of a variation in auricular reactivity during digestion; in the hours following ingestion of food he was able to describe the auricular areas sensitized subsequently by the digestive process such as stomach, duodenum, gallbladder, liver, etc.

To verify the hypothesis that a healthy subject has a lower number of points compared to other subjects with any type of disorder, I examined a consecutive group of patients attending my general practice. My aim was to find a possible association between the presence of sensitive points and the scoring of the General Health Questionnaire (GHQ), developed by Goldberg for the screening of minor mental disorders in the field of general and community medicine. It is an easily understandable questionnaire, validated in several languages, which proposes a series of questions on general health during the preceding weeks. A significant correlation was found between the intensity of the health disorder and the GHQ scores.5,6

I examined 121 consecutive subjects of my practice with the reduced form of GHQ (30 items) and I obtained a significant regression line between the number of tender points and the GHQ score (Fig. 5.4). We may therefore assume that a tender point does not indicate only the suffering of the corresponding structure of the body, but more generally a psychophysical indisposition which may be only slightly expressed.

WHAT IS THE AVERAGE PAIN THRESHOLD FOR PRESSURE ON THE AURICULAR POINTS?

So far, a systematic study of the pain threshold of the different parts of the ear has never been carried out. One reason is perhaps that a consensus has

GHQ scoring

Fig. 5.4 Regression line between GHQ scoring and the number of auricular tender points in 121 consecutive subjects.

never been reached on the methods to measure the degree of sensitivity felt when pressure is applied. Probably the simplest way is to ask the patient to indicate the point which is especially tender with either 'Now' or 'There'. Alternatively, we could use the same range of numerical or verbal responses used by Oleson in his historical article on auricular diagnosis (see Fig. 9.1). He proposed a score of 1-4: 1 for low-level tenderness; 2 for medium-level tenderness; 3 for high-level tenderness; and 4 for extremely high-level tenderness. It is also worth noting the behavior of the patient reacting to the application of the pressure-probe by knitting his brows or demonstrating the well-known 'grimace sign' described by Nogier.

As regards the pressure-probe invented by Nogier, this was composed of a small piston with a cross-section of 1 mm2 attached to a standardized spring. Practitioners consistently use pressure-probes which exert an intermediate pressure such as 250 g and try to apply them on the majority of the ears they examine. That means that in the case of a particularly sensitive person they will apply half or less than half of the pressure allowed by the instrument, whereas in patients with a high threshold they will probably unconsciously add more than 250 g of pressure.

I have always been concerned about the issue of how to determine the real sensitivity of auricular points. With this in mind I made a preliminary identification of tender points on 41 unselected consecutive patients with Sedatelec's pressure-probe of 250 g maximal pressure. The points were marked with ink and tested again with a Lutron digital dynamometer (model FG 5000 A) which is able to record a pressure from 0 to 5 kg with a precision of 1%. The tip of the probe was blunt and had the same diameter as the above mentioned probe (about 1 mm).

The points tested were 173 (on average 4.2 per patient). Each of them was retested three times consecutively and the average pressure was retained for comparison. I was rather surprised to find that the average threshold of the points was 468 g, almost double that supplied by the blue 'palpeur' (pressure-probe) which I use regularly in my daily work. The pain threshold was, however, not the same for the different parts of the auricle: the cartilaginous parts in fact showed a higher threshold compared to the non-cartilaginous parts (for example 590 g in the anthelix vs. 385 g in the ear lobe).

The therapist should therefore be aware of this issue and possibly adopt more than one probe, as advised by Nogier himself. For example the complete Sedatelec set is composed of pressure-probes with 130, 400 and 600 g of pressure. It is essential when conducting clinical research to rely on adjusted commercially available instruments rather on self-made pressure-probes.

Another characteristic of the pain threshold of an auricular point is that it may vary when using the probe repeatedly: the threshold usually increases and this reset is probably due to the stimulation provoked by the PPT itself. This phenomenon, which is observable in almost every patient, has also been called 'relativity of tenderness'. In my opinion it is not given sufficient consideration by those conducting clinical research, but may represent an interesting method for selecting points for treatment in a hierarchical order (see section 'Which strategy should be used in selecting points?' in Chapter 10).

ARE THERE OTHER TECHNIQUES FOR EXPLORING THE PINNA WITH THE PRESSURE-PROBE?

Another interesting technique consists of sliding the probe across the skin surface of larger areas of the outer ear. When the tip of the instrument encounters local swellings and cellulite there is a slowdown and sometimes a halt in the sliding movement. Sometimes the area concerned is sufficiently consistent to allow the tip of the probe to jump it. Exactly in these areas one or more sensitive points are hidden which have to be discovered point by point, smoothly and without abruptness, holding the probe perpendicularly to the skin. The combination of sliding-pressure allows the practitioner to save time when he is examining the patient blindly or when the symptoms described by the patient are not clear.

WHAT IS THE GENERAL DISTRIBUTION OF TENDER POINTS ON THE OUTER EAR?

The regular use of the sectogram allows the practitioner to record each patient's location of points from one session to the next.

Since 325 patients examined blindly presented an equivalent number of tender points on the right ear and on the left ear (average 4.2 and 4.4), it would be natural to expect too a fairly equal distribution of points on both ears. This was not the case in my group of patients. Cluster analysis showed an asymmetrical distribution with a larger number of sectors of high value on the left ear (Fig. 5.5).

These asymmetries, which also emerge when applying electrical detection methods, seem to have different origins: the higher concentration of points on the craniocervical area of the body (sectors 5 and 8-11) and on the thoracolumbar area (17-19) may be explained by the relevant number of people who say they have suffered backache and neck pain at least once in their life.

Another hypothesis is that these sectors could correspond to dysfunctions of the autonomic nervous system (ANS) which constantly accompany several health disorders. Even if the ANS seems homogeneously spread out on the whole body we can suppose that some parts of it have a major representation on the auricle, such as the cranial para-sympathetic and the cervical sympathetic systems on sectors 5-11 and the abdominal sympathetic system, also called 'abdominal brain', on sectors 17-19.

The larger number of sectors of high value on the left ear may indicate lateralization phenomena possibly associated with the laterality of cerebral functions of the human brain such as language, handedness, etc. (see Ch. 9).

THE ROLE OF PPT IN IDENTIFYING AREAS RELATED TO SYMPTOMS COMMONLY MET IN PRACTICE: THE MUSCULOSKELETAL SYSTEM

My diagnostic work throughout this chapter is not aiming to replace the existing maps but rather to help the practitioner to detect in every patient the most sensitive points related to his ailments. Mus-culoskeletal pain disorders are ranked first because they account for 32.7% of the total symptoms identified in my group of 506 patients.

16

15

14

13

12

Fig. 5.5 Distribution of tender points and sectors of high value in 325 patients.

16

15

14

13

W /\

12

There are some important issues which have not yet been fully resolved, for example the different representations of the lower limb and the 'shorter' representation of the lumbar and cervical tract of the spine.

THE REPRESENTATION OF THE LOWER LIMB

The experienced acupuncturist knows very well that the representation of the lower limb is quite different in the French and the Chinese schools of thought. The Russian school, represented by Ruben Durynian, agreed with the Chinese and located the lower limb on the upper branch of the anthelix. The French map shows clearly that the lower and upper limb are separated by a neutral area, whereas on the Chinese map they are represented as being close together. The latter somatoto-pic arrangement is very similar indeed to that drawn by Bachmann in the first historical map of the ear (see Fig. 1.9). Some other drawn parts coincide with the later Chinese map, as for example the toe (AH2 zhi), whereas others coincide with the later French map, such as the heel; the knee was, however, reproduced on the boundary line between the fossa triangularis and the anthelix.

I would also like to direct the reader's attention to some other somatic areas of Bachmann's drawing which were faithfully reproduced on the standardized Chinese map, such as shoulder (SF4 and SF5 jian), clavicle (SF6 suogu), abdomen (AH8 fu) and chest (AH10 xiong) (see Fig. A1.2).

I made my contribution to the question of the representations of the lower limb by identifying the tender points using a pressure-probe of 250 g on selected patients affected by pain disorders on the different parts of the lower limb. Figure 5.6 shows the tender areas related to heavy coxarthro-sis (nine cases), knee sprain (10 cases), ankle sprain (10 cases) and toe pain of traumatic origin (12 cases). As can be seen, the distribution of tender points, even in such small groups of patients, allows the identification of some partially overlapping areas which extend themselves from the fork of the upper and lower branch of the anthelix to the internal border of the helix. The axis of orientation of these areas lies in the middle, between the Chinese and French representations of the lower limb: it is possible therefore that both representations are valid, but also that the point to treat for a specific disorder needs to be identified case by

Fig. 5.6 Representation of some parts of the lower limb affected by painful disorders: a = osteoarthritis of the hip joint; b = knee sprain; c = ankle sprain; d = toe pain of traumatic origin.

case. Another possibility, however, is that different parts of the anatomical structure represented on the ear may have a different topography coinciding more with one map than with the other. This hypothesis was forwarded by Caterina Fresi using the needle contact test (NCT) for identifying the origin of knee and ankle pain. From her study it is possible that a knee pain caused by the injury of the medial capsule-ligament complex may sensitize sectors 21 and 22, whereas a disorder of the lateral complex may sensitize sectors 20 and 21. In a similar way a lesion of the medial malleolus of the ankle may correspond to sector 22, whereas the lateral malleolus appears to be represented more on sector 21 (see Fig. 8.5).

THE REPRESENTATION OF THE THORACOLUMBAR SPINE

As regards the 'shorter' representation of the thor-acolumbar spine on the Chinese maps, the divergence with Bachmann's reproduction of the spine is still mysterious. The puzzle is that both schools agreed with the representation of sciatic nerve but never reached a consensus on the representation of these parts of the spine. Nogier carried out what is probably the most accurate study, identifying single vertebrae of the thoracolumbar tract, one by one, through his system of radii centered on point 0 (see Fig. 3.19). Chinese acupuncturists, on the other hand, on the maps published before standardization, placed the lumbosacral vertebrae where Nogier located the thoracic tract of the spine. The neurophysiologist Durynian reproduced the thoracolumbar spine in his work in a similar way to the Chinese maps. On the standardized map the lumbosacral vertebrae (AH9 yaodizhui) occupy a large area of the anthelix which is separated from the sciatic area by the gluteus area (AH7 tun). This area seems to be a key area for the treatment of every kind of backache, even if Bachmann drew the gluteus point very close to that which was historically cauterized for sciatic pain.

I have always been intrigued by this issue, asking myself why the Chinese spine was 'shorter' than the French one. Racial differences were absolutely not to be considered, whereas a different interpretation of back pain could be presumed. It should be remembered that lumbago arising from the facet joints of the thoracolumbar region is indeed common and erroneously attributed to pathological changes in the lower back.

One of the authors who has faced this issue systematically for many years is Robert Maigne.7,8,9 He demonstrated that this pain commonly stems from the irritation of the lateral branch of the posterior ramus of the lower thoracic and/or the first lumbar spinal nerves, carrying motor and sensory fibers. Classically the cutaneous innervation of the lower lumbar and gluteal regions has been attributed to the cutaneous branches of L1-L2-L3. Anatomical dissections have shown, however, that the cutaneous innervation of the gluteal region originates more often from the lateral branches of the posterior rami of the nerves of T11-T12-L17 (Fig. 5.7).

From the clinical point of view Maigne indicated that the palpation of the iliac crest, where the lateral branches emerge on the surface, evokes a sharp pain which is similar to the patient's complaint. In these areas he also noted a thickening and hypersensitivity of the skin and the subcutaneous tissues, folding them gently between the thumb and forefinger (skin-rolling test).

Fig. 5.7 Anatomical dissection showing the lateral branches of the posterior ramus of T11, T12 and L1 spinal nerves crossing the iliac crest and innervating the upper part of the gluteal area. The iliac crest is marked with black dots and white pins (with permission of Robert Maigne).

Maigne confirmed the relation between the thor-acolumbar tract of the spine and the iliac-gluteal region by a diagnostic block, injecting a solution of procaine 1 cm lateral to the spinal process directly into the joint region. After the injection, when the diagnosis of 'thoracolumbar junction syndrome' (TLJS) was correct, the backache disappeared and the skin-rolling test was subsequently negative. Maigne8,9 examined 320 patients with lumbago and found 138 patients with TLJS, 120 with low back pain (L4-L5 or L5-S1) and 62 of mixed origin.

Before the diagnostic block, however, he systematically examined the spine segments from T9 to L5 with the patient prone. One of the most reliable methods for determining the source of pain was pressure applied by the thumb on the spinal processes both vertically and laterally, either from right to left or vice versa. Once a clear tenderness was elicited on one side, the contralateral side was challenged with the so-called 'opposed thumbs technique' on the upper and lower level (Fig. 5.8). As one of these movements provoked

Chapter 5 The pressure pain test 119

Tenderness

101 Power Tips For Preventing and Treating Headaches

101 Power Tips For Preventing and Treating Headaches

Are you fed up with your frequent headache pain? 101 Simple Ways to Attack Your Headache BEFORE the Pain Starts Guaranteed No Pain, No Fear, Full Control Normal Life Again Headaches can stop you from doing all the things you love. Seeing friends, playing with the kids... even trying to watch your favorite television shows.

Get My Free Ebook


Post a comment