Zero Point:A Critical Assessment Through Advanced Auricular Therapy Bryan Frank, MD Nader Soliman, MD
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Terry Oleson, PhD

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A Journal For Physicians By Physicians
Spring / Summer 1999 - Volume 11 / Number 1 "Aurum Nostrum Non Est Aurum Vulgi"


Medical Acupuncture



zero point

Zero Point: A Critical Assessment Through Advanced Auricular Therapy Bryan Frank, MD Nader Soliman, MD

ABSTRACT      Zero Point is situated at the junction of the conchal ridge and the root of the ascending helix. It is one of the most recognized auricular points and is used in the treatment of many ailments. Zero Point is thought to have a powerful influence in treating various conditions including pain, sedation, addiction treatment, and inflammation. While Zero Point is universally recognized in the auricular acupuncture world, it is not associated with any specific organ. It was derived from observations of functional effects, not necessarily with respect to the body's anatomy. However, the Nogier French auricular system has developed with anatomical and embryological understanding and consistency with respect to localizations of the points or zones. Through this understanding, the physician will more completely comprehend the patient's pathophysiology and may experience better clinical results through proper stimulation of auricular zones. KEY WORDS      Acupuncture, Auricular Acupuncture, Auricular Therapy, Auricular Medicine, Zero Point, Paul Nogier

     The somatotopic presentation of the body within the ear was first recognized through persistent clinical investigations of Dr Paul Nogier of France.1, 2, 3 Nogier first recognized that the point commonly known as "sciatic point" correlated to the lower lumbar vertebral segments. With this starting reference point, he hypothesized and confirmed the primary auricular correspondence system, known as the "inverted fetus"4, 5, 6, 7 (Figure 1). Early in the development of the French auricular microsystem, the Zero Point (Figure 2) was recognized and identified on auricular charts. Auricular Medicine practitioners' understanding of the significance and meaning of Zero Point has evolved through the years. Most auriculotherapy practitioners continue without these newer developments of Zero Point's significance. Developmental Perspectives     Nogier's identification of the Zero Point initially occured because of its perceived functional value. this point served as reference point to "zero," or set the sensitivity of early auicular electrodiangnostic devices. Within several years, however, this point was recognized to be pathologic in many patients. Thus, it does not serve well as a reference point. 4 Nogier and colleagues continued to investigate auricuolar correspondeces and pursue identifucation of points through anatomical and embryological understandings.
      The original presentation of auricular correspondence or the "inverted fetus" presentation came to be recognized as a somatotype that corresponds to normal physiology, acute pain, and dysfunction. In this model, the musculoskeletal (mesodermal) structures present in the upper aspect of the ear, covering the helix, antihelix, scaphoid fossa, and triangular fossa 1, 5,7, 8, 9 (Figure 3). Visceral organs (endoderm) are identified in the concha, and the cephalic structures (ectoderm) present in the lobule.10,11      In time, Nogier recognized that chronic and degenerative conditions were represented in alternate auricular presentations, depending on the stage of illness. The respective embryologic tissue layers will shift in their auricular representation based on their phase status.7 According to this model, degenerative conditions are identified in phase 2 presentation, wherein the fetus presentation "morphs" to an upright position (Figure 3).3, 7 In phase 2, the mesoderm presents in the concha, the endoderrn in the lobule, and the ectoderm in the upper ear (Figure 4). Degenerative conditions are more dense in their pathological presentation and represent the most serious progression of pain or a functional problem. Generally, progression to phase 2 will take weeks to months from the onset of the injury or illness.
     Chronic conditions are identified as phase 3 auricular correspondences; phase 3 presents with the mesoderm in the lobule, the endoderm in the upper ear, and the ectoderm in the concha (Figure 4). The homunculus is now seen in a transverse presentation. Chronic presentations will generally emerge within several days or weeks of the initial insult or injury. Depending on the stage of a patient's illness, the pathology may be identified in I or more loca- tions within the ear. 3,7
    As disease progresses, it is now known that the auricular reflection will shift from phase 1 to 3 to 2. Phase 2 was recognized second, and it is thus labeled "2," despite the fact that phase 2 represents a condition more chronic and degenerative than those seen in phase 3. Recovery of illness follows the reverse pattern, from phase 2 to 3 to I (Figure 4). 1,3      Through extensive clinical observation, Nogier and colleagues also identified 7 zones of the auricle that demonstrate favorable response to specific frequencies of electrical stimulation (Figure 5). These zones are further influenced by specific Master Points within the respective zones, which exert generalized influence over their zone. In this model, the concha is identified as Zone "B" and includes the location of Zero Point (Figure 6).1,3 Specifically, Zero Point corresponds to the Master Point of Zone B and thus, has influence over the entire concha.
     Often a physician's confusion regarding the significance of an auricular point will become clear when the anatomy and embryology are considered within these phase dynamics. Furthermore, a study of the auricular neurology and an appreciation of the influence of the zonal Master Points may lead to greater understanding of the clinical efficacy of various auricular points. Zero Point      Functionally, as noted above, the Zero Point was used early as a reference site for auricular point electrodetection. Zero Point has also been referred to as the "umbilicus ... .. vitelline duct," or "solar plexus" of the ear.1, 10 Its central physiologic importance for many body functions is clearly indicated.     
Anatomically, Zero Point lies in an area of innervation by the vagus nerve. Stimulation of the point may yield a significant parasympathetic effect that may be important for all endodermal structures found in the concha. Included in the superior concha are the phase 1 representations of the abdominal viscera, including the small and large bowels, gall bladder, pancreas, etc. Within the inferior concha are the lungs (Figure 7). This parasympathetic effect has also been recognized to affect the auricular energetics in general. Clinically, the parasympathetic tone may be enhanced or diminished depending on the specific direction of auricular massage. A centrifugal massage will diminish the parasympathetic tone as a probe or rod is used to massage outward from the Zero Point. Conversely, a centripetal massage toward the Zero Point will enhance the parasympathetic tone of the ear. I The point has also been used to treat panic attacks by needling the nondominant ear (generally ipsilateral to the dominant hand).1

     The location of Zero Point also corresponds to the phase 2 cerebellum zone (Figure 8). Cerebellar functions include coordination of somatic motor activity, regulation of muscle tone, and mechanisms of equilibrium.12,13 Its positive effects on emotional status and drug detoxification have been recognized among auricular therapists. With such significant impact on the body's fundamental coordinating functions, it is not surprising that this point may be identified as an active point through electrostimulator detection in patients with pain or functional problems.
     The Zero Point location is also shared by the phase 3 corpus callosum (Figure 9). The role of the corpus callosum as neural relay is imperative for proper neurophysiological function. Abundant fibers connect to the cortex from the lower brainstern and spinal cord; inte gration of information between the hemispheres is vital to carry information that is essential to proper brain function. Disturbances of this neural integration may manifest as attention deficit disorder/attention deficit-hyperactivity disorder, stuttering, dyslexia, confusion with directions, and visual and auditory processing disturbances. Chronic pain or functional illness may thus be represented at the Zero Point location because of the disturbance of corpus callosum.      Thus, practicing advanced Auricular Therapy, with consideration of phase dynamics rather than just the simple "inverted fetus," will give further clarification to the nature of the presenting pain or illness. Specific and definitive identification to the phase of presentation is made only through the energetic techniques of Auricular Medicine using the VAS of the radial pulse and the EMF signal of the auricle.3 While futher detail of Auricular Medicine is beyond the scope of this article, it is important to note that these are the techniques used to specifically identify the exact nature of the disturbance. With advanced Auricular Therapy techniques, clinicians have much greater information to be able to recognize an active auricular zone as a distubance in I of 3 phase presentations, rather than as a single point on the basic auricular somatotopic model.
CONCLUSION      The significance of Zero Point may be more specifically recognized when the physician understands the neurological, anatomical, and embryological implications, rather than simply the functional importance of this zone.5, 6, 7 Additionally, this advanced auricular acupuncture approach will lead to clearer diagnostic interpretation of a presenting illness as it is represented in I or more areas on the auricle. Ultimately, more enduring clinical effects may be realized with treatment of properly identified points. Proper identification and usage of auricular points is encouraged to enable the physician to treat the patient's auricle in a true medical model, rather than in a cursory technical approach.
REFERENCES 1. Bourdiol R. Elements of Auriculotherapy. Ste Ruffine, France: Maisonneuve; 1982.
2. Huang H, trans. Ear Acupuncture: A Chinese Medical Report. Emmaus, Pa: Rodale Press Inc; 1974.
3.Nogier PFM. From Auriculotherapy to Auricular Medicine. Ste Ruffine, France: Maisonneuve; 1983.
4. Kropej H. The Fundamentals of Ear Acupuncture. Heidelberg, Germany: Karl F. Haug Publishers; 1987.
5. Nogier PFM. Handbook to Auriculotherapy. Ste Ruffine, France: Maisonneuve; 1969.
6. Nogier PFM, Nogier R. The Man in the Ear. Ste Ruffine, France: Maisonneuve; 1985.
7. Frank BL, Soliman NE. Shen Men: a critical assessment through advanced auricular therapy. Medical Acupuncture. 1999; 10(2):17-19.
8. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995.
9. Oleson TD, Kroening RJ, Bresler DE. An experimental evaluation of auricle diagnosis: the somatotopic mapping of musculoskeletal pain at ear acupuncture points. Pain. 1980;8:217-229.
10. Oleson TD. Auriculotherapy Manual: Chinese and Western Systems of Ear Acupuncture. 2nd ed. Los Angeles, Calif: Health Care Alternatives; 1996.
11. Soliman NE, Frank BL. Atlas of Auricular Therapy and Auricular Medicine. Richardson, Tex: Integrated Medicine Publishers; 1999.
12. Carpenter MB. Human Neuroanatomy. 7th ed. Baltimore, Md: Williams & Wilkins; 1976.
13. Raj PR, ed. Practical Management of Pain. 2nd ed. St Louis, Mo: Mosby -Year Book Inc; 1992.
AUTHORS INFORMATION Dr Bryan L. Frank is an Anesthesiology/Pain Medicine specialist in Richardson, Texas. He serves as President of the American Academy of Medical Acupuncture, and has taught at the Academy's Annual Symposia and other national and international medical acupuncture forums. Dr Frank is a Clinical Instructor for the UCLA Medical Acupuncture for Physicians program, and is President of Integrated Medicine Seminars.
Bryan L. Frank, MD* P.O. Box 831111 Richardson, TX 75083-1111 Phone: 972-489-4286 - Fax: 972-437-9644 - E-mail:
Dr Nader Soliman is Director of the Washington Alternative Medicine and Integrated Pain Management Center in Rockville, Maryland, is a Clinical Instructor for the UCLA Medical Acupuncture for Physicians program, and is President of Integrated Medicine Seminars. Dr Soliman has taught physicians auricular medicine, with particular interest in integrating auricular medicine into biomedical and medical acupuncture practices.
Nader Soliman, MD 15001 Shady Grove Rd #100 Rockville, MD 20850 Phone: 301-251-2335 - Fax: 301-972-4671 - E-mail:
*correspondence and reprint requests

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A Journal For Physicians By Physicians
Fall 1999 / Wiinter 2000- Volume 11 / Number 2 "Aurum Nostrum Non Est Aurum Vulgi"

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The journal of the American Academy of Medical Acupuncture with acupuncture research articles, reviews, abstracts and case studies.


Medical Acupuncture



Table of Contents


differential localization
Terry Oleson, PhD
ABSTRACT      Neurophysiological studies have examined the theoretical work of Dr Paul Nogier regarding differential correspondence of internal visceral disorders to the central concha of the ear, musculoskeletal problems to the surrounding antihelix on the auricle, and neurological pain to the outer helix of the ear. Double-blind studies of auricular diagnosis have shown that specific areas of Nogier's antihelix auricular zone correspond to the actual area of musculoskeletal pain, while coronary problems were identified by bioelectrically reactive auricular reflex points in the central concha of the ear. Animal investigations have demonstrated that stimulation of the stomach tissue led to the development of low resistance points on the concha of the ear, whereas stimulation of the concha points themselves led to differential activation of firing patterns in hypothalamic neurons. When animals were tested for threshold to tooth shock pain, stimulation of the auricular point for the trigerninal nerve led to an elevation of pain threshold and a reduction of brain-evoked potentials. Research demonstrating release of endorphins by stimulation of auricular acupuncture points provides a neurobiological basis for the clinical actions of auricular acupuncture.
KEY WORDS      Auricular Acupuncture, Nogier Embryological Zones, Musculoskeletal Pain, Visceral Disorders, Neurophysiological Recordings
Introduction      A previous article in Medical Acupuncture1 examined the clinical application of treating different zones on the external ear for relieving varying types of pain. The opportunity to examine the electrophysiological research that supports clinical studies of auricular acupuncture was recently provided at an international scientific symposium ("New Directions in the Scientific Exploration of Acupuncture," May 1999, University of California, Irvine). The findings by Cho et al2 that differential changes in functional magnetic resonance images (MRI) of the brain are selectively activated by stimulating different acupuncture points has initiated renewed interest in understanding the neurophysiological mechanisms for acupuncture. The inverted fetus, somatotopic perspective of the external ear, has been principally derived from clinical experiences in conducting auricular acupuncture with patients in China3 and Europe.4 There is now an accumulation of scientific studies examining electrophysiological data obtained from animals and humans that provide neurobiological support for these clinical findings.5      Different anatomical regions of the external ear are shown in Figure 1,
whereas the specific functional zones of the ear are represented in Figure 2. The central concha of the ear is innervated by the vagus nerve and is thought to serve as the region for autonomic regulation of pain and pathology originating from internal organs. The surrounding antihelix and antitragus ridges of the ear represent somatic nerve processing of myofascial pain, backaches, and headaches. The outer helix tail and earlobe represent the spinal cord and brain regions, which are reported to affect neuropathic pain such as peripheral neuropathies and trigerninal neuralgia. The body organs represented on the external ear can be viewed as 3 concentric rings. According to Nogier,6 the embryologicallybased endodermal organs are found at the center of the ear, the mesodermal tissue that becomes the somatic 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 3 auricular regions depicts body orientation in an inverted somatotopic pattern. Higher organs of the actual lungs, shoulder, or cerebral cortex are represented on lower areas of the auricle; lower organs of the actual intestines, leg, or lumbar spinal cord are represented on higher areas of the auricle (Fig. 3).
Neurophysiological Theories of Acupuncture and Microacupuncture Systems      The author has previously proposed7 that the relief of pain by auricular acupuncture can be best understood by the theory of stimulation-produced analgesia. Liebeskind et al8 developed this theory to account for the pain-relieving effects following electrical stimulation of neurons in the brain. In addition to the classicallyknown, ascending, pain-sensation pathway, there is a descending, pain-inhibitory pathway. The pain-inhibitory system travels from the brainstem, down the spinal cord, then activates pain-suppressive neurons in the dorsal horn of the spinal cord. In their gate control theory of pain, Melzack and Wall9 focused on the inhibition of input from nociceptive neurons by input from tactile neurons interacting through spinal cord interneurons. However, they further allowed that supraspinal gates in the brain could produce descending messages to these same inhibitory interneurons, thus blocking the ascending pain signal.
     Basbaum and Fields10 showed that lesions in the descending, dorsolateral funiculus tract in the spinal cord blocked behavioral analgesia from deep brain stimulation. There is both a descending pain facilitation system and a descending pain-inhibition system in the central nervous system, comparable to the Yin and Yang of Taoist theory. Wei et al11 have shown that destruction of both descending, serotonergic, raphe pathways, and descending, noradrenergic, locus coeruleus pathways leads to an increase in the fos protein activity of nociceptive spinal neurons. Conversely, destruction of descending, reticular, gigantocellular pathways leads to a decrease in the fos protein activity of nociceptive spinal neurons. The pain-inhibition system was selectively damaged by the raphe and locus coeruleus lesions, whereas the pain-facilitation system was disconnected by the reticular lesion. Acupuncture may also utilize this pain inhibitory system.12      The most potent area for obtaining stimulation-produced analgesia in rats was the midbrain periaqueductal gray,8 a region with neurons specifically responsive to noxious stimuli. Research in primates" has shown that deep brain stimulation in the subcortical thalamus is a more potent site for creating stimulation-produced analgesia in higher species. Examination of deep brain stimulation in humans has shown similar findings.14 Research also has confirmed that nociceptive pain messages activate positron emission tomographic (PET) scan activity in the periaqueductal gray, thalamus, hypothalamus, somatosensory cortex, and prefrontal cortex regions of humans;15 included is the same brainstern and thalamic areas that are able to suppress pain messages. While direct connections between auricular acupuncture points and these antinociceptive brain pathways have not yet been investigated, neurophysiological investigations of body acupuncture points suggest that the regions of the brain related to pain inhibition are also affected by the stimulation of acupoints.16      According to Dale,17 the holographic homunculus pattern shown on the external ear is one of several microacupuncture systems that connect peripheral regions of the body to the central nervous system (CNS). Dale hypothesized that ear acupoints have remote reflex connections to other parts of the body through neuronal pathways in the CNS. Dale proposed that there are both organo-cutaneous reflexes that allow the microsystern to reveal underlying body pathology and cutaneo-organic reflexes that enable microacupuncture stimulation to heal the pathological condition. Foot reflexology, hand acupuncture, and scalp acupuncture are other examples of such microacupuncture systems, each serving as peripheral terminals in the body that connect to a central brain computer.7      Lee has developed a thalamic neuron theory to account for reflex connections between acupuncture points and the brain.18,19 Pathological changes in peripheral tissue will eventually lead to firing pattems in corresponding 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 a homunculus. The CNS institutes corrective measures intended to normalize the disordered neural circuits; 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. Thus, pain and disease are attributed to learned, maladaptive programming of these dysfunctional neural circuits. Stimulation of acupuncture points on the body or 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. The invisible meridians that purportedly run over the surface of the body may actually be due to nerve pathways projected onto neuronal chains in the thalamus. The auricular acupuncture system is more noticeably arranged in a somatotopic pattern on the skin surface of the external ear.      There have been 4 main thrusts in acupuncture research designed to examine these neurophysiological theories. First, whether the existence of auricular and body acupuncture reflex points can be substantiated by electrophysiological measures. Second, whether the areas of the brain associated with stimulation-produced analgesia also are affected by the stimulation of acupuncture points. Third, whether changes in the natural opiates, the endorphins and enkephalins, reliably account for the pain-relieving effects of auriculotherapy and body acupuncture. Finally, whether there is evidence that the sornatotopic pattern described for the auricle is specifically associated with changes in neural activity in different parts of the brain.
Electrodermal Determination of Acupuncture Points      The first double-blind assessment to scientifically validate the somatotopic pattern of reflex points on the auricle was conducted by the author and his colleagues.20 Forty patients with specific musculoskeletal pain were first evaluated by a physician or nurse to determine the exact location of their physical pain. They were then draped with a sheet so that only their external ear was exposed. Crutches and braces were removed from the room to prevent any clues as to the nature of their condition. A second physician who had extensive training in auricular acupuncture procedures then examined each patient's ear. This second physician 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 that corresponded to 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 uA of electrical conductivity, and the parts of the body with musculoskeletal pain. Non-reactive ear points corresponded to parts of the body with no reported pain. The statistically significant, overall correct detection rate was 75.2%. When the pain was located on only 1 side of the body, electrical conductivity was significantly greater at the sornatotopic ear point on the ipsilateral ear than at the corresponding area of the contralateral ear. These results support the concept that specific areas of the ear are related to specific areas of the body.      Double-blind assessment of auricular points that are related to heart disorders was conducted by Saku et al in Japan.21 Reactive electropenneable points on the ear were defined as auricular skin areas that had conductance of electrical current greater than 50 uA, 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 infarction and angina pain than for a control group of healthy subjects (I I %). 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 (I I %), or eye (3%) was the same for coronary patients as for individuals without coronary problems. Whereas our findings" supported the concept that Nogier's mesodermal zone on the antihelix of the ear corresponds to the musculoskeletal system, Saku et al21 established that specific points on the endodennal concha region of the ear are associated with a visceral condition such as heart disease.    Quantified examinations of the electrical properties of the skin have provided the most objective demonstration of the scientific validity of acupuncture points.22-25 Observations that acupuncture points exhibited higher levels of skin conductance or lower levels of skin resistance than surrounding skin surface areas were first reported in the 1950s. In the 1970s, Matsumoto showed that 80% of acupuncture points could be detected as low resistance points.26 The electrical resistance of acupuncture points was found to range from 100 to 900 kQ, (Please note: Wherever you see kQ, please read k and Omega symbol) whereas the electrical resistance of nonacupuncture points ranged from 1,100 to 11,700 kQ. Reichmanis et al27 further showed that meridian acupuncture points exhibit even lower electrical resistance when there is pathology in the organ they represent. For instance, electrodermal resistance on the lung meridian is lower in the presence of a respiratory disorder. The normal, bilateral symmetry of the electrical resistance of acupuncture points is disturbed when there is unilateral pathology in the body. Those acupuncture points that are ipsilateral to the site of body discomfort exhibit a lower electrical resistance than the corresponding meridian point on the contralateral side of the body. We found that auricular points showed a similar ipsilateral pattern.20      Subsequent research on the differential electrodermal activity of acupoints has continued to verify these earlier studies. Hu et al28 examined 68 healthy adults for computerized plotting of low skin resistance points (LSRPs). 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 4 limbs, investigators moved the electrode along the known meridians. The resistance of low skin impedance points (LSIPs) was approximately 50 kQ, whereas the impedance at non-LSIPs was typically 500 kQ. The LSIPs were distributed predominantly along the 14 classic acupuncture meridian channels. A total of 64% of LSIPs were located exactly on a channel; 83.3% were located within 3 mm of a channel. Individual LSIPs could be found in non-channel 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; the distribution of LSIPs was considerably stable and replicable from one day to the next.      The topography of LSRP's in rats was examined by Chiou et al.29 A movable search electrode consisted of a polished acupuncture needle applied with uniform pressure that did not pierce the skin, while the reference electrode was a needle inserted into the tail. Specific LSRP loci were found to be distributed symmetrically and bilaterally over the shaved skin of the animal's ventral, dorsal, and lateral surfaces. The arrangement of these points 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 neural and vascular elements beneath the points. The LSRP's gradually disappeared within 30 minutes after the animal's death.      Skin and muscle tissue samples were obtained by Chan et al30 from 4 anesthetized dogs. Acupuncture points, defined by regions of low skin resistance, were compared with control points that exhibited higher electrodermal resistance. 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 somatoautonomic reflex that could account for the clinical observations of specific acupuncture points that are both electrically active and tender to palpation.      Experimentally-induced changes in auricular reflex points in rats were examined by Kawakita et al.31 The submucosal tissue of the stomach of anesthetized rats was exposed. Acetic acid or saline was then injected into the stomach tissue. 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; a needle was inserted into subcutaneous tissue to serve as the reference electrode. Injection of acetic acid led to the gradual development of LSRP's on central regions of the rats ears, auricular areas that correspond to the gastrointestinal region of human ears. In healthy rats and in experimental rats before the 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 kQ) and moderate impedance points (100-500 kQ), but a decrease in high impedance points (>500 kQ). These results demonstrated a reduction in the electrodermal resistance response to experimentally-induced irritation of the internal organ that corresponded to that auricular point. Histological investigation could not prove the existence of sweat glands in the rat auricular skin.      The authors suggest that the low impedance points are in fact related to sympathetic control of blood vessels. It would have been intriguing if the investigators had conducted further evaluation of the auricular low resistance sites for concentrations of substance P, as Chan et at30 had done for body acupoints. The study by Kawakita et al31 I provides objective support for the organo-cutaneous reflexes described by Dale,17 wherein low resistance auricular acupuncture points appear in response to pathology of the corresponding internal organ.
Changes in Brain Activity Following Auricular Acupuncture for Obesity      An intriguing potential of auricular acupuncture has been its clinical application for weight control. Sun and Xu32 treated obese patients with otoacupoint stimulation, another term for ear acupressure. All patients were also given body acupuncture during the 3-month study. The acupuncture group consisted of 110 patients determined to be at least 20% over ideal body weight. They were compared with 51 obese patients in a control group given an oral medication (1500 mg of Capsulae Olei Oenothera Erythrosepalae) for weight control. An electrical point finder was used to determine the following auricular points: mouth, esophagus, stomach, abdomen, hunger, Shen Men, lung, and endocrine. Pressure pellets made from vaccaria seeds were applied to the appropriate points of both ears. The body acupuncture points needled were ST 25, ST 36, ST40, SP6, and PC 6. The acupuncture group exhibited an average reduction of 5 kg of body weight, which was significantly greater than the average 2-kg reduction in the control group. The percentage of body fat was reduced by 3% in the acupuncture group and by 1.54% in the control group, while the triglyceride levels were diminished 66.7 mg/dL in the acupuncture group and 38.4 mg/dL in the control group. Total cholesterol levels were reduced by 27.6 mg/dL in the acupuncture group and 33.3 mg/dL in the controls.      Arandomized controlled trial conducted by Richards and Marley33 found that weight loss was significantly greater for women in an auricular acupuncture group than in a control group. Women in the acupuncture group were given surface electrical stimulation to the ear acupoints for stomach and Shen Men, whereas controls were given transcutaneous electrical stimulation to the first joint of the thumb. Auricular acupuncture was theorized to suppress appetite by stimulating the auricular branch of the vagal nerve and by raising serotonin levels, both of which increase smooth muscle tone in the gastric wall. Rather than examine changes in weight measurements, Choy and Eidenschenk34 examined the effect of tragus clips on gastric peristalsis in 13 volunteers. The duration of single peristaltic waves was measured before and after the application of ear clips to the tragus. The frequency of peristalsis was reduced by one-third with clips on the ear, and was returned to normal levels with clips off. The ear clips were thought to produce inhibition of vagal nerve activity, leading to a delay of gastric emptying, which would then lead to a sense of fullness and early satiety. These obesity studies on human subjects have received potential validation from neurophysiological research in animals.      The areas of the brain that have been typically related to weight control include 2 regions of the hypothalamus. The ventromedial hypothalamus (VMH) has been referred to as a satiety center; when the VMH is lesioned, animals fail to restrict their food intake. In contrast, the lateral hypothalamus (LH) is referred to as a feeding center, since stimulation of the LH induces animals to start eating. Asamoto and Takeshig35 studied selective activation of the hypothalamic satiety center using auricular acupuncture in rats. Electrical stimulation of inner regions of the rat ear, which correspond to auricular representation of the gastrointestinal tract, produced evoked potentials in the VMH satiety center but not in the LH feeding center.      Stimulation of more peripheral regions of the rabbit ear did not activate hypothalamic-evoked potentials, indicating the selectivity of auricular acupoint stimulation. Only the somatotopic auricular areas near the region representing the stomach caused these specific brain responses. Acupuncture needles were subsequently placed into the same auricular sites as those that led to evoked potentials in the VMH. After 16 days, the body weights of rats in the auricular acupuncture group were significantly lower than those of a control group. The same auricular acupuncture sites that led to hypothalamic activity associated with satiety led to behavioral changes in food intake. Moreover, auricular acupuncture had no effect in a different set of rats that had incurred bilateral lesions of VMH. These results provide a compelling connection between auricular acupuncture and a part of the brain associated with neurophysiological regulation of feeding behavior.      In support of this evoked-potential research, Shiraishi et al36 recorded single-unit neuronal discharge rates in the VMH and LH of rats. Neurons were recorded in the hypothalamus following electrical stimulation of low resistance regions of the inferior concha of the rat ear, areas of the auricle innervated by the vagus nerve and corresponding to the stomach. Auricular stimulation tended to facilitate neuronal discharges in the VMH and inhibit neural responses in the LH. Of 162 neurons recorded in the VMH, 44.4% exhibited increased neuronal discharge rates in response to auricular stimulation, 3.7% exhibited decreased activity, and 51.9% showed no change. Of 224 neurons recorded in the LH feeding center of 21 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 behaviorally responding to auricular acupuncture stimulation, 49.5% of LH neurons were inhibited, 15.5% were excited, and 35% were not affected by auricular stimulation. A different set of rats was given lesions of the VMH which led to significant weight gain. In these hypothalamic obese rats, 53.2% of I I I LH neurons were inhibited by auricular stimulation, 1.8% showed increased activity, and 45% were unchanged. These neurophysiological findings suggest that auricular acupuncture can selectively alter hypothalamic brain activity, and is more likely to produce sensations of VMH satiety than reduction of LH appetite.
Reduction of Nociceptive Neural Responses by Acupuncture Stimulation      A central focus of neurophysiological research on acupuncture treatment has been the assessment of changes in neural responses related to pain. As stated previously, deep brain stimulation of the periaqueductal gray area leads to pain reduction in rats, cats, monkeys, and humans,8 an analgesic effect that can be reversed by the opiate antagonist naloxone. Such stimulation-produced analgesia by brain electrodes directly elevates cerebrospinal fluid and blood plasma levels of endorphin in animals37 and humans.14,38 A review of the neurophysiological literature by Kho and Robertson16 provides empirical support for the role of the thalamus in acupuncture analgesia. Afferent acupuncture impulses are thought to activate nociceptive inhibitory pathways and selectively alter specific neurotransmitters.     Pert et al37 showed that 7-Hz auricular electrical stimulation through needles inserted into the concha of the rat ear produced an elevation of hot plate threshold that was reversed by administering naloxone. The behavioral analgesia to auricular electroacupuncture was accompanied by a 60% increase in radioreceptor activity in cerebrospinal fluid levels of endorphins, a level that was significantly greater than that found in a control group. Concomittant with these cerebrospinal fluid changes, auricular electroacupuncture produced depletion in P-endorphin radioreceptor activity in the VMH and the medial thalamus, but not the periaqueductal gray area.      Similar findings in patients with back pain were made by Clement-Jones et al.39 Low-frequency electrical stimulation of the concha led to relief of pain within 20 minutes of the onset of electroacupuncture, and an accompanying elevation of radioassays for cerebrospinal fluid B-endorphin (Note: B- is Beta) activity in all 10 subjects. Abbate et al40 examined endorphin levels in 6 patients undergoing thoracic surgery with 50% nitrous oxide and 50-Hz auricular electroacupuncture, compared with 6 control patients who underwent surgery with 70% nitrous oxide but no acupuncture. The auricular acupuncture patients needed less nitrous oxide than the controls; acupuncture led to a significant increase in B-endorphin immunoreactivity.      Kalyuzhny41 applied 15-Hz electrostimulation to the auricular lobe of rabbits, an area corresponding to the jaw and teeth in humans. Behavioral reflexes and cortical somatosensory-evoked potentials were measured in response to tooth pulp stimulation. Auricular electroacupuncture produced a significant decrease in both behavioral reflexes and cortical evoked potentials to tooth stimulation. For most animals, the suppression of behavioral and neurophysiological effects were abolished by injection of naloxone, suggesting endorphinergic mechanisms. However, in a few rabbits, auriculoacupuncture stimulation did not induce this naloxone-reversible effect. Naloxone injections themselves led to an analgesic effect. It was suggested that this paradoxical effect could be explained by an inhibition of an antiopioid substance in select individuals.      Electrical stimulation of auricular acupuncture points on the earlobe of rabbits, the auricular area that corresponds to the trigerninal nerve, was performed by Fedoseeva et al.42 Auricular electroacupuncture led to a reduction of the amplitude of cortical somatosensory potentials evoked by tooth pulp stimulation. Intravenous injection of naloxone diminished the analgesic effect of auricular electroacuncture at 15-Hz stimulation frequencies, but not at 100-Hz stimulation. Conversely, injection of saralasin, an antagonist for angiotensin 11, blocked the analgesic effect of 100-Hz auricular acupuncture but not 15-Hz stimulation. The amplitude of cortical potentials evoked by electrical stimulation of the hind limb was not attenuated by stimulation of the auricular area for the trigeminal nerve.      Simmons and Oregon43 examined naloxone reversibility of auricular acupuncture analgesia to acute, induced pain in human subjects. 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 I of 4 groups: true auricular electrical stimulation followed by an injection of naloxone, true auricular electrical stimulation followed by an injection of saline, placebo stimulation of the auricle followed by naloxone, or placebo stimulation of the auricle followed by saline. Dental pain thresholds were significantly increased by auricular electrical stimulation 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 stimulation; those given saline showed a further increase in pain threshold. The minimal changes in dental pain threshold shown in the sham auriculotherapy group were not significantly affected by either saline or naloxone.      Both Sjolund and Eriksson44 and Simmons and Oregon43 noticed that pain threshold levels did not completely return to baseline after naloxone administration, suggesting nonopioid as well as endorphinergic brain mechanisms.      Auricular acupuncture has also been shown to suppress autonomic electrodermal activity associated with the startle reflex to arousing stimuli. Young and McCarthy45 conducted a controlled clinical trial of 38 healthy volunteers. Forearm electrodermal recordings (EDRs) 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. Evoked EDR activity was consistently higher when needles were placed in the placebo auricular point than in the sympathetic point. There was thus a selective difference between the electrodermal effects of appropriate and inappropriate auricular acupuncture stimulation, suggesting that auriculotherapy attenuated the autonomic startle reflex.
Mechanisms for Withdrawal From Opiate Drugs by Auricular Acupuncture      The discovery by Wen and Cheung46 that auricular acupuncture facilitates withdrawal from narcotic drugs has led to a plethora of studies demonstrating the clinical use of this technique for substance abuse.47,48 Auricular electroacupuncture has been shown to raise levels of metenkephalin in humans," and B-endorphin levels in mice withdrawn from morphine.50-52      Kroening and Oregon53 examined 14 patients with chronic pain who were switched from their original analgesic medication to an equivalent dose of oral methadone, typically 80 mg/d. An electrodermal point finder was used to determine areas of low skin resistance for the lung and Shen Men points. Needles were bilaterally inserted into these 2 ear points and electrical stimulation was initiated between 2 pairs of needles. After 45 minutes of electroacupuncture, these 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 adverse withdrawal effects. All 14 patients were withdrawn from methadone within 2 to 7 days (mean, 4.5 days). Only a few Patients reported minimal adverse effects of mild nausea and agitation. The authors proposed that 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 after auricular acupuncture, it was theorized that opiate receptor sites can be allowed to gradually return to their original state.      Other biochemical changes also accompany auricular acupuncture. Debrecini54 examined changes in plasma corticotropin and gonadotropin hormone levels after 20-Hz electrical stimulation through needles inserted into the adrenal point on the tragus of the ears of 20 healthy females. While gonadotropin hormone secretions increased after electroacupuncture, corticotropin levels remained the same. Jaung-Geng et al55 evaluated lactic acid levels from pressure applied to ear vaccarie seeds positioned over the liver, lung, San Jiao endocrine, and thalamus (subcortex) points. Using a within-subjects design, pressure applied to ear points produced significantly lower levels of lactic acid after a treadmill test than when ear seeds were placed over the same auricular points but not pressed. Actual stimulation of these auricular acupressure points appeared to reduce the toxic elevations of lactic acid build-up more than did the control condition, perhaps due to improved peripheral blood circulation.
CONCLUSION     The electrophysiological studies conducted to date provide intriguing support for each of the theoretical issues addressed. The 2 controlled studies of auricular diagnosis both support the proposition that specific areas of the auricle are related to specific areas of the body. The neurophysiological evidence for a connection between acupuncture stimulation and brain pathways related to a pain inhibitory system has been better established for body acupuncture than ear acupuncture. However, both body points and ear points are associated with endorphin and enkephalin release. Research in rats and rabbits has shown that stimulation of the central concha of the ear, which corresponds to the stomach selectively, activates hypothalamic neurons associated with weight control; stimulation of the auricular lobe region representing the trigerninal nerve attenuates cortical-evoked potentials to tooth shock. These electrophysiological studies suggest that auricular acupoints correspond to some areas of body pathology; stimulation of lowresistance auricular points can lead to site-specific alteration of brain activity. The exact relationship of somatotopic points on the auricle to specific regions of the human brain remains to be determined.
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AUTHOR INFORMATION      Dr Terry Oleson is a licensed Clinical Psychologist practicing in West Hollywood, California. He is Chair of the Department of Psychology at the Califomia Graduate Institute, and President of the non-profit Center for Oriental Medical Research and Education (COMRE). Formerly, he was the Director of Research at the UCLA Pain Control Unit. Dr Oleson is the author of Auriculotherapy Manual.

Terry Oleson, PhD 8033 Sunset Blvd., PMB 2657 Los Angeles, CA 90048 Phone: 323-656-2084 - Fax: 323-656-2085 E-mail: