Chapter 9 How to interface auricular diagnosis with clinical status

THE VALIDATION OF AURICULAR DIAGNOSIS

The term auricular diagnosis was first proposed officially by Terry Oleson in 1980.¹ His study, conducted at the department of anesthesiology at the UCLA School of Medicine in Los Angeles, belongs to the history of ear acupuncture. Its aim was to evaluate the claims by French and Chinese acupuncturists that a somatotopic mapping of the body is represented upon the external ear. Forty patients were examined by a physician to determine which of 12 reported areas of their body suffered musculoskeletal pain (Fig. 9.1). Each patient was then covered with a sheet to conceal any visible physical problems. A second physician afterwards carried out a blind examination of the patient’s auricles for areas of higher tenderness or reduced electrical skin resistance. The ear points corresponding to body areas where the subject reported musculoskeletal pain were designated as ‘reactive points’, while ‘non-reactive points’ corresponded to areas of the body where the patient experienced no discomfort.

Fig. 9.1 The somatotopic mapping of musculoskeletal pain on the auricle according to Oleson (with permission of the author).

The results of Oleson’s study were as follows:

1. The correct identifications summed to 75.2%. In 12.9% of the total the points were false-positive and in 11.9% the points were false-negative; the association was highly significant with χ² (P<0.001). In 37 of the 40 subjects there were more correct identifications than incorrect, which was rated as significant by the sign test (P<0.01).

2. Both mean electrical conductivity and dermal tenderness at ear points related to specific areas of the body where pain problems were present were significantly higher with t-test (P<0.01).

3. As regards the laterality for ear points relative to the side of a body problem, the mean electrical conductance was significantly higher if the problem was ipsilateral (P<0.01); the mean tenderness of ear points, in the case of unilateral problems, did not differ between the right and left ear.

4. There were no significant differences in either auricular conductance or auricular tenderness between recent and old pain problems. Recent pain problems were defined as having occurred within the 6 months prior to the study, old problems as having occurred more than 6 months previously.

5. It was observed in 15% of the subjects that there was a localized region of white, flaky scaling of the dermis on the auricular areas corresponding to the part of the body where musculoskeletal pain was present. Oleson wrote on this subject: ‘although infrequently observed, abnormal morphological characteristics on the auricular surface were highly predictive of the presence of pathology in the corresponding area of the body’.

The interesting conclusions of the article by Oleson and colleagues were that:

this study also indicated that the auricular diagnosis technique is often sensitive to pathological problems of which the patient is only minimally aware. When some patients were told of their auricular diagnosis results, they suddenly remembered having a minor or old pain problem in that bodily area, a problem which they had neglected to mention during the medical evaluation. Since these post-hoc results were derived after the ear diagnosis had been made, these instances were not included in any statistical analyses. Nonetheless, such observations do suggest that auricular diagnosis may be effectively employed as part of a general medical evaluation designed to reveal all organic aspects of a patient’s pain complaint. Since there are also ear points for abdominal and thoracic bodily organs, auricular diagnosis could also be utilized with standard diagnostic procedures for analyzing pathological conditions related to internal pain or referred pain.¹

Since then Oleson’s research has become the major reference study and has been cited in several articles on ear acupuncture. A recent paper, however, re-examined the question of whether auricular maps were reliable for chronic musculoskeletal pain disorders.² Fortunately the authors had no intention of replicating Oleson’s study but only of proposing a different method for validating auricular diagnosis by using a 250 g algometer. The main shortcomings of this study were the limited number of patients examined (only 25), the lack of importance given to the posterior surface of the ear, which was not examined at all, and the adoption of an arbitrary somatotopic arrangement of the auricular zones which does not faithfully correspond either to the French or to the Chinese map. For example the knee was reproduced twice on two different areas roughly representing it, according to the schools just mentioned. It is not reported in the article which of the two the blind assessor had to consider as corresponding to a painful knee, or whether both corresponded. In contrast, in Oleson’s study the 12 different auricular regions chosen for the research were the faithful somatotopic representation of the body according to the Chinese map.

In my opinion the concept of parallelism between a topographical area of the body and the corresponding somatotopic auricular area expressed by Oleson has to be considered innovative. Actually, in the diagnostic process we need to speak about areas, especially if we are learning, or teaching beginners to select the most effective points for treatment within each area.

Bourdiol in particular introduced the concept of somatotopic area early, but the most interesting interpretation of the body’s representation on the auricle is probably that of Jean Bossy,³ former director at the Montpellier Institute of Anatomy and author of several books and articles on the neurophysiological basis of acupuncture. His representation of the homunculus on the auricle⁴ is probably more realistic and useful for the practitioner than the well proportioned fetus which we see on the common drawings of the ear. As in the homunculus sensitivus and motorius of Penfield, the hand and the thumb have a large representation as well as the lips, the nose and the jaws (Fig. 9.2).

Fig. 9.2 The representation of the homunculus according to Bossy (with permission of the author).

A NEW PROJECT FOR VALIDATING AURICULAR DIAGNOSIS

Starting from Oleson’s historical paper I tried to create a project for validating auricular diagnosis which could be acceptable and reproducible.

METHODOLOGY

Each new patient was invited to fill in a form with his past and recent symptoms and diseases in decreasing order of importance; the most relevant were listed at the top, the less important at the bottom. The patient was also asked to write down the type and number of surgical interventions experienced as well as any hospital admissions and injuries, and to list medication taken regularly, especially analgesic and psychoactive drugs, and their time of intake. My assistant had the task of removing any diagnostic material such as X-rays or laboratory tests which could influence my diagnosis.

The patient, seated, was invited to remain silent for a while and not give any information about his health. Inspection was the first diagnosis I performed, followed in random order by the pressure pain test (PPT) or the electrical skin resistance test (ESRT). For each method I used different sheets of the Sectogram, transcribing all possible symptoms and diseases I thought to be related with the topography of skin alterations or the location of the points identified with PPT and ESRT.

My assistant afterwards appeared on the scene and compared my diagnosis with the complaints listed by the patient. He had the delicate task of working out the number of consistent symptoms, but was free to interpret them as best he could, also speaking to the patient. For example, a ‘pain in the arm’ could be reinterpreted as a ‘painful shoulder’ or ‘cervical–brachial pain’; when the clinical condition was uncertain both terms could be retained. With mental disorders the different terms reported by the patient had to be harmonized. For example, ‘tension’ or ‘irritation’ were evaluated as anxiety, and ‘sadness’ or ‘melancholy’ were evaluated as depression.

PATIENT CHARACTERISTICS

Between 2002 and 2007 I examined a total of 506 patients: 371 females (average age 48.1 years, SD 14.6, range 17–84) and 135 males (average age 46.5 years, SD 14.9, range 13–80). The total number of symptoms reported/identified in my population of patients was 5641 (females averaged 11.9 symptoms, males averaged 9.2 symptoms).

The higher number of female patients attending my clinic is not unusual for therapists practicing complementary techniques. Several factors could explain this phenomenon: in my opinion it could be related to what today seems to be a stronger desire in females compared to males to preserve their health at its best, or perhaps to the search for alternative treatments to drugs with pronounced side-effects or which are feared to be potentially harmful.

Another characteristic in the patient population I examined was the relatively high percentage aged >60 years (22.3%). This factor is possibly due to the greater presence of musculoskeletal disorders in this phase of life. Indeed, if we consider the 5641 symptoms reported the most numerous are those related to the musculoskeletal system (32.7%), followed by psychological/psychiatric symptoms (22.5%). Table 9.1 lists further symptoms related to other organs and systems in decreasing order of frequency.

Table 9.1 Classification and percentage of 5641 symptoms declared/identified in 506 patients

Symptom	%
Musculoskeletal	32.7%
Psychological/psychiatric	22.5%
Gastrointestinal	14.7%
Cardiovascular	6.8%
Nervous system (central/peripheral)	4.6%
Dermatological	4.6%
Genitourinary	3.7%
Ear, nose and throat	2.9%
Endocrine and metabolic	2.7%
Teeth and temporomandibular joint	2.3%
Other	2.5%
Total	100%

It is possible that every practitioner may find or treat varying types of symptoms in his patients, according to his experience and interest in specific fields of medicine. Nevertheless my impression is that acupuncture for musculoskeletal pain is the most common application for the majority of therapists.

RESULTS

The aim of my validation was to find answers to the following questions:

1. Were the different diagnostic methods quantitatively equivalent in unveiling the patient’s problems?

2. Were the different methods equivalent in diagnosing recent and past problems?

3. In the case of musculoskeletal disorders, were the different methods equally effective in detecting the prevalent side of pain?

Were the different diagnostic methods quantitatively equivalent in unveiling the patient’s problems?

The three diagnostic methods used had different success rates for the identification of patients’ symptoms. First came inspection with 52.2%, followed by PPT with 33.7% and ESRT(−) with 33.2%. Interestingly, if a symptom had been identified by at least one method there was a success rate of 78.6% (Table 9.2a). The significance of this is evident: the experienced practitioner, who generally applies all the proposed methods, acquires a better understanding of patients’ conditions. This result is confirmed by the significantly higher diagnostic potentiality of the three methods together compared to the inspection alone (Table 9.2b).

Table 9.2 Diagnostic success rates (%) obtained in the identification of 5641 symptoms in 506 patients with three methods: inspection, PPT and ESRT(−) (a); comparison of the different methods with paired samples t-test (b)a)

As expounded in Appendix 2, the Agiscop device used in the diagnostic procedures reported in this book allows a double electrical test, choosing either the minus (–) or the plus (+) modality. In 202 patients out of the total group of 506 we added the + modality, even though the average number of identified points is usually lower than with the − modality and consequently appears to identify a lower number of disorders in the patient. The success rates according to the four methods employed were as follows: (i) inspection 52%; (ii) PPT 34%; (iii) ESRT(−) 33.3%; (iv) ESRT(+) 20.4%. Thus, as expected, the + modality showed a lower success rate than the − modality; nevertheless its application as a fourth diagnostic modality increased the total success rate to 80.9% (Table 9.3).

Table 9.3 Diagnostic success rates (%) obtained in the identification of 2495 symptoms in 202 patients with four methods: inspection, PPT, ESRT(−) and ESRT(+) (a); comparison of the different methods with paired samples t-test (b)a)