Are the concepts of ear acupuncture sound?

What does ear acupuncture mean? Auriculotherapy? Auriculomedicine? Chinese ear acupuncture? Ear acupuncture is a diagnostic and treatment system based on normalising the body’s dysfunction through stimulation of definite points on the ear.¹ But several questions remain: Which acupoints should be used? What is auricular diagnosis? Can ear acupuncture be a real diagnostic system too? Is ear acupuncture always safe? And the main question: Is it efficacious?

Auriculotherapy is a treatment that is spreading all over the world. Its patterns follow the principles of Chinese acupuncture, revised and updated with Chinese maps of the ear, the principles of Paul Nogier’s auriculomedicine, and the principles of reflexology based on somatotopic maps that do not recognise energetic stimulation. Many different tools are used to stimulate the ear: finger acupressure, laser, electricity, different types of needles, magnetic balls or seeds.

Diagnosis can only be conventional. Modern diagnostics have improved so much that it is impossible not to consider the high reliability of modern medical tools: molecular medicine, genomics, PET and so on. If we search Pubmed for ‘EKG and diagnosis and accuracy’ we find about 2300 papers, and repeating the search with ‘radiography’ comes up with about 17 000 papers. If we do the same with auriculomedicine or Chinese medicine or traditional Chinese medicine, we will find only 10 papers. So after thousands of years the question of diagnosis in terms of accuracy has not been systematically addressed.

The problems relative to evidence-based medicine are manifold. In recent years clinical and basic research have shown that ear acupuncture may be useful in the treatment of both acute and chronic pain, and of anxietyrelated disorders.1 In these specific diseases the influence of placebo effects can be really crucial for its physiological effect, as we would consider the possibility that a new drug or treatment may have no analgesic properties, but may enhance placebo-activated endogenous opioids.² This is a very important clue, because there is not one single placebo effect, there are many. We need to look for different mechanisms in different conditions.³

Basic research is trying to explain the effect of therapeutic reflexes induced by acupuncture, so behavioural analgesia produced by auricular acupuncture can be blocked by the opiate antagonist naloxone, indicating the role of endorphinergic systems in understanding the underlying mechanisms of auriculotherapy analgesia. ⁴ Ear stimulation in healthy persons is associated with changed activity in the sympathetic and parasympathetic nervous system, depending on the site of stimulation and period of observation.⁵ Actually one of the main internal methodological problems with auricular acupuncture is that there are so many maps of the ear and little agreement regarding point location, with a lack of definitive anatomic studies on ear skin and its somatotopic correspondence.⁶,⁷

Safety not only relates to harm caused in error, such as inserting a needle incorrectly, but also to harm caused by a delayed diagnosis and correct conventional treatment. Some CAM practitioners, especially non-physicians, tend to explain or misdiagnose disease through not only unconventional medicine but also unconventional diagnosis. In some cases this can be very dangerous for patients delaying effective treatments.⁸

References

1. Gori L, Firenzuoli F. Ear acupuncture in European traditional medicine.. Evid Based Complement Alternat Med 2007; 4((Suppl. 1)): 13–16.
2. Finnis DG, Benedetti F. Mechanisms of the placebo response and their impact on clinical trials and clinical practice.. Pain 2005; 114: 3–6. [Abstract]
3. Colloca L, Benedetti F. Placebos and painkillers: is mind as real as matter? Nat Rev Neurosci 2005; 6: 545–52. [Abstract]
4. Oleson T. Auriculotherapy stimulation for neuro-rehabilitation.. NeuroRehabilitation 2002; 17: 49–62.
5. Haker E, Egekvist H, Bjerring P. Effect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjects.. J Auton Nerv Syst 2000; 79: 52–9. [Abstract]
6. Andersson E, Persson AL, Carlsson CPO. Are auricular maps reliable for chronic musculoskeletal pain disorders? A double-blind evaluation.. Acupunct Med 2007; 25: 72–9.
7. Mayer-Gindner A, Lek-Uthai A, Abdallah O. Newly explored electrical properties of normal skin and special skin sites.. Biomed Tech 2004; 49: 117–24.
8. Iwa M, Tateiwa M, Sakita M. Anatomical evidence of regional specific effects of acupuncture on gastric function in rats.. Auton Neurosci 2007; 137: 67–76. [Abstract]

Edzard Ernst Auricular acupuncture (ear acupuncture, or auriculotherapy) is a form of acupuncture in which points located exclusively on the outer ear (auricle) are stimulated by needling or by other means. In several ways, it represents a fundamental departure from other forms of acupuncture.

In ‘normal’ acupuncture, several points located on the ear along meridians can be used. Thus, ‘normal’ acupuncture includes the ear, but auricular acupuncture focuses on it exclusively. In the 1950s, the French physician Paul Nogier postulated that all body parts are represented in the auricle — in fact, the auricle was a full representation of an inverted foetus in the mother’s womb (upside down so that the head is represented by the ear lobe). Nogier suggested that the auricle can be seen as a map. Stimulating a given point on the ear would, according to Nogier, affect the corresponding body part or organ. Conversely, detecting tenderness at one ear point would provide diagnostic information as to which body part is dysfunctional or diseased.¹

To the ears of a sceptic, this may sound naive, perhaps even absurd, but it cannot be rejected out of hand — after all, similar representations exist in the brain. There are, however, serious problems with Nogier’s theory and its application. The most obvious is that the ear maps used for auricular acupuncture do not always agree. A map that cannot tell us where exactly to find Rome, London or Berlin is arguably not useful.

The even more fundamental problem is that Nogier’s theory is not supported by sound evidence. Early reports about a link between ear and body sites were based on methodologically weak studies.e.g.³ Rigorous assessments of such representations do not confirm such representations. Anderson etal. recently demonstrated a lack of agreement between patients’ reported pain regions and tender zones in the auricle.³

Enthusiasts of auricular acupuncture might argue that even if the theory is flawed, the practice could still be effective. So, does auricular acupuncture work? Sure it helps patients for all sorts of conditions — but is it more than a placebo?

Dozens of RCTs of auricular acupuncture have been published; many of them have generated positive results. Close scrutiny, however, reveals that most of these studies are methodologically weak. Whenever the totality of the evidence is critically evaluated, as for instance in the case of auricular acupuncture for cocaine dependence, the results are either cautious or totally negative: ‘There is currently no evidence that auricular acupuncture is effective …’⁴

In summary, auricular acupuncture is based on a bizarre concept that has little or no biological plausibility. The trial evidence is mixed but, on critical assessment, far from convincing. Of course, we should keep an open mind — but let us be careful that in doing so our brains do not fall out.⁵

References

1. Nogier P. Moulins-les-Metz: Maisonneuve SA. Handbook to Auriculotherapy 1981;
2. Oleson TD, Kroening RJ, Kroening RJ. An experimental evaluation of auricular diagnosis: the somatotopic mapping or musculoskeletal pain at ear acupuncture point.. Pain 1980; 8: 217–29. [Abstract]
3. Andersson E, Persson AL, Carlsson CP. Are auricular maps reliable for chronic musculoskeletal pain disorders? A double-blind evaluation.. Acupunct Med 2007; 25: 72–9.
4. Gates S, Smith LA, Foxcroft DR. Auricular acupuncture for cocaine dependence.. Cochrane Database Syst Rev 2006; 1:CD 005192:
5. Skrabanek P. Demarcation of the absurd.. Lancet 1986; 1: 960–1.