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Autonomic Neuroscience: Basic and Clinical 138 (2008) 50 56 www.elsevier.


Investigation of specificity of auricular acupuncture points in regulation of autonomic function in anesthetized rats
Xin-Yan Gao a,b , Shi-Ping Zhang a,, Bing Zhu b , Hong-Qi Zhang a

School of Chinese Medicine, Hong Kong Baptist University, 7 Baptist University Road, Kowloon Tong, Kowloon, Hong Kong, China b Institute of Acupuncture & Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China, 100700 Received 2 August 2007; received in revised form 29 September 2007; accepted 22 October 2007

Abstract Auricular acupuncture has been used for various autonomic disorders in clinical practice. It has been theorized that different auricular areas have distinct influence on autonomic functions. The present study aims to examine the effects of acupuncture stimulation at different auricular areas on cardiovascular and gastric responses. In male SpragueDawley rats anesthetized with pentobarbital sodium, five auricular areas, which were located at the apex of the helix (A1), the middle of the helix (A2), the tail of the helix (A3), the inferior concha (A4) and the middle of the antihelix (A5), had been selected for stimulation with manual acupuncture (MA) and different parameters of electroacupuncture (EA). A mild depressor response (6%12% decrease from baseline) was evoked from A1, A3 and A4 by MA and from all five areas by EA (100 Hz1 mA). The biggest depressor response ( 18.4 3.1 mmHg, p b 0.001) was evoked from A4. A small bradycardia was evoked by MA from A4 and by EA at A3, A4 and A5. Increase in intragastric pressure (814 mmH2O) was evoked by MA from A1, A3 and A4 and by EA at A2. These results show that similar patterns of cardiovascular and gastric responses could be evoked by stimulation of different areas of the auricle. The present results do not support the theory of a highly specific functional map in the ear. Rather, there is a similar pattern of autonomic changes in response to auricular acupuncture, with variable intensity depending on the area of stimulation. 2007 Elsevier B.V. All rights reserved.
Keywords: Acupuncture; Blood pressure; Heart rate; Gastric motility; Vagus nerve; Ear map

1. Introduction Auricular acupuncture (AA) is the application of needle stimulation to the external ear, which is a form of acupuncture practice that has been described in ancient China as well as Egypt, Greece and Rome (Oleson, 2003a). In 1950s, French physician Nogier reawakened the interest in AA by proposing a theory that there is a somatotopic and viscerotopic representation on the auricle, such that different body regions and organs appear on the external ear to form a humunculus of inverted fetus (Nogier, 1987). The selection of AA point for treatment, therefore, has been based on this theory. Hence,

Corresponding author. Tel.: +852 34112466; fax: +852 34112461. E-mail address: (S.-P. Zhang). 1566-0702/$ - see front matter 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.autneu.2007.10.003

a disorder from a particular part of the body is treated by the corresponding point in the ear (Oleson et al., 1980; Nogier, 1987). Since then, AA has been used for pain relief (Usichenko et al., 2005a,b; Goertz et al., 2006), anxiety and sleep disorders (Chen et al., 2007, Pilkington et al., 2007), as well as various autonomic disorders including hypertension (Huang and Liang, 1992), gastrointestinal disorders (Takahashi, 2006), lower urinary tract symptoms (Capodice et al., 2007) and postoperative vomiting (Kim et al., 2003). However there was no scientific evidence supporting Nogier's theory, and the specificity of AA points is still a matter of conjecture. This can be problematic when selecting treatment and control points in clinic trials (e.g., Margolin et al., 1996). A better understanding of the specificity of auricular points will help to improve clinical practice and facilitate AA research.

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Fig. 1. Drawings showing auricular zones and nerve distribution of the human auricle. A, auricular zones based on recommendations of the 1990 WHO auricular nomenclature committee (Oleson, 2003b). Large dots indicate areas stimulated in the present study or in previous studies as mentioned in the text. B, C and D show nerve distribution (indicated by small dots) of the human auricle according to Peuker and Filler (2002).

It has been documented that the human auricle receives innervations from cervical and cranial nerves including the auricular branch of the vagus nerve, the great auricular nerve and the auriculotemporal nerve (Peuker and Filler, 2002). Study of the origin and peripheral distribution of the primary afferent fibers in the auricle of cats and rats showed that innervations of the central region of the auricle mainly came from the trigeminal ganglion, the geniculate ganglion, the superior ganglion of the vagus nerve, and to a lesser degree, the spinal ganglia. In contrast, the peripheral region of the auricle was mostly innervated by spinal nerves (Satomi and Takahashi, 1991; Folan-Curran et al., 1994). The central projections of the auricular branch of the vagus nerve, so called the Arnold's nerve, had been examined by the transganglionic horseradish peroxidase (HRP) tracing method in cats. HRP-labelled neuronal somata were seen in the superior ganglion of the vagus nerve and terminal labelling was seen mainly in the ipsolateral solitary nucleus (Nomura and Mizuno, 1984). Thus, in the theorized ear map, the areas representing somatic parts such as the helix and the scapha are mainly innervated by somatic afferents, and those representing visceral organs such as the superior and inferior concha are primary innervated by cranial nerves especially the vagus nerve (Fig. 1). In human, it has been suggested that the sensory vagus nerve is responsible for the ear-cough reflex seen clinically (Tekdemir et al., 1998). As well, stimulation of the inferior concha could induce a significant increase in parasympathetic activity as demonstrated by heart rate variability (Haker et al., 2000). In the study of point specificity, Young and McCarthy (1998) reported that stimulation of the sympathetic point at the lower limb of the antihelix (AH6 in Fig. 1) significantly decreased the stimulus-evoked electrodermal response when compared with stimulation of a controlled point in the middle of the helix (HX9 in Fig. 1). It had been found that AA at specific points such as Lung (CO14 in Fig. 1) and Shenmen (TF4 in Fig. 1) produced better analgesic effect than at non-

acupuncture points on the helix (Usichenko et al., 2005a,b). Taken together, evidence from anatomical studies and clinical observations suggest that there might be location specificity for auricular points. In this study, we set out to examine the specificity of auricular acupuncture points in regulation of autonomic function using gastric and cardiovascular changes as indicators. 2. Methods and materials 2.1. Animal preparation The experimental protocol was approved by the animal ethics committee of the Hong Kong Baptist University. Male SpragueDawley rats (n = 18), weighing 300380 g, were fasted overnight with free access to water. They were

Fig. 2. Photograph of the right ear of the rat showing areas being stimulated in the present experiments. A1, A2, A3, A4, and A5 correspond to HX6, HX9, HX12, CO15, and AH9 in the human auricular map as described in Fig. 1, respectively.


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Fig. 3. Computer chart records of a typical experiment. Changes in blood pressure (BP), heart rate (HR) and intragastric pressure (IGP) during manual acupuncture (MA) at five areas of the rat auricle are shown in the boxes. Schematic drawing of the right ear of the rat shows the location of the auricular areas being stimulated.

anesthetized with an initial dose of pentobarbital sodium (i.p., 50 mg/kg, Alfasan), with i.v. supplement (1520 mg/ kg/h) via the jugular vein using a syringe pump to maintain the level of anesthesia at a depth in which the withdrawal reflex to a noxious toe pinch was absent. After tracheal cannulation, animals breathed spontaneously and the core temperature was maintained at 37.0 0.5 C by a feedbackcontrolled electric blanket. Animals were sacrificed humanely with an overdose of pentobarbital sodium at the end of the experiments. For recording of mean arterial pressure (MAP), the left common carotid artery was cannulated with a polyethylene

tubing filled with normal saline containing heparin (500 IU/ ml, Sigma), and connected to a blood pressure transducer. Needle electrodes were placed at the forelimbs and the left hind limb for ECG recording (Bio Amp, ADInstruments), from which heart rate (HR) was derived. For recording of intragastric pressure (IGP), a midline laparotomy was made with a small latitudinal incision in the duodenum wall about 23 cm from the pylorus. A balloon (1 cm in diameter) made of flexible condom rubber was inserted into the pyloric antrum and kept in position by tying the connecting polyethylene tubing (ID 0.58 mm, OD 0.96 mm, PORTEX) to the duodenum (Kametani et al., 1979). The balloon was filled

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auricular area separated by approximately 1.5 mm with the aid of a piece of cotton wool. The EA stimulation consisted of biphasic rectangular pulses (0.45 ms) at four different intensities and frequencies: low frequencylow intensity (LL: 4 Hz0.4 mA), low frequencyhigh intensity (LH: 4 Hz 1.0 mA), high frequencylow intensity (HL: 100 Hz0.4 mA), high frequencyhigh intensity (HH: 100 Hz1.0 mA). Each episode of EA stimulation lasted for 30 s. All four parameters of EA induced twitch of the ear, indicating effective stimulation of auricular muscles. When tested on human subjects, LL and HL of EA were just above the detection threshold and were reported non-painful, whereas LH and HH of EA were sometimes reported to be painful but tolerable (personal observation). In a given experiment, MA and EA were examined for different auricular areas and the stimulations were arranged randomly and repeated 34 times. 2.3. Statistical analysis Baseline values of MAP and HR were measured by taking the average of 1 second record after needle insertion and just before acupuncture stimulation, when the signals were stable. Baseline IGP was determined by the last peak value of the peristaltic wave just before the stimulation. Changes in MAP and HR were measured by taking the average of a 1 second record with the biggest change during acupuncture stimulation, and change of IGP was measured by selecting the highest peak of peristaltic wave during the acupuncture stimulation period. Comparison between means was made by Student's-t test and one-way ANOVAwith LSD post-hoc test. Data were presented as mean S.E.M., and p b 0.05 was considered significant. 3. Results 3.1. Cardiovascular and gastric responses evoked by manual acupuncture (MA) Data had been obtained from 12 successful experiments. Before the start of any stimulation, the MAP was 116.4 8.9 mmHg, and the HR was 386.0 8.4 beats per minute (bpm). As seen in Fig. 3, MA at auricular areas of A1, A3, and A4 produced significant depressor responses ( 8.0 1.6 mmHg, 7.5 2.6 mmHg and 18.4 3.1 mmHg respectively,

Fig. 4. Histograms showing mean values ( S.E.M.) of mean arterial pressure (MAP), heart rate (HR) and intragastric pressure (IGP) before and after manual acupuncture (MA) in five different areas of the auricle (A1-5). *" s inside the bars indicates statistical significant difference between pre-MA and post-MA ( : p b 0.01; : p b 0.01;: p b 0.001; paired t-test). #s indicates statistical significant difference compared with A4 (one way ANOVA with LSD post-hoc test; #: p b 0.05; ##: p b 0.01; ###: p b 0.001).

with 0.30.8 ml water pre-warmed to 37.0 0.5 C and kept at a baseline pressure of 40250 mmH2O. IGP was measured from the intragastric balloon with a transducer connecting to an amplifier (ADInstruments). Background gastric motility was recorded for at least 30 min before AA stimulation. 2.2. Auricular acupuncture stimulation When the depth of anesthesia was stable, showing that the fluctuation of MAP and HR were less than 5% within a minute and the gastric peristaltic wave was stable, responses to manual (MA) or electroacupuncture (EA) were examined. Five auricular areas, which were located at the apex of the helix (A1), the middle of the helix (A2), the tail of the helix (A3), the inferior concha (A4) and the middle of the antihelix (A5), corresponding to HX6, HX9, HX12, CO15, and AH9 in human auricle respectively, were selected for MA and EA (Figs. 1 and 2). Acupuncture needle (0.2 mm 13 mm Hwato, China) was inserted to a depth of 12 mm from the skin surface before each stimulation. For MA, the needle was twisted right and left once every second for 30 s and then removed. For EA, a pair of needles was inserted into the same

Fig. 5. Histograms showing the effect of needle insertion on mean arterial pressure (MAP). indicates statistical significant difference between pre- and post-insertion in MAP (p b 0.001, paired t-test).


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Fig. 6. Histograms showing changes in mean arterial pressure (MAP), heart rate (HR) and intragastric pressure (IGP) for five auricular areas (A15) under different parameters of electroacupuncture. LL, low frequency (4 Hz), low intensity (0.4 mA) stimulation; LH, low frequency (4 Hz), high intensity (1 mA) stimulation; HL, high frequency (100 Hz), low intensity (0.4 mA) stimulation; and HH, high frequency (100 Hz), high intensity (1 mA) stimulation. s inside the bars indicate statistical significant change compared with baseline (p b 0.05; : p b 0.01; paired t-test); #s outside the bars indicate statistical significance compared with HH (one way ANOVA with LSD post-hoc test; #: p b 0.05; ##: p b 0.01; ###: p b 0.001).

p b 0.05, Fig. 4), which outlasted the duration of the stimulation. No significant change in MAP was observed during stimulation of A2 and A5. Changes in HR were rather variable and statistical difference could only be found during stimulation of A4 ( 4.5 1.6 bpm, p b 0.05). MA also led to an increase in IGP at A1, A3, A4 (14.7 4.3 mmH2O, 11.9 5.5 mmH2O and 12.8 3.8 mmH2O, p b 0.05, respectively). Thus, MA at A1, A3 and A4 evoked simultaneous changes in MAP and IGP, but simultaneous changes in MAP, and IGP as well as HR were evoked only at A4. A4 showed the biggest depressor response compared to other areas ( p b 0.01). Interestingly, it was observed that insertion of the needle evoked significant depressor responses at all auricular areas

( p b 0.001, Fig. 5). Compared to MA, the duration of the depressor responses evoked by insertion of the needle was less than that evoked by MA, lasting for a few seconds only, but the magnitude of the response was similar to that of manual acupuncture. However, no significant change in HR or IGP was observed during needle insertion. 3.2. Autonomic changes evoked by electroacupuncture (EA) As seen in Fig. 6, of the four types of EA applied to the five AA areas, HH evoked significant decrease in MAP at all areas ( 8.8 3.7 mmHg at A1, p b 0.05; 8.6 2.6 mmHg at A2, p b 0.01; 9.6 3.5 mmHg at A3, p b 0.05;

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7.6 1.9 mmHg at A4, p b 0.01 and 12.9 2.5 mmHg at A5, p b 0.01). HH at A3, A4 and A5 induced small bradycardia ( 7.0 1.4 bpm, 5.7 1.7 bpm and 8.3 1.8 bpm respectively, p b 0.05), and at A2 produced significant increase in IGP (7.6 2.4 mmH2O, p b 0.05). EA of HL evoked significant depressor effect at A3 ( 5.1 1.7 mmHg, p b 0.05). Low frequency EA at either low (LL) or high intensity (LH) did not evoke any significant change in MAP, HR or IGP (Fig. 6). Comparing the responses evoked by MA and EA of HH for a given area, the overall patterns of response appeared to be similar, except the depressor effect produced by MA was significantly bigger than that evoked by EA of HH at A4 ( p b 0.01), and the bradycardia evoked by EA of HH was bigger than that evoked by MA at A3 ( p b 0.05). 4. Discussion This is the first study that examines systematically the location specificity and response characteristics of autonomic changes using different methods of stimulation in auricular acupuncture. The major finding from this study is that stimulation of the auricle with either MA or strong EA (100 Hz1 mA) can evoke a characteristic pattern of response including decrease in blood pressure, bradycardia and gastric contraction, whereas mild EA is ineffective. Decrease in blood pressure is the most consistent response evoked by MA and EA. On the other hand, changes in HR and gastric contraction are more variable, depending on the area and method of stimulation. Cardiac dysrhythmias and bradycardia have been reported during insertion of an ear speculum and initial manipulation of the ear (Moorthy et al., 1985). Activation of the parasympathetic system by auricular acupuncture in man, as measured by heart rate variability, has also been reported before, although the same study fails to elicit any change in blood pressure and heart rate (Haker et al., 2000). The observation in the current study that needle insertion, manual needle manipulation and strong EA are effective in evoking autonomic responses, whereas weaker forms of EA are not, suggest that strong or even painful stimulation may be required to produce these responses. In a separate series of experiments aimed to explore the mechanism of the auricular-autonomic responses (Gao et al., unpublished data), we had observed that the responses evoked from A4 were abolished by blockade of vagal transmission with intravenous injection of the muscarinic receptor blocker atropine sulphate (0.5 mg/kg). That is, before atropine blockade the changes in MA, HR and IGP were 16.5 4%, 2.3 0.5% and 49.5 13.2%, respectively (n = 5, p b 0.05, paired t-test, compared with pre-acupuncture baseline), and after the blockade the changes in MA, HR and IGP were 2.7 1.7%, 0.7 0.6% and 4.5 2.9%, respectively (n = 5, p N 0.05, paired t-test, compared with post-atropine, pre-acupuncture baseline). These results suggest that the depressor response, bradycardia and gastric contraction induced by AA may be

due to an increase in vagal output, mediated by auricularvagal reflexes. In contrast, a different efferent pathway has been demonstrated in depressor response evoked by body acupuncture. For example, Ohsawa et al. (1995) showed in the rat that acupuncture-like stimulation at the hind limb reduced renal sympathetic nerve activity coupled with the depressor response. It is interesting to note that MA at only A4 of the inferior concha area evoked consistent bradycardia, whereas MA at other areas evoked increase or decrease in heart rate. Sato et al. (1976) reported that cutaneous noxious stimulation in anesthetized rats produced an increase in heart rate in about 70% of their tests, while in the other 30% induced either biphasic responses or no change. Activation of hind limb muscle afferents in the dog was also associated with either increase or decrease in heart rate (Tallarida et al., 1985). Taken together, the inferior concha represents a distinct region in which decrease in heart rate could be evoked consistently. It has been observed that for a given area, the patterns of response evoked by MA and EA can be different. This may be due to the fact that EA stimulates local receptors as well as nerve fibers that innervate other area passing through the area of stimulation, and that the effective stimulation area of EA may well exceed the area between the two inserted needles as a result of spreading of the electrical current. In contrast, manual manipulation stimulates receptors primary at the site of needle insertion. The differences in the response evoked by different methods of AA should be taken into consideration in clinical practice and research. As for the analysis of functionalanatomical relationships on the auricle, the results obtained from MA stimulation may be more precise, for reasons discussed above. The inferior concha produced the biggest depressor effect during MA in the present experiments, and it was the only site where bradycardia could be elicited. This coincides with previous findings that the conchae receives major innervations from the auricular branch of the vagus nerve (Fig. 1). However, apart from the inferior concha, the areas in which depressor response and gastric contraction have been elicited by MA in the current experiments include the apex of the helix and tail of the helix, which are innervated predominately by the auriculotemporal nerve and the great auricular nerve, respectively. This indicates that the hypotensive and gastric responses are not elicited solely from areas innervated by the vagus nerve. This is in agreement with previous findings that denervation of the auricular branch of the vagus nerve did not abolish gastric response evoked by auricular acupuncture in the rabbit, but complete denervation of all the nerves to the ear did (Liu et al., 1990). Taken together, it appears that the AA-evoked autonomic responses are mediated by the auricular branch of the vagus nerve, as well as other sensory nerves innervating the ear. Direct vagal nerve stimulation has been used in clinical practice for treatment of refractory epilepsy and major depression (Shafique and Dalsing, 2006). Recently, Kraus et al (2007) showed that non-invasive electrical stimulation of the outer auditory canal, aiming to activate vagal afferences, produced enhancement of well-being score coupled with deactivation of


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limbic and temporal brain structures, whereas stimulation of the ear lobe did not. It is interesting to note that AA point Heart (CO15 in Fig. 1 or A4 in Fig. 2) in the inferior concha has also been used for mood disorders in clinical practice (Pilkington et al., 2007; Wang et al., 2001). Taken together, convergent evidence supports that the concept that vagal afferents on the auricle provide a unique situation whereby autonomic and other nervous disorders may be corrected with the use of appropriate stimulation, such as acupuncture. 5. Conclusions Previous schemas of auricular acupuncture suggest that auricular points have high specificity. On the other hand, anatomical studies of auricular innervations have described an overlapping network of distribution of somatic and cranial nerves, although some areas do receive preferential innervations from one or two nerves. Our experiments show that the same pattern of reflex responses can be elicited from different areas with supposedly distinct nerve innervations. Taken together, evidence from anatomical and physiological studies does not support the concept of a highly specific functional map in the ear. Rather, there is a general pattern of autonomic changes in response to auricular acupuncture, with variable intensity depending on the area of stimulation. Our study suggests that the inferior concha is the most powerful site for regulation of autonomic functions. However, in clinical study, it should be cautious in using auricular points outside the conchae as control points, as they also have the potential to influence autonomic functions. Acknowledgements Dr. Xin-Yan Gao is supported by the Wofoo Postdoctoral Fellowship Scheme of Chinese Medicine from the Hong Kong Baptist University. The technical assistance of Miss Nickie Chan is appreciated. References
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