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A New Method in Auricular Medicine for the Investigation of the Nogier Reflex

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Background: Although there is as yet no scientific consensus on this topic, the Nogier reflex or reflex auriculo-cardiac (RAC; also vascular autonomic signal) is an important method in auricular medicine. This article introduces a new methodological approach for the detection and quantification of the RAC. Methods: A new high-resolution imaging technique for the registration of pulsatory surface changes might allow the RAC to be quantified reproducibly for the first time. The method combines an innovative microscope system (available at the Medical University of Graz), video analysis software, and special image processing software (from the Beijing University of Science and Technology). Results: Even small, pulse-dependent alterations of the skin surface could be clearly visualized. Conclusion: The pilot measurement confirmed the validity of the new methodological approach. Further investigations are necessary and in progress.
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Original Paper
Integr Med Int 2014;1:205–210
A New Method in Auricular Medicine for
the Investigation of the Nogier Reflex
Gerhard Litscher
a–c, e, f Frank Bahr
d Daniela Litscher
a–c Le-Quan Min
e
Pei-Jing Rong
f
a Research Unit for Complementary and Integrative Laser Medicine,
b Research Unit of Biomedical
Engineering in Anesthesia and Intensive Care Medicine, and
c TCM Research Center Graz, Medical
University of Graz, Graz , Austria;
d German Academy for Acupuncture, European Academy for
Traditional Chinese Medicine, Munich , Germany;
e Department of Information and Computing Science,
School of Mathematics and Physics, Beijing University of Science and Technology, and
f Institute of
Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing , China
Key Words
Auricular medicine · Auricular therapy · Nogier reflex · Reflex auriculo-cardiac · Vascular
autonomic signal · New method · Ear acupuncture · Image recognition
Abstract
Background: Although there is as yet no scientific consensus on this topic, the Nogier reflex
or reflex auriculo-cardiac (RAC; also vascular autonomic signal) is an important method in
auricular medicine. This article introduces a new methodological approach for the detection
and quantification of the RAC. Methods: A new high-resolution imaging technique for the
registration of pulsatory surface changes might allow the RAC to be quantified reproducibly
for the first time. The method combines an innovative microscope system (available at the
Medical University of Graz), video analysis software, and special image processing software
(from the Beijing University of Science and Technology). Results: Even small, pulse-dependent
alterations of the skin surface could be clearly visualized. Conclusion: The pilot measurement
confirmed the validity of the new methodological approach. Further investigations are neces-
sary and in progress. © 2015 S. Karger AG, Basel
Introduction
In the 1950s, Paul Nogier introduced the reflex auriculo-cardiac (RAC; also Nogier reflex
or vascular autonomic signal) [1, 2] . The RAC, according to Nogier, is a short-term reaction of
the human circulation to different kinds of acupuncture point stimulation of the ear [3] . This
Receive d: February 13, 2015
Accepted after revision: February 14, 2015
Published online: March 31, 2015
Gerhar d Litscher, Univ. Prof., MSc, PhD, MDsc
Medical University of Graz
Auenbruggerplatz 29
AT–8036 Graz (Austria)
E-Mail gerhard.litscher
@ medunigraz.at
www.karger.com/imi
DOI: 10.1159/000381147
This is an Open Access article licensed under the terms of the Creative Commons Attribution-
NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to
the online version of the article only. Distribution permitted for non-commercial purposes only.
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Integr Med Int 2014;1:205–210
DOI: 10.1159/000381147
Litscher et al.: A New Method in Auricular Medicine for the Investigation of the Nogier
Reflex
www.karger.com/imi
© 2015 S. Karger AG, Basel
reaction is supposed to last for a few seconds and can be felt and used for diagnostic purposes
by experienced therapists. However, it should be mentioned critically that RAC diagnosis is
not yet generally acknowledged by the scientific community [4–7] ; therefore, in the authors’
opinion, it represents one of the complementary medical methods that needs new investi-
gative approaches and methodical strategies.
In September 2014, a popular scientific journal published a video [8] demonstrating a
new video processing method, which had been developed by the Massachusetts Institute of
Technology (MIT) in Boston. In this film sequence, the human pulse is made visible, and it is
stated that this method should be introduced soon. The principle and the technical realization
of this video method can be seen in figures 1 and 2 .
The first two authors of this paper agreed that this method might be useful in RAC
research. On closer inspection, however, it was found that this method would only yield
limited new evidence with regard to the RAC, not least because of its low resolution. A new
approach was needed. Therefore, the research group at the Medical University of Graz started
testing a direct way of amplification at a high resolution. The aim of our method is to directly
‘amplify’ and show images of that part of the skin surface where the RAC is usually felt, using
state-of-the-art technical methods.
The results of a pilot measurement are introduced in this article, underlining the fact that
our new approach might indeed be a future-oriented option in RAC research.
Methods
First test measurements were carried out in November 2014 ( fig. 3 ), using an innovative
microscope system available at the Institute of Pathophysiology and Immunology at the
Medical University of Graz as of July 22, 2014: an Olympus fluorescence stereomicroscope
SZX16 and the dimension software package (Olympus; Shinjuku, Tokyo, Japan).
Having detected the changes of the pulse under the microscope and registered the video
signals using appropriate software packages, it is planned to analyze single images or image
sequences comprehensively with sophisticated mathematical methods. This should be done
using special image processing programs developed at the Beijing University of Science and
Technology [9] . This software allows the presentation of changes within image sequences
Fig. 1. Principle of the video analysis method carried out by the MIT. Modified from [8] .
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© 2015 S. Karger AG, Basel
using special mathematical algorithms; as a consequence, these alterations become quanti-
fiable. A further goal will be to replace the complex mathematical image processing programs
by standard software, thus simplifying analysis. A diagram representing the new procedure to
visualize dynamic structures on the skin surface at the radial artery can be seen in figure 4 .
The area, e.g. at the radial artery ( fig. 4 a), is amplified using a special microscope ( fig. 4 b)
and can be presented digitally with analysis programs ( fig. 4 c). Tiny hairs (black structures
in fig. 4 c) in the selected area serve as a token of scale. With the application of the image
analysis software from the Beijing University of Science and Technology ( fig. 4 d), special
areas can then be magnified ( fig. 4 e). This can be repeated many times until only single pixels
remain (areas framed red in fig. 4 f and 5 ). Such areas appear pulse synchronously because of
Spatial decomposition
Reconstruction
Tempo ra l f ilter s
į1
į2
įn–1
įn
Ʒ
Ʒ
Ʒ
Ʒ
Fig. 2. Technical implementation of the MIT video method. Modified from [8] .
Fig. 3. Experimental set up and
first RAC test measurement for
high-resolution imaging of pulsa-
tory surface changes at the labo-
ratory of the Institute of Patho-
physiology and Immunology at
the Medical University of Graz on
November 5, 2014.
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© 2015 S. Karger AG, Basel
the change of position of the surface relative to the microscope in the area of the vessel to be
investigated, and the regions of interest can then be quantified by analyzing the single pixels.
Using this approach, a quantification of the RAC seems possible.
Results
Some of the results of the pilot registration can be found in figure 5 . Sixteen images (a–p),
representing the chronology of 4 s, can be seen in figure 5 . The two-dimensional surface
changes that can be visualized during the dynamic process of the pulse beat are clearly seen.
These visualized alterations of the surface at the radial artery serve to quantify possible stim-
ulation-induced changes in the surface tension of a vessel (RAC), which up to now could only
be palpated by specially educated therapists.
Discussion
On one of his websites, Raphael Nogier, Paul Nogier’s son, reports that there have been
several attempts to prove the RAC beyond any scientific doubts since the 1970s [10] . Unfor-
tunately, these attempts lack convincing results and a scientific consensus with regard to this
question [11] .
In a promising study, Moser et al. [12] were able to find equivalents of the Nogier reflex
using modern circulatory-physiological measurement methods. They investigated 10 volun-
teers with a sensor jacket originally developed for space aviation medicine and found tran-
a
b
c
d
e
f
Fig. 4. Schematic illustration of the new method for the quantification of surface changes.
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© 2015 S. Karger AG, Basel
sient heart rate decelerations as well as biphasic changes of velocities and pulse amplitudes
in arteries on the arm. The chronological sequence of these phenomena corresponded well
with subjective descriptions of the RAC [12] . However, the authors stated critically that an
interference-free proof of the RAC was not possible with the chosen methods at that point in
time, and that ‘feasible’ results could only be achieved using averaging procedures [12] .
The methods applied in our pilot measurement take a different approach. A therapist’s
fingertip sensorium seems to be able to detect tissue changes and hence surface tension
subjectively, also with regard to direction. Using innovative instruments, the new method
aims to visualize even the smallest stimulation-induced changes of the skin surface and the
arteries beneath. The authors are of the opinion that research on the topic of the Nogier
reflex will play an important role in integrative medicine [13, 14] , especially in acupuncture
research.
In a pilot measurement, we have been able to show that the method developed at the
TCM Research Center Graz (a combination of a high-tech microscope and analysis software,
followed by sophisticated mathematical image processing) is able to visualize changes of
the pulse beat reliably, be they ever so small. The next step will be to test whether direction
phenomena [a shift of the pulse wave under the therapist’s palpating thumb tip towards
the patient’s thumb (positive RAC) or in the other direction (negative RAC)] can also be
quantified with the new procedure in order to further investigate reflex-based changes and
1 s
abcd
efgh
ijkl
m n o p
Fig. 5. Visualization of surface changes in the area of the pulsating radial artery. Note the alterations appear-
ing during the ‘maximum pulse’ (regions of interest framed red; color refers to the online version only).
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Integr Med Int 2014;1:205–210
DOI: 10.1159/000381147
Litscher et al.: A New Method in Auricular Medicine for the Investigation of the Nogier
Reflex
www.karger.com/imi
© 2015 S. Karger AG, Basel
the underlying changes in blood flow velocity. Further experiments might deal with the
RAC topic and laterality, as performed recently in a body acupuncture point laterality
study [15] .
Acknowledgments
The authors would like to thank the German Academy for Acupuncture for supporting the
scientific studies on the RAC topic. We would also like to thank Univ. Prof. Dr. Anton Sadjak,
head of the Institute of Pathophysiology and Immunology at the Medical University of Graz,
and his team, especially Assist. Univ. Mag. Dr. Nassim Ghaffari Tabrizi-Wizsy and Christina
Passegger, MSc, for their cooperation and for the possibility to carry out the pilot measurement
at the said institute. Further, the authors would like to thank Ingrid Gaischek, MSc (TCM
Research Center Graz, Medical University of Graz), for her help with manuscript preparation.
The auricular acupuncture measurements were performed in cooperation with the
Beijing University of Science and Technology and the Institute of Acupuncture and Moxi-
bustion at the China Academy of Chinese Medical Sciences. Prof. Litscher is Visiting Professor
at both institutions.
This paper was accepted in modified form as a first project report in the German language
under the title ‘Neue Strategien in der RAC (Reflex Auriculo-Cardiac) Forschung – Hochauflösende
Darstellung von pulsatorischen Oberflächenveränderungen im Labor’ (authors: G. Litscher, F.
Bahr and D. Litscher) by the journal Akupunktur & Aurikulomedizin for issue 1/2015.
Disclosure Statement
The authors declare that there are no conflicts of interest concerning the publication of
this article.
References
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... 6]. Litscher u. Mitarb.[7] veröffentlichten 2014 zusammen mit deutschen und chinesischen Forschern einen Originalartikel in Integrative Medicine International. ...
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Background: Using a modern scientific basis, this article examines clinical findings and experimentally reproducible data that demonstrate reliably the objective reality of the auriculotherapy procedures initiated by Paul Nogier, MD, of Lyon, France. Objective: The aims of this review are to: (1) identify the Chinese acupoints and all relevant related subjects; (2) offer a critical analysis of different auricle cartographies or ear maps; and (3) evaluate evidence for auriculotherapy with respect to the constant progress of our knowledge of nervous-system organization. Discussion: Acupuncture points have lower electrical impedance than nonacupoints. This was demonstrated by Niboyet and Terral, utilizing a sinusoidal current with the technical arrangements of different equivalent circuits made at Unit 103 of the French National Institute of Health and Medical Research (INSERM), Montpellier, France. This work demonstrated that physical behavior associated with acupuncture corresponds to a specific histologic structure located within the dermis termed the neurovascular complex (NVC). The concept of using sham points for testing acupuncture needs to be criticized. A reproducible experimental model of analgesia has been produced using the hind limb of a rabbit; this model is a proven demonstration of the positive action of acupuncture on pain. Acupuncture analgesia is a technique that has been used effectively by Chinese researchers in the 1970s for surgical applications. The different ear maps may have to be significantly modified because of the paucity of scientific validation of most of the localizations of organs or functions and, particularly, of nervous structures. Increased knowledge about complex nervous interactions should facilitate formulation of some scientifically acceptable hypothesis to explain the action of auriculotherapy. Conclusions: More scientific research should be performed to improve the scientific credibility of auriculotherapy.