"Neuropathic Pain: Auriculotherapy Potential" (in remembrance of Marco Romoli)

Abstract

Auriculotherapy is apt to treat pathological conditions based on a neurophysiological pattern. It acts on the neural networks, eliciting action potentials, urging and rebalancing hormones and neurotransmitters secretion. The fastest and the best results are obtained in treating painful syndromes of whatever origin. It has been acquired acupuncture to elicit synthesis of endorphin, enkephalin, dynorphin,, serotonergic, noradrenergic, and non-opioid neurotransmitters. It is conceivable the central-mediated effects of ear acupuncture to be involved in suppression of neuropathic pain, too. We aim to do an excursus of approaches to different patterns of neuropathic pain, starting with the Marco Romoli' s intellectual contribution and experience in patient observation and auricular diagnosis, without neglecting other methods, conceived on the pathophysiological basis for neuropathic painful syndrome. Some cases, mostly unpublished, treated by scientific western auriculotherapy, are reported. Nevertheless, it is necessary to bring efficacy trials, by means of applied research on suitable sample size of patients. To do this, the biggest challenge is to find financial and human resources, but the main requirement for researchers and clinicians, around the world, is to improve the communication skills to exchange details about their work and share the results of their ongoing studies.

Full text

Neuropathic Pain:
Auriculotherapy Potential
9th International Symposium on Auriculotherapy
10th-12th August, 2017
Singapore
Cornelia De Marchi

Thanks
! I heartily thank Im-Quah Smith to entrust
me with doing Marco Romoli’s
remembrance
! I’m honoured to have the opportunity to
remember a special man and scientist,
who was my first teacher of
Auriculotherapy (AUTh), in Bologna, then
a confident colleague
! I have a debt of gratitude towards him,
as a master and a friend

Neuropathic Pain:
Auriculotherapy Potential

Marco Romoli’s cultural
legacy
! This presentation collects the last work of
Marco Romoli on the auriculotherapy in
neuropathic pain treatment
! Firstly, I’ll present to you Romoli’s case
reports and the key points of his last
clinical work
! Secondly, I’ll add some case reports of
mine, treated according to the dictates of
neurophysiological auriculotherapy
! Finally, I’ll epitomize the founding
qualities of western auriculotherapy

May Auriculotherapy be
helpful in
the
integrated treatment of
neuropathic pain?
Are there specific auricular points and
areas
associated to neuropathic pain?

Marco Romoli’s inductive method
! Firstly, he completed the diagnostic evaluation by means of ear
inspection;
! then he assessed the ear tenderness to the Pain Pressure Test
(PPT) by means of adequate device
! Afterwards, he proceeded to the electrical detection of tender
points (ESRT) all over the pinna, by means of Pointoselect (or
similar device)
He drew on his sectogram the points sought out
! Thenceforth, he pricked all tender points detected on the ear
! So, he used to insert many needles on the ear for the chronic
pain syndromes
He applied acupunture treatment for pain, as long as the number
of the detected points decreased sharply
How did he teach to proceed in the
clinical work?

Romoli’s Sectogram: lateral surface

Romoli’s Sectogram: lateral and medial
surface

Reference.
Marco Romoli. Agopuntura Auricolare.
2003, UTET, Italy
! “The general indications of auricular
acupuncture are similar to those of
somatic acupuncture”
! If there are signs of compromising
sensitivity and muscular strength,
neurosurgical evaluation is always
necessary. If surgery is not indicated,
treatment with both acupuncture
techniques is to be considered
! It is possible that ear acupuncture is
more beneficial than somatic
acupuncture”

Reference.
Marco Romoli. Agopuntura Auricolare.
2003, UTET, Italy
In the case of cervico-brachialgia (neck and arm’s neuralgia), the
tender points are mostly detectable above the antihelix, in the
sectors 11 to 13
In lumbar sciatalgia, if the pain is neuropathic, it is good to
stimulate the ear particularly at helix, in the sectors 17-21”
If there is no ischial nerve compression, 1-2 needles are sufficient
on the representation of lumbo-sacral rachis
For Recurrent Inflammatory Lumbar-Sciatic Pain, it is better
! to check by PPT (Pain Pressure Test) the exact points, in order of
stimulating them both in erect posture (straight spine) and in
bent spine position”
! to use ASP needles
! to combine somatic and auricular acupuncture, in this order

On the left the classical site of cauterization for sciatic pain in the 1950’;
on the right sectors with a significantly higher number of PPT points,
with respect to the average number per sector, in 30 patients with
lumbar hernia submitted to a series of 3 epidural infiltrations
Romoli M, Greco Francesco et al. Auricular acupuncture diagnosis in patients
with lumbar hernia (submitted for publication)

Herpes V°, 1. branch

Herpes V°, 2. branch

73-year-old male with post-herpetic neuralgia C2-C3 since 8 months.
Limited therapeutic answer to a daily intake of GABAPENTIN 300 mg x 4.
50% improvement of neuropathic pain after 3 applications of ASP

Herpes Th4-Th5

Same patient:
1° treatment 2° treatment (15 days after)

Marco Romoli. Auricular Differential
Diagnosis in Neuropathic Pain. Med
Acupuncture,2014;26(2)
A consecutive group of 50 patients with lumbar /
lumbar-sciatic pain; 30 subjects carried lumbar
hernia
(identified by RM at L3-L4, L4-L5, L5-S1);
all of them insufficiently respondent
to the standard medication regimen.
Aim of the study:
to verify if
the 3 main areas, helix, posterior surface,
antihelix, have the same diagnostic significance in
respect to the neuropathic component of pain

Neuropathic pain is a chronic pain that is
“initiated or caused by a primary lesion or
dysfunction in the nervous system”
Merskey H, Bogduk N. Classification of chronic pain.
Seattle, WA: IASP Press 1997, p. 205-13
“arising as a direct consequence of a lesion or
disease affecting the somatosensory system”
Treede RD, Jensen TS, Campbell JN et al. Redefinition of
neuropathic pain and a grading system for clinical use:
consensus statement on clinical and research diagnostic
criteria. Neurology 2008; 140: 405-10

Examples:
PERIPHERAL
Post-herpetic neuralgia
Trigeminal neuralgia
Diabetic polyneuropathy
Post-surgical neuropathy
Post-traumatic neuropathy
CENTRAL
Stroke
Spinal cord injury
Multiple sclerosis
Examples:
Lumbar and cervical
radiculopathy
Oncologic pain
Carpal tunnel
syndrome
Examples:
SOMATIC PAIN from the
skin,
mucous membranes,
muscles,
bones, joints,
ligaments, tendons,
fasciae,
blood vessels etc.
VISCERAL PAIN

Sample of study
22 male and 28 female (total 50 pts),
average age 54.7
suffering with
lumbar / lumbar-sciatic pain
(since 1 month - 15 years),
were examined by Pain Pressure Test (PPT)
using an algometer of 250 maximal pressure.
Exclusion criteria:
• intake of analgesics and benzodiazepines at the day
of examination
• mood disorders and anxiety treated continuosly with
psycoactive drugs
Every patient underwent the usual orthopedic examination,
as regards the laterality and topography of pain and eventual
neurological signs
(hyposthenia, hypoesthesia, etc.)

Assessment tools for pain intensity and quality
• Verbal Numeric Scale (0 = no pain, 10 = worst pain)
• McGill Pain Questionnaire (MGPQ), the
most commonly used quality assessment tool for
any type of pain
Melzack R. The McGill Pain Questionnaire: major properties
and scoring methods. Pain 1975; 1: 277-299
• Neuropathic Pain Scale (NPS), designed
to assess the distinct qualities associated with
neuropathic pain
Galer BS, Jensen MP. Development and preliminary
validation of a pain measure specific to neuropathic pain:
the Neuropathic Pain Scale. Neurology 1997; 48: 332-8

Clusters of points detected with
PPT on the lateral surface
(squares) and on the medial
surface (triangles), on the cited 50
subjects of the study.
The lighter squares/triangles = a
lower concentration of tender
points,
The darker squares/triangles = a
higher concentration of tender
points
Helix area shows a significantly higher
number of tender points in patients carrying
a persistent lumbar / lumbar-sciatic pain
insufficiently responding to the normal
analgesic medication.
It is possible that these patients carry a
chronic “mixed” pain syndrome with a
variable amount of neuropathic pain.
Auricular diagnosis allows in these
cases to quantify the component of
neuropathic pain and to focus
on this part of the ear the auricular
treatment.
Conclusions
Results

Regression line in 50 patients
between the intensity of
pain and the total number of
tender points on the 3 main
areas of the ear (helix, medial
surface, antihelix)

Regression line in 50 patients
Between the total score of
NPS intensity and the total
number of tender points on
the 3 main areas of the ear
(helix, medial
surface, antihelix)

Regression line in 50 patients
between the total number of
words MGPQ of pain and the
total number of tender points
on the 3 main areas of the ear
(helix, medial surface,
antihelix)

Thanks
! I have been receiving training in
auriculotherapy both from Marco Romoli
and David Alimi. As a learner of this
discipline, I have a debt of gratitude
towards all my teachers
! And I keep seeking contact points
between the different teachings and
practices, given that the auricolotherapy
is a unique field of study, therefore it
must exist one corpus of knowledge, on
which to built its practice

David Alimi’s studies and teaching
! Different cartographies
! Substantial neurophysiological
foundations, on the basis of a deep
knowledge of neurosciences
! Embryology: the primary germ layers of
the embryo: mesoderm, ectoderm,
endoderm and specific types of tissues,
they give rise to
! Neurophysiology: the brain’s laws
! Biochemistry, Pathology, Neuropathology

!!!Endoderme
!
!
!!!Ectoderme !!!Mésoderme
!
29

30

Chronic Neuropathic Pain
(Treede RD, Rief W, Wang SJ, et al. A classification of chronic pain for
ICD-11. PAIN.2015;156(6))
Updates for identification of neuropathic
pain:
1. history of nervous injury
2. neuroanatomically plausible distribution
of the pain
3. demonstration of a lesion or disease
involving the somatosensory NS
(imaging, biopsy, etc)
4. presence of negative or positive sensory
signs compatible with the innervation
territory of the lesioned nervous
structure

Chronic Neuropathic Pain
(Treede RD, Rief W, Wang SJ, et al. A classification of chronic pain for
ICD-11. PAIN.2015;156(6))
! Peripheral / central neuropathic pain
! Spontaneous / evoked pain
! Increased response to a painful stimulus:
hyperalgesia
! Painful response to normally non painful
stimuli: allodynia

Assessment of no injury of nerve
fibres from periphery to spinal cord
Methodology
! Fibres A beta: superficial sensibility
! Fibres A delta: light pression with a dull point
! Fibres C: thermal stimuli (hot: 40°-42° C)
Thermal stimuli: are the most significant
If all mentioned stimuli are perceived, it is
supposed a nociceptive pain
If all mentioned stimuli are not perceived it is
supposed a neuropathic pain

Pain as complex subjective
phenomenon
Pain is a substantial sign to the brain
for managing the homeostasis
! It affects sensory and emotional
perception
! Chronic: if persists longer than 6-7
months, it becomes ‘suffering’.
Suffering: limbic involvement with
emotional components
! It is hallmarked by central
sensitization

CRPS
complex regional pain syndrome
One of the most challenging chronic
pain conditions to treat successfully
Invasive and expensive palliative
interventions are often used

CRPS Complex Regional
Pain Syndrome
! The current diagnostic label for the
syndrome historically referred to as Reflex
Sympathetic Dystrophy, Causalgia, and
other terms
! Associated to local edema and changes
suggestive of autonomic involvement,
! Sometimes changes of skin and altered
motion function may also occur
! CRPS-I absence of nerve injury
(algoneurodystrophia type I, type II)
! CRPS-II presence of documented nerve
injury, always of a motor nerve (causalgia)

CRPS is a disease of the
central nervous system
! CRPS patients display changes in somatosensory
system processing thermal, tactile, and noxious
stimuli
! Bilateral sympathetic nervous system (SNS)
changes are observed even in patients with
unilateral CRPS symptoms
! Somatomotor system may also be affected

Lesion - regeneration - pain
! Chaotic regeneration
! Ephapse: a point of contact between
neurons, generally from little to big
fibres, accounts for trasmission
dysfunction and pain
We observe:
1 Continuous pain: burning, tingling,
paresthaesia
2 Paroxysm: flashing, lighting, electrifying
3 Allodynia

Pain and Brain
! Brain is a valuable target organ for pain
therapy
! Personalized neuromodulation through
ear stimulation (needle, liquid freezing
device,etc) could provide effective
analgesia
! Multifaceted aspects of human pain can
be treated by means of auriculotherapy,
! that can interrupt painful messages
across the centripetal nervous afferences

Filters of Pain
1. Gate Control (Nuclei of Gall and Burdach);
pathway of descending inhibitory control
Dorsal Spinal Root, Spinal cord’s posterior horn
layers 2 and 4, Rolando’s Substantia Gelatinosa;
2. Reticular Formation (RF) in brainstem:
activanting ascendent system, inhibiting
descendent system.
It gathers auricolo-dermal potentials.
Threshold of the filter of perception is
genetically determined (specific). It is
corresponding to individual threshold for pain
perception
3. Thalamus: the obsession of stopping all pains,
before they could be transmitted to cortex, via
Corona Radiata (CR)
4. Cerebral Cortex: associative areas

Reference: D. Alimi
Schema for interruption of painful messages
across the centripetal nervous afferent pathways
! Strategy: treatment of nervous circuitry involved in
pathology
1. Involved Organ’s Points
2. Reticular Formation Master Point H 13
3. Thalamus Point G 14
4. Sensory Master Point D 17
(frontal - parietal - temporal associative areas)
! Frequency of session: one out 2 weeks

Reference: D. Alimi
Psychic Points for chronic pain
For symptomatology associated to chronic pain, and suffering:
! Cosmonauts’ Point F 6 anxiolytic point
! Sympathetic Master Point E 14 antidepressant
! Posterior Hypothalamus G 13 antidepressant
! Rhinencephalon C 19 limbic system
! Cortex of Adrenal Gland C 9 adaptation threshold

(by kind permission of David Alimi)

Case Description 1:
stump and phantom limb’s pain
About a month before the visit, a 52 yrs old woman had four
fingers of her left hand badly injured (squeezed into a textile
machine) and had them to be amputated
At the visit: Left hand bandaged and sutured. The patient
feels her hand cold and painful, that gets not warmed up. She
feels her third finger bent and stiff, and her fifth finger pierced
by a nail.
She complains of electrifying paroxysms in the arm from
elbow to the hand, of stinging of the phantom fingers, and
numbness.
Diagnosis: stump pain, early phantom limb’s segment
syndrome

Reference: D. Alimi.
Schema for Phantom Limb Pain
1. Omega Point C 18
2. Omega 2 Point A 4
3. Omega 1 Point H 8
4. Points of painful limb
5. Myelomeres s/m C 11
6. Thalamus G 14
7. Sensory Master Point D 17

Left: filter of pain messages’ interruption across the
centripetal pathways
Right: basic schema for phantom hand pain

Reference: D.Alimi.
Schema for CRPS II (causalgia)
1. Spinal (brachial/lumbar) Plexus s/m
2. Thalamus G 14
3. Synthesis Point D XVIII
4. Sensory Master Point D 17

Reference: D. Alimi. Schema for
CRPS - I (algoneurodystrophy)
! Omega 2 A 4
! Points of painful limb
! Gangliomere of limb
! Sympathetic Master Point E 14
! Thalamus G 14
! Sensory Master Point D 17
! Corpus Callosum K 12
! If it needs, Synthesis Point D XVIII
! Relax Triad

Case Description 1 BC66W
so, I chose to use cryotherapy …
… on the following points, in order to relieve sympathetically
mediated symptoms (coldness, pain):
a. Gangliomere C 7 (Stellar Ganglion) F 10
b. Sympathetic Master Point E 14
c. Thalamus G 14
d. Sensory Master Point D 17
e. Corpus Callosum K 12
Meanwhile, the patient’ s neurologist was going to
go practicing a treatment to prevent the formation
of neuromas and chaotic regeneration of nerve
fibres

Treatment done for the stump pain and
phantom finger syndrome
Firstly, on the lesion side, that’s left ear
• Omega 2 A 4, mesodermal and psychic point
• Master Point of Hand s/m B 5/F II Organ’s Point
• Stellar Ganglion G 10 sympathetic symptoms
• Sympathetic Master Point E 1 sympathetic hyperactivity,
antidepressant point
• Thalamus G 14 filter, of pain; compulsory for
sympathalgia
• Sensory Master Point D 17 filter, of pain; for neuroplasticity
• Corpus Callosum K 12 to restore hand’s function and
rebalance both hemispheres
Then, in the right ear: Relax Triad for anxiety, tied to pain and trauma’s memory
• Cosmonauts’ Point = Superior Lumbar Sympathetic Ganglion F 6
• Sensory Master Point D 17
• Corpus Callosum K 12

Case Description 1: outcome
Treatment by means of Liquid Freezing Device (Cryoalfa), a session.
It has been utilised auricular acupuncture in order to
! down-regulate sympathetic drive: the patient appears in a general state
of hypersympathetic drive
! relieve the stump pain and phantom fingers pain, sympathetically
sustained
! easy the brain charts’ remodeling (neuroplasticity)
! help the rebalance of both the hemispheres
Outcome. It is turned the presentation: after 10 minutes the hand warms
up, painful symptoms are reduced
Follow-up (after 4 months): mostly reduced phantom symptoms. The
patient uses her stump easily and coordinatedly with other arm. She drives
again her car:

Phantom Fingers by amputation,
caused by an accidental squeeze
of her left hand into a textile
machine
Right Ear: Relax Triad
Left Ear: Omega Point, Hand’s
Point s, Stellar Ganglion, Corpus
Callosum, Thalamus, Sympathetic
Master Point, Sensory Master
Point
Meanwhile I am stimulating the
Point B 5, the patient says: “I
feels a pain on my third
(amputated) finger
BCW: Cryotherapy
BCW: Cryotherapy

Case Description 2 and 3: CG38W
CGW left Occipital Neuralgia
CGW right Trigeminal (Gasserian) Neuralgia

Case description 2
Left Occipital Neuralgia
! Jan 2013. Woman, 75 yrs old, complains of paroxysmal stabbing
pain in the navicular dimple below the mastoid process, on the left
side (distribution of the third cervical root)
! Clinical examination: no vertigo, no headache, no cranial nerve
signs, no autonomic symptoms.
! Mastication/swallowing, little cervical movements, and faringo-
laryngeal movements trigger pain.
! History: nothing substantial
! NRS 9/10: Painkiller drug (acetaminophenl 500 mg) achieves a
partial effect: NRS 3/10
! Pain Pressure: most positive on the first cervical vertebromeres
(anti-helix’s crest), Thalamus Point, Reticular Formation Area

Hypothetical Diagnosis: cervical arthropathy
(such as facet joint lesion)?
spinal root C3 compression?

Occipital Neuralgia
Treatment: a session
Left Ear
! Cervical three-point frame (vertebra C 2 and C 4, the
interposed disc) F 12
! Reticular Master Point H 13
! Thalamus G 14
! Sensory Master Point D 17
! Corpus Callosum K 12
Right Ear
! Corpus Callosum K 12

Case description 2: outcome
AUTh by needles (type ASP classic – Sedatelec) for relieving the recent onset
pain via stimulation of the Organ’s Points and the pain filters
Outcome: rapid full remission of pain in a few days
Follow-up: no relapse (40 months)

Case Description 3
Trigeminal Neuralgia
May 2016. The same woman, now 78 yrs old, complains of pain
on her face’s right side with hyperalgesia, allodynia, flashing
pain .
! History: 3 yrs ago (2013), the patient treated for Occipital
Neuralgia in her left side of face. Sustained remission of pain.
Recently, itchy vesicles on her chin (hypothesis of shingles)
! Physical examination. She complains of a sudden neuropathic
pain spread on right side of her face. Palpation on her right
orbital area elicits pain. Hyperalgesia, allodynia (light touch)
NRS: 9/10
Hypothetical Diagnosis: Postherpetic Trigeminal Neuralgia (PHN)

Reference: D. Alimi
Trigeminal Neuralgia
Basic schema for Trigeminal Neuralgia
! Brainstem C 14
! Trigeminal branch V 1 B 17
! Trigeminal branch V 2 B 16
! Trigeminal branch V 3 C 15
! Sensory Master Point D 17
! Midbrain’s Reticular Formation H 15
! Thalamus G 14
! If it needs Cosmonauts’ F 6
! If it needs ACTH I 17
! If it needs FSH-LH F 16
Basic schema for Trigeminal Neuralgia

I adapted for Mrs CG38W…
! Brainstem C 14 syntonizing 5-HT incretion
! V 1 B 17 Organ Point
! V 2 B 16 Organ Point
! V 3 C 15 Organ Point
! Sensory Master Point D 17 Organ Point (eye)
! Midbrain’s Reticular Formation H 15 2° pain filter
! Thalamus G 14 3° pain filter
! Corpus Callosum K 12 balance 2 hemi-faces
Firstly side of lesion, then other side:
! Corpus Callosum K 12
! Pituitary Gland H 17 hormonal balance, >60yrs

Case description 2:
outcome
Treatment: a session of
auriculotherapy by needles ASP
classic – Sedatelec
Outcome: healing without other
trouble
Follow up (13 months): full
remission, no relapse.

Auriculotherapy Potential.
Conclusions
! AUTh appears an etiologic, not just a symptomatic treatment.
! The cases reported highlight its exceptional healing potential.
! We can use auriculotherapy as ex-adjuvantibus criterion for
settling diagnostic doubts
! It has the property of being ductile and easily adaptable to the
manifold individual comorbidities
! We can distinguish so the different components of a chronic
pain syndrome, as for the eventual psychic comorbid disorders,
and treat each of them one after the other
! Using its modulation action on nervous functions, AUTh
potential matches up to other very expensive and invasive ways
of treating neuropathic pain

Auriculotherapy Potential.
Conclusions
! So, we should design studies apted to light up the
effectiveness of auricular acupuncture, its peculiarity
and efficacy, since its ability to act is no longer to be
questioned.
! There is a lot of work to be planned for the future,
and be scheduled in that field

THE GREATER DANGER FOR MOST OF US IS NOT
THAT OUR AIM IS TOO HIGH AND WE MISS IT,
BUT THAT IT IS TOO LOW AND WE HIT IT
(ARISTOTLE)
Thank you of your attention