by Bonnie J. Horrigan*
Chronic pain affects millions of Americans, causing many to abandon their dreams and lead diminished lives as they fight for rare moments of relief. The majority of chronic pain patients ingest several different medications on a daily basis, which means that in addition to their original pain, they must also deal with the unpleasant side effects of the drugs. For many, the hope of living without pain is simply not in sight. This was Richard West’s life until he started receiving auricular therapy.
West, a 50-year-old military veteran, suffers from interstitial cystitis as well as complicated low back pain involving multilevel degenerative change (arthritis) and a broad-based disk bulge at L4-5 that causes nerve impingement. When he first started seeing Robert Bonakdar, MD, the director of Pain Management at the Scripps Center for Integrative Medicine in La Jolla, California, he was taking 60 mg of morphine sulfate three times a day, as well as 90 to 120 mg of morphine immediate release, 800 mg of ELMIRON (pentosan polysulfate sodium) and 10 mg of Atarax (Pfizer, New York, NY) once a day. He was also using 10 mg of Ambien (Sanofi Avetis, Bridgewater, NJ) each night to aid sleep. Sometimes he needed bladder installations to relieve painful flare-ups, and at least twice a year would end up in the emergency room. Although he had tried hydrotherapy, biofeedback, traditional acupuncture, physical therapy, dietary changes, and an array of dietary supplements, none of these interventions produced lasting results.
“I was desperate,” says West. “The drugs, which only controlled my pain part of the time anyway, were diminishing my capacity to stay alert and think clearly. It was like walking around with half my IQ, which is really a terrible way to live. I wanted my life back.”
Dr. Bonakdar suggested percutaneous auricular nerve stimulation (PANS), a diagnostic evaluation and therapeutic stimulation of auricular nerves that utilizes various biostimulation modalities. Having tried acupuncture before, West was skeptical but he agreed to try the therapy. The first three sessions did not produce a noticeable change, but during the fourth session, West experienced a significant reduction in his pain.
“It broke the cycle and changed the nature of the pain from unbearable to a tingling sensation,” West explains.
“After four treatments, West began to experience a quantifiable decrease in pain,” Dr Bonakdar confirms. “With ongoing treatment he has been able to discontinue his instillations and he has not needed any emergency room treatment. His total narcotic intake has gone down by two thirds and his overall function ability has increased.”
West, whose insurance will not cover the therapy, pays for it out of pocket, because “it works.”
Encountering Auricular Therapy
Dr. Bonakdar completed his undergraduate degree in psychobiology at Occidental College and his medical training at the University of Nevada School of Medicine, with a residency in family practice at Grossmont Hospital. He performed a Richter Fellowship in Southeast Asia, where he studied acupuncture, Tai Chi/Qigong, and Eastern spirituality, and subsequently completed the UCLA Acupuncture Course for Physicians. At Scripps Clinic, he completed a fellowship in integrative medicine, focusing on pain management. He has incorporated the use of traditional acupuncture into his symptom management programs for pain patients for several years and became intrigued with the ability of auricular stimulation to initiate a rapid clinical response.
“We know from the field of clinical anatomy that the ear has significant innervation including cranial nerve endings, such as the Vagus nerve, that are not easily accessible anywhere else on the surface of the body,” explained Bonakdar. “More invasive stimulation of these nerves has been utilized therapeutically by Western medicine in the successful treatment of seizures, pain, and depression. In the same vein, ear acupuncture has been utilized by Tradition Chinese Medicine practitioners for centuries.”
Dr. Bonakdar was aware of the growing body of evidence suggesting that ear acupuncture was helpful for migraines and for chronic lower back pain, but he was looking for something that would prolong its effects. His pain patients would be fine for a few days after an ear acupuncture treatment, but then the pain would return and they would go back on morphine. In 2006, he studied with Dr J.C. Szeles, a vascular surgeon from Austria who developed a device, the is-3, for providing continuous auricular stimulation for up to 96 hours. After this training, Bonakdar began using the is-3 with several of his shingles patients, all of who experienced significant relief in pain and were subsequently able to reduce medication levels. He has since used the is-3 with numerous pain patients, including those with fibromyalgia.
The Therapeutic Process
The first step is diagnostic. The physician employs a device called the multipoint, which utilizes visual and acoustic signals to locate areas of heightened sensitivity on the outer ear. “The traditional way was to observe surface skin changes as well as areas of point sensitivity,” Bonakdar explains. “These techniques are still helpful, but more recently we have electrodiagnostic tools that help to confirm the most potent areas of neuroanatomical stimulation.
Once the hot spots, which most always correspond to traditional acupuncture points, have been located, the next step is to use the is-3, an auricular stimulation device that provides percutaneous electrical stimulation to specific areas of the ear. First, small two-millimeter titanium acupuncture needles are placed in the selected points. The needles are attached by thin wires to the very small electrical device that provides the stimulation. This device is taped to the skin under the ear and is usually worn by the patient for four days. (Note: stimulated needles are only placed on one ear, either left or right. In certain cases, to increase therapeutic benefit, acupuncture needles or beads may be placed in the other ear in the same spots but with no electrostimulation.)
“The patient typically has a sensation of a tap every second—one-hertz frequency, one beat per second. It stimulates for three hours and then is off for three hours,” explains Bonakdar.
“You get used to the device relatively quickly,” West says. “When you are in pain for many years, you build up resistance and your ideas about the pain can be as bad as the pain itself. This treatment also changes my anxiety and my urgency. The pain is still there but it’s not that all-encompassing burning sensation. It’s greatly reduced.”
After the allotted time, the patient returns to have the device removed. According to West, one treatment can provide pain relief for up to two months.
Dr Bonakdar will be teaching the first hands-on national course on auricular therapy and PANS on September 8, 2008 at the American Academy of Pain Management annual meeting. More information about this meeting can be found at http://www.aapainmanage.org.
A Brief History of Auricular Acupuncture
The use of acupuncture as a therapeutic intervention was first documented in the Yellow Emperor’s Classic of Internal Medicine, a medical text compiled in China in 500 BCE. Among other information, this text described the meridians, named nine types of needles, outlined different needling techniques, and gave the location of 160 acupuncture points. The first known reference to auricular therapy was also made in China circa 100 BCE by Huang Di Nei Jing, who said, “All the vessels congregate in the ear.” Huang Di Nei Jing further developed acupuncture, naming 349 acupuncture points in his text, Systematic Classics of Acupuncture and Moxibustion.
Between 500 BCE and 100 CE, the practice spread from China throughout the Mediterranean. In the article “Ear Acupuncture in European Traditional Medicine” (Evid Based Complement Alternate Med. 2007;[suppl 1]:13-16), authors Luigi Gori and Fabio Firenzuoli note that, “The Ebers papyrus of 1550 BC (now in the British Museum) describes a system of channels and vessels in the body which approximates more closely to the Chinese system of channels than to any known system of blood vessels, lymph vessels or nerves. The Egyptologist Alexandre Varille (1909-1951) has documented that women in ancient Egypt who did not want any more children had their external ear pricked with a needle or cauterized with heat. Gold earrings worn by Mediterranean sailors were not just used as decorations, but were said to improve vision. Hippocrates, the father of Greek medicine, reported that doctors made small openings in the veins situated behind the ear to facilitate ejaculation and reduce impotency problems. Cutting of veins situated behind the ear was also used to treat leg pain. The Greek physician Galen introduced Hippocratic medicine to the Roman Empire in the second century CE and commented on the healing value of scarification at the outer ear.”
References can be found in Persian medical records describing treatments involving cauterization of the external ear for sciatic pain and sexual-related disease, and during the Renaissance, European clinical reports describe the use of ear cauterizations to relieve leg pain. Acupuncture continued to be used and developed throughout Chinese history, and from the 1600s to the 1800s, doctors working for the Dutch East India Company brought newer Chinese acupuncture practices to Europe, including those involving the ear.
The modern practice of auricular acupuncture was developed by Paul Nogier, a French physician who theorized that each part of the body is represented in a specific zone on the external ear and that through stimulation of these acupuncture points, therapeutic benefit in the corresponding body part would be derived. This became known as homunculus, or “the man in the ear.”