- Email: [email protected]
The active scar test
DZA
Akupunktur
Originalia | Original articles D O I : 1 0 . 1 0 1 6 / j . d z a . 2 0 1 4 . 0 2 . 0 0 2 6 D t. Z t s c h r . f. A k u p u n k t u r 5 7, 1 / 2 0 1 4
Deutsche Zeitschrift für
German Journal of Acupuncture & Related Techniques
M. Romoli 1,2,3, L. Linari 3, G. Montagnoni 2, A. Giommi 4
The active scar test An innovative application of RAC/VAS signal for identifying scars associated with postural disorders in patients with chronic cervical and lumbar pain syndromes
Der aktive Narbentest Eine innovative Anwendung des RAC/VAS-Signals zur Identifikation von Narben und deren Zusammenhang mit Haltungsstörungen bei Patienten mit chronischen zervikalen und lumbalen Schmerzsyndromen Abstract
Zusammenfassung
The RAC/VAS signal is a technique, which belongs to the different methods of auricular diagnosis and is proposed by physicians working with Auriculomedicine. We applied a similar method on 132 actives scars carried by 67 patients with postural disorders associated with chronic cervical/lumbar pain syndromes. The Active Scar Test was performed on all visible scars using the light of a HEINE Finoff transilluminator (HFT). The decrease of the radial pulse amplitude, called RAC(–) signal, was taken into consideration in our study followed by palpation of the scar. Only scars, which showed an RAC(–) signal and which were sensitive on palpation were treated with neural therapy, which is the diagnostic and therapeutic use of local anesthetics. Two independent observers took the radial pulse on both sides and measured the following parameters of the RAC signal: its intensity (0 = no signal, 1 = light decrease; 2 = moderate decrease; 3 = evident decrease with the sensation of a collapse of the pulse); the number of pulses elapsed after lighting and before the onset of RAC(–); the number of pulsations during which the signal was perceivable. A third observer rated the sensitivity on palpation of the scar on a 4-grade scale (0 = no pain; 1 = slight pain; 2 = moderate pain; 3 = evident pain on palpation). RAC(–) signal intensity and sensitivity at palpation seem to be positively correlated and may be used in combination for identifying an active scar. In those scars (48.5 % of the total), in which the HFT evoked a bilateral RAC(–), the signal was perceived significantly more intensely, earlier and longer on the ipsilateral pulse than on the contralateral one.
Die RAC/VAS-Signaltechnik zählt zu den Methoden der Ohrdiagnostik und wird von Ärzten empfohlen, die Aurikulomedizin praktizieren. Wir haben eine ähnliche Methode an 132 aktiven Narben bei 67 Patienten angewendet, deren Haltungsstörungen mit einem chronischen zervikalen/lumbalen Schmerzsyndrom einhergingen. Der Aktive Narbentest wurde mithilfe des Lichtes eines HEINE Finoff-Durchleuchters an allen sichtbaren Narben durchgeführt. Wir berücksichtigten in unserer Studie die Abnahme der Amplitude des Radialpulses, als RAC(–)-Signal bekannt, und palpierten die jeweilige Narbe anschließend. Es wurden nur Narben neuraltherapeutisch behandelt, die ein RAC(–)-Signal aufwiesen und bei Palpation empfindlich waren. Zwei Beobachter nahmen unabhängig voneinander den Radialpuls auf beiden Seiten und maßen die nachstehend aufgeführten Parameter des RAC-Signals: Intensität (0 = kein Signal, 1 = leichte Abnahme, 2 = moderate Abnahme, 3 = deutliche Abnahme mit Gefühl eines Puls-Kollapses), Anzahl der Pulse zwischen Beleuchtung und vor Einsetzen des RAC(–), Anzahl der Pulse während derer das Signal wahrnehmbar war. Ein dritter Beobachter beurteilte die Empfindlichkeit bei Palpation auf einer vierstufigen Skala (0 = kein Schmerz, 1 = leichter Schmerz, 2 = moderater Schmerz, 3 = deutlicher Schmerz bei Palpation). Die RAC(–)-Intensität und die Empfindlichkeit bei Palpation schienen positiv zu korrelieren und könnten zusammen zum Auffinden einer aktiven Narbe genutzt werden. Bei Narben (48,5 % der Gesamtheit), an denen der HEINE Finoff-Durchleuchter ein bilaterales RAC(–) auslöste, war das Signal signifikant intensiver, früher und länger beim ipsilateralen als beim kontralateralen Puls wahrnehmbar.
Keywords
Schlüsselwörter
Active scar test, postural disorders, RAC/VAS signal, neural therapy
Aktiver Narbentest, Haltungsstörungen, RAC/VAS-Signal, Neuraltherapie
Introduction In May 2013 we were encouraged and invited by Dr. Dominik Irnich and Dr. Thomas Ots to present a paper at the Acupuncture Week in Bad Nauheim during a special session dedicated to Ear Acupuncture and Auriculomedicine. The aim of the workshop was to present and compare the different systems of Ear Acupuncture in the world, especially the French and Chinese systems, trying in particular to add new scientific and clinical elements to the RAC test introduced by Paul Nogier himself back in the sixties of the last century. [1] The phenomenology of the radial pulse variations accompanying the stimulation of the outer ear received different names and acronyms in the West, like RAC Dr. med. Marco Romoli Facharzt für Allgemeinmedizin, Akupunktur, Neuraltherapie, Manuelle Therapie Società Italiana Riflessoterapia, Agopuntura e Auricoloterapia (S.I.R.A.A.)
(Réflexe Auriculo-Cardiaque) or VAS (Vascular Autonomic Signal); recently Dr. Anthony De Sousa, responsible for the teaching of Auriculomedicine at GLEM (Groupe Lyonnais d’Études Médicales) in Lyon, proposed a new definition of RAC and called it Réaction Autonome Circulatoire. We are not currently teaching or including RAC/VAS as a method of Auricular Acupuncture Diagnosis; however we have been intrigued and felt challenged to apply RAC/VAS for the identification of active scars disturbing the posture of patients with chronic cervical and lumbar pain syndromes. Therefore we collected a parallel series of consecutive patients from a trial regarding this type of subject, presen-
Via Sprone 1/4 – 59100 Prato (Italien) Tel.: +39 3288603161 Fax: +39 574 574129 [email protected]
1
Center for Integrative Medicine, University of Florence Associazione Medici Agopuntori Bolognesi (A.M.A.B.) Interdisciplinary Center for Postural Disorders POSTURA PRATO 4 Department of Statistics, Informatics and Applications, University of Florence 2 3
Originalia | Original articles M. Romoli, L. Linari, G. Montagnoni, A. Giommi
T h e a c t i v e s c a r t e s t : a n i n n o v at i v e a p p l i c at i o n o f R A C / V A S s i g n a l f o r i d e n t i f y i n g s c a r s a s s o c i at e d w i t h p o s t u r a l d i s o r d e r s i n p at i e n t s w i t h c h r o n i c c e r v i c a l a n d l u m b a r pain syndromes
ted at the 20th International Congress of Posturology (Marseille, 27–29 September 2013) organized by Dr. Bernard Bricot, president of CIES (Collège International Étude de la Statique). [2] As scientific validation of RAC/VAS is still low, we were faced with an essential question regarding this phenomenon: for our tests should we use one-finger or bi-digital perception of the radial pulse, as it is common routine by professionals to feel the pulse in medical examinations? In the literature on Auriculomedicine, one-finger contact is preferred because it is supposed that the tip of the thumb, with an approximate angle of 110° to the radial apophysis, may act as the best transmitter of the pulse wave. The coauthor of this article, GM, who is a cardiologist, found it quite difficult to perceive RAC/VAS with only one finger. Therefore for our study we opted for bi-digital perception of the radial pulse. In the pilot phase we tried various types of stimulation such as touching the scar with a finger or a cotton swab, but we found the white light of a HFT to be the most suitable for our research, as it is proposed also by Prof. Maximilian Moser of the Physiology Institute of Graz University [3, 4]. The HEINE Finoff transilluminator is conventionally used for general transillumination of tissue, and more specifically, for scleral transillumination. One observer moved the beam of light from one scar to the other and the other two observers took the patient’s left and right pulse and discussed and compared all variations. Besides some short-time variations in the frequency of pulse rate, the most impressive phenomenon was the decrease in amplitude when the light stimulated an active scar of small dimensions or the most active part of a larger/longer scar. We called this phenomenon RAC(–) as it is conventionally accepted by doctors practicing Auriculomedicine (opposed to RAC(+) which signifies an increase of pulse amplitude) [1] and scored its intensity with a 4- grade scale: 0 = no RAC; 1 = light decrease; 2 = moderate decrease; 3 = evident decrease with the sensation of a collapse of the pulse. During this pilot phase we noted two interesting factors: the first was that the light beam needed to stay on the active part of the scar to allow a steady and reliable perception of RAC. As soon as the light beam moved from the active spot, the RAC pheno-
Table 1
Percentage distribution of the 132 scars on the different skin segments
Segment
N°
%
Segment
N°
%
V1
4
3.1
Th5
1
0.7
menon indeed tended to lose its intensity and after a variable number of pulsations (30-60) the pulse amplitude returned to the initial status. The second was that RAC(–) could be perceived differently on the patient’s right and left side not only in its intensity, but also in the onset and duration of the phenomenon. For example, in some cases it was bilateral and synchronous, in others it was lacking on one side or the onset was delayed. As several professionals practicing neural therapy know (see the discussion below), an “active scar” may have a variable sensitivity to palpation. The aim of this study therefore was to test all scars of a consecutive group of patients affected by chronic cervical and lumbar pain syndromes with two methods: by RAC/VAS signal using the beam of a HFT and by palpation of the scar.
Materials and method 72 consecutive patients with chronic cervical and lumbar pain syndromes associated to postural disorders were examined in the following way: one author (LL) was responsible for performing the mapping of all visible scars in each patient and for transcribing their location on the segmental map of Hansen and Schliack [5)]. For every scar identified he recorded the date and origin, and asked the patient if it was spontaneously tender or more sensitive in certain situations such as changes in weather or wearing specific clothes etc. The other two authors (MR and GM), sitting one on each side, took the patient’s radial pulse with 2 fingers, ready to feel any variation. LL started, stimulating one scar after the other with the beam of light and the other 2 observers independently perceived any eventual RAC(–) during 30 pulses (more than 30 pulses without pulse amplitude variations were considered as RAC(–) absent). As soon as either of the observers felt a variation in the pulse he had to say “now” and LL had to continue to direct the beam of light without shifting it for at least 60 pulsations. Both observers had to score the number of pulsations during which RAC(–) was perceived and its intensity. Once the test was completed on all visible scars, LL palpated each scar and scored its sensitivity on a 4–grade scale (0 = no pain; 1 = slight pain; 2 = moderate pain; 3 = evident pain at palpation). In the different subgroups a T test for paired data compared the number of pulsations between the application of the beam of light and the RAC(–) signal perceived, the number of pulsations during which the phenomenon was perceptible and its intensity. A regression analysis was carried out to estimate the relation between the intensity of RAC(–) and sensitivity at palpation.
V2
1
0.7
Th8
1
0.7
V3
1
0.7
Th9
4
3.1
C2
3
2.3
Th10
3
2.3
Results
C3
4
3.1
Th11
5
3.8
72 consecutive patients with chronic lumbar and cervical pain associated with postural disorders were examined with the HFT and screened for at least one active scar showing an RAC(–) signal. 5 patients had no active scars at all and were excluded from our evaluation. The remaining 67 patients aged 18-77 years (19 male, 48 female), mean age 49.1 (SD 14.7) were included in our study: at the time of examination 38 of them (56.7 %) had suffered from chronic lumbar/sciatic pain for 10.3 years; 13 (19.4 %) had suffered from chronic cervical/cervicobrachial pain for 10.6 years; 8 (11,9 %) suffered from mixed cervical/lumbar pain; 8 (11,9 %) suffered from other pain syndromes associated with postural disorders such as knee pain, plantar fasciitis etc.
C4
1
0.7
Th12
13
9.8
C5
10
7.6
L1
9
6.8
C6
5
3.8
L2
2
1.5
C7
7
5.3
L3
11
8.3
C8
2
1.5
L4
24
18.2
Th1
3
2.3
L5
9
6.8
Th3
1
0.7
S1
5
3.8
Th4
1
0.7
S2
2
1.5
D t Z t s c h r f A k u p. 5 7, 1 / 2 0 1 4 7 D Z A
Akupunktur Deutsche Zeitschrift für
DZA
Originalia | Original articles
German Journal of Acupuncture & Related Techniques
Fig. 1: The segmental distribution of the 132 active scars.
The systematic mapping of all visible scars totaled 343 scars (1 to 11; on average 5.1, SD 2.6). The RAC(–) scars, however, totaled only 132 (1 to 4; on average 2.0 per patient, SD 0.9). The active scars had existed from 1 to 70 years; on average 23.6, SD 16.0. As regards the location of all scars, 76 of 132 (57.6 %) were located on the left side of the body, 49 (37.1 %) were located on the right and 7 were located in the midline (on Conception Vessel acupuncture meridian). As regards the segmental distribution of the active scars, all segments from V1 to S2 had at least one scar, except segments Th2, Th6 and Th7. However, the distribution of the scars was not uniform and some segments had a higher concentration than others, such as L4 with 18.2 % followed by Th12 (9.8 %), L3 (8.3 %), L1 and L5 (both with 6.8 %). Cervical segments C5 and C7 showed 7.6 % and 5.3 % respec-
Fig. 2: HEINE Finoff transilluminator (HFT)
tively (Table 1). Some parts of the body were indeed a preferred site of the active scars such as the knee (22.7 %), the lower part of the abdomen (18.2 %) and the external surface of the arm (7.6 %). These three parts had a significantly higher duration of the scars and showed some from childhood, typically injuries or bruising of the knees due to falls and those due to vaccinations for smallpox; active scars were found in previously performed abdominal surgery (for example appendicitis, inguinal hernia, caesarian delivery etc.). The location of the 132 active scars has been transcribed on the segmental map of Hansen and Schliack (Fig. 1). Of these scars, 64 (48.5 %) evoked a bilateral RAC(–) (group A), 48 (36.4 %) evoked an ipsilateral RAC(–) (group B) and 20 (15.1 %) evoked a contralateral RAC(–) (group C). With T test for paired data there were no significant differences be-
A
B
C
D
E
F
D Z A 8 D t Z t s c h r f A k u p. 5 7, 1 / 2 0 1 4
Fig. 3: A 77 year-old patient had been suffering for at least 15 years from chronic lowback pain irradiating to the right leg. Three active scars were found: two of them were located on C6 and L4 segment on the right side. The most sensitive scar, showing a bilateral RAC(–) signal, was however a 40year old scar on the left gluteus due to an abscess. On the posterior plane the body was shifted to the left with respect to the plumb line (green line) (Fig. 3 A) and was shifted forward especially as regards the head (Fig. 3 B). The baropodometric platform showed an asymmetric pressure on the left and right foot, respectively 55.1 % and 44.9 % (Fig. 3 C). After infiltration of the three scars the body tended to reduce its shifting both on the posterior and the sagittal plane (Fig. 3 D, E). Posture improved with a more proportioned distribution of pressure on the left and right foot, respectively 51.2 % and 48.8 % (Fig. 3 F). In the following weeks the pain syndrome and the relative disability improved and the patient could significantly reduce the intake of analgesics.
Originalia | Original articles M. Romoli, L. Linari, G. Montagnoni, A. Giommi
T h e a c t i v e s c a r t e s t : a n i n n o v at i v e a p p l i c at i o n o f R A C / V A S s i g n a l f o r i d e n t i f y i n g s c a r s a s s o c i at e d w i t h p o s t u r a l d i s o r d e r s i n p at i e n t s w i t h c h r o n i c c e r v i c a l a n d l u m b a r pain syndromes
tween the number of pulsations after initiating the application of the beam of light and no differences between the number of pulsations during which the RAC phenomenon was perceived. Intensity of RAC(–) perceived on the ipsilateral side, however, was significantly higher in subgroup A compared to subgroup B (p < 0.01). Another T test was carried out comparing the three parameters between the ipsilateral and the contralateral side in subgroup A. A significantly lower number of pulsations was perceived on the ipsilateral side in the interval between the application of the beam of light and the onset of RAC(–) (p < 0.01). RAC(–) moreover was perceived on the ipsilateral pulse for a
Table 2
significantly higher number of pulsations (p < 0.01) and the intensity of RAC was higher on the ipsilateral than on the contralateral side (p < 0.001) (Table 2). In group A the signal was therefore perceived more intensely, earlier and longer on the ipsilateral pulse than on the contralateral one. As regards regression analysis, a significant relationship seems to exist between the intensity of RAC(–) and the sensitivity at palpation.
Discussion For several years we had been aware that active scars may represent a focus able to cause various pain syndromes associated with postural disorders. One of the fundamental principles of neural therapy, a widespread discipline in German speaking countries but insufficiently appreciated in the English speaking world, is that “every part of the body can become an active focus (Störfeld = perturbation field) and may influence distant parts of the body”. The infiltration of the active scar with local anesthetics, as proposed by this discipline, however, rather than giving simple anesthesia, means to identify and neutralize/deactivate a chronic and underlying disturbing focus of the patient’s health. Skin is therefore very important for physicians practicing neural therapy and every little scar, bruise, burn, especially if they come from the early years of life, should be checked carefully. The results of our study show that active scars
T test for the comparison of paired data in 64 scars with bilateral RAC(–) signal. The signal was perceived earlier, longer and more intensely on the ipsilateral pulse than on the contralateral one T
P
Ipsilateral vs contralateral observer (N° puls. after the start of illumination)
4,16
< 0.01
Ipsilateral vs contralateral observer (N° puls. after the onset of RAC(–) signal)
4,31
< 0.01
Ipsilateral vs contralateral observer (Intensity of RAC(–) signal)
5,40
< 0.001
A
B
C
D
E
F
G
H
I
Fig. 4: A 34 year-old patient had been suffering for at least 10 years from both recurrent cervical and lumbar pain. The pain syndrome worsened after 2 caesarian deliveries in 2008 and 2011 (Fig. 4 G-I). In fact the double abdominal scar showed, especially on the left side, a bilateral RAC(–) signal (B) with an early synchronous appearance of the phenomenon (after 3-4 pulsations) and a long duration (during 60 pulsations) for both observers (Fig. 4 G). The double scar had at least two tender spots at palpation (Fig. 4 H); the whole left part of the double scar, the stitches included, were infiltrated with about 2 × 1.8 ml carpules of Mepivacaine chloridrate 3% (30G, 0.30 × 21 mm needles) (Fig. 4 I). Before infiltration the patient’s head and shoulders were shifted forwards with respect to the plumb line (green line) (Fig. 4 A). The baropodometric platform showed an asymmetric pressure both on the left and right foot, respectively 47.2 % and 52.8 %, and a prevalent pressure on the forefeet with respect to the heels, respectively 63.9 % and 36.1 % (Fig. 4 D). After the infiltration of the scar the body tended to reduce its forward shift and pressure on the forefeet reduced greatly to 44.2 % (Fig. 4 B and E). The improvement in posture was followed by a reduction of pain both on lumbar and cervical level. After one month the effect of stabilization of posture was accomplished: the plumb line (green line) crossed the outer ear correctly (Fig. 4 C) and pressure on the forefeet was maintained in a physiologic range of 45.0 % (Fig. 4 F).
D t Z t s c h r f A k u p. 5 7, 1 / 2 0 1 4 9 D Z A
DZA
Akupunktur
Originalia | Original articles
Deutsche Zeitschrift für
German Journal of Acupuncture & Related Techniques
Fig. 5: Postural disorders in a 30-years old patient suffering from recurrent cervical pain and tension headache. The removal of one of three earrings improved the posture and the muscular stiffness of the neck. The site of piercing was active at lighting with the HFT and the ipsilateral (right) radial pulse showed a strong RAC(–) signal of intensity 3, after 5 pulsations and persisting for at least 60 pulsations.
Fig. 6: 34-year old patient suffering for at least 10 years from recurrent sciatic pain on the right side. At the age of 7 the patient underwent an operation for appendicitis-peritonitis. The upper part of the scar was sensitive at palpation and was active at lighting with the HFT. A collapse of pulse was perceived bilaterally after 10 pulsations and persisted for at least 60 pulsations.
disturbing the posture of patients with longstanding or recurrent neck /low-back pain may be identified using the white light of a HFT. The Active Scar Test proposed by our group is of practical interest since it allows a rapid and systematic screening of all visible scars. This, of course, depends on the physician having learnt to take the radial pulse correctly and to perceive its variations of amplitude during stimulation by the beam of light. Upon identifying one or more active scars, the physician should always check for their sensitivity and select some of them for treatment with neural therapy. Scars being both RAC(–) and sensitive to palpation always should be infiltrated with procaine, lidocaine, mepivacaine etc.; scars, which are RAC(–) without being sensitive or inversely sensitive without RAC(–) signal also may be included in treatment. In contrast, it is our opinion that scars without RAC(–) signal and not sensitive to palpation should be left untreated or be re-examined during follow up if posture and its associated pain syndrome do not show improvement. However, some questions in our study remain to be considered: the first one concerns the quantity of light necessary to evoke the RAC(–) signal. The phenomenon in fact tends to manifest and be maintained during time only if the stimulation with light is thoroughly and constantly applied on the active scar or on its most active part. Our impression is that every active scar needs a certain quantity of light to be “warmed up” in order to emit the RAC(–) signal. A single sweep of light along the scar therefore may be insufficient and several movements of the lamp may be necessary. This applies in particular if the scar measures more than 4-5 cm. For this reason we subdivided the longer scars into short segments and examined them in succession. However, we do not know to which degree medical conditions such as diabetes, hypertension etc. and the relative required medications may influence the RAC phenomenon. The second
D Z A 1 0 D t Z t s c h r f A k u p. 5 7, 1 / 2 0 1 4
Fig. 7: A 56-year old patient suffering for at least 15 years from chronic neck pain. From the first day of life she was carrying a scar of large dimensions on the sacral and gluteus zones due to a burn with hot water. The postural attitude of the patient was poor both on posterior and sagittal view. The lighting with the HFT identified 13 spots with an RAC(–) signal, which however was perceived bilaterally (B) only in 5 points; in 6 points it was perceived on the right pulse (R) and the active spot was in 4 cases on the ipsilateral side and in 2 cases on the contralateral one; finally in 2 points the RAC(–) was perceived on the left pulse (L) and in both cases the active spot was located on the same side (Fig. 7 A). The burned area showed several overlapping tender spots on palpation (Fig. 7 B). All the tender and RAC(–) points were included into treatment with Neural therapy.
question relates to the parameters we have selected for measurement. The arbitrarily chosen threshold of 30 pulsations after onset of illumination should serve to differentiate subjects, in which the decrease or the collapse of the pulse amplitude was perceivable, from those in which the signal was absent. In fact this range of variability could be greater than assumed in our study. Moreover we do not know if the signal in certain cases may exceed the limit of 60 pulsations that we introduced in the study. The third question is: why does the RAC(–) signal tend to be perceived more intensely on the radial pulse ipsilaterally to the scar? Does our vegetative system have an emisomatic relationship to an ipsilateral focus as described by neural therapy? However, the scientific approach to the RAC phenomenon remains a fundamental issue. Manual/clinical perception of the pulse amplitude variations may not be sufficient and we need to propose further research with appropriate and reliable instruments.
Conclusions The Active Scar Test as proposed in this study may be an interesting tool for identifying an active scar causing postural disorders in patients with chronic pain syndromes, especially if they are insufficiently responding to acupuncture and other complementary methods.
References 1. Nogier PFM. Traité d’Auriculothérapie. Maisonneuve, Sainte-Ruffine 1969 2. Romoli M, Linari L. Cicatrices actives et troubles posturaux dans les cervicalgies et les lombalgies chroniques. Actualité posturale en 2013. Marseille, 27–29 September 2013 3. Moser M, Dorfer L, Muhry F et al. Untersuchungen zur Physiologie des Nogier-Reflexes. Akupunktur/Aurikulomedizin 1998;2:3–13 4. Moser M, Auerbach D, Dorfer L et al. Réflexe auriculocardiaque (RAC, NogierReflex) und Orientierungsreaktion. Schmerz & Akupunktur 2005;3:129–134 5. Hansen K, Schliack H. Segmentale Innervation: ihre Bedeutung für Klinik und Praxis. Thieme Verlag, Stuttgart 1962
Akupunktur
Originalia | Original articles D O I : 1 0 . 1 0 1 6 / j . d z a . 2 0 1 4 . 0 2 . 0 0 2 6 D t. Z t s c h r . f. A k u p u n k t u r 5 7, 1 / 2 0 1 4
Deutsche Zeitschrift für
German Journal of Acupuncture & Related Techniques
M. Romoli 1,2,3, L. Linari 3, G. Montagnoni 2, A. Giommi 4
The active scar test An innovative application of RAC/VAS signal for identifying scars associated with postural disorders in patients with chronic cervical and lumbar pain syndromes
Der aktive Narbentest Eine innovative Anwendung des RAC/VAS-Signals zur Identifikation von Narben und deren Zusammenhang mit Haltungsstörungen bei Patienten mit chronischen zervikalen und lumbalen Schmerzsyndromen Abstract
Zusammenfassung
The RAC/VAS signal is a technique, which belongs to the different methods of auricular diagnosis and is proposed by physicians working with Auriculomedicine. We applied a similar method on 132 actives scars carried by 67 patients with postural disorders associated with chronic cervical/lumbar pain syndromes. The Active Scar Test was performed on all visible scars using the light of a HEINE Finoff transilluminator (HFT). The decrease of the radial pulse amplitude, called RAC(–) signal, was taken into consideration in our study followed by palpation of the scar. Only scars, which showed an RAC(–) signal and which were sensitive on palpation were treated with neural therapy, which is the diagnostic and therapeutic use of local anesthetics. Two independent observers took the radial pulse on both sides and measured the following parameters of the RAC signal: its intensity (0 = no signal, 1 = light decrease; 2 = moderate decrease; 3 = evident decrease with the sensation of a collapse of the pulse); the number of pulses elapsed after lighting and before the onset of RAC(–); the number of pulsations during which the signal was perceivable. A third observer rated the sensitivity on palpation of the scar on a 4-grade scale (0 = no pain; 1 = slight pain; 2 = moderate pain; 3 = evident pain on palpation). RAC(–) signal intensity and sensitivity at palpation seem to be positively correlated and may be used in combination for identifying an active scar. In those scars (48.5 % of the total), in which the HFT evoked a bilateral RAC(–), the signal was perceived significantly more intensely, earlier and longer on the ipsilateral pulse than on the contralateral one.
Die RAC/VAS-Signaltechnik zählt zu den Methoden der Ohrdiagnostik und wird von Ärzten empfohlen, die Aurikulomedizin praktizieren. Wir haben eine ähnliche Methode an 132 aktiven Narben bei 67 Patienten angewendet, deren Haltungsstörungen mit einem chronischen zervikalen/lumbalen Schmerzsyndrom einhergingen. Der Aktive Narbentest wurde mithilfe des Lichtes eines HEINE Finoff-Durchleuchters an allen sichtbaren Narben durchgeführt. Wir berücksichtigten in unserer Studie die Abnahme der Amplitude des Radialpulses, als RAC(–)-Signal bekannt, und palpierten die jeweilige Narbe anschließend. Es wurden nur Narben neuraltherapeutisch behandelt, die ein RAC(–)-Signal aufwiesen und bei Palpation empfindlich waren. Zwei Beobachter nahmen unabhängig voneinander den Radialpuls auf beiden Seiten und maßen die nachstehend aufgeführten Parameter des RAC-Signals: Intensität (0 = kein Signal, 1 = leichte Abnahme, 2 = moderate Abnahme, 3 = deutliche Abnahme mit Gefühl eines Puls-Kollapses), Anzahl der Pulse zwischen Beleuchtung und vor Einsetzen des RAC(–), Anzahl der Pulse während derer das Signal wahrnehmbar war. Ein dritter Beobachter beurteilte die Empfindlichkeit bei Palpation auf einer vierstufigen Skala (0 = kein Schmerz, 1 = leichter Schmerz, 2 = moderater Schmerz, 3 = deutlicher Schmerz bei Palpation). Die RAC(–)-Intensität und die Empfindlichkeit bei Palpation schienen positiv zu korrelieren und könnten zusammen zum Auffinden einer aktiven Narbe genutzt werden. Bei Narben (48,5 % der Gesamtheit), an denen der HEINE Finoff-Durchleuchter ein bilaterales RAC(–) auslöste, war das Signal signifikant intensiver, früher und länger beim ipsilateralen als beim kontralateralen Puls wahrnehmbar.
Keywords
Schlüsselwörter
Active scar test, postural disorders, RAC/VAS signal, neural therapy
Aktiver Narbentest, Haltungsstörungen, RAC/VAS-Signal, Neuraltherapie
Introduction In May 2013 we were encouraged and invited by Dr. Dominik Irnich and Dr. Thomas Ots to present a paper at the Acupuncture Week in Bad Nauheim during a special session dedicated to Ear Acupuncture and Auriculomedicine. The aim of the workshop was to present and compare the different systems of Ear Acupuncture in the world, especially the French and Chinese systems, trying in particular to add new scientific and clinical elements to the RAC test introduced by Paul Nogier himself back in the sixties of the last century. [1] The phenomenology of the radial pulse variations accompanying the stimulation of the outer ear received different names and acronyms in the West, like RAC Dr. med. Marco Romoli Facharzt für Allgemeinmedizin, Akupunktur, Neuraltherapie, Manuelle Therapie Società Italiana Riflessoterapia, Agopuntura e Auricoloterapia (S.I.R.A.A.)
(Réflexe Auriculo-Cardiaque) or VAS (Vascular Autonomic Signal); recently Dr. Anthony De Sousa, responsible for the teaching of Auriculomedicine at GLEM (Groupe Lyonnais d’Études Médicales) in Lyon, proposed a new definition of RAC and called it Réaction Autonome Circulatoire. We are not currently teaching or including RAC/VAS as a method of Auricular Acupuncture Diagnosis; however we have been intrigued and felt challenged to apply RAC/VAS for the identification of active scars disturbing the posture of patients with chronic cervical and lumbar pain syndromes. Therefore we collected a parallel series of consecutive patients from a trial regarding this type of subject, presen-
Via Sprone 1/4 – 59100 Prato (Italien) Tel.: +39 3288603161 Fax: +39 574 574129 [email protected]
1
Center for Integrative Medicine, University of Florence Associazione Medici Agopuntori Bolognesi (A.M.A.B.) Interdisciplinary Center for Postural Disorders POSTURA PRATO 4 Department of Statistics, Informatics and Applications, University of Florence 2 3
Originalia | Original articles M. Romoli, L. Linari, G. Montagnoni, A. Giommi
T h e a c t i v e s c a r t e s t : a n i n n o v at i v e a p p l i c at i o n o f R A C / V A S s i g n a l f o r i d e n t i f y i n g s c a r s a s s o c i at e d w i t h p o s t u r a l d i s o r d e r s i n p at i e n t s w i t h c h r o n i c c e r v i c a l a n d l u m b a r pain syndromes
ted at the 20th International Congress of Posturology (Marseille, 27–29 September 2013) organized by Dr. Bernard Bricot, president of CIES (Collège International Étude de la Statique). [2] As scientific validation of RAC/VAS is still low, we were faced with an essential question regarding this phenomenon: for our tests should we use one-finger or bi-digital perception of the radial pulse, as it is common routine by professionals to feel the pulse in medical examinations? In the literature on Auriculomedicine, one-finger contact is preferred because it is supposed that the tip of the thumb, with an approximate angle of 110° to the radial apophysis, may act as the best transmitter of the pulse wave. The coauthor of this article, GM, who is a cardiologist, found it quite difficult to perceive RAC/VAS with only one finger. Therefore for our study we opted for bi-digital perception of the radial pulse. In the pilot phase we tried various types of stimulation such as touching the scar with a finger or a cotton swab, but we found the white light of a HFT to be the most suitable for our research, as it is proposed also by Prof. Maximilian Moser of the Physiology Institute of Graz University [3, 4]. The HEINE Finoff transilluminator is conventionally used for general transillumination of tissue, and more specifically, for scleral transillumination. One observer moved the beam of light from one scar to the other and the other two observers took the patient’s left and right pulse and discussed and compared all variations. Besides some short-time variations in the frequency of pulse rate, the most impressive phenomenon was the decrease in amplitude when the light stimulated an active scar of small dimensions or the most active part of a larger/longer scar. We called this phenomenon RAC(–) as it is conventionally accepted by doctors practicing Auriculomedicine (opposed to RAC(+) which signifies an increase of pulse amplitude) [1] and scored its intensity with a 4- grade scale: 0 = no RAC; 1 = light decrease; 2 = moderate decrease; 3 = evident decrease with the sensation of a collapse of the pulse. During this pilot phase we noted two interesting factors: the first was that the light beam needed to stay on the active part of the scar to allow a steady and reliable perception of RAC. As soon as the light beam moved from the active spot, the RAC pheno-
Table 1
Percentage distribution of the 132 scars on the different skin segments
Segment
N°
%
Segment
N°
%
V1
4
3.1
Th5
1
0.7
menon indeed tended to lose its intensity and after a variable number of pulsations (30-60) the pulse amplitude returned to the initial status. The second was that RAC(–) could be perceived differently on the patient’s right and left side not only in its intensity, but also in the onset and duration of the phenomenon. For example, in some cases it was bilateral and synchronous, in others it was lacking on one side or the onset was delayed. As several professionals practicing neural therapy know (see the discussion below), an “active scar” may have a variable sensitivity to palpation. The aim of this study therefore was to test all scars of a consecutive group of patients affected by chronic cervical and lumbar pain syndromes with two methods: by RAC/VAS signal using the beam of a HFT and by palpation of the scar.
Materials and method 72 consecutive patients with chronic cervical and lumbar pain syndromes associated to postural disorders were examined in the following way: one author (LL) was responsible for performing the mapping of all visible scars in each patient and for transcribing their location on the segmental map of Hansen and Schliack [5)]. For every scar identified he recorded the date and origin, and asked the patient if it was spontaneously tender or more sensitive in certain situations such as changes in weather or wearing specific clothes etc. The other two authors (MR and GM), sitting one on each side, took the patient’s radial pulse with 2 fingers, ready to feel any variation. LL started, stimulating one scar after the other with the beam of light and the other 2 observers independently perceived any eventual RAC(–) during 30 pulses (more than 30 pulses without pulse amplitude variations were considered as RAC(–) absent). As soon as either of the observers felt a variation in the pulse he had to say “now” and LL had to continue to direct the beam of light without shifting it for at least 60 pulsations. Both observers had to score the number of pulsations during which RAC(–) was perceived and its intensity. Once the test was completed on all visible scars, LL palpated each scar and scored its sensitivity on a 4–grade scale (0 = no pain; 1 = slight pain; 2 = moderate pain; 3 = evident pain at palpation). In the different subgroups a T test for paired data compared the number of pulsations between the application of the beam of light and the RAC(–) signal perceived, the number of pulsations during which the phenomenon was perceptible and its intensity. A regression analysis was carried out to estimate the relation between the intensity of RAC(–) and sensitivity at palpation.
V2
1
0.7
Th8
1
0.7
V3
1
0.7
Th9
4
3.1
C2
3
2.3
Th10
3
2.3
Results
C3
4
3.1
Th11
5
3.8
72 consecutive patients with chronic lumbar and cervical pain associated with postural disorders were examined with the HFT and screened for at least one active scar showing an RAC(–) signal. 5 patients had no active scars at all and were excluded from our evaluation. The remaining 67 patients aged 18-77 years (19 male, 48 female), mean age 49.1 (SD 14.7) were included in our study: at the time of examination 38 of them (56.7 %) had suffered from chronic lumbar/sciatic pain for 10.3 years; 13 (19.4 %) had suffered from chronic cervical/cervicobrachial pain for 10.6 years; 8 (11,9 %) suffered from mixed cervical/lumbar pain; 8 (11,9 %) suffered from other pain syndromes associated with postural disorders such as knee pain, plantar fasciitis etc.
C4
1
0.7
Th12
13
9.8
C5
10
7.6
L1
9
6.8
C6
5
3.8
L2
2
1.5
C7
7
5.3
L3
11
8.3
C8
2
1.5
L4
24
18.2
Th1
3
2.3
L5
9
6.8
Th3
1
0.7
S1
5
3.8
Th4
1
0.7
S2
2
1.5
D t Z t s c h r f A k u p. 5 7, 1 / 2 0 1 4 7 D Z A
Akupunktur Deutsche Zeitschrift für
DZA
Originalia | Original articles
German Journal of Acupuncture & Related Techniques
Fig. 1: The segmental distribution of the 132 active scars.
The systematic mapping of all visible scars totaled 343 scars (1 to 11; on average 5.1, SD 2.6). The RAC(–) scars, however, totaled only 132 (1 to 4; on average 2.0 per patient, SD 0.9). The active scars had existed from 1 to 70 years; on average 23.6, SD 16.0. As regards the location of all scars, 76 of 132 (57.6 %) were located on the left side of the body, 49 (37.1 %) were located on the right and 7 were located in the midline (on Conception Vessel acupuncture meridian). As regards the segmental distribution of the active scars, all segments from V1 to S2 had at least one scar, except segments Th2, Th6 and Th7. However, the distribution of the scars was not uniform and some segments had a higher concentration than others, such as L4 with 18.2 % followed by Th12 (9.8 %), L3 (8.3 %), L1 and L5 (both with 6.8 %). Cervical segments C5 and C7 showed 7.6 % and 5.3 % respec-
Fig. 2: HEINE Finoff transilluminator (HFT)
tively (Table 1). Some parts of the body were indeed a preferred site of the active scars such as the knee (22.7 %), the lower part of the abdomen (18.2 %) and the external surface of the arm (7.6 %). These three parts had a significantly higher duration of the scars and showed some from childhood, typically injuries or bruising of the knees due to falls and those due to vaccinations for smallpox; active scars were found in previously performed abdominal surgery (for example appendicitis, inguinal hernia, caesarian delivery etc.). The location of the 132 active scars has been transcribed on the segmental map of Hansen and Schliack (Fig. 1). Of these scars, 64 (48.5 %) evoked a bilateral RAC(–) (group A), 48 (36.4 %) evoked an ipsilateral RAC(–) (group B) and 20 (15.1 %) evoked a contralateral RAC(–) (group C). With T test for paired data there were no significant differences be-
A
B
C
D
E
F
D Z A 8 D t Z t s c h r f A k u p. 5 7, 1 / 2 0 1 4
Fig. 3: A 77 year-old patient had been suffering for at least 15 years from chronic lowback pain irradiating to the right leg. Three active scars were found: two of them were located on C6 and L4 segment on the right side. The most sensitive scar, showing a bilateral RAC(–) signal, was however a 40year old scar on the left gluteus due to an abscess. On the posterior plane the body was shifted to the left with respect to the plumb line (green line) (Fig. 3 A) and was shifted forward especially as regards the head (Fig. 3 B). The baropodometric platform showed an asymmetric pressure on the left and right foot, respectively 55.1 % and 44.9 % (Fig. 3 C). After infiltration of the three scars the body tended to reduce its shifting both on the posterior and the sagittal plane (Fig. 3 D, E). Posture improved with a more proportioned distribution of pressure on the left and right foot, respectively 51.2 % and 48.8 % (Fig. 3 F). In the following weeks the pain syndrome and the relative disability improved and the patient could significantly reduce the intake of analgesics.
Originalia | Original articles M. Romoli, L. Linari, G. Montagnoni, A. Giommi
T h e a c t i v e s c a r t e s t : a n i n n o v at i v e a p p l i c at i o n o f R A C / V A S s i g n a l f o r i d e n t i f y i n g s c a r s a s s o c i at e d w i t h p o s t u r a l d i s o r d e r s i n p at i e n t s w i t h c h r o n i c c e r v i c a l a n d l u m b a r pain syndromes
tween the number of pulsations after initiating the application of the beam of light and no differences between the number of pulsations during which the RAC phenomenon was perceived. Intensity of RAC(–) perceived on the ipsilateral side, however, was significantly higher in subgroup A compared to subgroup B (p < 0.01). Another T test was carried out comparing the three parameters between the ipsilateral and the contralateral side in subgroup A. A significantly lower number of pulsations was perceived on the ipsilateral side in the interval between the application of the beam of light and the onset of RAC(–) (p < 0.01). RAC(–) moreover was perceived on the ipsilateral pulse for a
Table 2
significantly higher number of pulsations (p < 0.01) and the intensity of RAC was higher on the ipsilateral than on the contralateral side (p < 0.001) (Table 2). In group A the signal was therefore perceived more intensely, earlier and longer on the ipsilateral pulse than on the contralateral one. As regards regression analysis, a significant relationship seems to exist between the intensity of RAC(–) and the sensitivity at palpation.
Discussion For several years we had been aware that active scars may represent a focus able to cause various pain syndromes associated with postural disorders. One of the fundamental principles of neural therapy, a widespread discipline in German speaking countries but insufficiently appreciated in the English speaking world, is that “every part of the body can become an active focus (Störfeld = perturbation field) and may influence distant parts of the body”. The infiltration of the active scar with local anesthetics, as proposed by this discipline, however, rather than giving simple anesthesia, means to identify and neutralize/deactivate a chronic and underlying disturbing focus of the patient’s health. Skin is therefore very important for physicians practicing neural therapy and every little scar, bruise, burn, especially if they come from the early years of life, should be checked carefully. The results of our study show that active scars
T test for the comparison of paired data in 64 scars with bilateral RAC(–) signal. The signal was perceived earlier, longer and more intensely on the ipsilateral pulse than on the contralateral one T
P
Ipsilateral vs contralateral observer (N° puls. after the start of illumination)
4,16
< 0.01
Ipsilateral vs contralateral observer (N° puls. after the onset of RAC(–) signal)
4,31
< 0.01
Ipsilateral vs contralateral observer (Intensity of RAC(–) signal)
5,40
< 0.001
A
B
C
D
E
F
G
H
I
Fig. 4: A 34 year-old patient had been suffering for at least 10 years from both recurrent cervical and lumbar pain. The pain syndrome worsened after 2 caesarian deliveries in 2008 and 2011 (Fig. 4 G-I). In fact the double abdominal scar showed, especially on the left side, a bilateral RAC(–) signal (B) with an early synchronous appearance of the phenomenon (after 3-4 pulsations) and a long duration (during 60 pulsations) for both observers (Fig. 4 G). The double scar had at least two tender spots at palpation (Fig. 4 H); the whole left part of the double scar, the stitches included, were infiltrated with about 2 × 1.8 ml carpules of Mepivacaine chloridrate 3% (30G, 0.30 × 21 mm needles) (Fig. 4 I). Before infiltration the patient’s head and shoulders were shifted forwards with respect to the plumb line (green line) (Fig. 4 A). The baropodometric platform showed an asymmetric pressure both on the left and right foot, respectively 47.2 % and 52.8 %, and a prevalent pressure on the forefeet with respect to the heels, respectively 63.9 % and 36.1 % (Fig. 4 D). After the infiltration of the scar the body tended to reduce its forward shift and pressure on the forefeet reduced greatly to 44.2 % (Fig. 4 B and E). The improvement in posture was followed by a reduction of pain both on lumbar and cervical level. After one month the effect of stabilization of posture was accomplished: the plumb line (green line) crossed the outer ear correctly (Fig. 4 C) and pressure on the forefeet was maintained in a physiologic range of 45.0 % (Fig. 4 F).
D t Z t s c h r f A k u p. 5 7, 1 / 2 0 1 4 9 D Z A
DZA
Akupunktur
Originalia | Original articles
Deutsche Zeitschrift für
German Journal of Acupuncture & Related Techniques
Fig. 5: Postural disorders in a 30-years old patient suffering from recurrent cervical pain and tension headache. The removal of one of three earrings improved the posture and the muscular stiffness of the neck. The site of piercing was active at lighting with the HFT and the ipsilateral (right) radial pulse showed a strong RAC(–) signal of intensity 3, after 5 pulsations and persisting for at least 60 pulsations.
Fig. 6: 34-year old patient suffering for at least 10 years from recurrent sciatic pain on the right side. At the age of 7 the patient underwent an operation for appendicitis-peritonitis. The upper part of the scar was sensitive at palpation and was active at lighting with the HFT. A collapse of pulse was perceived bilaterally after 10 pulsations and persisted for at least 60 pulsations.
disturbing the posture of patients with longstanding or recurrent neck /low-back pain may be identified using the white light of a HFT. The Active Scar Test proposed by our group is of practical interest since it allows a rapid and systematic screening of all visible scars. This, of course, depends on the physician having learnt to take the radial pulse correctly and to perceive its variations of amplitude during stimulation by the beam of light. Upon identifying one or more active scars, the physician should always check for their sensitivity and select some of them for treatment with neural therapy. Scars being both RAC(–) and sensitive to palpation always should be infiltrated with procaine, lidocaine, mepivacaine etc.; scars, which are RAC(–) without being sensitive or inversely sensitive without RAC(–) signal also may be included in treatment. In contrast, it is our opinion that scars without RAC(–) signal and not sensitive to palpation should be left untreated or be re-examined during follow up if posture and its associated pain syndrome do not show improvement. However, some questions in our study remain to be considered: the first one concerns the quantity of light necessary to evoke the RAC(–) signal. The phenomenon in fact tends to manifest and be maintained during time only if the stimulation with light is thoroughly and constantly applied on the active scar or on its most active part. Our impression is that every active scar needs a certain quantity of light to be “warmed up” in order to emit the RAC(–) signal. A single sweep of light along the scar therefore may be insufficient and several movements of the lamp may be necessary. This applies in particular if the scar measures more than 4-5 cm. For this reason we subdivided the longer scars into short segments and examined them in succession. However, we do not know to which degree medical conditions such as diabetes, hypertension etc. and the relative required medications may influence the RAC phenomenon. The second
D Z A 1 0 D t Z t s c h r f A k u p. 5 7, 1 / 2 0 1 4
Fig. 7: A 56-year old patient suffering for at least 15 years from chronic neck pain. From the first day of life she was carrying a scar of large dimensions on the sacral and gluteus zones due to a burn with hot water. The postural attitude of the patient was poor both on posterior and sagittal view. The lighting with the HFT identified 13 spots with an RAC(–) signal, which however was perceived bilaterally (B) only in 5 points; in 6 points it was perceived on the right pulse (R) and the active spot was in 4 cases on the ipsilateral side and in 2 cases on the contralateral one; finally in 2 points the RAC(–) was perceived on the left pulse (L) and in both cases the active spot was located on the same side (Fig. 7 A). The burned area showed several overlapping tender spots on palpation (Fig. 7 B). All the tender and RAC(–) points were included into treatment with Neural therapy.
question relates to the parameters we have selected for measurement. The arbitrarily chosen threshold of 30 pulsations after onset of illumination should serve to differentiate subjects, in which the decrease or the collapse of the pulse amplitude was perceivable, from those in which the signal was absent. In fact this range of variability could be greater than assumed in our study. Moreover we do not know if the signal in certain cases may exceed the limit of 60 pulsations that we introduced in the study. The third question is: why does the RAC(–) signal tend to be perceived more intensely on the radial pulse ipsilaterally to the scar? Does our vegetative system have an emisomatic relationship to an ipsilateral focus as described by neural therapy? However, the scientific approach to the RAC phenomenon remains a fundamental issue. Manual/clinical perception of the pulse amplitude variations may not be sufficient and we need to propose further research with appropriate and reliable instruments.
Conclusions The Active Scar Test as proposed in this study may be an interesting tool for identifying an active scar causing postural disorders in patients with chronic pain syndromes, especially if they are insufficiently responding to acupuncture and other complementary methods.
References 1. Nogier PFM. Traité d’Auriculothérapie. Maisonneuve, Sainte-Ruffine 1969 2. Romoli M, Linari L. Cicatrices actives et troubles posturaux dans les cervicalgies et les lombalgies chroniques. Actualité posturale en 2013. Marseille, 27–29 September 2013 3. Moser M, Dorfer L, Muhry F et al. Untersuchungen zur Physiologie des Nogier-Reflexes. Akupunktur/Aurikulomedizin 1998;2:3–13 4. Moser M, Auerbach D, Dorfer L et al. Réflexe auriculocardiaque (RAC, NogierReflex) und Orientierungsreaktion. Schmerz & Akupunktur 2005;3:129–134 5. Hansen K, Schliack H. Segmentale Innervation: ihre Bedeutung für Klinik und Praxis. Thieme Verlag, Stuttgart 1962