JOURNAL OF CHINESE MEDICINE NUMBER 17 JANUARY 1985

Modern Needle Techniques and Clinical Practice

by Peter H. Fraser.
Abstract The modern adaptation of traditional needle techniques of acupuncture are described - those for increasing, reducing pain and dispelling 'perverse' Qi. A review is made of those techniques which are considered to be clinically effective and those which are less important. An analysis of the methods is made, with comments on the main features of those which are clinically important, leading to a consideration of the role of pressure in the traditional techniques. The various needling techniques used for thousands of years in various regions of China have in recent years been the subject of investigation, and many of the traditional methods have been tested on numbers of subjects with control groups, in order to evaluate the clinical significance, if any, of the various actions which are taken to manipulate the needle once it is inserted. One experiment of interest was designed to evaluate the change in local skin temperature which is evident during an acupuncture treatment. During a visit to China in late 1983 I had the opportunity of talking with Associate Professor Wu Xiu Jin, of Zhongshan Hospital, Guangzhou. I was told that it has been established that certain needle techniques at certain points can alter the local skin temperature, and that a similar temperature change is frequently recorded on the bilaterally placed point to that being unilaterally needled. Furthermore, this sensation of heat which the patient reports in the local area around the needle can be propagated along the course of the acupuncture channel. Associate Professor Wu mentioned that it had been known that this subjective sensation of heat could travel from Hegu (L.1.-4) as far as Tianshu (ST25). Later in my visit I was able to find out how this effect was induced. Reproduced below in Table I are the results of an experiment where the skin temperature of a number of subjects was measured around the area of the needle and was measured after half an hour of "bufa" or increasing technique, and also after half an hour of "xiefa" or reducing technique. Each of these techniques was applied repeatedly every three minutes for a total of half an hour. A control group was tested at the same time but was given no needles.
GROUP BUFA GROUP XIEFA GROUP CONTROL INITIAL TEMP C 30.3 29.2 31.5 TEMP 30 MINS LATER C 31.5 27.7 31.7 AVERAGE CHANGE C +1.2 -1.5 +0.2 NUMBER OF SUBJECTS 23 22 5

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What is the criterion of clinical effectiveness, and how can this be used to evaluate different methods? The best one is the temperature change which can be induced since this is readily measurable. Does the temperature change mean that the needling was clinically effective? The answer is yes. This is because the temperature change can only be effected if the needling technique is correctly carried out, that is, the temperature change is not generally spontaneously achieved. Also, in order to make the technique work, it is necessary first to obtain the sensation of "deqi". Thus we can see the temperature change as a by-product of the deqi sensation. Method of Increasing Technique Professor Jin Rui, a renowned teacher and author of many texts on acupuncture, spent considerable time both in lectures and in an informal interview explaining the four or five major methods of needling still used in China. Very simply put, there are two important features of these methods. Firstly, obtain Qi sensation, then act on the needle to move the Qi. Surprisingly, the ancient theory of Heaven, Earth and Man has penetrated into the theory of needle technique. Briefly, the theory holds that the yang nature of Heaven created the Earth which is more towards neutral in quality, and that Mankind is a product of both Heaven and Earth. In the case of needle technique, the theory merely appears to refer to three levels of tissue beneath the acupuncture point. These three levels do not appear to have a physiological existence and relate solely to the concept of different levels of manipulation with the needle. To increase the energy, insert the needle painlessly into the skin, and wait for the sensation of deqi to develop. It may require some prompting however - and this is done by holding the head of the needle firmly for a few minutes. If no Qi arrives then the handle of the needle may be scratched several times, setting up a gentle vibration. It may take several minutes for Qi to arrive at the needle. When it does, the needle is pushed very slowly into the flesh to a level just below the skin which represents the "Heaven" position. Wait a few moments, then begin to thrust deeper to the next level, called the "Earth" position. Wait again for a short time, then thrust to the third level, or "Man" level. This whole process may take several minutes from the time the thrusting begins. This is what is meant by slow insertion! To complete the action required to increase the Qi, the needle is withdrawn in one rapid movement to the upper level where Qi was first obtained. This is the level at which the needle is retained when no action is being taken. The whole process is repeated every three minutes or so, or a lesser number of times depending upon the tolerance of the patient. Generally, it is only necessary to repeat the process twice during period of retention of the needle. Strong Increasing Technique There is a supplementary technique often used after the basic increasing technique, and this is called "The Dragon Shakes his Tail". The dragon in traditional thought is a mythical entity related to fire, which is yang in nature. So we know that this method is one of increasing effect. After the needle has been withdrawn to the upper level it is angled
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JOURNAL OF CHINESE MEDICINE NUMBER 17 JANUARY 1985

towards the diseased area of the body. The needle is then wagged back and forth across the meridian between 21 and 27 times according to the judgement of the practitioner. The method is supposed to assist the movement of Qi, and is to enhance the increasing method. Method of Reducing Technique Now we turn to the methods of calming the Qi. This time after the needle is inserted it is not left at the surface to obtain Qi. It is inserted to about half the depth to which it is possible to insert the needle on that point. Bear in mind that needle depths given in current Chinese texts refer to the maximum depth of insertion. Wait for the sensation of Qi to arrive at this intermediate level, then gently begin to withdraw the needle in three stages with a short waiting period between each movement. The whole process of withdrawal may take many minutes, and the whole series of actions may be repeated every few minutes for up to half an hour. If it is done correctly the local temperature of the skin will change by about 1C. Strong Reducing Technique This too is a method of enhancing the basic reducing technique described above. It is called "The White Tiger Shakes his Head". The tiger traditionally belongs to water, indicating that the technique has a cooling or reducing effect. Pressing in front of the needle causes the Qi to go behind. That is, finger pressure may be used to direct Qi in one direction or another. The thumbnail is placed about one inch from the needle, along the course of the channel. Then the handle of the needle, which should be still deep in the tissue at the end of the basic reducing technique, is bent gently toward the thumb. This will cause a very strong sensation of Qi in some patients. The handle of the needle is then wagged back and forth across the channel a number of times. This method is supposed to mobilise the jing Qi. Classically there are supposed to be an even number of movements since the even numbers were thought to be yin in nature. A variation of this technique is described in "Acupuncture - A Comprehensive Text". It involves describing the rim of a basin with the head of the needle to cause a reducing effect. Slanting the Needle The effect of the methods described above is to send the Qi sensation along the course of the channel. It follows then that these methods are used on the distal points of command. A simple way to reinforce these methods is to slant the needle at the end of the series of manipulations. It should be noted that slanting the needle on its own does not constitute a clinically valid technique. The needle may be given a final thrust fairly rapidly in the direction of the flow of the channel to increase, and against to reduce. It should be made clear that the needle is always inserted perpendicularly at the outset, and may be slanted later on at the end of a series of manipulations. Technique for Local Painful Points While the above methods may be used on the command points, they are not used close to the disease focus, since the effect would be too strong for the comfort of the patient. So a different technique is applied to "ah shi" points.
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For example in the case of fixed Bi syndrome the needle is inserted into the points painful to light pressure which correspond to acupuncture points. The needle is gently lifted and twisted to induce a feeling of numbness. This technique is intended to have a reducing effect. Now that Qi has been obtained, the head of the needle is warmed by placing a large slice of a moxa stick onto the head of the needle. In China a piece over three quarters of an inch long may be used once or-twice during a treatment. This needle technique had a local effect and is not used to treat distant parts of the body. Needling to Reduce Perverse Qi The classical texts all agree that 'perverse Qi' (due to invasion by external pathogenic factors) should be sedated. That is, the reducing needle technique is used to disperse it. At the same time, however, the true energy is to be reinforced. Dr. Gu, a post-graduate researcher at the Guangzhou Hospital of Traditional Chinese Medicine told me that in the treatment of 'perverse Qi' the reducing technique is used initially, for one third of the time chosen for the treatment. For the remaining two thirds of the time the reinforcing or increasing technique is used. Some Less Effective Methods The practice of inserting the needle then twirling it half a turn to the left or right was mentioned by Professor Rui. He said that it belonged to a period about 800 years ago, and that it was one of the traditional methods of needling which had been clinically evaluated. In his opinion, it had no value since the direction of the twirling has been shown to have no clinical significance. What matters is not the direction of the twist, nor the number of twists, since these relate to some of the more doctrinaire aspects of the ancient yin-yang theory. The therapeutic effect of the needle is however directly related to the obtaining of deqi, and to the propagation of that sensation along the channel. Another classical method which has fallen into disuse is that of breathing in or out as the needle is inserted or withdrawn. These techniques may be as much related to Qigong theory as classical acupuncture. In the context of clinical acupuncture they appear to have little effect. In any case, this method was only ever used on the needles inserted into the thorax and abdomen. The "Comprehensive Text" of the Shanghai College agrees that this method has little clinical effect. In the classical references to the needle techniques there is always a mention of closing the point with the finger after the needle has been removed from the body, to reinforce, while the point is left open when reducing. Professor Rui mentioned that this technique was only ever used in diseases of the internal organs, and like the breathing techniques, has limited clinical usefulness.

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The common technique which has reached the West which involves inserting the needle then rotating it six times or nine times to the left or right is more effective as a means of obtaining Qi than it is to increase or reduce. Incidentally, the increasing and reducing techniques described in this article are so time consuming that in practice, only one or two of the major command points are ever manipulated in this way during one treatment session. Evaluating Clinical Usefulness It is known that acupuncture points respond to light, heat, temperature, pressure and cold as well as to electrical currents in various waveforms. Inferences from the descriptions of needle techniques discussed here are that the common feature of the effective techniques is one of pressure, which is applied slowly and consistently to the needle in various ways. The definition of effectiveness is the ability of the technique to alter the surrounding skin temperature, as well as to induce a strong deqi sensation. Application of pressure causes Qi sensations to be propagated along the meridian, and it may be that the meridian theory itself owes something to communication between groups of pressure receptors beneath the skin. Furthermore, it may be that the direction of the application of pressure to the needle is an important factor. Pressure in the techniques I have described is applied in several different directions - but sometimes it increases and sometimes it reduces. When it is applied downwards or towards the body (i.e. thrusting) the Qi is increased, but when it is applied upwards, or away from the body (i.e. lifting) Qi is reduced. Another factor seen in the "strong" techniques is the application of gentle pressure along the meridian flow or against it. The pressure theory is a possible explanation although it does not explain why pressure in one direction appears to increase local skin temperature and reduce it in another. But the concept is not at all alien to science. The piezoelectric effect is used on many modern microphones. A vibration caused by the pressure of a voice or other sound sets up electrical impulses in crystals which are then amplified greatly. The analogy is of course there but the body does not have crystals which are needed for this effect to occur. It is more likely -that the pressure receptors which are activated by the needling techniques are in some way acting on the vascular system to cause the local effects which I have outlined in this article. The effect of acupuncture on the vascular system has already been studied and it is known that it regulates blood pressure when applied at certain points. References Lectures by Professor Jin Rui, Guangzhou College of TCM. Acupuncture - A Comprehensive Text, tr. O'Connor J and Bensky D. Eastland. 1981

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