Acupuncture is a technique that uses very fine needles to puncture the surface of the skin and underlying tissues at specific points along energy channels or pathways known as meridians and collaterals. These sites are called acupoints, and are chosen according to Chinese medicine theories in order to elicit specific therapeutic effects. Following diagnosis of the disease and syndrome (symptom/sign complex), the treatment principle and acupuncture prescription is formulated. Needles are inserted and manipulated using a variety of techniques, each having a specific therapeutic effect.
The practice of acupuncture is guided by the major theories of Chinese medicine including the Yin-Yang theory, zang-fu theory, five-element theory and in particular, the theory of meridians and collaterals. These will be discussed in later chapters of this book. According to these theories, acupoints are points through which the meridian qi and qi of the zang-fu organs are transported to the body’s surface. The number of acupoints on each meridian varies from nine on the heart and pericardium meridians to 67 on the bladder meridian.
Acupoints can have a local effect and/or a distal effect, i.e., an effect on another part of the body remote from the acupoint. Acupoints on the same meridian share common functions; in addition, each acupoint has its own specific function(s). For example, the acupoint Qu Chi (Large Intestine 11) near the elbow shares common functions with several other points on the
large intestine meridian including the treatment of pain, numbness and motor impairment (such as immobility and spasm) of the lateral arm and shoulder. However, its special function is relieving fever and is usually the acupoint of choice for conditions with high fever. Each regular meridian3 has specific points with functions that are common to all meridians. For example, each meridian has a Yuan or primary point that is used to treat deficiency-type conditions, and a Xi-Cleft point that is used to treat acute disorders.
In treatment, a variety of points may be chosen. Acupoints are usually chosen from the affected side of the body; however, in some cases, acupoints from the opposite side may be chosen (this is called cross-needling). Local points are those that overlie or are very close to the diseased area of the body. Adjacent points are those nearby. Distal points of the regular meridians have actions on parts of the body remote from their location. Distal points are located below the elbow and knees and are primarily chosen from the meridian involved in the disorder, being commonly used to treat conditions of the head, chest, abdomen and back. For example, the acupoint He Gu (Large Intestine 4) on the hand is commonly chosen to treat conditions of the head, face and eyes such as headache, sinusitis, conjunctivitis, toothache and facial paralysis. In practice, a combination of local, adjacent and distal points are commonly chosen to treat pain and disorders of the zang-fu organs.
According to the zang-fu theory, each zang organ (considered deeper in the body) is connected or paired with a more superficial fu organ, and the connection is provided by the respective meridians (this is described as an interior–exterior relationship). In the treatment of a disorder of a particular zang-fu organ, points from its paired meridian may also be chosen. For example, in the treatment of a lung disease, a point from the lung meridian’s paired meridian, the large intestine meridian, may be chosen. Empirical points are those that have a historically established and specific effect that does not necessarily bear a relationship with its course. For example, Lie Que (Lung 7) is traditionally used to treat headache even though the lung channel does not pass to the head. There are also combinations of points that historically have been found to be effective.
Acupoints may be chosen according to many principles that include:
•From the front of the body to treat the back and vice versa;
•From the lower body to treat the upper body and vice versa;
•From one meridian to treat its interior–exteriorly related meridian;
•Selection of empirical points or empirical combinations;
•From the opposite side of the body (cross-needling); and
•Treatment of the root cause (ben) and the secondary manifestations (biao) (Deadman et al., 1998).
Following the formulation of an acupuncture prescription, the patient is generally asked to lie on the treatment couch. The skin is cleaned and swabbed with an alcohol swab and an appropriate sterile needle chosen. Acupuncture commonly uses very fine filiform needles that have a handle at one end and the needle at the other. A modern variation on traditional needles is the addition of plastic guide tubes may be supplied with the needle that limit the initial depth of insertion of the needle into the skin: once inserted, the guide tube is removed and the needle inserted deeper and/or manipulated. The needles vary in length and thickness. For insertion into an area of abundant muscle such as the buttocks, a needle of greater length and usually greater thickness is chosen, whereas for insertion into, for example, areas on the face where only superficial insertion is needed, a shorter and finer needle is generally chosen.
The angle, direction and depth of needle insertion are all important factors in acupuncture technique. The needle may be inserted at right angles (90º) to the body surface, inserted obliquely (approximately 45º to the body surface) or transversely (at an angle of 15º). A transverse insertion is usually used where the muscle coverage is thin, such as acupoints on the head or face. An oblique insertion is usually used when the needle is to be inserted into acupoints near important organs or close to bones. A perpendicular insertion is used in areas where soft tissue is thick and on the limbs.
Direction of insertion depends on where on the body the needle is to be inserted and is related to angle of insertion. Depth of insertion depends on where on the body the needle is to be placed and the overlying musculature and fat. Extreme care with depth of insertion must be taken when needling acupoints close to or overlying vital internal organs. Depth of insertion is less for a thin person with little body fat and muscles, for example, than someone who has a lot of muscle. Shallow insertion is suitable for those with a poorer constitution or who are weaker, such as elderly people, whereas deeper insertion is suitable for those with a strong constitution, and generally young and middle-aged people.
The therapeutic effect of needling depends on achievement of the “arrival of qi” or “de qi”. This is a subjective sensation felt by the practitioner and the patient. The patient may feel as sensation of heaviness around where the needle is inserted. In some cases, the sensation may be like a tiny electric shock that travels along the course of the meridian (that the acupoint belongs to). The practitioner feels a sensation akin to the needle having been grasped by the tissue.
Once the needle is inserted, the needle is generally left in the body for 15–30 min, although for certain conditions, the needle retention time is only a matter of seconds (usually in acute conditions
such as pain syndrome and in conditions such as hay fever). During the period of needle retention, the practitioner may manipulate the needle. Again, there are a variety of manipulation techniques that have different therapeutic effects. For example, the needle may be lifted up and thrust down again, or twirled and rotated continuously. Another technique is to shake the needle or cause it to vibrate. Force and speed of needle manipulation, depth of insertion and amplitude of rotation of the needle have therapeutic significance. For example, in order to reinforce in the case of a deficiency-type condition,4 the needle is rotated gently and slowly using a small amplitude: this is called a reinforcing technique. In comparison, in order to reduce an excess-type condition,5 the needle is rotated rapidly using a large amplitude: this is called a reducing technique.
At the end of the treatment, the needle is removed from the patient. Again, the technique of removal has therapeutic significance. For example, in a reinforcing technique, the removal of the needle is gentle whereas it is more forceful in a reducing technique. The acupoint is generally pressed with a sterile cotton swab or ball after removal of the needle in order to prevent swelling around the site that may be cause by bleeding beneath the skin or to stem spot bleeding from the acupoint if it occurs.
There are other kinds of acupuncture needles and techniques. For example, the dermal hammer is a hammer-shaped instrument with many fine needles in the head. It is tapped against the skin to cause superficial bleeding. It is used to treat mainly musculoskeletal conditions in which there is blood stasis.
Acupuncture is used for a wide range of conditions including pain relief, treatment of musculoskeletal problems (such as lower back pain, sprains and strains, frozen shoulder, tennis and golfer’s elbow), digestion problems, women’s health problems, asthma, chronic fatigue syndrome, urinary dysfunction, infertility, common cold, fever, sore throat, constipation and diarrhoea — to name only a few.
The purpose of acupuncture is to bring the body back into internal balance, harmonising the Yin and Yang and qi and blood of the body. In Chinese medicine, acupuncture is believed to have immediate action on the vital energy via the meridians and collaterals. In the past, acupuncture was believed to be one of the most effective methods in treatment of medical emergencies. This role obviously has been diminished due to the advancement of Western medicine; however, it is still frequently used for acute pain management. Recent research has also demonstrated the value of acupuncture for the management for disorders including various pain syndromes (acute and chronic), urinary tract infection, nausea, vomiting, morning sickness and hay fever.
Risks of acupuncture are minimised by correct technique and adherence to infection control guidelines. Problems can include broken or bent needles, stuck needles and haematoma (swelling around the acupuncture site due to bleeding beneath the skin) (Cheng, 1987). Fainting can also occur, particularly in patients who are very nervous, over-fatigued or have a weak constitution. For this reason, the practitioner should monitor the patient’s response carefully, and in general, first-time patients should be needled lying down, not sitting up. More serious problems can include puncture of major body organs such as the lung (e.g., pneumothorax), and infection of the local acupuncture site or even introduction of pathogens deeper into the body. There are risks to the practitioner too. These can include needle-stick injury where the practitioner accidentally pricks himself/herself with a needle that has been used on the patient. Aseptic technique is vital in order to avoid infection of the body. The use of disposable single use needles (instead of re-usable needles) is recommended in order to decrease the risks of contamination and spread of infection. Blood-borne diseases including HIV-AIDS and hepatitis B and C can be spread with contaminated needles.
Care must be taken with first-time patients and those who are particularly nervous or of weak constitution to avoid fainting. Acupuncture should be avoided in patients who are over-fatigued, over-hungry or intoxicated. Strong needling techniques should not be used in patients who are very weak and deficient in qi or blood. Certain acupoints are contraindicated in pregnant females, particularly those on the abdomen or lumbo-sacral areas (lower back region) and those that stimulate blood circulation. There are points that can stimulate uterine contraction and obviously these must be avoided in pregnancy. Acupuncture should also be avoided during menstruation unless it is for the purpose of regulating menstruation. Acupuncture should not be performed on patients who are prone to spontaneous bleeding and is contraindicated in local areas where there are skin infections, ulcers or other lesions, broken skin, some rashes, scars or a tumour.
Electro-acupuncture is a relatively modern variation on acupuncture in which electrodes are attached to the handles of the filiform needles once inserted into the body, and a small electrical current applied. In terms of the Western biomedical model, application of the electrical current has the effect of altering ion concentration and distribution in the body tissues and can be used to regulate the functioning of the body, promote analgesia and regulate muscle tone. In terms of Chinese medicine theories, it is able to promote the circulation of qi and blood. Different waveforms of electrical activity may be applied and each has its own therapeutic action.
Electro-acupuncture has a similar wide range of indications as regular needling. However, it is contraindicated in patients with pacemakers and caution must be taken to avoid the current loop passing the heart for persons with heart disease. It is generally not recommended for use in pregnant females.
In modern times, the use of magnets as a form of acupuncture therapy has started in some centres. Magnets in the form of beads or sheets are applied to an acupuncture point, setting up a magnetic field. Magnetic sheets may also be placed opposite each other, for example, on either side of a limb. Such placement allow the magnetic force to penetrate deep into the tissue. Magnet therapy is used for a range of disorders including hypertension, sprains and muscular strains, heart disease, asthma, joint pain, period pain and dizziness.
Based on the principle that all meridians directly or indirectly communicate with the ear and each meridian is related to a zang-fu organ, theory holds the ear is closely related with the zang-fu . The body structures are mapped onto the surface of the ear in the shape of an inverted foetus. Not only are there areas on the ear surface that correspond to body parts, but there are also specific points that have particular therapeutic functions. For example, the ear acupuncture point Shen Men is commonly used for insomnia because of its therapeutic function of calming the heart and mind. According to Chinese medicine theories, sleep (quality and quantity) depends on the state of the shen (spirit) or mind, and the heart is the zang-fu organ that controls the mind.
Acupuncture needles are inserted into points in the ear. Alternatively, small seeds backed with sticking plaster are taped onto specific ear acupuncture points. They are generally left on the ear for 2 to 3 days and pressed daily 2 to 3 times per day in order to stimulate the point and elicit the proper therapeutic effect. Like in regular acupuncture, an acupuncture prescription is formulated following diagnosis of disorder and differentiation of syndrome according to Chinese medicine theories.
Acupoints may be chosen according to:
•Chinese medicine theory (e.g., for disorders involving the spleen, the spleen point is chosen);
•Disease location (e.g., for bronchitis or cough, the lung point is chosen);
•Modern medical knowledge (e.g., the sympathetic point is chosen for disorders involving the sympathetic nervous system); and
•Clinical experience (e.g., Shen Men is chosen for insomnia or manic depression).
Ear acupuncture is not only used as a treatment option. Knowledge of the ear acupoints can aid in diagnosis. For example, when there is disease, corresponding areas on the ear may become tender or show a change in colour or form. Ear acupuncture is indicated for a wide range of disorders including palpitations, insomnia, hypertension, hypotension, tonsillitis, dysmenorrhoea, epilepsy, constipation, various skin disorders, headache and sciatica.
Scalp acupuncture differs from regular acupuncture or ear acupuncture in that areas on the scalp rather than specific points are stimulated, in general, the areas over specific regions of the brain that they have a therapeutic effect on (and after which they are named). For example, there is a sensory area overlying the Sensory Area of the brain (indicated for sensory disorders such as numbness, migraines and vertigo), a Motor Area (indicated for disorders such as paralysis of the lower limbs), a Speech III Area overlying the parietal area of the skull used for treatment of sensory aphasia (disturbance in understanding speech) and a Visual Area overlying the occipital lobe of the brain used to treat cortical (brain-related) visual problems.
Electro-acupuncture is commonly used to treat cerebral or encephalic disorders such as stroke, epilepsy, chorea, paralysis, aphasia and vertigo. It may also be used to treat different kinds of neuralgia, lower back and leg pain, nocturnal eneuresis and other disorders.
Electro-acupuncture may be applied to stimulate the specific regions of the scalp. Alternatively, manual manipulation of the needle may be performed; following rapid needle insertion, the needle is rotated very rapidly at a frequency of approximately 200 times per minute for approximately 30–60 s. This manipulation is usually followed by a break of several minutes, and thereafter, the manipulation/break sequence is repeated twice.