Positioning the Patient
Selecting a position for the treatment depends to a great extent on the clinical condition of the patient and on the location of points chosen for acupuncture. The supine and prone positions are preferred by most acpuncturists because patients are more likely to feel relaxed and comfortable than when sitting upright. Acupuncturists also note less syncopes associated with the procedure when these positions are used. A lateral, recumbent position should be used for points over the lateral aspects of the thigh and knee. The lithotomy (dorsosacral) position is used for points in the perinea} region. For points located on the face, the head, the back, and the extremities, a recumbent or sitting position may be used if preferred. A sitting position is recommended when the head is to be turned sideways or bent forward. There are no preferred positions for very old and very young patients, or for obese or emaciated individuals. In each case, the comfort and convenience of the patient should be the guide.
The earliest known needles, dating back to Neolithic humans-seventh to fifth centuries B.C.-were made of flint. As time went on, bamboo was used, then iron, bronze, copper, silver, and gold. The handles were usually of bronze or silver. More recently, aluminum and stainless steel have become popular. Disposable needles have now been put on the market and their use is expected to become widespread.
The Nei Ching describes nine types of needles, each with a different shaped tip: arrowheaded, blunt, puncturing, spear-shaped, ensiform, round, capillary, long, and large. Each needle consists of a handle, a root, a stem, and a tip.
Today’s needle lengths vary from 0. 5 to 4.0 tsun (15-100 mm), and their gauge varies from 0.28 to 0.45 mm (26-32 G). The most commonly used needle is the stainless steel capillary needle; it is 1.5 tsun (40 mm) in length and has a gauge of 28-32 G. Unless otherwise indicated, this is the needle of choice. Needles of 0.5 (15 mm) to 1.0 tsun are preferred for superficial points on the face, around the eyes, and in the chest; those of 1.5-2.0 tsun in length are preferred for the trunk and extremities; and still longer ones are preferred for muscular areas where deeper penetration is required.
Care and Preparation All needles should be sterilized routinely before each use. Each one should be carefully examined before use to ensure that it is not bent, that the tip is not hooked in any way, and that there is no rust or spotting on the stem. The handle should be tested to make sure that it fits firmly and tightly to the stem. Before each procedure, the acupuncturist should clean his or her hands and also carefully clean the patient’s skin at all acupuncture points, using 70% alcohol. Needling at sites of apparent infection or where there are open wounds should, of course, be scrupulously avoided.
Insertion To insert needles as quickly and painlessly as possible, one of the following techniques should be used:
1. Stretch the skin over the acupuncture point between the thumb and index finger while applying moderate pressure. Using the other hand, grasp the needle firmly by its handle and pierce the skin rapidly. This minimizes any sensation of pain or discomfort and
the needle can then be inserted to the desired depth.
2. Pinch the skin over the acupuncture point and press it firmly between the thumb and index finger. Puncture rapidly with the needle and insert to desired depth.
3. Press the thumb firmly as close as possible to the point selected and puncture the skin rapidly. Then advance needle to desired depth.
For maximum accuracy, it is important that the hand holding the needle be as steady as possible. To ensure this, rest the wrist against the patient’s body, making certain that there is sufficient freedom for rapid movement when placing the needle into the patient’s skin.
Angles Needles may be inserted in three ways:
Perpendicularly at 90° This angle is used for points which are deep-seated or are located in heavy muscle.
Obliquely at 30-60° This angle is used for points in the proximity of bone or the thoracic or lumbar areas, and is particularly useful for avoiding possible pneumothorax.
Horizontally at 10-20° This angle is used for points on the head and face and other areas where there is minimal subcutaneous tissue and muscle; also when penetration from one point through to an adjacent one is recommended.
When needles have been placed successfully, the patient is likely to experience a sensation known as Teh Chi. This can be described as a feeling of fullness, numbness, tingling, and warmth, with some local soreness and a feeling of distension around the acupuncture point. It is not necessary, however, for the patient to experience Teh Chi for a treatment to be successful.
Once the needles are in place, and after Teh Chi has been obtained, the needles should be manipulated in one or more of the following ways:
1. By rotating the needle between finger and thumb through not more than 180°. More than this can cause tissue damage and should be avoided. While rotating, the shaft can be scratched gently and it can be tapped; these movements help to conduct the acupuncture effect to the structures surrounding the point being acupunctured.
2. By oscillating the needle back and forth while holding the handle firmly between index finger and thumb. This conveys a gentle tremor to the area around the point and enhances the acupuncture effect.
3. By twirling the needle rapidly between the index finger and thumb, or by using rapid “pecking” movements up and down. This is useful when strong stimulation is required.
4. By electric stimulation at selected points.
Stimulation of needles at acupuncture points using electrically powered or battery-operated units recently introduced into China is now coming into general use in the West. It offers a number of advantages over the traditional hand manipulation of needles. The degree of stimulation, for example, is easily controlled by the practitioner, and a more continuous, uniform, and relatively standardized degree of stimulation can be delivered than is possible with the manual method. It is also possible to obtain stronger stimulation. It is particularly helpful when lengthy treatments must be undertaken, as these have, in the past, tended to become highly fatiguing for the practitioner.
Many different kinds of power units are now readily available. These include stimulators using direct or alternating current, buzzer stimulators using induced current, and units with vacuum tubes or transistors. The most popular units are solid state stimulators that work on the principle of the electric doorbell and generate uniform, steady pulses. The most commonly used stimulators are 6- or 9-V battery-operated transistors, generating frequencies ranging from 120 to 2,400 pulses/min. The output potential of such a unit varies from 0 to 70 V. Intensity is generally 50 V for the positive portion of the pulse and 35 V for the negative portion of the pulse. The width of the positive pulse is 0.5 msec and that of the negative pulse, 0.25 msec. This type of stimulator can produce pulse frequencies of 120 to 2,400 cycles/min, to a maximum of 5 ,000 cycles for continuous wave, and frequencies as low as 14 to 26 cycles/min for interrupted or variable internal waves.
To use an electric stimulator, pairs of two, four, or six acupuncture points in close proximity to one another are chosen. When the needles have been inserted correctly, the positive electrode is connected to one of the paired needles and the negative electrode is connected to the other. The stimulator is then switched on and the current gradually increased. Optimum stimulation is achieved when the patient experiences either Teh Chi, or a tingling sensation, or is just below the threshold of tolerance.
This form of treatment is usually given over a 15- to 20-min period but can be extended when necessary, as in some cases of chronic muscle or joint pain for which 30-40 min is more appropriate. Continuous electric stimulation has been given safely for up to 4 or 5 hr, particularly during major surgery, with no known ill effects or complications developing. It should be avoided, however, in pregnant women and in patients with cardiac pacemaker implants for obvious reasons.
In addition to the usual complications said to be associated with acupuncture and described elsewhere in this book, electroacupuncture may cause unexpected skin reactions, bums, or nerve or muscle damage. Electric bums can occur because excessively high current is used or because the electrodes are spaced too closely together. Faulty connections may be a cause of electrocution, and high current may cause ventricular fibrillation and death. Battery-powered units are, therefore, the safest to use.
Whatever unit is selected, it must always be carefully and frequently tested before each use. Electrical output, voltage, polarity of the electrodes, and grounding provisions should also be meticulously and frequently checked out.
Degree of Stimulation
Strong stimulation is used when analgesic, sedative, or hypnotic effects are desired. Twirling and rotating needles rapidly while increasing the arc through which they are moved back and forth usually increases the strength of the stimulation at the point of acupuncture. Fifteen minutes is considered adequate time for treatment.
Weak stimulation is used clinically for functional disturbances or in diseases in which emaciation and wasting occur. Once the needle is inserted and Teh Chi obtained, it should be left in place for 10-15 min with no further manipulation.
Medium stimulation is the most usual type of stimulation used in acupuncture. Fifteen minutes is considered adequate time to obtain the maximum effect of acupuncture in most cases, and needles can be with-
drawn after this period.
The foregoing applies to both manual and electric stimulation.
Needles can be easily removed by gentle twirling and quick withdrawal. If slight bleeding occurs, local pressure should be applied to the point for 1 min.
Bent Needles – A bent needle is usually the result of undue force being exerted on a needle and causing enough stress on it to change the angle of insertion beyond the limit of tolerance. This may happen if a patient shifts position suddenly, thus causing unexpected stress on one or more needles, or it may be a result of the acupuncturist using too much force to overcome unusual resistance while twirling or rotating needles during a treatment.
Bent needles should be withdrawn carefully by easing them out slowly and allowing for the angle of insertion and degree to which they have become bent; this will help to avoid breakage. Such needles should never be straightened out and used again but should be discarded immediately.
“Frozen” Needles – A needle may on occasion seem to be caught tightly in tissue and appear impossible to remove. This is usually due to muscle spasm around the acupuncture point and can be easily overcome. The patient should be calmed and reassured, and then slight vibration applied to the needle accompanied by gentle massage to the surrounding skin and muscles. This will relieve the muscle spasm and loosen the needle for easy removal.
A second needle inserted close to the “frozen” one may also help reduce muscle spasm. It is important to avoid haste or unnecessary force when removing such needles, otherwise bending or breakage may occur.
Broken Needles – Broken needles are caused by a variety of circumstances, including improper quality control that results in poor quality materials being used for needles, the handle or shaft becoming loose or worn, or, once again, the patient who shifts position during acupuncture placing too much stress on a needle and causing it to break.
Since prevention is always better than cure, all needles should be carefully examined for possible flaws and wear and tear before each use. However, once a needle does break while in a patient, a pair of forceps should be used to remove the broken fragments. Gentle pressure to the surrounding tissue may help force small pieces out. In rare instances, surgical intervention may be necessary.
All these hazards should be taken into account and special attention paid when acupuncture is given to patients who are subject to convulsive seizures.
Complications During Treatment
Fainting occurs occasionally at the time needles are being inserted. It is seen most frequently in patients who are either severely emaciated or suffering from nervous tension or anxiety stress. Those who are extremely fatigued or hungry also have a tendency toward syncope. Such individuals should be observed closely during treatment for signs of restlessness, pallor, cold sweats, and cyanosis of the lips; they may also complain of dizziness and blurring of vision. When fain ting does occur, it is more likely due to vasovagal reflex than to injuries to vital organs or major blood vessels. However, careful examination should be done to rule out accidental injury to major organs and vessels during needling. The patient should be made to lie down with the legs elevated and the airway kept open, and all needles should be removed immediately. If loss of consciousness ensues, manual massage over the following points may help stimulate the patient: Jen Chung (Shui Kou), Tsu San Li, Chung Chung, Nei Kuan, or Pai Hui.
When a patient is either emaciated or very nervous, weak stimulation should be used, particularly at the time of the first visit. The strength of the stimulation can be increased gradually with each visit, as the patient’s tolerance increases.
Although rare, pneumothorax may arise as a result of needles being inserted deep into the thorax or the upper back. Symptomatology includes cough, sudden chest pain, the onset of shortness of breath, cyanosis, cold sweats, syncope, hypotension, and tachypnea. Pneumothorax can be almost completely avoided if several simple precautions are taken; acupuncture points over the thorax and upper back should be selected with great care and deep insertion of needles avoided, particularly when vertical insertion is recommended. Oblique or horizontal insertion of needles should be performed at all times. The patient should be immobilized properly and prevented from coughing during treatment.
If pneumothorax should develop, the patient should be kept in a semi-Fowler position. Small amounts of air can usually be reabsorbed into the body with no treatment necessary. However, if the pneumothorax is more severe, a chest tube should be inserted immediately and air removed by suction or underwater seal drainage.
Injury to Vital Organs
A thorough understanding of anatomical relationships of major organs and body systems near acupuncture points should be a basic requirement for every practitioner of acupuncture if possible injuries to vital organs such as the heart, liver, kidneys, and spleen are to be avoided.
Pyrogenic infections can be avoided by observing standard sterilization practices. The incidence of hepatitis spread by acupuncture needles is unknown but is probably minimal. This hazard can be eliminated by the use of the new disposable needles now available on the market.
Reaction to Foreign Bodies
Granuloma has been known to occur around broken needle fragments when these have been left in the body. Careful removal of all such fragments is therefore mandatory.