Does needling sensation (de qi) affect treatment outcome in pain? Analysis of data from a larger single-blind, randomised controlled trial

ACURATE: A guide for reporting sham controls in trials using acupuncture

OBJECTIVE

To promote better reporting quality regarding sham acupuncture in clinical trials for a precise appraisal of the adequacy of the sham acupuncture procedure.

METHODS

A three-stage online Delphi survey was conducted to a group of experts. Items with higher than 80% consensus from the initial checklist were selected as the final candidates. Further discussion among the working group was convened to preclude potential redundancy among the items.

RESULTS

A total of 23 experts out of 35 (66%) responded to the Delphi process. The final checklist consists of 23 items in six categories: type of sham acupuncture, details of sham acupuncture manipulation, location of sham acupuncture, treatment regimen, practitioner, and protocol and settings.

CONCLUSION

This paper presents the Acupuncture Controls gUideline for Reporting humAn Trials and Experiments (ACURATE) checklist, an extension of The Consolidated Standards for Reporting of Trials (CONSORT) and to be used along with STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) when sham acupuncture needles are used in the study. This checklist focuses on a clear depiction of sham needling procedures to enhance replicability and enable a precise appraisal. We encourage researchers to use ACURATE in trials and reviews involving sham acupuncture to assist reporting sham acupuncture procedures and the related components.

Effect of acupuncture at Zusanli (ST36) point on antral contraction function under ultrasound guidance: study protocol of a randomized controlled trial

BACKGROUND

Although the relationship between deqi sensations and curative effect has always been controversial, deqi sensations has been regarded as the key indicator of clinical efficacy of acupuncture therapy. There is little evidence for standardization or visualization of the mechanism of acupuncture's therapeutic effect. This trial aims to evaluate the effect of needling at Zusanli (ST36) on antral contraction function as visualized by ultrasound.

METHODS

This is a two-arm, single-blind, randomized, controlled trial. A total of 116 acupuncture-naïve healthy subjects will be randomly allocated to the acupuncture group or sham acupuncture group in a 1:1 ratio. Participants in the acupuncture group will receive manual acupuncture at Zusanli (ST36) with the needling depth at crural interosseous membrane. Those in the sham acupuncture group will be given penetrating needling depth at the superficial fascia layer. The primary outcome will be the changes in antral contraction frequency (ACF) before and after acupuncture. The secondary outcomes will be the changes in the thermal infrared spectrum of gastric area skin, the antral contraction amplitude (ACA), the antral movement index (AMI), and the scores on the Chinese version of Massachusetts General Hospital Acupuncture Sensation Scale (C-MASS). The adverse events will be evaluated and recorded in detail.

DISCUSSION

This study may provide visual and objective evidence regarding the safety and efficacy of manual acupuncture at Zusanli (ST36). In addition, the results of this study will help to identify the role of Zusanli (ST36)in the inducing deqi.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000040686 . Registered on 8 December 2020.

The Effect of Electroacupuncture on Dynamic Balance during Stair Climbing for Elderly Patients with Knee Osteoarthritis

Background

Poor balance is one of the risk factors for falls in patients with knee osteoarthritis (KOA), which is related to the symptoms. Electroacupuncture (EA) is one of the traditional Chinese conservative methods commonly used to improve the symptoms in patients with KOA.

Objective

To assess whether EA increases the dynamic balance during stair negotiation among patients with KOA.

Methods

A total of 40 KOA patients were assigned to two groups randomly (true electroacupuncture vs. mock electroacupuncture). Acupoints around the knee were selected in the true electroacupuncture (TEA) group with electrical stimulation (2 Hz). In the mock electroacupuncture (MEA) group, about 2 cm next to the above acupoints, the needles were inserted superficially without electrical stimulation. All the participants received 11 sessions of stimulation treatment in three weeks. The primary outcome was margin of stability (MOS). Secondary outcomes included hip kinematics and kinetics as well as pain.

Results

There was no significant difference between the two groups for self-reported pain (p=0.585). During ascent, there was no difference between groups in MOS value in both directions, which was the anterior-posterior (A/P) direction and medial-lateral (M/L) direction at initial contact and toe-off as well as the midstance in the gait cycle, and no difference for the hip kinematics and kinetics between the groups was detected (p > 0.05). For descent, at the toe-off event, the TEA group was more unstable as compared to the MEA group in the A/P direction (p=0.029) but not in the M/L direction, and the hip showed a larger internal rotator moment (p=0.049); at the midstance, the TEA group showed a lower abductor moment than the MEA group (p=0.003).

Conclusions

Based on the assessment results from the chosen patients with KOA, the TEA did not demonstrate a significant effect in improving the dynamic balance during stair negotiation in comparison with the MEA. This finding does not support EA as a conservative treatment to improve the dynamic balance in such patients.

Understanding Acupoint Sensitization: A Narrative Review on Phenomena, Potential Mechanism, and Clinical Application

As part of traditional Chinese medicine, acupoints are considered a dynamic functional area, which can reflect the internal condition of the body. When the body is suffering from disease or injury, corresponding acupoints are believed to be activated and manifest in several sensitized forms, including expansion of the receptive field, pain sensitization, and heat sensitization. Such phenomena are believed to gradually disappear concomitantly with recovery from the disease. Acupoint states are therefore changeable according to health status, a phenomenon known as acupoint sensitization. This review aims to provide an overview of acupoint sensitization based on existing research results and determine priorities for future research. Systematic literature retrieval was conducted in Medline, Embase, Cochrane Library, CINAHL, and AMED from inception to 18 July 2018. Current evidence from research findings to date indicate that acupoint sensitization is based on neurogenic inflammation and that stimulation of sensitized acupoints presents a potential trend of generating a better clinical effect when compared with stimulation of unsensitized points.

Correlation between acupuncture dose and effectiveness in the treatment of knee osteoarthritis: a systematic review

BACKGROUND

Acupuncture is a widely used treatment for knee osteoarthritis, but evidence of its effectiveness from randomised controlled trials (RCTs) is contradictory.

OBJECTIVE

To systematically review RCTs to determine whether the effect of acupuncture is dose dependent for symptom management in knee osteoarthritis.

METHODS

Seven English/Chinese databases were searched through January 2017. Study quality was assessed using the Cochrane Collaboration tool. Slavin's qualitative best-evidence synthesis approach was used to provide methodological rigour. Included RCTs were separated into three categories according to the dose of acupuncture treatment: high dosage (HD), medium dosage (MD) and low dosage (LD). Correlation between dose and effect of treatment was analysed.

RESULTS

Eight RCTs with a total of 2106 subjects met the eligibility criteria. Numbers of studies using the various doses of acupuncture were 1 for LD, 1 for MD and 6 for HD, respectively. Compared with LD and MD acupuncture treatments, strong evidence showed that there was a positive correlation between HD acupuncture treatment and positive outcomes.

CONCLUSION

The effect of acupuncture may be associated with dose of acupuncture, with a higher dosage related to better treatment outcomes in terms of relief of pain and dysfunction in patients with knee osteoarthritis.

Influence of the Intensity, Components, and Spreading of the Deqi Sensation on the Analgesic Effect of SP6 Needling in Primary Dysmenorrhea Patients: A Secondary Analysis of a Randomised Controlled Trial

Although deqi, the phenomenon whereby excitation of Qi in the meridians occurs with needling, is critical to the practice of acupuncture and its efficacy, it is poorly understood. So we investigate the influence of the deqi sensation on the analgesic effects of acupuncture in patients who were enrolled in a randomised controlled trial for the treatment of patients with primary dysmenorrhea, a painful and common condition, and cold and dampness stagnation. Two groups were assessed: a deqi group (undergoing deep needling with thick needles and manipulation, n=17) and a non-deqi group (undergoing shallow needling with thin needles and no manipulation, n=51). The Sanyinjiao (SP6) was needled for 30 min in both groups. Pain scores at baseline, upon needle removal, and at 10, 20, and 30 min after needle removal were evaluated by the Visual Analogue Scale for pain. The deqi sensation was evaluated by the Acupuncture Deqi Clinical Assessment Scale. Patients who experienced a genuine deqi sensation (n=39) were selected for further analysis. Compared with patients in the non-deqi group who experienced deqi (n=25), patients who self-reported deqi in the deqi group (n=14) felt a stronger deqi sensation, experienced soreness and fullness more frequently, felt a greater intensity of soreness, fullness, electric sensation, spreading, and radiating, and experienced larger spreading distances. In those who experienced the deqi sensation in the deqi group, the intensity of the sensation, as well as their degree of soreness and fullness, was negatively correlated with pain reduction. In patients who experienced the deqi sensation in the non-deqi group, deqi intensity was positively correlated with pain reduction, while soreness was negatively correlated with pain reduction. The distance of spreading was not correlated with pain reduction in either group. We found, in SP6 needling of patients with primary dysmenorrhea with cold and dampness stagnation, that a moderate deqi response predicted a prolonged analgesic effect better than a strong deqi response.

Acupuncture and Neural Mechanism in the Management of Low Back Pain-An Update

Within the last 10 years, the percentage of low back pain (LBP) prevalence increased by 18%. The management and high cost of LBP put a tremendous burden on the healthcare system. Many risk factors have been identified, such as lifestyle, trauma, degeneration, postural impairment, and occupational related factors; however, as high as 95% of the cases of LBP are non-specific. Currently, LBP is treated pharmacologically. Approximately 25 to 30% of the patients develop serious side effects, such as drowsiness and drug addiction. Spinal surgery often does not result in a massive improvement of pain relief. Therefore, complementary approaches are being integrated into the rehabilitation programs. These include chiropractic therapy, physiotherapy, massage, exercise, herbal medicine and acupuncture. Acupuncture for LBP is one of the most commonly used non-pharmacological pain-relieving techniques. This is due to its low adverse effects and cost-effectiveness. Currently, many randomized controlled trials and clinical research studies have produced promising results. In this article, the causes and incidence of LBP on global health care are reviewed. The importance of treatment by acupuncture is considered. The efforts to reveal the link between acupuncture points and anatomical features and the neurological mechanisms that lead to acupuncture-induced analgesic effect are reviewed.

Patient blinding with blunt tip placebo acupuncture needles: comparison between 1 mm and 2 mm skin press

OBJECTIVE

To investigate the influence of the depth of skin press in blunt tip placebo acupuncture needles on patient blinding and its relationship to needle diameter.

METHODS

Forty healthy volunteers were enrolled as subjects for patient blinding. Four acupuncturists applied the following needles randomly at three points in each forearm: 0.18 mm and 0.25 mm diameter penetrating needles inserted to a depth of 5 mm, and 0.18 mm and 0.25 mm diameter skin-touch needles depressing the skin at the acupoint to a depth of 1 mm and 2 mm from the skin surface. The subjects reported their guesses at the nature of needles they received, and rated needle pain and de qi. A blinding index was calculated to define the success of blinding for subjects.

RESULTS

The blinding status of subjects for 1 mm press needles of 0.18 mm diameter was "random guess", but "unblinded" for 1 mm press needles of 0.25 mm diameter. For 2 mm press needles of both diameters, the blinding status was "opposite guess" and the blinding status for penetrating needles of both diameters was "unblinded." The percentages of "felt pain" with 2 mm press needles of both diameters were similar to that with penetrating needles, but those were not similar for 1 mm press needles. The frequency of de qi occurrence with 2 mm press needles of 0.18 mm diameter was similar to that of penetrating needles of both diameters.

CONCLUSION

Placebo needles of 2 mm press made more subjects guess that the needles penetrated the skin than 1 mm press needles. The use of small diameter needles increased patient blinding.

A Double-Blind Study on Acupuncture Sensations with Japanese Style of Acupuncture: Comparison between Penetrating and Placebo Needles

To investigate the acupuncture sensations elicited by the Japanese style of acupuncture, penetrating acupuncture and skin-touch placebo needles were randomly administered at various insertion depths (5 and 10 mm for the penetrating needles and 1 and 2 mm for the placebo needles) at LI4 to 50 healthy subjects. Among the 12 acupuncture sensations in the Massachusetts General Hospital Acupuncture Sensation Scale (MASS), “heaviness” was the strongest and most frequently reported sensation with the 10 mm needles, but not with the 5 mm needles. There were no significant differences in number of sensations elicited, MASS index, range of spreading, and intensity of needle pain for 5 mm penetration versus 1 mm skin press and 10 mm penetration versus 2 mm skin press. The MASS index with 2 mm skin-touch needles was significantly larger than that with 1 mm skin-touch and 5 mm penetrating needles. The factor structures in the 12 acupuncture sensations between penetrating and skin-touch needles were different. The acupuncture sensations obtained in this study under satisfactorily performed double-blind (practitioner–patient) conditions suggest that a slight difference in insertion depth and skin press causes significant differences in quantity and quality of acupuncture sensations.

The quality of reporting in randomized controlled trials of acupuncture for knee osteoarthritis: A cross-sectional survey

OBJECTIVE

To assess the reporting quality of acupuncture trials for knee osteoarthritis (KOA), and explore the factors associated with the reporting.

METHOD

Three English and four Chinese databases were searched from inception to December 2016 for randomized control trials testing effects of acupuncture for knee osteoarthritis. We used the standard CONSORT (2010 version), CONSORT Extension for Non-Pharmacological Treatments, and STRICTA for measuring the quality of reporting. Using pre-specified study characteristics, we undertook regression analyses to examine factors associated with the reporting quality.

RESULTS

A total of 318 RCT reports were included. For the standard CONSORT, ten items were substantially under-reported (reported in less than 5% of RCTs), including specification of important changes to methods after trial commencement (0.6%), description of any changes to trial outcomes (0.0%), implementation of interim analyses and stopping guidelines (0.6%), statement about why the trial ended or was stopped (1.6%), statement about the registration status (4.4%), accessibility of full trial protocol (4.7%), implementation of randomization (4.7%), description of the similarity of interventions (3.5%), conduct of ancillary analyses (3.8%) and presentation of methods for additional analyses (4.4%). Four of the STRICTA items were under-reported (reported in less than 10% of RCTs), including description of acupuncture style (8.5%), presentation of extent to which treatment varied (1.3%), statement of practitioner background (7.2%) and rationale for the control (9.1%). For CONSORT Extension, the reporting was poor across all items (reported in less than 10% of trials). Trials including authors with expertise in epidemiology or statistics, published in English, or enrolling patients from multiple centers were more likely to have better reporting.

CONCLUSIONS

The reporting in RCTs of acupuncture for KOA was generally poor. To improve the reporting quality, journals should encourage strict adherence to the reporting guidelines.

Trends in deqi research: a text mining and network analysis

Background

Deqi is a term describing a special state of the human body, which is ready to cure itself through acupuncture stimulation and is believed to be a key factor in acupuncture treatment. However, knowledge about deqi remains subjective. Therefore, in this study, we aimed to determine the factors related to deqi generation based on present studies to promote the progression of deqi research.

Methods

A term frequency–inverse document frequency (Tf-idf) was used to extract key elements from the abstracts of 148 articles searched from Pubmed, and the network structure between key elements was analyzed.

Results

A total of 37 items were extracted from the abstracts. Each item was categorized into one of three groups (acupuncture-related sensation, interventions or organ/mechanism). Acupuncture-related sensation was studied by comparing the items in the interventions group with the organ/mechanism group. Key elements related to deqi generation included muscles from the organ/mechanism group and intensity, depth and pressure from the interventions group. Items that belonged to the acupuncture-related sensation group were divided into two clusters: one cluster consisted of pain, tingling, aching, soreness, heaviness, fullness and numbness; the other included warm, cold and dull.

Conclusion

We could find out that the trend of deqi was leaning towards the interventions group, which related to the generation of deqi; thus, authors concluded that the mechanism studies, which are aimed to investigate why deqi is generated or what kind of meanings it has, are needed for evolution of acupuncture theory and application of the brand new technologies and related devices.

Influences of De Qi induced by acupuncture on immediate and accumulated analgesic effects in patients with knee osteoarthritis: study protocol for a randomized controlled trial

Background

De Qi is a special sensational response upon acupuncture needling. According to traditional acupuncture theory, the treatment is “effective only after Qi arrival”; that is, De Qi is an important indicator of therapeutic efficacy and good prognosis. However, it is still disputable whether De Qi improves the efficacy of acupuncture therapy. This prospective, randomized controlled trial aims to explore the influence of De Qi induced by acupuncture on immediate and accumulated analgesic effects in patients with knee osteoarthritis (KOA).

Methods/design

Eighty-eight patients with KOA will be recruited and randomly assigned to the De Qi group (enhanced stimulation to evoke De Qi) and the control group (weak stimulation to avoid De Qi) in the Department of Acupuncture and Physical Therapy, Beijing Luhe Hospital Affiliated to Capital Medical University. Each patient will receive three 30-minute sessions per week for 4 consecutive weeks and undergo a 1 month follow-up. The severity of knee pain, as measured on a 100-mm visual analog scale (where 0 indicates no pain and 100 indicates intolerable pain) will be used as the primary outcome, and the Knee injury and Osteoarthritis Outcome Score will be used as the secondary outcome. Both indexes will be measured before and after the 1^st (for evaluating the immediate analgesic effects), 3^rd, 6^th, 9^th, and 12^th (for evaluating the accumulated analgesic effects) treatments and at the end of the follow-up. The intensity of the De Qi sensation will be assessed by the Chinese-Modified Massachusetts General Hospital Acupuncture Sensation Scale at the end of each treatment. Side effects during the treatments will be recorded and analyzed as well. The comparisons between the De Qi group and the control group will be done by using both an intention-to-treat analysis and a per-protocol analysis.

Discussion

This prospective randomized controlled study will be helpful in enhancing our understanding of the analgesic effect of De Qi on patients with KOA and may provide a clinical basis for further investigation of the relationship between De Qi and the therapeutic efficacy of acupuncture, thereby offering some evidence for the role of De Qi in an efficacious acupuncture therapy.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-IIR-16008972. Registered on 4 August 2016 Additional file 2.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1975-7) contains supplementary material, which is available to authorized users.

The role of touch in acupuncture treatment

Acupuncture is a therapeutic treatment that is characterised by the insertion of a needle at a particular location on the body. Acupuncture stimulation includes sensory-discriminative and affective-social touch dimensions. In this review, we discuss the role of touch during acupuncture stimulation with an emphasis on the therapeutic, sensory-discriminative and affective-social aspects. In the discriminative dimension, de qi, which is associated with needling, includes a combination of various sensations, such as heaviness, numbness, soreness and distension. Achieving the appropriate de qi sensation appears to be fundamental to the therapeutic outcome following acupuncture treatment. In the affective dimension, the acupuncture procedure typically includes gentle manual touch stimulation, which induces feelings of calm and well-being, perhaps by activating C tactile fibres. Enhanced activity of C tactile afferents may induce a 'limbic touch' response, resulting in emotional and hormonal reactions. Because acupuncture is a 'therapist intensive' and complex intervention, it is necessary to understand the role of social touch between the practitioner and patient. Both sensory-discriminative and affective-social touch aspects play an important role in the therapeutic effect of acupuncture treatment in clinical practice.

Multidimensional Aspects of de qi Sensations in MASS and ASQ Assessment: A Pilot Study

Background. De qi comprises varied senses depending on the individual. No single method can yet fully measure the multiple dimensions of de qi adequately. Objective. We examined the advantages of implementing multiple questionnaires for de qi measurement. Methods. Fourteen participants completed a preacupuncture questionnaire regarding their perception toward acupuncture treatment. After acupuncture stimulation at the HT7 point, de qi sensations were measured by MASS and ASQ. In groups with different levels of expectation, we compared the subtotal scores of each phase in the ASQ, as well as the VAS de qi intensity and MASS index using Kruskal-Wallis test. For the structural comparison of questionnaires, we first performed Spearman’s rank correlation test between the scores of individual descriptors in MASS and ASQ. The subtotal scores of each phase in ASQ was compared with VAS de qi intensity and MASS index. Results. The subtotal score of the manipulation phase in ASQ strongly correlated with the VAS score of de qi intensity (Spearman’s ρ=0.654, p=0.011) and MASS index (Spearman’s ρ=0.488, p=0.076). MASS and ASQ showed strong correlations in certain analogous descriptors. Unpleasant perceptions toward acupuncture treatment did not significantly correlate with overall de qi intensity. Conclusions. De qi sensations in acupuncture treatment have multidimensional aspects. Intensity of stimulation, ASQ, and MASS index assess somewhat restricted aspects of de qi. Those questionnaires have exclusive differences of sets in spite of their strong intersections. Use of multiple questionnaires may enable a more comprehensive understanding of de qi properties and the elicitation of relevant construction in de qi features of acupuncture.

Immediate analgesic effect of needling acupoints (bilateral De Qi vs unilateral De Qi) on primary dysmenorrhea: a multi-center, randomized, controlled trail

OBJECTIVE

To analyze the effect of needling acupoints (bilateral vs unilateral) with De Qi using data collected from 501 primary dysmenorrhea (PD) patients participating in multi-center, randomized, controlled trail.

METHODS

De Qi was defined as at least one of the feelings in soreness, numbness, fullness or heaviness at the acupoints when stimulated with needles. The 501 patients were grouped in 3 groups in terms of De Qi or not De Qi in one side (unilateral) or both sides (bilateral) of the body: bilateral De Qi group, unilateral De Qi group, and non-De Qi group. The abdominal pains were measured using visual analog scale (VAS).

RESULTS

In 501 patients, 472 acquired De Qi at unilateral acupoints, 24 De Qi at bilateral acupoint, and 5 had no De Qi at any acupoint. The data of non-De Qi group was excluded as the sample was less than 5% of that in the bilateral De Qi group. There was significant difference in the VAS before and after treatment between unilateral and bilateral De Qi group (P < 0.01). After stratified by acupoints, for the patients needled at Sanyinjiao (SP 6) and Xuanzhong (GB 39), VAS scores in the bilateral De Qi group were larger than those in the unilateral De Qi group (P < 0.05).

CONCLUSION

Bilateral De Qi was possibly superior to unilateral De Qi in enhancing the immediate analgesic effect of needling the acupoints, but no statistical significance was observed on the patients of needling at non acupoint, which preliminarily suggested this immediate analgesic effect was perhaps along meridians.

Acupuncture to improve tolerance of diagnostic esophagogastroduodenoscopy in patients without systemic sedation: results of a single-center, double-blinded, randomized controlled trial (DRKS00000164)

Background

Sedation prior to esophagogastroduodenoscopy is widespread and increases patient comfort. However, it demands additional trained personnel, accounts for up to 40 % of total endoscopy costs and impedes rapid hospital discharge. Most patients lose at least one day of work. 98 % of all serious adverse events occurring during esophagogastroduodenoscopy are ascribed to sedation. Acupuncture is reported to be effective as a supportive intervention for gastrointestinal endoscopy, similar to conventional premedication. We investigated whether acupuncture during elective diagnostic esophagogastroduodenoscopy could increase the comfort of patients refusing systemic sedation.

Methods

We performed a single-center, double-blinded, placebo-controlled superiority trial to compare the success rates of elective diagnostic esophagogastroduodenoscopies using real and placebo acupuncture. All patients aged 18 years or older scheduled for elective, diagnostic esophagogastroduodenoscopy who refused systemic sedation were eligible; 354 patients were randomized. The primary endpoint measure was the rate of successful esophagogastroduodenoscopies. The intervention was real or placebo acupuncture before and during esophagogastroduodenoscopy. Successful esophagogastroduodenoscopy was based on a composite score of patient satisfaction with the procedure on a Likert scale as well as quality of examination, as assessed by the examiner.

Results

From February 2010 to July 2012, 678 patients were screened; 354 were included in the study. Baseline characteristics of the two groups showed a similar distribution in all but one parameter: more current smokers were allocated to the placebo group. The intention-to-treat analysis included 177 randomized patients in each group. Endoscopy could successfully be performed in 130 patients (73.5 %) in the real acupuncture group and 129 patients (72.9 %) in the placebo group. Willingness to repeat the procedure under the same conditions was 86.9 % in the real acupuncture group and 87.6 % in the placebo acupuncture group.

Conclusions

Esophagogastroduodenoscopy without sedation is safe and can successfully be performed in two-thirds of patients. Patients planned for elective esophagogastroduodenoscopy without sedation do not benefit from acupuncture of the Sinarteria respondens (Rs) 24 Chengjiang middle line, Pericard (Pc) 6 Neiguan bilateral, or Dickdarm (IC) 4 Hegu bilateral, according to traditional Chinese medicine meridian theory.

Trial registration

DRKS00000164. Registered on 10 December 2009.

Influences of Deqi on Immediate Analgesia Effect of Needling SP6 (Sanyinjiao) in Patients with Primary Dysmenorrhea in Cold and Dampness Stagnation Pattern: Study Protocol for a Randomized Controlled Trial

Deqi, according to traditional Chinese medicine, is a specific needle sensation during the retention of needles at certain acupoints and is considered to be necessary to produce therapeutic effects from acupuncture. Although some modern researches have showed that Deqi is essential for producing acupuncture analgesia and anesthesia, the data are not enough. It is a paper of a multicenter, randomized controlled study protocol, to evaluate the influences of Deqi on acupuncture SP6 in Cold and Dampness Stagnation pattern primary dysmenorrhea patients, in terms of reducing pain and anxiety, and to find out the relationship between Deqi and the temperature changes at SP6 (Sanyinjiao) and CV4 (Guanyuan). The results of this trial will be helpful to explain the role of Deqi in acupuncture analgesia and may provide a new objective index for measuring Deqi in the future study. This trial is registered with ChiCTR-TRC-13003086.

A survey of the practice and perspectives of chinese acupuncturists on deqi

Deqi refers to the special sensation and reaction sensed mainly by both acupuncturist and patient when a needle was inserted into the acupoints and is considered to be vital to achieve acupuncture effect. For acupuncturist, it is important to judge and control Deqi in clinical practice. However, enough attention is paid to patients' feelings rather than acupuncturists' nowadays. We thus conducted this survey to determine acupuncturists' perspectives about Deqi and to further find the proper way to induce Deqi. A total of 250 questionnaires were sent out to acupuncturists and 202 (80.8%) were returned. According to the results, most acupuncturists believe that Deqi is vital to obtain preferable clinical effects. The reliability of acupuncturists' Deqi sensation ranks as sinking> tightening> astringent. The reliability of patients' Deqi sensations ranks as sourness> numbness> distention> heaviness> pain. The reliability of influential factors ranks as manipulation> specificity of acupoint> TCM constitution> disease status> patient's psychological condition> acupuncturists' psychological guidance> clinical environment. This study is believed to provide additional evidence to the qualitative and quantitative research of Deqi in the future.

Historical and clinical perspectives on de qi: exposing limitations in the scientific study of de qi

De qi is a concept most often associated with patient experiences during needling in acupuncture treatment. A review of the early historical literature on acupuncture shows that texts tended to describe de qi and its associated concept, qi zhi more in terms of practitioner-based phenomena and that this is something more in the realm of the experienced practitioner (i.e., it is skill based). Many modern authors in Asia and the West also describe the importance of practitioner-based experiences in the de qi of acupuncture, further implying that this may lie at the heart of the treatment effects of acupuncture. A review of scientific studies on de qi shows that qualitative studies have focused almost exclusively on patient-based aspects of de qi while quantitative studies have focused exclusively on them. There thus exists a gap in current research on the phenomenon of de qi that possibly reveals weakness in the wider study of acupuncture. It is important that precise qualitative studies of the practitioner-based aspects of de qi begin soon and as they become better understood, quantitative research also is initiated. This research will not only better inform clinical trials and physiologic research of acupuncture in general but could contribute significantly to rethinking of how to train practitioners.

Acupoints Initiate the Healing Process

Background: As an important modality of Traditional Chinese Medicine, acupuncture has been widely accepted by the Western world in the past 4 decades because of this modality's efficacy and safety. A vast amount of acupuncture research has been done. However, the mechanisms of acupuncture actions are still elusive. It is believed that the effects of acupuncture treatment begin from the moment of needle insertion. Methods: This review focuses on the acupuncture points and the three major reactions at the acupuncture points when needling is performed. These initial reactions may be the beginning of the healing process that initiates downstream effects through neuronal and humoral pathways. In addition to the physical reactions, this article also discusses the possibility of the effects of acupuncture on the healing process through a holistic pathway. Conclusions: Needling is the first step of traditional acupuncture therapy. Needling reactions- neuronal, biophysical, and biochemical-are the beginning of healing. The messengers of the three reactions involved may include neurotransmitters, cytokines, hormones, and inflammatory factors. Healing may be potentiated through these messengers in neuronal and humoral pathways. The reactions manifest as erythema and De Qi-both of which are common phenomena used as positive signs in acupuncture treatment. Acupuncture may also play a role in the healing process through the holistic pathway, which needs further study.

Pain and sensory detection threshold response to acupuncture is modulated by coping strategy and acupuncture sensation

BACKGROUND

Acupuncture has been shown to reduce pain, and acupuncture-induced sensation may be important for this analgesia. In addition, cognitive coping strategies can influence sensory perception. However, the role of coping strategy on acupuncture modulation of pain and sensory thresholds, and the association between acupuncture sensation and these modulatory effects, is currently unknown.

METHODS

Electroacupuncture (EA) was applied at acupoints ST36 and GB39 of 61 healthy adults. Different coping conditions were experimentally designed to form an active coping strategy group (AC group), who thought they could control EA stimulation intensity, and a passive coping strategy group (PC group), who did not think they had such control. Importantly, neither group was actually able to control EA stimulus intensity. Quantitative sensory testing was performed before and after EA, and consisted of vibration (VDT), mechanical (MDT), warm (WDT), and cold (CDT) detection thresholds, and pressure (PPT), mechanical (MPT), heat (HPT) and cold (CPT) pain thresholds. Autonomic measures (e.g. skin conductance response, SCR) were also acquired to quantify physiological response to EA under different coping conditions. Subjects also reported the intensity of any acupuncture-induced sensations.

RESULTS

Coping strategy was induced with successful blinding in 58% of AC subjects. Compared to PC, AC showed greater SCR to EA. Under AC, EA reduced PPT and CPT. In the AC group, improved pain and sensory thresholds were correlated with acupuncture sensation (VDTchange vs. MI: r=0.58, CDTchange vs. tingling: r=0.53, CPTchange vs. tingling; r=0.55, CPTchange vs. dull; r=0.55). However, in the PC group, improved sensory thresholds were negatively correlated with acupuncture sensation (CDTchange vs. intensity sensitization: r=-0.52, WDTchange vs. fullness: r=-0.57).

CONCLUSIONS

Our novel approach was able to successfully induce AC and PC strategies to EA stimulation. The interaction between psychological coping strategy and acupuncture sensation intensity can differentially modulate pain and sensory detection threshold response to EA. In a clinical context, our findings suggest that instructions given to the patient can significantly affect therapeutic outcomes and the relationship between acupuncture intensity and clinical response. Specifically, acupuncture analgesia can be enhanced by matching physical stimulation intensity with psychological coping strategy to acupuncture contexts.

TRIAL REGISTRATION

KCT0000905.

Effect of acupuncture on Deqi traits and pain intensity in primary dysmenorrhea: analysis of data from a larger randomized controlled trial

Background

Deqi is a central concept in traditional Chinese acupuncture. We performed a secondary analysis on data from a larger randomized controlled trial (RCT) in order to assess the effect of acupuncture on deqi traits and pain intensity in primary dysmenorrhea.

Methods

A total of 60 primary dysmenorrhea patients were enrolled and randomly assigned to one of three treatment groups. Acupuncture was given at SP6, GB39 or nonacupoint. Subjective pain was measured by a 100-mm visual analogue scale (VAS) before and after acupuncture. The Massachusetts General Hospital acupuncture sensation scales (MASS) with minor modification was used to rate deqi sensations during acupuncture.

Results

The results showed that VAS scores of pain after acupuncture were significantly decreased comparing to before acupuncture treatment in all three groups (P = 0.000). However, no significant differences were found among three groups at the beginning or end of acupuncture treatment (P = 0.928, P = 0.419).

Conclusions

There was no statistical difference among three groups in terms of intensity of deqi feeling. The types of sensation were similar across the groups with only minor differences among them.

Trial registration

Trial registration number: Controlled-Trials.com ISRCTN24863192.

Effect of bidirectional rotation of an acupuncture needle at LI10 on acupuncture needle sensation and experimentally-induced contact heat pain in healthy human volunteers

INTRODUCTION

There is insufficient evidence of a relationship between acupuncture needle sensations (de qi) and hypoalgesia. The aim of this study was to investigate the effects of bidirectional needle rotation at LI10 on acupuncture needle sensations and heat pain thresholds.

METHODS

Twenty-two healthy participants received one acupuncture needle at LI10 with bidirectional rotation of the needle in one experimental session and one acupuncture needle at LI10 with mock rotation in a separate session, in a randomised order. Measurements of heat pain thresholds were taken before needle insertion, during needle retention and 15 min after needle removal. At each measurement time point, participants rated needle sensations using the Massachusetts Acupuncture Sensation Scale (MASS) and a visual analogue scale (VAS) of overall intensity of needle sensation.

RESULTS

Bidirectional needle rotation produced significantly higher scores for VAS, MASStotal, MASSpain and MASSsensation compared with mock rotation (all p<0.001). There were significantly higher pain thresholds relative to pre-intervention baseline during (p=0.014) and after (p<0.001) bidirectional needle rotation but not during (p=0.1) or after (p=0.62) mock bidirectional needle rotation. Bidirectional needle rotation increased the pain threshold relative to baseline 15 min after the needles were removed (p=0.009). A significant but low correlation between needle sensation and change in pain threshold after needling was only found when data from mock and rotation interventions were combined.

CONCLUSIONS

Needle rotation increases the magnitude of hypoalgesia. There is tentative evidence that needle sensation may be associated with the amount of change in pain threshold.

The historical development of deqi concept from classics of traditional chinese medicine to modern research: exploitation of the connotation of deqi in chinese medicine

Although it is difficult in fully clarifying its mechanisms and effects, Deqi still can be considered as an instant "sign" of acupuncture response of the patient and acupuncturist, which has a significant value in clinic and research. This paper aims to take a history trace to the development of Deqi theory, understand the connotation of Deqi based on Chinese medicine theory, and establish an evaluation methodology accordingly. We believe that Deqi is not only the needling sensation, but also the perception of changes of qi (') flowing of the patient elicited by needling on acupoints. The signs of Deqi include the patient's subjective perception (needling sensation), the objective physiological changes (common referred to the skin redness around the acupoints and the response of brain), and the acupuncturists' perception. Although Deqi is essential for attaining the effect, it may not be the necessary sign of the ideal efficacy. It is found that the characteristics of Deqi sensations, Deqi's intensity, time duration, and the propagation will all affect the efficacy. Thus, acupuncturists should pay attention to elicit and control Deqi state, which is also the key point in modern research on the therapeutic implications of Deqi.

Acupuncture Deqi Intensity and Propagated Sensation along Channels May, Respectively, Differ due to Different Body Positions of Subjects

Acupuncture as an essential component of complementary and alternative medicine is gradually recognized and accepted by the mainstream of contemporary medicine. For obtaining preferable clinical effectiveness, Deqi is commonly regarded as efficacy predictor and parameter which is necessary to be achieved. Influential factors for acupuncture efficacy, like Deqi sensation as well as propagated sensation along channels (PSCs), enjoyed a long history in acupuncture basic research. Concerning this study, taking into account different positions on acupuncture Deqi sensation and PSCs, we would like to attest whether different body positions for subjects during needling procedure yield differed acupuncture Deqi sensation, particularly in terms of intensity, and PSCs. Methods. We used self-controlled method and selected 30 healthy subjects to perform needle insertion at Futu point (ST32) bilaterally. Then they were instructed to record the value of intensity of acupuncture sensation and the length and width of PSCs after removing the needle. Results. In regard to intensity of Deqi, kneeling seat position is stronger than supine position, accounting for 90% of the total number of subjects. In length of PSCs, kneeling seat position is greater than supine position, accounting for 56.7%. In width of PSCs, kneeling seat position is greater than supine position, accounting for 66.7%. Conclusion. Our findings show that needle inserting at Futu point (ST32) in kneeling seat position achieve better needle sensation and provide reference for clinical.

Seeing the Body: A New Mechanism for Acupuncture Analgesia?

The use of visual illusions to study how the brain gives rise to a representation of the body has produced surprising results, particularly in relation to modulation of pain. It seems likely that this research has relevance to how we understand acupuncture analgesia. Acupuncture supplies several different kinds of signal to the brain: touch in the preliminary examination for tender areas; needle stimulation, mainly of Aδ fibres; and sometimes visual input from the patient's sight of the needle insertion. In the light of recent research, all these are likely to modulate pain. There are implications here for clinical practice and for research. Acupuncture may be more effective if patients can see the needles being inserted. The use of non-penetrating stimuli to the skin or minimal needle insertion at non-acupuncture points as control procedures becomes more than ever open to question and this, in turn, has relevance for claims that acupuncture is indistinguishable from placebo.

Characterization of deqi sensation and acupuncture effect

Acupuncture stimulation elicits deqi, a composite of unique sensations. According to traditional Chinese medicine (TCM), deqi experienced by patients is often described as suan (aching or soreness), ma (numbness or tingling), zhang (fullness, distention, or pressure), and zhong (heaviness) and is felt by the acupuncturists (needle grasping) as tense, tight, and full. It is believed that deqi may be an important variable in the studies of the mechanism and efficacy of acupuncture treatment. In recent years, great efforts have been made to understand deqi, which include a couple of questionnaires to qualify and quantify deqi sensations, neuroimaging studies of deqi and acupuncture, physiological mechanisms of deqi, and the relation between deqi and clinical efficacy. However, many problems need to be resolved, and more researches are required to be made in the future.

A literature review of de qi in clinical studies

OBJECTIVES

De qi is a sensation experienced by a patient or an acupuncturist during acupuncture treatment. Although de qi is considered to be important in acupuncture treatment, there are not many studies about de qi and its character. The purpose of this study is to review de qi questionnaires and evaluate the relationship between de qi and acupuncture points, stimulation and treatment effects.

METHODS

A search was conducted using three English-language databases (PubMed, Cochrane and ScienceDirect) and seven Korean databases with the keywords 'de qi' and 'needle sensation'. The included studies were then categorised as following: (1) de qi measurement tools, (2) the relationship between de qi and acupuncture points, (3) the relationship between de qi and stimulation, (4) the relationship between de qi and treatment effects and (5) attitudes and opinions toward de qi.

RESULTS

Several questionnaires have been developed to evaluate de qi, and the most frequent sensation in those questionnaires was 'heavy' and 'numb'. Although a few studies showed specificity to acupuncture points, information is still lacking to be able to draw a clear conclusion about the relationship between de qi and acupuncture points. Also, greater de qi was elicited in real acupuncture than placebo acupuncture in many studies. The relationship between de qi and treatment effects was controversial.

CONCLUSIONS

It seems that real acupuncture induced greater de qi than sham acupuncture, and the relationship between de qi, acupuncture points and treatment effects was controversial. However, the current literature evaluating de qi is not sufficient to derive clear conclusions. Further studies with more objective indices and rigorous methodologies are needed.

Does the effect of acupuncture depend on needling sensation and manipulation?

BACKGROUND

Acupuncture sensation and manipulation have been considered to be an important component of acupuncture in traditional Asian medicine. However, there has been limited research as to whether acupuncture sensation is associated with therapeutic benefit. This study investigated the relationship between acupuncture sensation and analgesic effect according to acupuncture manipulation.

METHOD

Fifty-three healthy volunteers received three different forms of acupuncture in a single-blinded crossover design: superficial needling (0.3 cm), deep needling (2 cm) and needling with bi-directional rotation. The effects of acupuncture were evaluated by using the pressure pain threshold. Acupuncture sensation measurement was done in two ways.

RESULTS

Both total acupuncture sensation and increase of the pressure pain threshold were maximum in needling with rotation, followed by deep needling and superficial needling. Repeated-measure analysis of variance (ANOVA) analysis was carried out to assess whether there was a significant difference; both showed significant difference (p = 0.000, 0.003). A paired sample t-test was carried out, which revealed that needling with rotation showed significant difference from both superficial needling and deep needling. Further, the correlation between the total acupuncture sensation and changes in pressure pain threshold were calculated using Pearson correlation; there was a significant correlation (p = 0.002, p = 0.013).

CONCLUSION

Acupuncture sensation and pressure pain threshold increase according to the depth and rotation of acupuncture. Especially, both display significant increase with needle rotation. Further, there is a significant correlation between acupuncture needling sensation and increase in pressure pain threshold. It seems that needle rotation and acupuncture sensation play an important role in verifying the effect of acupuncture.

What Is the de-qi-Related Pattern of BOLD Responses? A Review of Acupuncture Studies in fMRI

de-qi, comprising mostly subjective sensations during acupuncture, is traditionally considered as a very important component for the possible therapeutic effects of acupuncture. However, the neural correlates of de-qi are still unclear. In this paper, we reviewed previous fMRI studies from the viewpoint of the neural responses of de-qi. We searched on Pubmed and identified 111 papers. Fourteen studies distinguishing de-qi and sharp pain and eight studies with the mixed sensations were included in further discussions. We found that the blood oxygenation level-dependent (BOLD) responses associated with de-qi were activation dominated, mainly around cortical areas relevant to the processing of somatosensory or pain signals. More intense and extensive activations were shown for the mixed sensations. Specific activations of sharp pain were also shown. Similar BOLD response patterns between de-qi evoked by acupuncture stimulation and de-qi-like sensations evoked by deep pain stimulation were shown. We reckon that a standardized method of qualification and quantification of de-qi, deeper understanding of grouping strategy of de-qi and sharp pain, and making deep pain stimulation as a control, as well as a series of improvements in the statistical method, are crucial factors for revealing the neural correlates of de-qi and neural mechanisms of acupuncture.

Neural acupuncture unit: a new concept for interpreting effects and mechanisms of acupuncture

When an acupuncture needle is inserted into a designated point on the body and mechanical or electrical stimulation is delivered, various neural and neuroactive components are activated. The collection of the activated neural and neuroactive components distributed in the skin, muscle, and connective tissues surrounding the inserted needle is defined as a neural acupuncture unit (NAU). The traditionally defined acupoints represent an anatomical landmark system that indicates local sites where NAUs may contain relatively dense and concentrated neural and neuroactive components, upon which acupuncture stimulation would elicit a more efficient therapeutic response. The NAU-based local mechanisms of biochemical and biophysical reactions play an important role in acupuncture-induced analgesia. Different properties of NAUs are associated with different components of needling sensation. There exist several central pathways to convey NAU-induced acupuncture signals, Electroacupuncture (EA) frequency-specific neurochemical effects are related to different peripheral and central pathways transmitting afferent signals from different frequency of NAU stimulation. More widespread and intense neuroimaging responses of brain regions to acupuncture may be a consequence of more efficient NAU stimulation modes. The introduction of the conception of NAU provides a new theoretical approach to interpreting effects and mechanisms of acupuncture in modern biomedical knowledge framework.