ACUPUNCTURE AND MOXIBUSTION THERAPY

Technique of Acupuncture and Moxibustion

Acupuncture and moxibustion are two distinct therapeutic methods frequently used in conjunction in the clinic. Acupuncture treats disease by puncturing certain points of the human body with metal needles while moxibustion is applying heat produced by ignited moxa-wool over the points of the skin surface. Though equipment of material used in the methods are different, the therapeutic and preventive results in both are achieved through promoting smooth circulation of the channels and adjusting qi and blood by stimulating the points and channels. In this chapter, some of the commonly used methods of acupuncture and moxibustion are introduced. As the filiform needle in the instrument most frequently used in acupuncture, stress is placed on its manipulation.

1. Manipulation of the Filiform Needle
1. The Needles and How to Use Them
1. The Needle: The needles may be of gold, silver or alloy. The needles in most common use today are made of high quality stainless steel. On the basis of structure, the filiform needle may be divided in four parts (the handle, the root, the body and tip – (see Diagram)

The size and length of the needles most commonly used are as follows:

A good needle is one that is strong and flexible and has a round, smooth body and tip shaped like a pine-needle.

2. How to practice needling: The filiform needle is very fine and flexible, and so demands precise finger force to insert it into the skin skillfully and manipulate it freely. In order to minimize possible pain to the patient, appropriate finger force must be mastered through practice, and it is advisable to start practicing with a shorter and thicker needle, progressing to a finer and longer one.

1.   Practice with sheets of paper. Fold fine soft tissue into a small packet about 5 X 8 cm. In size and 1 cm. Thick. Try puncturing it. Hold the paper packet in the left hand and the handle of the needle with the thumb, index and middle fingers of the right hand. Rotate the needle in and out. As your finger force grows stronger, the thickness of the packet may be increased (see Diagram)

2.   Practice with a small cotton cushion of about 5-6 cm. In diameter wrapped in gauze. Hold the cushion with the left hand and the needle with the thumb, index and middle fingers of the right hand. Insert the needle into it and practice the lift-thrust and rotation procedure.

3.   Practice on your own body: This may follow the manipulation methods of paper packet and cotton cushion, so as to have personal experience of the acupuncture sensation in clinical practice.

2. Preparation for Giving Treatment
1. Equipment: Needles of various sizes, a tray, forceps, sterilized cotton balls, and alcohol. Inspect the needles carefully for any bends or erosion. The tip of needle should be neither to dull or to sharp or should it be hooked.
2. Sterilization: Strict sterilization of the needle is imperative. The area on the body surface selected for puncture should be sterilized with alcohol and iodine. The operator’s fingers should be sterilized routinely.
3. Posture of the patient:
1. Full exposure of the points selected determines the patient’s position. The operator must be able to work without hindrance, while the patient is relaxed and comfortable. Clinically, there are the following postures of the patient according to the points selected.
3. Sitting position with forearms resting on table; sitting erect with both elbows flexed the resting on the table; and lying in lateral recumbent, supine or prone position (see Diagrams)
4. Insertion and Withdrawal of the Needle
1. Insertion:
1. Generally, the needle is held with the right hand, known clinically as the puncturing hand, with the thumb and index fingers holding the handle of the needle and the middle finger backing the index finger near the needle root. The left hand, known as the pressing hand, presses upon the area close to the point. The co-ordination of the two hands is conducive to a swift penetration of the needle tip into the skin, which reduces pain on insertion.
2. According to the length of the needle and the location of the point, there are various methods of insertion. The four main techniques are as follows:
1. Inserting the needle aided by the pressure of the finger of the pressing hand: Press beside the acupuncture point with the nail of the thumb or the index finger of the pressing hand then insert the needle into the point against the nail. This method is suitable for puncturing with short needles, such as those used for puncturing Neiguan (P.6) or Zhaohai (K.6.)
2. Inserting the needle with the help of the puncturing and pressing hands. Hold the tip of the needle wrapped in a cotton ball with the thumb and index fingers of the pressing hand; fix it directly over the selected point; meanwhile hold the handle of the needle with puncturing hand. As the pressing hand pushes the needle tip into the skin, the puncturing hand presses it downward to required depth. The method is suitable for puncturing with long needles, such as those used in puncturing Huantiao (G.B. 30) or Zhibian (U.B. 54.)
2. Inserting the needle with the fingers stretching the skin: Stretch the skin where the point is located to cause tension with the thumb and the index finger of the pressing hand to facilitate the insertion of the needle. This method is indicated for points where the skin is loose, such as Tianshu (St. 25) or Guanyuan (Ren 4) (see Diagram)
1. Inserting the needle by pinching up the skin: Pinch up the skin at the point with thumb and index finger of the pressing hand, insert the needle into the skin sidewise with the right hand. This method is suitable for puncturing points of the head and face where the soft tissue is thin, such as Zanzhu (U.B. 2) or Dicang (St. 4) (see Diagram)
3. The angle formed by the needle and skin surface: The degree of the angles formed by the needle and skin surface in puncturing depends upon the location of the point and the therapeutic purpose. The following are the three angles:
1. Perpendicular, in which the needle is inserted perpendicularly forming a 90° angle with skin surface. Most points on the body can be punctured perpendicualrly.
2. Oblique, in which the needle is inserted obliquely to form an angle of approximately 45° with the skin surface. This method is indicated for points located where the muscle is thin or close to important viscera, such as Lieque (Lu. 7) of the forearm or Jiuwei (Ren 15.)
3. Transverse, also known as horizontal puncture when the needle enters the skin forming an angle of the 15° -25° with its surface. This method is preferred for pints on the face and head where the muscle is thin, such as Baihui (Du 20) or Touwei (St. 8), of the head.
4. Depth of needle insertion: This depends upon the thickness of the tissue where the point is located, pathological condition, and the strength of sensation the patient experiences. As a rule, points on the extremities, abdomen and lumbosacral region may be punctured deep.
5. Withdrawal of the needle: To prevent bleeding at the site of puncture and after-sensation, it is necessary to rotate the needle back and the forth gently before withdrawing it, then press the puncture site gently with a cotton ball upon withdrawal.
5. The Appearance of Qi (Needing Reaction) and the Method of Reinforcing and Reducing.
1. The arrival of Qi (needling reaction) and inducing qi (needling reaction): When the needle is inserted to a certain depth, the patient may feel soreness, numbness or distension around the point. The operator at the same time may feel tenseness around the needle. This is what is know as "arrival of Qi." Then according to the pathological condition, the reinforcing (bu) or reducing (xie) procedure is applied. If Qi (needling reaction) is absent, check to see whether the point is located accurately or the direction of the needle is correct. If Qi still does not "arrive", the needle may be retained for a short time, or manipulated gently with lift-thrust movements. The needle reaction may also be induced by such auxiliary manipulations as:
1. Twirling the needle with the thumb and index finger of the right hand in one direction with an amplitude of 360° or more, repeating the manipulation once or twice if necessary.
2. Scraping of the handle of the needle: when the needle is retained, steady it by placing the thumb of the right hand lightly on top of it, then scrape the handle with the nail of the index or middle finger upward from the bottom.
3. Vibrating the needle: Hold the needle with the right hand and apply quick lift-thrust movement with small amplitude to cause vibration. Delay in the arrival of Qi in some patients may be due to local obstruction of the channel. In that case, cease forceful manipulation and apply mild moxibustion. Or select other points to evoke the vital energy of the channels.
2. Commonly used reinforcing and reducing methods: There are various manipulation methods, but their action does not go beyond reinforcing (bu, supplementing or increasing) and reducing (xie, diminishing or decreasing.) Because the nature of a disease relates either to xu (deficiency) or shi (excess), the methods used should correspond. The reinforcing procedure is to correct the deficiency of vital function and strengthen body resistance, while reducing is to eliminate the excess of pathogenic factor. Therapeutic results are generally achieved by these methods, and rich experience has been accumulated in their use by doctors of all ages. Following is a brief description of some of the frequently used methods.
1. Lifting and thrusting the needle: The effect of reinforcing and reducing is achieved through the speed and the forces in repeated lifting and thrusting of the needle.
1. Reinforcing: Once the needling sensation is felt, lift the needle gently and slowly, then thrust it heavily and rapidly.
2. Reducing: Once the needling sensation is felt, lift the needle gently and slowly, then thrust it heavily and rapidly.
2. Method of rotating the needle: The effect of re-enforcing and reducing depends on the amplitude and speed of the needle rotation.
1. Reinforcing: When the needle reaches a certain depth, rotate it back and forth continuously with small amplitude and slowly.
2. Reducing: Rotate the needle continuously back and forth with large amplitude and rapidly.
3. Even movement: This method is used in treating diseases with are typical of both the xu (deficiency) and shi (excess) nature. Application is by inserting the needle to a certain depth till sensation is felt, then rotating, lifting and thrusting the needle evenly and gently at then rotating, lifting and thrusting the needle evenly and gently at the moderate speed to cause a mild sensation. The needle is withdrawn also at moderate speed.
4. The lift-thrust and rotation methods can be used coordinately with either of the two as the main method. The application of the above manipulation methods depends upon the nature of the disease, i.e.,. xu or shi, and the location of the points over thin or thick muscle.
5. The effect of the reinforcing and reducing method of needling depends mainly on the general health of the patient. When the vital energy is undamaged and there is sound body resistance and prompt response to acupuncture, a marked therapeutic result will be obtained; otherwise the therapeutic result will be indefinite. In other words, the effect of the reinforcing and reducing procedures is closely connected with the vital function of the organism.
6. Moreover, the effect of the reinforcing and reducing is affected by the pathological condition. That is to say, different manifestations of the lowering of blood pressure in a patient with hypertension, and raising it in hypertension. Similarly, needling may have a spasmolytic effect to intestinal spasm, while promoting peristalsis in intestinal paralysis.
7. The effect of reinforcing and reducing manipulation is also connected with the therapeutic properties of the points. Needling points Zusanli (St. 36), Qihai (Ren 6), Guanyuan (Ren 4), Shenshu (U.B. 23) will have reinforcing effect in promoting functional activity. On the other hand, reducing effect may be obtained by pricking Shixuan (Extra), Weizhong, U.B. 40), Quze (P.3) in order to bring down fever and expel the excess of the pathogenic factor. Hence, clinically, choosing points according to the pathological condition of xu and shi nature is also an important way to obtain reinforcing and reducing effects.
6. Precautions:
1. It is advisable to apply few needles or to delay giving acupuncture treatment for patients who are either famished or over-eaten, intoxicated over fatigued or very weak.
2. It is contraindicated to puncture points on the lower abdomen and lumbosacral region for women pregnant under three months. After three months pregnancy it is contraindicated to puncture, in addition, points of the upper abodomen, andthose causing strong sensation such as Hegu (L.I. 4), Sanyinjiao (Sp. 6), Kunlun (U.B. 60) and Zhiyin (U.B. 67.) The fontanelle of infants should not be punctured.
3. Historic medical literature of the past contraindicated certain points on the human body for puncture or deep puncture. Most of these points are located close to vital organs or large blood vessels, such as Chengqi (St. 1) located below the pupil, Jiuwei (Ren 15) near the important viscera, Jimen (Sp. 11), the femoral artery, etc.,. These points should generally be punctured obliquely or horizontally to avoid accident.
7. Management of Possible Accidents in Acupuncture
1. Fainting: This may occur due to weakness or to nervous tension on receiving acupuncture for the first time, or to too forceful manipulation. The prodromes are dizziness and vertigo, irritability, nausea, pallor, staring eyes and dull appearance. In server cases there may be shock and unconsciousness, deep pulse. The needles should be removed at once and the patient asked to relax, the operator help him to lie down. In mild cases, offer warm drinks. The symptoms will disappear after a short rest. In severe cases, press Renzhong (Du 26) with the fingernail, or puncture Renzhong (Du 26) and Zhongchong (P.9.) Moxibustion may be applied to Baihui (Du 20) and Zusanli (St. 36.) Generally the patient will respond, but if not, then other emergency measures should be taken.
2. Stuck Needle: After the needle is inserted, if is found at times difficult or impossible to rotate, lift and thrust. This situation, known as stuck needle, may be due to various causes. If it is due to muscle spasm, the needle should be retained for a while, and then rotated for removal. Another method is to press the area around the needle, or puncture another point nearby, to relieve the muscle tension. If the needle is entangled with fibrous tissue, rotate it gently and slowly to disentangle it. Lift and thrust slightly until the muscle is completely relaxed, then withdraw the needle.
3. Bent Needle: This generally happens when the needle is inserted with uneven finger force or too forcefully, or the needle strikes hard tissue. The handle of the needle may be struck accidentally, or the patient may suddenly change position while the needle is in place. If the bend is slight, the needle may be removed slowly without rotation. If pronounced, move the needle slightly and withdraw it by following the course of the bend. If the patient has changed position, move him to his original position and then withdraw the needle.
4. Broken Needle: Forceful manipulation of the needle, muscle spasm, the patient changing position, or poor quality of the needle or eroded base of needle all may be cause the needle to brake. The operator should be calm and advise the patient not to move. If the broken needle protrudes above the skin, remove it with forceps. If not, press the tissues around the site until the broken end is exposed, then remove with forceps. If it is completely under skin, surgery should be resorted to. To prevent accident, careful inspection of the quality of the needle should be made. The needle must be somewhat longer than the required depth of the insertion.
5. Hematoma: After withdrawal of the needle, a pin-point red mark may remain. This is considered normal, and it will disappear. If a bruise of swelling occurs due to injury to vessels, the site should be massaged and hot compresses applied to promote absorption of the hemostasis.
6. After withdrawal of the needle, there may remain an uncomfortable feeling due to over stimulation. If the sensation is not too severe, it may be relieved by gently massaging the local area. If the discomfort persists, it may be relieved by applying moxibustion.
1. Other Acupuncture Methods
1. The Three-Edged Needle
1. The needle: The head is triangular in shape, with a sharp tip. Stainless steel is the material most often used (see Diagram)
2. Indications: High fever mental disorders, sore throat, local congestion and swelling.
3. Manipulation: Prick superficially 0.05-0.1 inch deep at the selected point to cause bleeding.
4. Precaution: Pricking should be light and superficial, the amount of bleeding determined by the pathological condition. Vigorous pricking is not permissible, nor is it advisable to apply this method for weak patients, expectant mother or patients hemorrhagic diseases.
2. The Cutaneous or Tapping Needle
1. The needle: The cutaneous needle is used to prick the skin superficially by tapping. Two types are used:
1. The seven-star needle, composed of seven short stainless steel needles inlaid onto a small round plate attached vertically to a handle 5-5 inches long.
2. The plum-blossom needle, composed of 5 stainless steel needles in a bundle and attached perpendicularly to a handle one foot long. The points of the needles should be even and not too sharp so as to avoid pain and bleeding (see Diagram)
3. Indications: This superficial tapping method is particularly suitable for women, children and those who are sensitive to pain. It is indicated in headache, dizziness and vertigo, insomnia, enterogastric disorders, chronic disorders in women, and some types of skin diseases.
4. Manipulation: Hold the handle of the needle and tap the skin surface with flexible movement of the wrist only. Tapping may be light or heavy according to the constitution of the patient and the nature of the disease. Duration and number of taps depends on the individual patient. Bleeding does not occur in light tapping, while heavy tapping should draw very little blood. Location for tapping necessarily depends on the pathological condition, distribution of the channels and location of points.
3. The Intradermal or Imbedding Needle
1. The needle is short and made from stainless steel or sterling silver and is used for subcutaneous implantation, there are two types:
1. The thumbtack type, which is about 0.3 cm. Long with a head like a thumbtack.
2. The grain-like type, about 1 cm. Long with a head like a grain of wheat.
2. Indications: Chronic diseases of the internal organs, persistent and multiple painful diseases.
3. Manipulation: The grain-like type needle is suitable for implantation at points and tenderness on various parts of the body, while the thumbtack type is suitable for implantation in the ear.
4. Precautions: The duration of implantation depends on the season of the year. In summer, the duration should be limited to 1-2 days, care should be taken to prevent infection at the puncture site due to perspiration. In autumn and winter, the needles may be retained longer according to the need in specific cases.
2. Moxibustion:
3. Moxibustion treats and prevents diseases by applying heat to points or certain locations of the human body. The material used is mainly "moxawool" in form a large cigarette or small cones.
4. Moxawool is made of dry moxa, or mugwort leave (Artemisia vulgaris), ground finely, with the course stems removed. It has the properties of warming and removing obstruction of the channels, eliminating cold and damp and thus promoting normal function of the organs. Burning moxawool has the following advantages; the heat is mild and penetrates deep beneath the skin giving a sensation of comfort.
5. Moxawool can be kneaded into small cones of various sizes, is easy to ignite, aromatic and drives away damp and foul air.
6. Artemisia vulgaris grows extensively and profusely in China. It has been used for curative pruposes in China for several thousand years.
1. Preparation
1. The moxibustion tray contains moxawool, moxa sticks and matches.
1. Making moxa cones: Place a small amount of moxawool on a board, knead it into a cone with thumb, index and middle fingers. Three sizes may be made; small, medium and large. The two smallest size are suitable for direct moxibustion, while the largest is suitable for indirect moxibustion (see Diagram)
2. Making mox sticks. There are much more convenient to use than moxa cones. Simply roll moxawool (other herbal medicine may be mixed in) into the shape of a large cigarette, using paper made of mulberry bark, or any other that is soft yet strong (see Diagram)
2. Posture of the patient: The patient should be placed according to the location of the points selected. The patient should be comfortable and able to maintain the position for the required time of treatment.
2. Classification of Moxibustion: There are three methods of applications; moxa cones, moxa sticks and warming of needle.
1. Moxibustion with moxa cones may be direct or indirect.
1. Direct: A moxa cone is placed directly on the skin the ignited. This type may be scarring or non-scarring according to the degree of cauterization.
1. Scarring moxibustion: A small cone is placed on the point and burned, followed by another. This cause a local burn, blister formation, festering, and final healing with scar formation. Indications are certain chronic persistent disease such as asthma.
2. Non-scarring moxibustion: A moxa cone is placed on a point and ignited. When half to two thirds of it is burnt and the patient feels scorching, remove and renew it several times. No blister should be formed, and there should be no festering and scar formation. Indications are asthma, chronic diarrhea, indigestion, etc.,. of the chronic deficient and cold nature. The range of indications is broader than for scarring moxibustion (see Diagram)
2. Indirect moxibustion: The ignited moxa cone does not rest on the skin. According to the substance insulating the cone and skin, there are three kinds of indirect moxibustion.
1. On ginger: Cut a slice of ginger about 0.2 cm. Thick, punch numerous holes in it and place it on the selected point, adding a large moxa cone and igniting it. When the patient feels it scorching, remove it the light another. This method is indicated in symptoms of weakness of the stomach and spleen such as diarrhea, abdominal pain, painful joint and symptoms of deficiency of yang (see Diagram)
2. On garlic: Cut a slice of garlic (a large single clove of garlic is desirable), punch holes in it, put it between the point and the ignite the moxa cone. Renew the cone when the patient feels it scorching. This method is indicated in scrofula, the early stage of skin infections, poisonous insect bite, etc.,.
2. With salt: Fill the umbilicus to the level of the skin, place a large moxa cone on top and ignite it. This method is applied mainly in cases of collapse with symptoms of cold limbs and undetectable pulse after sever abdominal pain, vomiting and diarrhea (see Diagram)
3. Moxibustion using the stick form: Apply a lighted moxa-stick over the selected point from some distance to cause a mild warmth to the local area until it becomes hot the pink. The moxa stick may be moved up and down like a sparrow feeding. This method is convenient and can be applied on points where cones are not suitable (see Diagram)
4. With warming needle: With the filiform needle retained to the point, wrap the handle tight in moxawool and ignite it to cause a mild heat around the area of the point. This method is suitable for patients for whom a retained needle and moxibustion are indicated, such as those suffering from painful joints due to cold and damp (see Diagram)
3. Precautions and remarks:
1. If moxibustion is to be applied to the upper and lower parts of the body at one sitting, treat the upper part first. Threat the back before the abdominal aspect, the head and body before the extremities. But consideration should be given to the pathological condition and the number of sites to be treated.
2. In determining the size of a moxa-cone or how many cones should be used, or the duration of the moxa stick application, the patient’s pathological condition, general constitution and age, and the site where moxibustion is to be applied should be taken into consideration. Generally, 3-5 cones are used for each point, and 10-15 minutes for the application of moxa-stick.
3. Moxibustion is contraindicated in high fever either due to exogenous factors or deficiency of yin.
4. Scarring moxibustion is not suitable for face and head for cosmetic reasons. Moxibustion should not be applied to the lower abdomen or sacral region of pregnant women. Some ancient medical literature proscribes as not suitable for moxibustion certain points most of which are close to important organs or arteries.
5. Moxibustion may leave various degrees of burn in local area. This ranges from heat sensation local redness which will disappear of itself, to blister formation. Take care not let small blisters break, as the fluid will be absorbed with infection. Large blisters, however, should be punctured and drained. If pus is formed, the blister should be dressed to prevent further infection.
7. Cupping: Cupping is the treatment of disease by suction to the skin surface by attaching small jars in which a vacuum is created by introducing heat in the form of an ignited alcohol soaked cotton ball. The jars may be of bamboo or glass and in various sizes. The rims must be even and smooth.
1. Indications: Rheumatism, painful joints, sprains, facial paralysis and asthma.
2. Manipulation: Ignite a cotton ball soaked in 95% alcohol and hold in forceps, thrust it inside the jar, remove it and swiftly cup the jar on the selected area. The sucking up of the skin may generally be allowed to go on for 10-15 minutes. To remove, let air into the jar by holding it in the right hand and pressing the skin at the rim of the jar with left. To remove, let air into the jar by holding it in the right hand and pressing the skin at the rim of the jar with the left.
3. Precautions:
1. It is not advisable to apply cupping to patients with high fever, convulsion, allergic skin disease, edema, or hemorrhagic tendency, or to the abdominal area of women during pregnancy.
2. It is undesirable also to apply cupping at articulated areas where the surface is not smooth, on hairy areas or where the skin is loose.
3. When applying cupping, be sure the fire is strong enough to create a vacuum. Hold the jar with the rim close to the local area and cup it to the skin swiftly and deftly. Therapeutic result depends on the sucking action
4. The local area will show blood congestion after cupping, the bruise on the skin surface gradually disappearing within a few days. If minute blister form, they may also be absorbed after one of two days. However for any large blisters, it is advisable to drain the fluid with a sterilized syringe, and apply antibiotics.