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Angle, Direction, and Depth of Acupuncture
The angle, direction, and depth of acupuncture refer to the specific operational requirements after the needle is inserted subcutaneously. Mastering the correct angle, direction, and depth during acupuncture is crucial for achieving the desired sensation, performing tonification or sedation, maximizing the effects of acupuncture, enhancing treatment efficacy, and preventing accidental injuries. The accuracy of point selection not only refers to the surface location on the skin but must also be combined with the correct angle, direction, and depth to exert the therapeutic effect of the acupoint. Therefore, acupoints should not be viewed merely as small dots but rather as three-dimensional concepts. Clinically, when needling the same acupoint, variations in angle, direction, and depth can lead to differences in the tissue structures reached, the sensations produced, and the therapeutic outcomes. For clinicians, the proficiency in acupuncture operations is closely related to their ability to appropriately master the angle, direction, and depth of needling. The angle, direction, and depth of needling should be flexibly adjusted based on the treatment site, therapeutic needs, and the patient’s constitution and physique.
(1) Angle of Acupuncture
The angle of acupuncture refers to the angle formed between the needle shaft and the skin surface during insertion. The size of this angle should be determined based on the characteristics of the acupoint location, the nature of the disease, and the requirements of the technique. Acupuncture angles are generally classified into three categories: perpendicular, oblique, and horizontal.
1. Perpendicular: This means the needle shaft is at a 90-degree angle to the skin surface, inserted vertically into the acupoint. This method is suitable for most acupoints, especially those located in areas with abundant muscle.
2. Oblique: This means the needle shaft is at approximately a 45-degree angle to the skin surface, inserted at an incline into the acupoint. This method is suitable for areas where the skin is thin, where important organs are located, or where deep insertion is not advisable, as well as for acupoints located at joints. It is also commonly used when employing certain techniques to regulate Qi.
3. Horizontal: Also known as lateral insertion, this means the needle shaft is at approximately a 15-degree angle to the skin surface, inserted horizontally into the acupoint. This method is suitable for acupoints located in areas with thin skin and little muscle, such as those on the scalp, face, and sternum. Techniques like lateral insertion in scalp acupuncture and wrist-ankle acupuncture also utilize this method.
(2) Direction of Acupuncture
The direction of acupuncture refers to the direction the needle tip is facing during and after insertion, abbreviated as needle orientation. The direction is generally determined based on the pathway of the meridians, the distribution of acupoints, and the targeted tissue structures. While the direction is related to the angle of insertion, such as using horizontal insertion for acupoints on the head and face, oblique insertion for acupoints in the neck and throat, horizontal insertion for acupoints along the midline of the chest, oblique insertion for lateral chest acupoints, vertical insertion for abdominal acupoints, and either oblique or vertical insertion for lumbar and back acupoints, the angle is primarily based on the characteristics of the acupoint location, while the direction is determined by the treatment needs for different conditions. For example, when needling the Jia Che (Jaw Chariot) acupoint for treating jaw disorders, cheek pain, or lockjaw, the needle tip should be directed towards the temple at an oblique angle to radiate the sensation throughout the cheek; when treating facial paralysis or crooked mouth, the needle tip should be directed horizontally towards the mouth; when treating mumps, the needle tip should be directed obliquely towards the parotid gland; and for toothache, a vertical insertion is used.
(3) Depth of Acupuncture
The depth of acupuncture refers to how deeply the needle penetrates the skin and flesh at the acupoint. Mastering the depth of needling should adhere to the principle of achieving a sensation beneath the needle without injuring the underlying tissues or organs. The appropriate depth for each acupoint must also consider various factors such as the patient’s age, constitution, condition, acupoint location, depth of the meridian, seasonal variations, the practitioner’s experience, and the need for obtaining Qi. As stated in the Suwen (Plain Questions), “Needling has its shallows and depths, each according to its principle… If the depth is inappropriate, it can lead to significant harm,” emphasizing that the depth of needling must be appropriate. To correctly master the depth of needling, attention must be paid to the following aspects:
1. Age: The Ling Shu (Spiritual Pivot) states, “For infants and thin individuals, needle shallow and quickly; for strong and overweight individuals, needle deep and retain;” the elderly, being weak, have declining Qi and blood; children, being delicate, have immature Yin and Yang, thus should not be needled deeply. Young adults, with robust Qi and blood, can tolerate deeper needling.
2. Constitution: The patient’s physique and body shape vary in terms of thinness and strength. The Suwen states, “One must first assess the physique’s thinness and strength to adjust the Qi’s deficiency and excess,” and Zhang Zhicong also said, “Knowing the physique’s thinness and strength allows one to know the depth of needling.” Thus, for thin and weak individuals, shallower needling is advisable; for strong and robust individuals, deeper needling can be applied.
3. Location: Acupoints on the head, face, and chest/back should be needled shallowly, while acupoints on the limbs and abdomen can be needled deeper.
4. Meridians: The distribution and attributes of meridians in the body vary in depth, with distinctions between Yin and Yang. Ancient texts suggest that deeper meridians can be needled deeply, while superficial collaterals should be needled shallowly; Yang meridians, being superficial, should be needled shallowly, while Yin meridians, being deeper, should be needled deeply. As stated in the Ling Shu, “Needling Yin should be deep and retained; needling Yang should be shallow and quick.” Generally, meridians that run through the elbow, arm, and knee areas are deeper, thus should be needled deeply; those running through the wrist, ankle, fingers, and toes are shallower, thus should be needled shallowly.
5. Condition: The Ling Shu states, “Diseases change in terms of floating and sinking depths, which cannot be fully explored; each is in its place. For intermediate conditions, needle shallowly; for severe conditions, needle deeply; for intermediate conditions, needle small; for severe conditions, needle more; adjust according to changes in Qi.” The Ling Shu also states, “For a full pulse, needle deeply to release Qi; for a weak pulse, needle shallowly to prevent Qi from leaking out, thus nourishing the pulse and expelling evil Qi,” indicating that the depth of needling must be based on the nature and mechanism of the disease.
6. Technique: The Yixue Renmen (Medical Doorway) states, “For tonification, take Qi from the Wei (Defensive) level, needle lightly and shallowly, following the Wei Qi to assist the deficiency; for sedation, abandon the Qi from the Ying (Nourishing) level, needle heavily and deeply, taking the Ying Qi to the front to drain it.” The Nanjing (Classic of Difficult Issues) states, “Needling Ying should not harm Wei; needling Wei should not harm Ying,” indicating that the depth of needling in techniques must be precise. If deep is done when shallow is needed, it may harm the Wei without reaching the Ying; if shallow is done when deep is needed, it may excessively drain and harm the Ying.
7. Seasonal Variations: The human body is closely related to seasonal changes, and needling must vary with the seasons. The Suwen states, “Spring, summer, autumn, and winter each have their regulations.” In terms of needling depth, it should be based on the condition and combined with seasonal variations. The Ling Shu states, “In spring, take from the collaterals and the major meridians between the flesh; for severe cases, needle deeply; for intermediate cases, needle shallowly; in summer, take from the collaterals and the skin; in autumn, take from the major collaterals, following the spring method; in winter, take from the wells and major collaterals, desiring deep retention.” Generally, it is believed that shallow needling is suitable in spring and summer, while deep needling is suitable in autumn and winter. This rule is based on the Nanjing stating, “In spring and summer, Yang Qi is above, and human Qi is also above, thus should be taken shallowly; in autumn and winter, Yang Qi is below, and human Qi is also below, thus should be taken deeply.” If not following seasonal rules, it may lead to what the Suwen describes as “In all four seasons, needling that goes against the rules leads to significant illness, which cannot be ignored.”
8. Sensation: When needling, if the sensation beneath the needle is strong, rapid, and the patient is tense or fearful of needling, the needling should be shallower; if the sensation is slow or weak, the needling should be deeper. As stated in the Zhen Jiu Da Cheng (Great Compendium of Acupuncture and Moxibustion), “In all needling, the depth should be adjusted according to the sensation, aiming to obtain Qi.” The angle, direction, and depth of needling are interrelated. Generally, deeper needling is often done with perpendicular insertion, while shallower needling is often done with oblique or horizontal insertion. For acupoints located in areas with important organs, such as the medulla, eyes, chest, and abdomen, it is even more crucial to master the angle, direction, and depth of needling to prevent accidental injuries.
Needling Techniques
After inserting the needle, the methods used to elicit a sensation in the patient, adjust the strength of the sensation, and direct the sensation in a specific direction are referred to as “needling techniques,” also known as “needle manipulation.” Needling techniques include basic techniques and auxiliary techniques.
(1) Basic Techniques
The basic techniques of needling are fundamental actions in acupuncture, with the most commonly used being the lifting and thrusting technique and the twisting technique. These two basic techniques can be applied individually or in combination during clinical practice.
1. Lifting and Thrusting: This technique involves inserting the needle to a certain depth and then performing upward lifting and downward thrusting movements. The action of pushing the needle from a shallow layer to a deeper layer is called thrusting, while the action of withdrawing the needle from a deeper layer to a shallower layer is called lifting. This repetitive vertical movement is known as the lifting and thrusting technique. The amplitude of lifting and thrusting, the changes in layers, the speed of frequency, and the duration of operation should be flexibly adjusted based on the patient’s constitution, condition, acupoint location, and the purpose of needling. When using the lifting and thrusting technique, the force applied should be consistent, and the amplitude should not be excessive, generally around 3-5 cm, with a frequency not exceeding 60 times per minute, maintaining the needle shaft vertical without altering the angle, direction, or depth of insertion. It is generally believed that a larger amplitude and faster frequency during lifting and thrusting result in greater stimulation; conversely, a smaller amplitude and slower frequency result in less stimulation.
2. Twisting: This technique involves inserting the needle to a certain depth and then performing forward and backward twisting movements. This repetitive rotation of the needle within the acupoint is known as the twisting technique. The size of the twisting angle, the speed of frequency, and the duration of operation should be determined based on the patient’s constitution, condition, acupoint location, and the purpose of needling. When using the twisting technique, the force applied should be consistent, and the angle should be appropriate, generally controlled between 180-360 degrees. Twisting in only one direction should be avoided, as it may cause the needle shaft to become entangled with muscle fibers, leading to local pain and difficulty in withdrawing the needle. It is generally believed that a larger twisting angle and faster frequency result in greater stimulation; conversely, a smaller twisting angle and slower frequency result in less stimulation.
(2) Auxiliary Techniques
Auxiliary techniques in needling are supplementary to the basic techniques, aimed at facilitating the acquisition of Qi and enhancing the sensation of needling. Commonly used auxiliary techniques include the following:
1. Circulating Technique: When Qi is not obtained during needling, the circulating technique can be used to promote Qi. This method involves the practitioner gently pressing along the pathway of the meridian above and below the acupoint with their fingers. The Zhen Jiu Da Cheng states, “Whenever the needle is inserted, if Qi does not arrive, use the fingers along the pathway of the corresponding meridian to press up and down, left and right, to promote the flow of Qi and blood, ensuring even circulation, allowing Qi to arrive naturally beneath the needle.” This method can stimulate Qi and blood, activating the meridian Qi, making it easier to obtain Qi after needling.
2. Flicking Technique: After needling and during the retention of the needle, lightly flicking the needle tail or handle with the fingers can create slight vibrations in the needle body to enhance the sensation and assist Qi movement. The Suwen mentions, “Flick and urge it,” and the Zhen Jiu Wen Dui states, “If Qi does not flow, lightly flick the needle to promote its movement.” This technique serves to stimulate and promote Qi movement.
3. Scraping Technique: After inserting the needle to a certain depth, if Qi has not arrived, using the thumb or index finger to press against the needle tail, the practitioner can scrape the needle handle repeatedly from bottom to top with the thumb, index, or middle finger nail to promote the arrival of Qi. The Suwen mentions, “Scrape it down,” and Yao Zhian notes, “Scraping is done with the nail.” This technique can stimulate meridian Qi when Qi has not been obtained, or enhance the transmission and diffusion of the sensation if Qi has already been obtained.
4. Shaking Technique: After inserting the needle to a certain depth, the practitioner can gently shake the needle handle to promote the flow of meridian Qi. The Zhen Jiu Wen Dui records, “Shake to promote Qi.” There are two types of shaking: one is to keep the needle shaft upright while shaking to enhance the sensation of obtaining Qi; the other is to lay the needle shaft down while shaking to direct the meridian Qi in a specific direction.
5. Flying Technique: If Qi has not been obtained after needling, the practitioner can hold the needle handle with the thumb and index finger, gently twisting it several times, then releasing the fingers, repeating this action several times, resembling a bird spreading its wings, hence the name flying. The Yixue Rumen states, “Twist the needle with the thumb and index finger, twisting three times as if the hand trembles, called flying.” This technique serves to stimulate and promote Qi movement, enhancing the sensation of needling.
6. Trembling Technique: After inserting the needle to a certain depth, the practitioner holds the needle handle and performs small amplitude, high frequency lifting and thrusting or twisting movements to create slight tremors in the needle body. This technique can promote the arrival of Qi beneath the needle and enhance the sensation of needling.
The basic needling techniques of lifting and thrusting and twisting are applied according to clinical situations, supplemented by appropriate auxiliary techniques. Techniques like scraping and flicking can be used for acupoints where large-angle twisting is not advisable; the flying technique can be applied to certain acupoints in areas with abundant muscle; shaking and trembling techniques can be used for relatively superficial acupoints. Through the application of basic and auxiliary needling techniques, the primary goal is to facilitate the arrival of Qi after needling or enhance the sensation of needling, thereby unblocking the meridians, harmonizing Qi and blood, and achieving the purpose of disease prevention and treatment.
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