Acupuncture Techniques - Discussion on Needle Insertion Techniques (Part 2)

Acupuncture Techniques – Discussion on Needle Insertion Techniques (Part 1)

6. Needle Manipulation Techniques

After the fine needle is inserted into the acupoint, the operational methods used to elicit the sensation of needling in the patient, adjust the intensity of the sensation, and direct the sensation in a specific direction are referred to as “needle manipulation,” also known as “needle movement.” The techniques of needle manipulation are generally divided into two main categories: basic techniques and auxiliary techniques.

1. Basic Techniques

The basic techniques of needle manipulation are fundamental skills in fine needle acupuncture, commonly including the lifting and thrusting method and the twisting method.

(1) Lifting and Thrusting Method: After the needle is inserted into the acupoint, this method involves moving the needle up and down within the acupoint, as shown in Figure 5-10.

Lifting: The needle is withdrawn from a deeper layer to a shallower layer.

Thrusting: The needle is inserted from a shallower layer to a deeper layer.

The amplitude of lifting and thrusting, the changes in depth, the speed of manipulation, 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 method, the force applied by the fingers should be even and consistent, and the amplitude should not be excessive, generally maintained at 3-5 minutes, with a frequency not exceeding 60 times per minute, keeping the needle body vertical without changing the angle or direction of insertion. A larger amplitude and faster frequency will increase the stimulation; a smaller amplitude and slower frequency will decrease it.

(2) Twisting Method: After the needle is inserted to a certain depth in the acupoint, the right thumb and the middle and index fingers hold the needle handle to perform a back-and-forth twisting motion, as shown in Figure 5-11.

The size of the twisting angle, the speed of manipulation, and the duration should be determined based on the specific conditions such as constitution, condition, acupoint location, and purpose of needling. When using the twisting method, the force applied by the fingers should be even, and the angle should be appropriate, generally around 180 degrees. Twisting in one direction only should be avoided, as it may cause the needle body to become entangled with muscle fibers, leading to pain and needle retention during needling. It is generally believed that a larger twisting angle, faster frequency, and longer duration will increase stimulation; a smaller angle, slower frequency, and shorter duration will decrease it. Both of these basic methods can be used independently or in combination, and in clinical practice, they must be flexibly adjusted according to the patient’s specific situation to achieve their intended effects.

2. Auxiliary Techniques

Auxiliary techniques are operational methods used to assist needle manipulation during needling, commonly including six types, as shown in Table 5-9 and Figure 5-12.

The fine needle manipulation techniques primarily use lifting and thrusting, and twisting as basic operational methods, supplemented by corresponding auxiliary techniques based on clinical conditions.

Table 5-9 Auxiliary Techniques

Name	Key Points of Operation	Function	Source
Circular Method	This method involves gently pressing along the pathway of the meridian above and below the acupoint with the fingers of the practitioner.	Promotes Qi, stimulates blood flow, activates meridian Qi, and facilitates the arrival of Qi after needling.	As stated in “The Great Compendium of Acupuncture and Moxibustion”: “When needling, if Qi does not arrive, use your fingers to follow the pathway of the corresponding meridian, pressing gently up and down to ensure Qi and blood circulate evenly, and Qi will naturally arrive at the needle site.”
Flicking Method	After needling and while retaining the needle, lightly flick the needle tail or handle with the fingers to create gentle vibrations in the needle body.	Stimulates Qi, promotes Qi flow, and enhances the sensation of needling.	As stated in “Questions and Answers on Acupuncture”: “If Qi does not flow, lightly flick the needle to promote its rapid movement.”
Scraping Method	After the fine needle is inserted to a certain depth and Qi has not arrived, use the thumb or index finger to press against the needle tail, and scrape the needle handle up and down frequently with the thumb, index, or middle finger nail.	Used to disperse meridian Qi when Qi has not arrived; if Qi has already arrived, it can enhance the conduction and diffusion of the sensation of needling.
Shaking Method	After the fine needle is inserted to a certain depth, hold the needle handle and gently shake the needle.	There are two methods: one is to keep the needle upright while shaking to enhance the sensation of Qi; the other is to lay the needle down while shaking to direct the meridian Qi in a specific direction.	As recorded in “Questions and Answers on Acupuncture”: “There is a record of ‘shaking to promote Qi.'”
Flying Method	When Qi does not arrive after needling, hold the needle handle with the right thumb and index finger, twist it several times, then open the fingers, alternating between twisting and releasing repeatedly, resembling a bird spreading its wings.	Stimulates Qi, promotes Qi flow, and enhances the sensation of needling.	As stated in “Introduction to Medicine”: “Using the thumb and index finger to twist the needle three times, resembling a trembling hand, is called flying.”
Trembling Method	After the needle is inserted to a certain depth in the acupoint, hold the needle handle with the right hand and use small amplitude, high frequency lifting and thrusting or twisting techniques to create slight tremors in the needle body.	Facilitates the arrival of Qi under the needle and enhances the sensation of needling.

Figure 5-12 Auxiliary Needle Manipulation Techniques

7. Arrival of Qi, Waiting for Qi, Promoting Qi, and Guarding Qi

1. Arrival of Qi

The arrival of Qi, formerly known as “Qi arriving,” and recently referred to as “needle sensation,” refers to the sensation of meridian Qi at the needling site after the fine needle is inserted to a certain depth, followed by the application of twisting or lifting and thrusting techniques.

(1) The manifestations of the arrival of Qi are shown in Table 5-10.

Table 5-10 Differences in Sensation of Arrival of Qi between Patient and Practitioner

Subject

Arrival of Qi

No Arrival of Qi

Patient’s Sensation

Experiences corresponding sensations of fullness, numbness, swelling, heaviness, etc., which can radiate along specific pathways in a certain direction.

No sensations of fullness, numbness, swelling, heaviness, etc.

Practitioner’s Sensation

Feels a sensation of heaviness and/or tightness under the needle.

Feels emptiness under the needle.

As described by Dou Hanqing in “The Mark of the Ghost”: “Light and smooth but not yet arrived, heavy and tight but already arrived… The arrival of Qi is like a fish swallowing a hook, floating and sinking; when Qi has not arrived, it is like a deep and secluded hall.” This is a vivid description of whether Qi has arrived or not.

(2) The significance of the arrival of Qi: The arrival of Qi is closely related to the therapeutic effect of needling. As stated in “The Spiritual Pivot: Nine Needles and Twelve Origins”: “The key to needling is the arrival of Qi for effectiveness.” In “The Mark of the Ghost,” it is stated: “Qi arrives quickly, and the effect is quick; Qi arrives slowly, and the effect is slow.” This indicates that needling must achieve the arrival of Qi, which directly affects the treatment outcome. Generally speaking, if Qi arrives quickly, the therapeutic effect is good; if Qi arrives slowly, the effect is poor; if Qi does not arrive, there is no therapeutic effect.

(3) Factors affecting the arrival of Qi: Incorrect acupoint location; incorrect angle of insertion; inappropriate depth.

2. Waiting for Qi

As stated in “The Great Compendium of Acupuncture and Moxibustion”: “In needling, waiting for Qi is paramount.” When Qi does not arrive under the needle, the method of retaining the needle to wait for Qi should be employed. Intermittent needle manipulation techniques such as lifting, thrusting, and twisting can also be applied to await the arrival of Qi. Patience is required when waiting for Qi; one should not be overly anxious.

3. Promoting Qi

Promoting Qi refers to the various techniques used to encourage the rapid arrival of meridian Qi. As stated in “The Divine Response Classic”: “Using the right thumb and index finger to hold the needle, gently shake, move in and out, and twist, resembling a trembling hand, is called promoting Qi.” Additionally, the auxiliary techniques discussed earlier, such as scraping the needle handle, flicking the needle handle, and following the meridian, also serve to promote Qi.

4. Guarding Qi

The arrival of Qi is crucial for achieving therapeutic effects in clinical practice. Once Qi has arrived, it must be carefully guarded. Practitioners should employ methods to maintain the Qi under the needle to ensure the sensation lasts. As stated in “The Plain Questions: Discussion on the Complete Form of Life”: “Once the meridian Qi has arrived, be cautious not to lose it.” In “The Spiritual Pivot: Explanation of Small Needles”: “Those who guard Qi know how to maintain it… Once Qi is obtained, it is essential to guard it carefully. Only by guarding the Qi under the needle can the needling continue to exert its regulatory effects on the body.

8. Supplementing and Draining Techniques of Fine Needling

1. Single Supplementing and Draining Techniques

The summary of single supplementing and draining techniques is shown in Table 5-11.

Table 5-11 Summary of Single Supplementing and Draining Techniques

Name	Supplementing Method	Draining Method
Twisting Supplementing and Draining	Small twisting angle, light force, slow frequency, short duration, thumb forward, index finger backward.	Large twisting angle, heavy force, fast frequency, long duration, thumb backward, index finger forward.
Lifting and Thrusting Supplementing and Draining	Shallow first, then deep, heavy thrusting, light lifting, small amplitude, slow frequency, short duration, primarily thrusting.	Deep first, then shallow, light thrusting, heavy lifting, large amplitude, fast frequency, long duration, primarily lifting.
Rapid and Slow Supplementing and Draining	Slow insertion, fast withdrawal.	Fast insertion, slow withdrawal.
Following and Leading Supplementing and Draining	The needle tip follows the direction of the meridian to insert.	The needle tip goes against the direction of the meridian to insert.
Breathing Supplementing and Draining	Insert the needle during exhalation, withdraw during inhalation.	Withdraw during exhalation, insert during inhalation.
Opening and Closing Supplementing and Draining	After withdrawing the needle, press the needle hole closed.	Do not press the needle hole closed when withdrawing, or enlarge the needle hole.
Even Supplementing and Draining	After obtaining Qi, perform even lifting, thrusting, and twisting.

2. Composite Supplementing and Draining Techniques

The summary of composite supplementing and draining techniques is shown in Table 5-12.

Table 5-12 Summary of Composite Supplementing and Draining Techniques

Name

Key Points of Operation

Indications

Burning Mountain Fire

Insert the needle into the upper third (heavenly part) of the acupoint to the appropriate depth, after obtaining Qi, perform twisting supplementing method, then insert the needle into the middle third (human part), obtain Qi, perform twisting supplementing method, and finally insert the needle into the lower third (earth part), obtain Qi, and perform twisting supplementing method. Repeat this operation three times, then press the needle firmly to the earth part and retain it. During the operation, the breathing supplementing method can be combined with the supplementing method.

Commonly used to treat cold bi syndrome, stubborn numbness, and cold-related diseases.

Piercing the Sky Coolness

Insert the needle into the lower third (earth part) of the acupoint to the appropriate depth, after obtaining Qi, perform twisting draining method, then lift the needle to the middle third (human part), obtain Qi, perform twisting draining method, and finally lift the needle to the upper third (heavenly part), obtain Qi, perform twisting draining method, and then slowly press down to the lower third. Repeat this operation three times, lifting the needle to the upper third to retain it. During the operation, the draining method from the breathing supplementing method can be combined.

Commonly used to treat heat bi syndrome, acute pain and swelling, and other heat-related diseases.

9. Factors Affecting the Effects of Supplementing and Draining Techniques

1. The Functional State of the Body

This is the primary factor influencing the effects of supplementing and draining techniques.

Under different pathological states, acupuncture can produce different effects, resulting in either supplementing or draining effects. For example, when the body is in a state of deficiency, acupuncture can have a supplementing effect; when the body is in a state of excess, presenting as heat, closed syndrome, or solid syndrome, acupuncture can drain excess, clear heat, open closed pathways, and drain solid conditions. For instance, in cases of gastrointestinal spasms and pain, acupuncture can relieve spasms and alleviate pain; when gastrointestinal motility is slow, acupuncture can enhance motility and restore normal function.

2. The Relative Specificity of Acupoint Functions

The therapeutic functions of acupoints not only have universality but also relative specificity. For example, some acupoints are suitable for supplementing deficiency, while others are suitable for draining excess. Acupoints such as Guanyuan (CV4), Qihai (CV6), Mingmen (GV4), and Gaohuang (BL43) can invigorate the body’s vital energy, promote vigorous function, and have a strengthening effect, making them suitable for supplementing deficiency and benefiting loss; while acupoints such as Shuigou (CV3), Weizhong (BL40), Shierjing (TW1), and Shixuan (PC8) can disperse pathogenic factors, inhibit excessive bodily functions, and have a draining effect, making them suitable for expelling pathogens and draining excess.

3. Factors Related to the Needle and Techniques

The effects of supplementing and draining techniques are directly related to the thickness and length of the needles used, the angle and depth of insertion, and the techniques employed during needle manipulation.

10. Retaining and Removing Needles

1. Retaining Needles

Retaining needles refers to the practice of leaving the needle in the acupoint after needling and performing techniques.

Purpose of Retaining Needles:To enhance the effects of needling and facilitate continued manipulation.

Key Points of Operation:Generally, for common conditions, once Qi is obtained under the needle and appropriate supplementing or draining techniques are applied, the needle can be retained for 10-20 minutes. For chronic, stubborn, painful, or spasmodic diseases, the retention time can be appropriately extended; for acute abdominal pain, trigeminal neuralgia, dysmenorrhea, etc., the retention time can reach several hours, allowing for intermittent manipulation during retention to enhance and consolidate the therapeutic effect.

Precautions:In clinical practice, whether to retain needles or the duration of retention should not be generalized but should be determined based on the patient’s specific condition.

2. Removing Needles

Removing needles refers to the method of withdrawing the needle after completing the manipulation. It is also known as “lifting the needle” or “withdrawing the needle.” After achieving the intended purpose and therapeutic requirements of needling, the needle can be removed.

Key Points of Operation:Generally, use the left thumb and index finger to hold a disinfected cotton ball gently against the needling site, while the right hand gently twists the needle and slowly withdraws it just beneath the skin (do not use excessive force with one hand). Wait a moment, then remove the needle. Depending on the different requirements of supplementing and draining, the methods of “rapid withdrawal” or “slow withdrawal” as well as “rapid pressing on the needle hole” or “enlarging the needle hole” should be employed.

Precautions:After removing the needle, unless there are special needs, a disinfected cotton ball should be pressed against the needle hole for a moment to prevent bleeding or pain at the needle site. After removal, carefully check the needle hole for bleeding, inquire about any discomfort at the needling site, verify the number of needles used, and pay attention to any delayed reactions such as fainting.

11. Handling and Prevention of Abnormal Situations

Although acupuncture is relatively safe, if operations are careless, negligent, or if contraindications are violated, or if needling techniques are improper, or if there is a lack of comprehensive understanding of human anatomy, some unexpected abnormal situations may occur. The common ones are as follows.

1. Fainting

Definition	Fainting that occurs during the needling process.
Causes	Patient Factors	Due to mental tension, weak constitution, excessive fatigue, hunger, or after excessive sweating, diarrhea, or blood loss.
Practitioner Factors	Improper positioning or excessive force during the procedure.
Symptoms	Light cases may present with dizziness, pale complexion, palpitations, shortness of breath, cold sweat, nausea, fatigue, and a weak pulse.
Severe cases may present with cold limbs, low blood pressure, loss of consciousness, incontinence, cyanosis of lips and nails, and a faint pulse.
Management	Immediately stop needling, withdraw all needles, and have the patient lie flat, ensuring warmth.
Light Cases	Rest for a moment, provide warm water or sugar water, and the patient should return to normal.
Severe Cases	After the above management, acupuncture points such as Renzhong (GV26), Suxi (PC8), Neiguan (PC6), and Zusanli (ST36) can be needled, and moxibustion can be applied to Baihui (GV20), Qihai (CV6), and Guanyuan (CV4) to restore consciousness. If the patient remains unresponsive, with weak breathing and pulse, consider additional treatments or emergency measures.
Patient Aspects	For patients receiving acupuncture for the first time or those who are mentally tense or physically weak, proper explanations should be provided to alleviate concerns about needling. Comfortable and stable positioning is recommended, preferably lying down, with fewer acupoints selected and gentle techniques used. If the patient is hungry, fatigued, or excessively thirsty, they should be allowed to eat, rest, and hydrate before needling.
Practitioner Aspects	During acupuncture treatment, practitioners should maintain focus, observe the patient’s complexion, and inquire about their sensations. If any discomfort or signs of fainting occur, early intervention measures should be taken to prevent further issues.

2. Needle Retention

Definition	The phenomenon where the practitioner feels resistance under the needle during manipulation, making twisting, lifting, and withdrawal difficult, while the patient experiences pain.
Causes	Patient Factors	Due to mental tension, strong muscle contraction at the needling site after needle insertion.
Practitioner Factors	Improper manipulation techniques, excessive twisting in one direction, causing muscle fibers to entangle with the needle body, leading to needle retention. Prolonged needle retention may also cause needle retention.
Symptoms	The needle feels stuck in the body, making twisting, lifting, and withdrawal difficult. Forcing these actions may cause unbearable pain for the patient.
Management	Address the underlying causes.
Patient Factors	If the patient is tense and the local muscles are overly contracted, the retention time can be slightly extended, or gentle pressing or flicking of the needle handle near the retention site can be performed, or another needle can be inserted nearby to disperse Qi and blood, alleviating muscle tension.
Practitioner Factors	If improper manipulation or excessive twisting has occurred, the needle can be twisted back in the opposite direction, and scraping or flicking techniques can be used to release the entangled muscle fibers, thus eliminating needle retention.
Prevention	For patients who are tense, proper explanations should be provided to alleviate their concerns. Attention should be paid to manipulation techniques to avoid excessive twisting in one direction. When using the flicking method, it should be combined with the lifting and thrusting method to prevent muscle fibers from entangling with the needle body and avoid needle retention.

3. Bent Needle

Definition	The phenomenon where the needle body bends inside the body during insertion or after the needle is inserted into the acupoint.
Causes	Practitioner factors include unskilled insertion techniques, excessive force or speed causing the needle to hit hard tissue, and inappropriate patient positioning. Changes in position during needle retention can also lead to bending due to external pressure on the needle handle.
Symptoms	The needle handle changes direction and angle during insertion or retention, making twisting, lifting, and withdrawal difficult, while the patient experiences pain.
Management	Once a bent needle is detected, do not perform lifting, twisting, or other manipulations. Avoid forcibly withdrawing the needle to prevent breaking it and leaving it inside the body.
Withdrawal Method	For slight bending, the needle should be slowly withdrawn while turning it in the direction of the bend. For more severe bending, the needle should be withdrawn in the direction of the bend. If the bending is due to a change in patient position, the patient should be slowly returned to the original position, allowing the local muscles to relax before gently withdrawing the needle.
Prevention	Practitioners should be skilled in their techniques, applying gentle force to avoid excessive speed or force during insertion. Patients should be positioned comfortably, and during needle retention, they should not change positions arbitrarily. The needling site and needle handle should not be subjected to external pressure.

4. Broken Needle

Definition	Also known as a fractured needle, it refers to the needle body breaking inside the human body.
Causes	Poor quality of needles, or damage to the needle body or root due to corrosion, and lack of inspection before use. Full insertion of the needle during needling, followed by excessive lifting, thrusting, or twisting, can cause strong muscle contractions. Changes in patient position during needle retention, or failure to address bending or retention issues promptly and correctly, can also lead to breakage, as can external pressure.
Symptoms	During manipulation or after withdrawal, the needle body is found to be broken, with part of the needle body still exposed above the skin, or the broken end completely buried beneath the skin.
Withdrawal Method	If the broken end is exposed, it can be removed with fingers or tweezers. If the broken end is level with or slightly recessed beneath the skin, the left thumb and index finger should be pressed down vertically on either side of the needle hole to expose the broken needle, and then it can be removed with tweezers. If the broken end is completely buried beneath the skin or deep in the muscle, it should be located under X-ray guidance and surgically removed.
Prevention	To prevent needle breakage, needles should be carefully inspected, and any that do not meet quality standards should be discarded. Avoid excessive force or speed during needling; during needling or retention, patients should be instructed not to change positions arbitrarily. When inserting the needle, do not fully insert it into the acupoint; leave part of the needle exposed to facilitate removal in case of breakage. If bending occurs during needling, the needle should be withdrawn immediately; do not forcefully insert or manipulate the needle. Timely and correct handling of needle retention issues is also essential to prevent breakage.

5. Hematoma:

Definition	Refers to subcutaneous bleeding at the needling site, resulting in swelling and pain.
Causes	Caused by a bent needle tip or hook damaging the skin or injuring blood vessels.
Symptoms	After needle withdrawal, the needling site may swell and hurt, followed by the skin turning purple.
Management	If there is minor subcutaneous bleeding with a small area of bruising, generally no treatment is needed, as it will resolve on its own. If there is significant swelling and pain, and the area of bruising is large and affects mobility, cold compresses can be applied to stop bleeding, followed by gentle heat application and light massage to promote the absorption of the bruised area. Prevention includes careful inspection of needles, familiarization with human anatomy to avoid blood vessels, and applying pressure with a disinfected cotton ball immediately after needling to prevent bleeding.

12. Precautions for Needling

Due to factors such as physiological states and environmental conditions, the following aspects should also be considered during acupuncture treatment.

Constitution	Patients who are overly hungry, fatigued, or excessively tense should not undergo needling immediately. For patients who are thin, weak, or deficient in Qi and blood, the techniques used should not be too forceful, and lying down is preferred. Pregnant women in their first three months should avoid needling acupoints in the lower abdomen.
Women	Women who are more than three months pregnant should avoid needling acupoints in the abdomen and lower back, as well as acupoints such as Sanyinjiao (SP6), Hegu (LI4), Kunlun (BL60), and Zhiyin (BL67), which promote circulation and blood flow. During pregnancy, needling should also be avoided during menstruation unless it is for menstrual regulation.
Children	Acupoints on the top of the head should not be needled until the fontanelle has closed.
Condition	Patients with spontaneous bleeding or those who bleed excessively after injury should not be needled. Areas with skin infections, ulcers, scars, or swelling and pain should not be needled. For patients with urinary retention, care should be taken with the direction, angle, and depth of needling in the lower abdomen to avoid injuring the bladder or other organs.
Special Acupoints	Acupoints located over the chest, ribs, waist, and back should not be needled deeply or directly. Special caution should be taken with patients who have liver or spleen enlargement, or emphysema, particularly with acupoints around the eyes and neck, as well as spinal acupoints. Careful angles should be maintained, and excessive lifting, thrusting, and prolonged needle retention should be avoided to prevent injury to important tissues and organs, which could lead to serious adverse consequences.

Acupuncture Techniques – Discussion on Needle Insertion Techniques (Part 2)

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