Study of the relationship between acupuncture dose and effect

Acupuncture dose–effect relationship is the essential feature of acupuncture and the key factor of acupuncture's therapeutic effect. It is a comprehensive category, including needle direction, needle strength, needle depth, selection of specific techniques, length of time between acupuncture treatment sessions, length of needle retention time, and frequency of treatment, all of which play a decisive role in the curative effect and prognosis of diseases[1]. 1 Historical evolution of the relationship between acupuncture dose and effect A lot of diseases and syndromes in the Inner Canon of Huangdi (Huáng Dì Nèi Jīng) are mainly treated by acupuncture. There are detailed records on the relationship between acupuncture depth, manipulation, needle retaining time, de qi, treatment frequency, and curative effect in the relationship between acupuncture dosage and effect. Since then, clinicians have focused on the above points in the development of the acupuncture dose–effect relationship. 1.1 Relationship between acupuncture depth and curative effect In the Inner Canon of Huangdi, the depth of acupuncture is regarded as the key factor influencing the effect of acupuncture, and certain principles are followed[2]. The depth of acupuncture is also discussed in Classic on Medical Problems (Nàn Jīng) (Table 1). Table 1 - Relationship between acupuncture depth and curative effect in ancient medical books. Literature Content Remarks Inner Canon of Huangdi There are differences between diseases on the surface and in the interior. The needling methods differ between shallow needling and deep needling. Diseases on the surface should be treated with shallow needling, diseases in the interior should be treated with deep needling, and each should reach a certain part (where the disease is located), but no deeper than necessary. If the puncture is too deep, the internal organs will be damaged; if the puncture is too shallow, not only will it not reach the diseased area but also, the qi and blood on the surface will be blocked, giving the diseased pathogen an advantageous opportunity. Therefore, the improper depth of acupuncture can cause great harm to the human body, cause disorder of the five organs’ function, and serious diseases[3]. Improper acupuncture depth can cause medical injury. Inner Canon of Huangdi If a needle stabs the bone, it will not hurt the tendon; if a needle stabs the tendon, it will not hurt the muscle; if a needle stabs the muscle, it will not hurt the pulse; if a needle stabs the pulse, it will not hurt the skin……[3] Only reasonable depth can achieve a good curative effect. Classic on Medical Problems When reinforcing, qi should be drawn from the wei; when reducing, qi should be drawn from the ying[4]. The reinforcing method entails approaching deeper regions with the needle from more shallow depths, taking the qi from the wei fen, and pushing it into the interior slowly; the reducing method entails inserting the needle into the deep of the ying fen, and gradually lead the evil qi out from the deep to shallow tissue. Classic on Medical Problems Stabbing rong does not hurt wei, stabbing wei does not hurt rong[4]. —— Wuwei Medical Bamboo Slips of the Han Dynasty (Wǔ Wēi Hàn Dài Yī Jiǎn) Then, the needle punctures 5 inch below the knee, 10.00 mm deep, leave the needle as if cooking a liter of rice. The needle is called Sanli (ST36). The earliest record on the depth of acupuncture at a certain point[5]. It is clearly indicated that the “Sanli (ST36)” point depth is 10.00 mm in the rong. “rong” and “ying” have the same meaning. The so-called “ying” and “wei” also represent the depth of acupuncture. A-B Classic of Acupuncture and Moxibustion (Zhēn Jiǔ Jiǎ Yǐ Jīng) Piercing into Hegu (LI4) 10.00 mm[6], piercing into Huantiao (GB30) 33.33 mm[6]. Volume 3 of A-B Classic of Acupuncture and Moxibustion written by Mi Huangfu of the Jin Dynasty, elaborates the acupuncture depth of 342 of 349 acupoints, respectively. Although the acupuncture depth of some acupoints was revised by later physicians, the book of A-B Classic of Acupuncture and Moxibustion has undoubtedly made an important contribution to the standardization and quantification of acupuncture at that time.To summarize, during treatment, the depth of acupuncture should be modified according to the patient's specific situation of cold and heat, and deficiency and excess[8]. Compendium of Acupuncture and Moxibustion (Zhēn Jiǔ Dà Chéng) People acquire diseases; there are therapeutic variations between cold before heat, heat before cold. Clinicians using treatment methods should pay attention to the difference between different orders of different treatments, and previous treatment. If we are not aware of similarities and differences between current and past treatments, we cannot understand patterns. What else can we rely on to achieve the treatment according to the disease[7]? —— Inner Canon of Huangdi In spring, the vital energy of the human body lies in the hair on the body surface, in summer in the skin layer, in autumn in the space between muscles, and in winter in the tendon and bone layer. Acupuncture treatment for the same disease must be based on the depth of qi in the body at each of the four seasons, and the depth of acupuncture should be consistent with the season[9]. The depth of acupuncture is also closely related to seasons. Acupuncture Guide (Zhēn Jiǔ Zhǐ Nán) Spring and summer are yang. Its qi is outside, and its popularity is also floating. Those who needle should insert shallowly. Autumn and winter are yin. The qi is inside, and the qi is in the viscera. Those who needle should insert deeply[10]. —— Inner Canon of Huangdi For yin and yang of the hand, the way of receiving qi is close, and the source of qi is quick. The depth of acupuncture is not more than 6.67 mm[9]. The depth of needling is also related to the selected meridians. The hand meridians acquire qi quickly, so needling should be shallow. 1.2 The relationship between acupuncture manipulation and curative effect The implementation of acupuncture manipulation is the key step of acupuncture treatment. Different acupuncture manipulation will inevitably produce different stimulation intensities and different degrees of stimulation will produce different acupuncture effects. Ancient physicians conducted simple quantitative analyses of acupuncture manipulation, some of which are described in Table 2. Table 2 - Relationship between acupuncture manipulation and curative effect discussed in ancient medical books. Literature Content Remarks Inner Canon of Huangdi Slowly insert the needle and hand-manipulate the needle, quickly remove the needle and press the needle hole tightly, this is the complement. The needle should be inserted quickly and removed slowly without closing the needle hole[11]. If the evil qi is strong, the needle should be inserted quickly and removed slowly. The stimulation amount should be “heavy,” and the needle hole should be enlarged to eliminate entry of evil qi. The complement law indicates that the needle should be inserted slowly and removed quickly. The stimulation degree should be “light,” and the needle hole should be closed to prevent the healthy qi from leaking out and the evil qi from entering[11]. Inner Canon of Huangdi The reducing method should adopt a round and fluent technique, directly stab the region of illness and turn the needle, so that the healthy qi can be operated. During the operation, the needle should be inserted quickly and removed slowly to induce evil qi to exit. When the needle is inserted, the direction of the needle tip should be in the direction of the meridian qi. When the needle is removed, the needle hole should be widened, and the evil qi will leak out quickly. For complement therapy, it is necessary to adopt a correct and calm technique. First, massage the skin to relax the patient and observe the acupoints. Gently twist the needle and slowly insert it. When inserting the needle, the body must be upright. The person inserting the needle should remain calm and wait for the arrival of qi patiently and persistently. After the arrival of qi, the needle should be maintained in the current position. When the meridian qi is unobstructed, the needle should be quickly removed. Then, the practitioner should knead and press on the skin of the acupoint to make the needle hole close quickly, so that the real qi can be stored inside and not leak out[9]. —— Biaoyou Fu (Biāo Yōu Fù) During a full moon, there is no remedy, during a new moon, there is no reduction. According to the phase of the moon, the corresponding reinforcing and reducing methods are adopted, the excess is not replenished and the deficiency is not reduced. 1.3 The relationship between needle retention time and curative effect Needle retention time is another important factor in the acupuncture effect. Medical books such as Inner Canon of Huangdi suggest that needle retention time should be considered from the aspects of patients’ constitution, viscera, meridians, etc[12], as shown in Table 3. Table 3 - Relationship between needle retention time and curative effect in ancient medical books. Literature Content Remarks Inner Canon of Huangdi In the prime of life, people with a strong physique have sufficient blood gas and strong skin. They are sick because of external pathogens. Acupuncture should be deep and needles retained. This is the method of acupuncture for the treatment of obese individuals. Thin people display thin skin, lack of blood color, thin muscles, thin lips, and soft voices. Their serum is thin and smooth, and their qi is easily collapsed and their blood is easily lost. Acupuncture for this kind of person should be shallow and quick[9]. The length of needle retention is different with different constitutions. Inner Canon of Huangdi When puncturing the yin meridian, deep needling and retained needling should be performed; when puncturing the yang meridian, shallow needling and quick removal should be performed[9]. It is better to keep the needle in place for a long time for the visceral diseases of yin and for a short time for the visceral diseases of yang. Inner Canon of Huangdi Puncturing the foot yangming meridian should be deep at 20.00 mm, retain needle position for ten breaths; puncturing foot taiyang meridian deep 16.67 mm, retain needle position for seven breaths; puncturing foot shaoyang meridian deep 13.33 mm, retain needle position at 16.67 mm; puncturing foot taiyin meridian deep 10.00 mm, retain needle position for four breaths; puncturing foot shaoyin meridian deep 6.67 mm, retain needle position for three breaths; puncturing foot jueyin meridian deep 3.33 mm, retain needle position for two breaths. In the meridian of the hand, the way of receiving qi is close, and the coming of qi is quick. The depth of acupuncture should not be more than 6.67 mm, and the time for needle retention should not be more than one breath[9]. When needling different meridians, the time of retaining needles should be selected according to the corresponding breath. Compendium of Acupuncture and Moxibustion The acupuncture of hand meridians can stop at 24 breaths in spring and summer, and the acupuncture of foot meridians can stop at 36 breaths in autumn and winter[13]. —— 1.4 Relationship between de qi and curative effect Ancient doctors regarded “qi arrival” or “de qi” as the judgment for the standard of “minimum effective stimulation amount.” Achievement of de qi or lack of de qi is the most accurate judgment of the therapeutic effect of acupuncture stimulation amount. Therefore, “de qi” is closely related to acupuncture curative effect[14]. Doctors of all dynasties attach great importance to it, as shown in Table 4. Table 4 - Relationship between de qi and curative effect in ancient medical books. Literature Content Remarks Inner Canon of Huangdi The key to effective acupuncture is when qi arrives[9]. The symbolic significance of de qi. Inner Canon of Huangdi When breathing in, twist the needle to acquire qi[15]. —— Inner Canon of Huangdi The basic principle of acupuncture treatment is to achieve the harmony of yin and yang and then stop acupuncture[9]. —— Classic on Medical Problems In spring and summer, yin qi (one yin) is drawn from the deep (liver and kidney), while in autumn and winter, yang qi (one yang) is drawn from the shallow (heart and lung)[4]. It is emphasized that the reinforcing and reducing operation by “pushing in and reinforcing” or “moving and extending and reducing” can be conducted only after acquiring qi. Classic on Medical Problems The so-called “reality and emptiness” refer to the firmness or softness of the feeling under the needle. When reinforcing the emptiness, the feeling of firmness and firmness under the needle indicates the acquisition of qi; when reducing the emptiness, the feeling of softness and emptiness under the needle indicates the loss of qi, allowing clinicians to determine the acquisition or loss of qi[4]. Later clinicians’ understanding of the subjective feeling when acquiring qi under the needle was first eluded to in this article and this kind of feeling under the needle is regarded as the symbol of acquiring qi[16]. Biaoyou Fu The sensation of lightness, weakness, and slowness under the needle indicates that qi has not arrived, while the feeling of sinking, astringency, and tightness under the needle indicates that qi has arrived. When the qi reaches the point of needling sensation, the cold syndrome should be considered for the retention technique and the hot syndrome should be considered for quick removal of the needle. When qi does not arrive, we should wait for qi according to the patient's deficiency and excess. If qi arrives, the clinician will experience a sensation in their hands like a fish swallowing hooked bait and floating. If qi does not arrive, the clinician will experience a feeling of vast emptiness[17]. This describes in detail the sensation in the doctor's hands when qi arrives. 1.5 The relationship between treatment frequency and curative effect It has been suggested in the Inner Canon of Huangdi that the appropriate frequency of acupuncture treatments varies among different diseases. For example, Simple Questions (Sù Wèn) states[15], “The wind evil invades the human body, and the symptoms of cold or heat appear. If the symptoms are hot, sweating occurs. If the symptoms occur several times a day, you should first acupuncture the muscle and collaterals. If the symptoms are still cold or hot, you can acupuncture once every 3 d, and the disease will be cured after 100 d of treatment. The cause of the disease is gale attack, with heavy joints, beard, and eyebrow falling off. The disease is called gale. Acupuncture should be applied to the muscles to make them sweat. After 100 d of continuous treatment, acupuncture should be applied to the bone marrow to make them sweat. The treatment should also be applied for 100 d, with a total of 200 d. Acupuncture can be stopped until the beard and eyebrows grow again.” Ancient acupuncture scholars attached great importance to the amount of acupuncture treatment. However, because ancient Chinese medicine was passed on by teachers or families, the language and demonstration teaching was more comprehensive than that of written words. The differences between ancient and modern Chinese medicine and a variety of acupuncture reinforcing and reducing techniques entailed virtually no standardized quantitative provisions. The description of the appropriate number of acupuncture treatments was too general and vague and was not scientifically operationalized. The lack of standardization and accuracy makes it difficult for later scholars to understand correctly. The principles of reinforcing and reducing remain in doubt, which limits the ongoing development of acupuncture techniques. This requires modern acupuncture researchers to deeply explore the classical theory and further quantify the parameters of acupuncture treatment amount. 2 Proposal and development of acupuncture manipulation metrology Since the 1970s, I have studied more than 10 kinds of diseases with remarkable effects by acupuncture and moxibustion. Many diseases have been studied using manual metrology, including a prescription for acupuncture, acupoint acupuncture direction and depth, selection of manual and operation time, acupuncture time, and of have some operation methods and techniques, the for standardization on an of ancient medical with the of modern I the theory of acupuncture manipulation metrology The of acupuncture manipulation metrology is to determine and the therapeutic dose of acupuncture. This the first to scientifically the four of acupuncture the direction of acupuncture the of acupuncture the operation time, and the between two acupuncture The of this is to make acupuncture more and to the acupuncture treatment from the reinforcing and reducing techniques to the quantitative The four of acupuncture manipulation are shown in Table Table 5 - of acupuncture manipulation factor points direction The direction of the is one of the important to determine to and reducing techniques, which is the first of reinforcing and reducing meridians are on the and meridians. When the of hands to the direction of is as the The clinician a position the The direction of is as a and is as is to the twist direction is to the and the twist direction is for The specific operation is to when and when twist and one turn are reducing method is the of the The direction of the is on that the is and the is reinforcing and reducing are directly related to the which is the of reinforcing and and frequency, the is turn and the frequency is times or and frequency, the is more than one and the frequency is times the implementation of the the and then to a frequency to the meridian qi slowly. When the the and with each and the is which can quickly the meridian qi, to achieve the of qi for the time The for the of reinforcing reducing manipulation is This is based on a and of points and more than points of meridian acupoints. between two acupuncture treatments The for the between two treatments is determine the time of the effective effect of acupuncture, more than of diseases studied and the parameters for the of each acupoint in the treatment of different diseases should be according to the above four of acupuncture there are great differences in the of the stimulation by the body, which should be according to the patient's and The depth of acupuncture is another important the degree of acupuncture which is Since the theory of acupuncture manipulation was first has indicated that acupuncture manipulation has a on Different acupuncture can produce degrees of stimulation and a variety of acupuncture effects. If the appropriate degree of stimulation cannot be it is difficult to achieve the therapeutic in the dose–effect relationship and of acupuncture has been conducted to further the dose–effect relationship of acupuncture. This the most diseases treated with acupuncture as the and the treatment that have been effective in and quantitative operation and effective meridians and to explore the of acupuncture treatment frequency on the acupuncture and its internal indicates that there is a relationship between acupuncture dose and and there is an of acupuncture that can the acupuncture effect. The key factor the relationship between acupuncture dose and effect is which indicates that the of is of great significance to the acupuncture effect. This further that the of the therapeutic dose of acupuncture will the of acupuncture After of acupuncture manipulation is in the treatment of and diseases. This in acupuncture treatment from to quantitative the in the of acupuncture, makes an important step to of acupuncture into and the and of acupuncture. the of acupuncture manipulation metrology has into a comprehensive including acupuncture time, frequency, direction, strength, depth, and The of acupuncture manipulation metrology has the and of acupuncture a language for and further the of acupuncture 3 Problems and Acupuncture manipulation metrology an important position in the development of the acupuncture the acupuncture method as an example, the for its as a treatment for disease its effect is not to can be made its it is that it is because of its acupuncture manipulation metrology parameters this method is to and to It has good and the past clinicians and have been in this it has and good and It has to the of Chinese medicine and its with a acupuncture manipulation quantitative operation the curative effects of acupuncture have been by in and acupuncture manipulation metrology has between and the acupuncture by in and basic The have from the and teaching The has a and the comprehensive of acupuncture and moxibustion. Acupuncture manipulation metrology an important role in this Only by a of metrology parameters can the effective acupuncture in ancient books and be and then In importance to metrology and is not only to acupuncture and but also to the development of the of Chinese on the has been by in and in metrology is also a of attention to the dose–effect when with a number of and Therefore, on metrology is the key to the development of the of Chinese medicine in the the on the acupuncture dose–effect relationship has made which also has a on the and on acupuncture, but related to this The first is that of the subjective of “de “de qi” and the and relationship between stimulation degree and effect amount is not consistent with the of the acupuncture The or lack of the “de qi” sensation is based on the feeling and experience of the and the and an Therefore, the of “de qi” is an important in the of more and methods should be to this in with metrology as the the quantitative of acupuncture is an important of the standardization of acupuncture acupuncture manipulation is and difficult to Although some can the parameters of acupuncture manipulation, there are still some in the standardization For example, methods can only the operation of hand acupuncture aspects of simple and twist and frequency but cannot the and of hand acupuncture. This from acupuncture in the that acupoint and acupuncture achieve the acupuncture by the frequency, and of to the of acupuncture and the degree of acupuncture stimulation is another for researchers at Acupuncture to the acupuncture Although we have made some into acupuncture it is still a area in the of manipulation further into acupuncture is direction in acupuncture manipulation the of acupuncture is The influencing acupoint de qi, body acupuncture manipulation, stimulation and not in also the time, acupuncture frequency, and to However, in the of an acupuncture which play a decisive role Therefore, I that the effects of and their should be or and can be for to more the dose–effect relationship of acupuncture I that acupuncture to the of and should have a and of The standardization of acupuncture manipulation metrology is the only by which acupuncture can quantitative and This in its and requires the and full of all acupuncture scholars of