Is Deqi Required For Acupuncture Treatment?

My first experience of acupuncture was on my shoulder from a colleague who had just completed his training in dry needling. I was very impressed with the effects and speed in my recovery, and therefore decided that I needed to learn this technique for the benefit of my patients. I started my training with a short course in acupuncture before moving on to more advanced training and eventually a master’s degree in acupuncture which included western medical, Japanese and traditional Chinese style acupuncture. During my training, I found that there was no definitive answer to whether deqi is required. From clinical experience, I have found no significant difference in treatment outcome whether I elicit deqi during treatment or not. What I have found to have a more important influence on treatment outcome is the choice of acupoints, accurate location of acupoints, treatment duration of at least 20 minutes, needle manipulation depending on whether the condition is acute or chronic, and whether the needles are placed on the torso or on the extremities. Western medical and Japanese style acupuncture does not focus on deqi needling sensation; however, their treatment outcome is just as effective as traditional Chinese style acupuncture, which has a strong focus on deqi as this is where the concept originates.

The term deqi means the arrival of Qi and refers to the participant’s subjective sensations, which are felt around the needle or radiating away from the site of needle insertion and objective body responses, as well as the acupuncturist’s perceptions.

In traditional Chinese medicine (TCM), deqi is considered to be one of the most important principles and the key to successful acupuncture treatment since it is associated with clinical efficacy.^1–3 The concept of deqi is discussed in early Chinese medical texts; however, details of deqi phenomena, which may include the acupuncturist’s and/or the patient’s experience, have only been fully described in the past hundred years.⁴ Versluys⁵ reviewed the Ode of the Golden Needle by Xu Feng, which was written in 1439, and outlined 14 vigorous needling techniques to obtain deqi. Xu Feng reports that the patient feels a hot or cold sensation under the needle. These reported sensations of deqi do not support the findings of current literature with regards to reported sensations of deqi.

The deqi sensation

Kong et al.⁶ developed the Subjective Acupuncture Sensation Scale (SASS) and later revised it to the Massachusetts General Hospital Acupuncture Sensation Scale (MASS) for more scientific application.⁴ The MASS consisted of 12 deqi associated sensations (soreness, aching, deep pressure, heaviness, fullness/distension, tingling, numbness, sharp pain, dull pain, warmth, cold and throbbing). It is important to note that when the MASS was used in Chinese studies, researchers removed “sharp pain” from the scale because it is not regarded as a sensation of deqi.⁷ The removal of sharp pain is supported by fMRI studies^8–13 which have demonstrated that dull pain deactivates the limbic system and sharp pain activates it.

MacPherson and Asghar¹⁴ reported that aching, dullness, heaviness, numbness, radiation, spreading and tingling are closely associated with acupuncture deqi in patients they assessed. The most common types of needling sensations reported by 200 Chinese subjects were distension (94%), soreness (81%), electric shock (81%) and numbness (78%).¹⁵ Park et al.¹⁶ questioned 1095 patients and found distension, soreness, pulling, heaviness, tingling, and numbness was the most common deqi sensation reported during manual acupuncture (MA), electro-acupuncture (EA) and laser acupuncture (LA).

What nerves are involved in the deqi sensation?

The differences between sharp pain and dull pain on brain activity during deqi sensation may be explained by a variety of nerves that transmit impulses from the acupoint to the central nervous system. The neurones in the sensory nervous system involved in the transmission of pain, pressure, and light touch are the A-delta, A-beta and C fibres. Numbness is conveyed mainly by A-beta fibres, distention, heaviness,²⁰ and pricking sensation²¹ by A-delta fibres, while soreness,²⁰ dull and pressing sensations are conveyed by C fibres.²¹

Depending on the type of stimulation, it may result in the nerve impulse ascending the spinothalamic tract which projects to various brain centres such as the thalamus, limbic system, somatosensory cortex, etc. The type of deqi sensation may also indicate which area of the central nervous system (CNS) is affected and the resulting treatment outcome. For example, sharp pain was shown to activate the limbic system while dull pain deactivates the limbic system.^8–13 Deqi sensations of numbness and soreness were found to be significantly associated with acupuncture analgesia. However, stabbing, throbbing, tingling, burning, heaviness, fullness or aching did not show any correlation when needling LI-4, ST-36, and SP-6.⁶

The Importance of deqi for clinical efficacy

It is believed in TCM that deqi sensation plays a vital role in the clinical efficacy of acupuncture^19–22 and it is understood that achieving deqi is associated with a positive treatment outcome.^23,24 Numerous TCM texts discuss the importance of deqi sensation that is experienced by the patient and the practitioner; however, an association between deqi and the efficacy of acupuncture is still inconclusive in clinical trials.^6,25–27 Studies investigating osteoarthritis have reached conflicting conclusions, and some have questioned the need for deep stimulation and deqi in achieving analgesia.^3,28–30

Kong et al.⁶ and Takeda and Wessel²⁷ found that subjects who experienced deqi had better treatment outcomes than those who did not, suggesting that deqi sensations might be a useful clinical indicator of effective treatment. In contrast with these findings, a systematic review of 9 randomised controlled trials (RCTs) that investigated the effects of acupuncture in the management of tinnitus found 6 RCTs that considered deqi to be an important factor in treatment outcome.³¹ However, the review found no statistical supportive evidence that deqi exerted an important influence on clinical outcome during acupuncture treatment. In support of these findings White et al.²⁵ and Foster et al.³² compared the association of deqi and pain relief of patients with osteoarthritis and found no significant difference in pain relief between those who experienced deqi and those who did not.

Deqi sensation at acupoints and non-acupoints

Vincent et al.³³ assessed needle sensations in 65 volunteers after acupuncture needles were applied to three classical acupuncture points and three non-acupuncture points of the hands, feet and legs. They found no significant differences in needle sensations between classical acupuncture points and non-acupuncture points for any locations. Therefore, the findings of this study did not support the contention that the sensations of deqi occur more frequently at classical acupuncture points.

Park et al.³⁴ assessed the sensation of deqi at acupuncture and non-acupuncture points at four different tissue depths (epidermis, dermis, fascia and muscle). Results showed that there were no significant differences between acupuncture point and non- acupuncture point needle sensations at the epidermis, dermis and fascia levels. However, there were differences when needling into the muscle.

Kuo and colleagues³⁵ showed that when the needles were inserted in acupoints and non-acupoints and deqi elicited, a significant difference was observed in skin blood flow and palm temperature.

Strength of deqi and treatment outcome

It is believed by many TCM practitioners and Chinese acupuncture patients that the strength of deqi is important for a successful clinical outcome. A survey of acupuncture treatment for tinnitus³⁶ found that most of the patients and acupuncturists believed that stronger needle sensations led to better treatment results. Mao et al.¹⁵ found that 82% of 200 Chinese acupuncture participants believed that needling sensation was very important for acupuncture treatment and 68% further indicated that the stronger the needling sensation, the more effective the therapy would be. However, the scientific evidence has not supported these beliefs. Spaeth et al.³⁷ stated that real acupuncture, which produced stronger deqi sensations, could also produce significant improvement in pain and function compared with sham acupuncture. Yet, when they performed a Pearson’s correlation analysis to explore the relationship between acupuncture sensations and clinical outcomes, they found there were no significant correlations between the overall perceived intensity of deqi sensations and changes (baseline versus endpoint) in any of the sub-scales of the osteoarthritis outcome score. These findings were in agreement with White and associates²⁵ who assessed the importance of the strength of deqi on the clinical outcome in osteoarthritic pain in a larger randomised, single-blind, multifactorial trial involving three interventions – real acupuncture, Streitberger needle, and mock electrical stimulation – for the treatment of patients with osteoarthritis of the hip and knee. They found no significant correlation between the strength of deqi and improvement in pain. Furthermore, there was no significant difference in pain relief between those who felt deqi and those who did not, using the deqi sub-scale of the Park questionnaire.

Conclusion

The overall findings from current studies indicate that there is no significant difference in deqi sensation at acupuncture points and non-acupuncture points. But there is an association with the depth of needle insertion (into the muscle) and the strength of deqi. The findings do suggest that the effect of deqi on the central nervous system might be associated with the function of the acupuncture points. There remains insufficient evidence to support the effects of deqi on clinical outcome particularly when you consider that Japanese style acupuncture takes a gentle approach and uses very sharp fine needles for a smooth painless insertion. Japanese style acupuncture generally inserts needles to a depth of 1–5mm with gentle stimulation and does not aim to elicit deqi, yet the effect of treatment is very successful. Within a research setting, Japanese style acupuncture is generally used as a form of sham acupuncture and has commonly been shown to have a similar effect with no significant difference in treatment outcome compared with that of deeper needling where a stronger deqi sensation can be elicited. As suggested by Kuo and colleagues,³⁵ strong deqi sensation enhances local blood flow. This may suggest that a short-term local sympathetic response is induced when strong deqi is applied causing a greater blood flow to the area and would be better used in chronic conditions. However, if the condition is acute, a parasympathetic response would be more appropriate in order to desensitise the local area, deactivate the limbic system and reduce swelling and pain. In this case, shallow needling into the skin with gentle or no deqi would be recommended.

 

References

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