Acupuncture belongs to a stimulation-based therapy. Acupuncture has been suggested to act as neuromodulating inputs to the nervous system [
Acupuncture practitioners try to generate an optimal input for the improvement of the patient’s health by developing and performing the sophisticated art of it, which includes palpation, insertion, manipulation, and withdrawal of the needle. The question remains whether the administration of a predetermined set of procedures to a patient is appropriate or not. In other words, predetermined protocols may not represent real acupuncture because real acupuncture necessitates incessant feedback from patients and adjustment of needling. Furthermore, it is debatable whether there are any reliable markers for the practitioner to get consistent information about the progression and reaction of the patient following the applied procedures. Diverse sensations are induced by acupuncture, and differential brain areas are activated accordingly [
We report for the first time on the
This study implemented a crossover design trying to observe (1) changes in acupuncture perception in relation to differential acupoints, needling depths, and manipulations and (2) correlations between the practitioner’s and the subject’s perception.
All the study procedures were performed at the Kyung Hee University. The study protocol was reviewed and approved by a local ethics committee. Participants were college students who attended an acupuncture practicum class. All the participants were genetically homogenous Koreans and had previously experienced acupuncture both as a practitioner and as a receiver. Only the data obtained from those who provided an informed consent were collected and analyzed. Data obtained from 81 out of 112 participants were included in the analysis (Table
Demographic data of the participants.
Gender ( |
20/61 |
Age (years) | 23.6 ± 3.3 |
Handedness ( |
81/0 |
Data are presented as number (
Subject’s acupuncture perception was documented using a modified Korean version of the acupuncture perception scale [
The practitioner’s acupuncture perception was documented using a Korean version of the acupuncture practitioner’s perception scale which was of self-report type and comprised four items: thick, tangled, solid, and empty feeling (Table
Acupuncture practitioner’s perception scale.
Instruction: check the intensity of the feeling of the tissue felt through the needle and needling fingers (0: none, 6: strongest imaginable). | |||||||
---|---|---|---|---|---|---|---|
Thick feeling | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Tangled feeling | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Solid feeling | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Empty feeling | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
Every two participants were instructed to pair up as an acupuncture practitioner and an acupuncture subject. Disposable needles used were 0.25 mm (diameter) × 40 mm (length) and made of stainless steel (Dongbang Acupuncture, Boryeong, Republic of Korea). Acupoints LI4 and ST36 were chosen as they are frequently used in acupuncture manipulation training considering safety, accessibility, and feasibility to induce or experience acupuncture perception [
Acupuncture perception ratings over four phases of stimulation for each acupoint were compared using one way analysis of variance followed by Duncan
Practitioner’s ratings over four phases of needle insertion were significantly different for total, thick, tangled, solid (
Intensity of acupuncture perception. Practitioners (
Practitioner’s ratings over four phases of needle insertion were significantly different for tangled (
The ratings of both the practitioners and the subjects were higher for LI4 compared to S36 for all feelings. The thick and solid feeling was significantly different only at deep depth, with the empty feeling significantly different only after the twirling manipulation. Subject’s feelings were significantly different in all four phases of acupuncture stimulation (Figure
Practitioner’s rating and subject’s rating for all four phases of acupuncture stimulation (
Correlation coefficients between the practitioner’s and the subject’s perceptions over four needling phases for the acupoint LI4.
Practitioner’s perception | |||||
---|---|---|---|---|---|
Total | Thick | Tangled | Solid | Empty | |
Subject’s perception | |||||
Total | 0.215 |
0.173 |
0.184 |
0.182 |
−0.039 |
Pain | 0.194 |
0.183 |
0.134 |
0.170 |
−0.011 |
Transmission | 0.119 |
0.084 | 0.122 |
0.091 | 0.041 |
Dullness | 0.191 |
0.128 |
0.172 |
0.179 |
−0.117 |
Soreness | 0.180 |
0.142 |
0.200 |
0.112 |
−0.053 |
Four-phase method: insertion into shallow (P1), middle (P2), and deep depths (P3), followed by twirling manipulation (P4).
Practitioner’s rating and subject’s rating for all four phases of acupuncture stimulation (
Correlation coefficients between the practitioner’s and the subject’s perceptions over four needling phases for the acupoint ST36.
Practitioner’s perception | |||||
---|---|---|---|---|---|
Total | Thick | Tangled | Solid | Empty | |
Subject’s perception | |||||
Total | 0.197 |
−0.006 | 0.174 |
0.182 |
0.150 |
Pain | 0.239 |
0.225 |
0.185 |
0.204 |
0.000 |
Transmission | 0.118 |
0.091 | 0.143 |
0.072 | 0.029 |
Dullness | 0.129 |
0.111 |
0.150 |
0.072 | −0.043 |
Soreness | 0.171 |
0.138 |
0.181 |
0.122 |
−0.013 |
Four-phase method: insertion into shallow (P1), middle (P2), and deep depths (P3), followed by twirling manipulation (P4).
Main finding of this study includes the correlation between the acupuncture practitioner’s and the subject’s perception. The practitioner’s facet of acupuncture needle perception is first reported here. Variations in acupuncture perception were also observed in relation to the insertion depths and twirling manipulation, which were reflected in both the practitioner’s and the subject’s perceptions.
Traditional training of classical style of acupuncture involves the development of clinical art of palpation, even in locating an acupoint [
Unlike the verbal response of the subjects, palpation provides instant and rather objective additional information about the subjects’ state and response of the tissues palpated. While inserting and manipulating the needle, tissue state and response around the inserted acupoint can be felt through the needle. This may belong to a type of palpation in classical acupuncture practice. This palpation is performed through the needle being inserted into the tissue of acupoint and the fingers grasping the needle. This feeling is another source of constant feedback information other than verbal response of the subjects and should be developed through clinical experience and training. The practitioner’s objective feeling is the other side in the definition of “
Until now,
This study dealt with the acupuncture perception of the practitioner and found that the practitioner’s perception showed a correlation with the normal subject’s perception, meaning that the practitioner’s acupuncture perception felt through the needle may well be utilized as a way of monitoring the tissue state or the response of the subjects. This monitoring skill of the practitioner through the needle may be practiced and further developed to get more information on the subject’s current status. The practitioner’s acupuncture perception could be considered as a kind of palpation where, in a sense, the acupuncture needle is an extension of palpating fingers. It possibly delivers clinically useful information, although the reliability or validity of palpation is still controversial [
Consistent with previous reports [
The results and discussions of this study may inevitably accompany limitations; (1) the study population may not be large enough to represent the whole population including both the healthy ranging and the unhealthy ranging from the younger to the elder, (2) the correlation coefficients is not fairly high, (3) the needling depths and manipulation were not rigidly controlled, and (4) the observation in this study was limited to the possible correlation between acupuncture practitioner’s and subject’s perceptions without considering the correctness of the precise acupoint location and the possible clinical effect of acupuncture needle manipulation. These issues may have to be further reviewed and addressed in later studies.
The findings of this study may present clinically useful subjects of discussion. Is it worth to further develop the clinical art of palpation in acupuncture training courses and clinical practice? Considering that subjective and objective acupuncture perception may vary according to the insertion depths and needle manipulation, optimal stimulation intensity and type may have to be differentially found even when acupuncture treatment is administered to the same acupoint. Given that acupuncture perception intensity and type varied in relation to the stimulated acupoint and the stimulation method, one rigid criterion of acupuncture perception may not well fit into clinical reality. More flexible criteria or flexibly applied variations of one preset criterion might be necessary.
In this study, there may have been random variations in the insertion depth and twirling of the needle over different practitioners and insertion phases, partly because of the practitioner’s skill and partly because of the innate nature of manual manipulation. Possible variations in the insertion depth and twirling of the needle may be within reasonable limit and may not be a problem interpreting the result of this study, considering that the aim of this study was not to contrast acupuncture perception with needling parameters but to contrast a practitioner’s perception with a subject’s perception. In this study, a practitioner’s perception and a subject’s perception under the same parameters of needling were recorded and were compared. However, further researches with a more robust design considering a crossover or parallel design, diverse needling parameters, needling skills, and participants such as an experienced clinical acupuncturists group and an acupuncture naive age- and health-matched control group may show more definite data with minimized possibilities of random variations.
In conclusion, the practitioner’s acupuncture perception was successfully documented and analyzed in relation to the subject’s acupuncture perception and different needling conditions.
The authors declare that there are no financial or other relationships that might lead to a conflict of interests.
This research was supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education, Science and Technology (no. 2005-0049404). This work was supported by the National Research Foundation (NRF) (R11-2005-014 and NRF-2015M3A9E3052338).