Whilst practicing acupuncture, one of the most common questions I field is, ‘How deeply do you have to needle?’ Of course patients generally hope that I say “not deeply at all.’ But amongst the practitioner crowd there are a number of opinions and some clearly defined camps, ranging from the superficial to the deep needling crew. In this article I would like to have a look at what the Ling Shu has to say on the subject of acupuncture needle insertion depth and then provide a little diddy from clinical practice that seems to exemplify what is said in the Ling Shu.
Ling Shu Chapter 1 is about the ‘way of acupuncture”. It introduces the reader to the nine needles of classical acupuncture and explains the names, the shapes and the specific purposes of each needle. In so doing, it clearly identifies that some of the nine needles are non-insertion needles, some are designed to penetrate the skin and some to penetrate deeper tissue such as muscles, tendons, vessels and bones. Chapter 1 also explains that each of the needles ‘has that which it governs’. It says that, ‘the skin, the flesh, the muscles and the channels have their proper dwelling. So, for disease, each has that needle which is suitable.’ Check out the discussion for yourself, it identifies the dangers of acupuncture and describes a number of needling techniques that you’ll find useful. I particularly like the section that says, ‘On understanding the moving power and its way: the onset of a therapeutic effect is faster than shooting an arrow.’
The ancient 9 needles
http://www.acupuncturemoxibustion.com/acupuncture/nine-classical-needles/
So now that we know that a variety of needles and insertion depths have been used in classical acupuncture since great antiquity, the question is no longer ‘How deep do you go’ but rather ‘How do you know when to needle deeply and when to needle superficially?’ Well, happily, the answer to this question can be found in a number of places throughout the Ling Shu but I think chapter 7 says it nicely. It explains that there are 3 classifications of needling methods. There are the 5 needling methods, the 9 needling methods and the 12 needling methods. Together these classification methods provide the reader with a rationale for the choice of needle, depth of insertion, direction of needling, needle manipulation methods and even the development of point prescriptions and the number of needles to be used in any given situation. For me, the most concise and foundational explanation of how to determine correct needling depth can be found in the discussion about the 5 needling methods.
In chapter 7 it says, ‘In the totality of acupuncture there are 5 methods which resonate with the 5 viscera.’ These methods are variously known as:
Half needling method;
Leopard spot method;
Joint needling method;
Join valley needling method; and the
Transport point needling method.
The half needling method is characterised by shallow insertion and swift withdrawal of the needle. The needle penetrates the skin but does not penetrate the muscles. Because of the depth of insertion the half needling method is said to resonate with the Lungs and, therefore, is used to treat problems of the skin.
The Leopard spot needling method is characterized by pricking with a three-edged needle around the point. Ling Shu 7 says that the needle is moved ‘…left and right, front and back (of the point)’. This sort of needling is said to affect the centre of the channel and is used to treat problems of the Blood. As such this method is said to resonate with the Heart.
The joint needling method is characterized by puncturing the tendon close to the joint. Ling Shu 7 says the needle is moved ‘left and right directly to exhaust the upper muscles (tendons)’. In performing this method we are cautioned to, ‘Take care not to draw blood’. The method is said to resonate with the Liver and is used for pain and numbness of the connective tissue.
The join valley needling method is characterized by needling obliquely left and right in the same hole. Ling Shu 7 says the needle spreads out like the claws of a chicken into ‘the division between the flesh’. It is used to treat rheumatism of the muscles and is said to resonate with the Spleen.
The transport point needling method is characterized by deep perpendicular puncture all the way to the bone. Ling Shu 7 says this needle is inserted directly and removed directly and is used to treat rheumatism of the bones. This method is said to resonate with the Kidneys.
In clinical practice, the application of each of the 5 methods and any decisions about needling depth are entirely guided by the practitioner’s diagnosis. In other words, if, in the totality of your investigation, you determine that your patient’s problem is due to a pathology of the Lungs, then the correct needling method is to needle the tissue of Lung, that is, the skin. Likewise, if the pathology is in the Spleen, then you need to needle to the flesh. If the pathology is in the Heart, then you need to needle to the blood vessels. If the pathology is in the Liver, then you need to needle to the tendons. And if the pathology is in the Kidneys, then you need to needle to the bones. Simple isn’t it! First determine were the pathology is and then needle the appropriate tissue. When you combine this method with understanding that emerges from studying the other classification of needling methods in Ling Shu 7 the treatment process becomes even more nuanced. You notice that the actual site of pathology is rarely, if ever, needled. Instead, ‘like’ tissue in a related area of the body located some distance from the site of pathology is generally what’s needled. When you get it right the change is so swift you will hear the strum of the string as the arrow leaves the bow. Check out an example of what I mean below.
A little diddy
One of the best examples I have of the importance of needling to the correct depth and tissue type comes from a recent encounter with a 3rd year acupuncture student and a member of staff in a student clinic that I supervise. The staff member was a teacher from another faculty who had visited the clinic on a number of occasions for a wrist problem that was characterised by significant restriction in ROM and strong pain. Neither I nor the student had seen this person before and, to date, the results of treatment had been largely disappointing; there had been no improvement in ROM and pain levels associated with movement remained consistent. The student and I both had the feeling that we needed to get good results soon or the patient would walk. As I didn’t want a staff member from another faculty developing a poor impression of acupuncture, I took a personal interest in the case.
For those not familiar with the student clinic experience, the supervisor’s first contact with the patient typically comes via the student’s report of findings. This is usually presented after the student performs an initial consultation aimed at gathering information about the chief complaint and all other pertinent signs and symptoms. The student then presents this information, along with a working diagnosis, treatment plan and point prescription to the supervisor for discussion. In this particular case I had been impressed by the student’s grasp of the issue. She described the problem as being along the LI channel on the RHS wrist in the vicinity of LI 5, involving Qi and Blood stagnation of the abductor pollicis longus muscle (APLM) near where it passes through the flexor retinaculum of the hand. ‘Nice’, I thought, ‘let’s run with it’, I said… In retrospect, I wonder just how many times I have been duped by the clever words and powerful convictions of a student?
Back in the treatment room the student asked the patient to demonstrate the offending ROM once again. In addition, she asked that the pain be rated from 0-10 (0=no pain). When everyone in the room was acquainted with the situation, a needle was placed in Liver 4 and angled towards the tendonous sheath of the APLM. The patient was then asked to repeat the offending movement. Though I’m not quite sure what the student was hoping for, I was expecting a significant change in ROM and pain ratings. Unfortunately, there was almost no affect whatsoever from the needle. If anything there was a slight increase in ROM but only of a couple of millimetres at best.
At this point I decided to intervene and asked the patient to describe the event that resulted in the injury. Turns out the condition hadn’t developed slowly over months as suspected by the student. Instead, it had occurred rather suddenly, following a fall that had been broken by stretching the hand out and landing heavily on the palm. The resulting impact injured the wrist joint on the radial side between the trapezium, scaphoid and radial bones. In other words, the injury was in the general area described by the student but was not associated with inflammation of the tendons but with the space between the joints. I instructed the student to modify the location of Liver 4 by moving it 3 mm away from the tendon and aiming the tip of the needle for the joint space between the tibia and talus and guess what? When the patient was asked to repeat the offending ROM, the wrist joint freed up with a clunk and returned to normal in an instant, minus the pain. What was the difference you might ask? Well, it was simple really. We were in the right area but we were targeting the wrong tissue. When we modified the angle and depth of insertion and targeted the tissue between the joints, instead of the tendons above the joint, the tissue in the wrist released.
This was an interesting case and can be explained using a number of Chinese medicine theories including 5 element theory, 6 divisional theory and even Zang Fu theory. In this particular case we borrowed from Bie-jing, or branching channel theory, in which the mutual attraction between channels that sit opposite each other on the horary clock is exploited. This is a simple theory with far reaching implications that says that Tai Yin channels treat Taiyang channels, Shao yin channels treats Shao Yang channels and Jue Yin channels treat Yang Ming channels (and vice-versa BTW). Read more about the Bei-Jing here. In this case we used the Jue Yin Liver channel to treat the Yang Ming Large Intestine channel. We also combined holographic imaging theory and notions from Ling Shu 7 about needling the correct tissue in order to help narrow our point selection options down to Liver 4.
We were all delighted with the outcome. The patient was happy because results had been a long time coming and, now, were undeniable. The student was happy because they had never had such fast results using acupuncture. And I was happy because I’d been privy to an ‘Ah ha’ moment when a student of traditional Chinese medicine had learnt how to apply a classical acupuncture principle regarding needling depth and achieved a therapeutic effect ‘faster than shooting an arrow’.
Bibliography
O’Connor, J., & Bensky, D. 1981. Acupuncture: A Comprehensive Text. Seattle, WA: Eastland Press.
Tan, R. 2007. Acupuncture 1, 2, 3 San Diego, CA. Self Published
WHO standard acupuncture point locations in the Western Pacific Region. 2008. Manila, Philippines: World Health Organization, Western Pacific Region.
Wu, J-N., 2004. Ling Shu or Spiritual Pivot. University of Hawai’i Press, Hawai’i
