Howard Moffet, Kaiser Permanente Division of Research
10 December 2007
Hui et al[1] reported on their investigation into sensations elicited by acupuncture needling which are known as deqi. The authors have previously made significant contributions to our understanding of how the brain responds to acupuncture stimulation.[2]
The present study of deqi is motivated by the premise that “this state [sic] is essential for clinical efficacy,”[1] but two years ago, they professed merely that deqi is “related to clinical efficacy.”[2] In fact, there is little evidence for the necessity of deqi, in part because “there is lack of adequate experimental data to indicate what sensations comprise deqi.”[1] Non-invasive forms of acupuncture point stimulation, including acupressure, moxibustion and Toyo Hari acupuncture, are not known to depend on deqi. While deqi may reflect relevant nervous system input, the belief that deqi is necessary for clinical effectiveness is unsubstantiated.
The study investigators enlisted an acupuncturist whose “sensitivity to needle manipulation was pretested, aiming to reliably elicit deqi sensations.”[1] Unfortunately, the authors fail to state how or by what criteria the acupuncturist was pretested. The study aim was to characterize deqi phenomenon, but the intervention was chosen for its ability to reliably produce the outcome they sought to study. Thus they reported that the predetermined outcome has reliable characteristics! Clinical investigations are more informative when they are less tautological.
The authors described the needling technique, but failed to mention the depth of needle insertions (0.5-1.0” are minimum depths typically prescribed for these points).[3] For the control, “superficial tactile stimulation was performed by gentle tapping with a size 5.88 von Frey monofilament;”[1] that is, with no insertion. The subjects reported that the “frequency and intensity of individual sensations were significantly higher in acupuncture” than in superficial tactile stimulation.[1] That subcutaneous needling feels more intense than superficial stimulation is neither surprising nor informative.
The authors claim that they “have provided experimental evidence to support the occurrence of a unique composition of sensations termed deqi,”[1] but they determined only that the sensations are different from those produced by one type of superficial tactile stimulation and have failed to demonstrate uniqueness. Patients naturally experience diverse sensations depending on the needling technique and their own health status.[3] Moreover, needling sensations experienced by healthy volunteers, even if consistent, may have little or no relevance to those in ill patients.
If we grant that the investigators have demonstrated that one acupuncturist can reliably elicit deqi, can this (or any) acupuncturist perform acupuncture which reliably does not elicit deqi? That is, can the acupuncturist choose to elicit deqi or not? Deqi may simply be an artifact of needling and not essential for clinical effectiveness.
Reference List
1. Hui KK, Nixon EE, Vangel MG, Liu J, Marina O, Napadow V et al.: Characterization of the "Deqi" Response in Acupuncture. BMC Complement Altern Med 2007, 7: 33.
2. Hui KK, Liu J, Marina O, Napadow V, Haselgrove C, Kwong KK et al.: The integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 as evidenced by fMRI. Neuroimage 2005, 27: 479-496.
His first, regarding the necessity, or otherwise, of obtaining a de qi response is covered by the authors in the Background information when they clearly state in the first sentence that 'Acupuncture stimulation elicits deqi, a composite of unique sensations that is essential for clinical efficacy according to traditional Chinese medicine (TCM).' They do not indicate their intention to study other non-invasive forms of acupuncture, or indeed any methods which do not rely upon obtaining a de qi response such as Japanese acupuncture, merely TCM acupuncture.
The use of an experienced acupuncturist was clearly important for the study and 25 years of clinical experience of acupuncture would, I suggest, equip him to elicit the appropriate de qi response and at the appropriate depth of needling for the selected point.
The purpose of the exercise was not to specify how deeply the needles were inserted but that a de qi response was obtained. It would have been of interest to know the depth (although the information can be readily obtained elsewhere) but not essential.
The study aim was to characterise de qi phenomena so it is unsurprising that the investigators wanted to elicit such a response. It seems surprising that this can be misconstrued as predetermining the outcome.
The tapping of points with a monofilament prior to needling provided a control and also introduced another element into the equation, which is that even gently touching an acupuncture point will elicit a response.
As to the final comment, ANY competent acupuncturist can perform acupuncture without eliciting a de qi response - tapping a needle into a point through a guide tube and then leaving it should fulfil the criteria. However, Mr Moffett still misses the point of the study. It is not whether achieving de qi is necessary when carrying out an acupuncture treatment, or even whether it is possible to perform acupuncture without achieving de qi. It is characterising the de qi response.
The truthiness of deqi
10 December 2007
Hui et al[1] reported on their investigation into sensations elicited by acupuncture needling which are known as deqi. The authors have previously made significant contributions to our understanding of how the brain responds to acupuncture stimulation.[2]
The present study of deqi is motivated by the premise that “this state [sic] is essential for clinical efficacy,”[1] but two years ago, they professed merely that deqi is “related to clinical efficacy.”[2] In fact, there is little evidence for the necessity of deqi, in part because “there is lack of adequate experimental data to indicate what sensations comprise deqi.”[1] Non-invasive forms of acupuncture point stimulation, including acupressure, moxibustion and Toyo Hari acupuncture, are not known to depend on deqi. While deqi may reflect relevant nervous system input, the belief that deqi is necessary for clinical effectiveness is unsubstantiated.
The study investigators enlisted an acupuncturist whose “sensitivity to needle manipulation was pretested, aiming to reliably elicit deqi sensations.”[1] Unfortunately, the authors fail to state how or by what criteria the acupuncturist was pretested. The study aim was to characterize deqi phenomenon, but the intervention was chosen for its ability to reliably produce the outcome they sought to study. Thus they reported that the predetermined outcome has reliable characteristics! Clinical investigations are more informative when they are less tautological.
The authors described the needling technique, but failed to mention the depth of needle insertions (0.5-1.0” are minimum depths typically prescribed for these points).[3] For the control, “superficial tactile stimulation was performed by gentle tapping with a size 5.88 von Frey monofilament;”[1] that is, with no insertion. The subjects reported that the “frequency and intensity of individual sensations were significantly higher in acupuncture” than in superficial tactile stimulation.[1] That subcutaneous needling feels more intense than superficial stimulation is neither surprising nor informative.
The authors claim that they “have provided experimental evidence to support the occurrence of a unique composition of sensations termed deqi,”[1] but they determined only that the sensations are different from those produced by one type of superficial tactile stimulation and have failed to demonstrate uniqueness. Patients naturally experience diverse sensations depending on the needling technique and their own health status.[3] Moreover, needling sensations experienced by healthy volunteers, even if consistent, may have little or no relevance to those in ill patients.
If we grant that the investigators have demonstrated that one acupuncturist can reliably elicit deqi, can this (or any) acupuncturist perform acupuncture which reliably does not elicit deqi? That is, can the acupuncturist choose to elicit deqi or not? Deqi may simply be an artifact of needling and not essential for clinical effectiveness.
Reference List
1. Hui KK, Nixon EE, Vangel MG, Liu J, Marina O, Napadow V et al.: Characterization of the "Deqi" Response in Acupuncture. BMC Complement Altern Med 2007, 7: 33.
2. Hui KK, Liu J, Marina O, Napadow V, Haselgrove C, Kwong KK et al.: The integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 as evidenced by fMRI. Neuroimage 2005, 27: 479-496.
3. O'Connor J, Bensky D: Acupuncture, a comprehensive text. Chicago: Eastland Press; 1981.
Competing interests
None.
Response to Howard Moffet
11 January 2008
Howard Moffet makes several misleading comments.
His first, regarding the necessity, or otherwise, of obtaining a de qi response is covered by the authors in the Background information when they clearly state in the first sentence that 'Acupuncture stimulation elicits deqi, a composite of unique sensations that is essential for clinical efficacy according to traditional Chinese medicine (TCM).' They do not indicate their intention to study other non-invasive forms of acupuncture, or indeed any methods which do not rely upon obtaining a de qi response such as Japanese acupuncture, merely TCM acupuncture.
The use of an experienced acupuncturist was clearly important for the study and 25 years of clinical experience of acupuncture would, I suggest, equip him to elicit the appropriate de qi response and at the appropriate depth of needling for the selected point.
The purpose of the exercise was not to specify how deeply the needles were inserted but that a de qi response was obtained. It would have been of interest to know the depth (although the information can be readily obtained elsewhere) but not essential.
The study aim was to characterise de qi phenomena so it is unsurprising that the investigators wanted to elicit such a response. It seems surprising that this can be misconstrued as predetermining the outcome.
The tapping of points with a monofilament prior to needling provided a control and also introduced another element into the equation, which is that even gently touching an acupuncture point will elicit a response.
As to the final comment, ANY competent acupuncturist can perform acupuncture without eliciting a de qi response - tapping a needle into a point through a guide tube and then leaving it should fulfil the criteria. However, Mr Moffett still misses the point of the study. It is not whether achieving de qi is necessary when carrying out an acupuncture treatment, or even whether it is possible to perform acupuncture without achieving de qi. It is characterising the de qi response.
Competing interests
None declared