# A Survey of the Practice and Perspectives of Chinese Acupuncturists onDeqi

Authors: Yu-lan Ren; Tai-pin Guo; Huai-bin Du; Hua-bin Zheng; Ting-ting Ma; Li Fang; Yu-jie Gao; Xu-guang Yang; Xue-zhi Li; Jing Shi; Liang Chen; Yi-wei Liu; Ru-wen Zhang; Hui Zheng; De-hua Li; Xi Wu; Fan-rong Liang
Journal: Evidence-Based Complementary and Alternative Medicine
 (2015)

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## Abstract

Deqi refers to the special sensation and reaction sensed mainly by both acupuncturist and patient when a needle was inserted into the acupoints and is considered to be vital to achieve acupuncture effect. For acupuncturist, it is important to judge and control Deqi in clinical practice. However, enough attention is paid to patients’ feelings rather than acupuncturists’ nowadays. We thus conducted this survey to determine acupuncturists’ perspectives about Deqi and to further find the proper way to induce Deqi. A total of 250 questionnaires were sent out to acupuncturists and 202 (80.8%) were returned. According to the results, most acupuncturists believe that Deqi is vital to obtain preferable clinical effects. The reliability of acupuncturists’ Deqi sensation ranks as sinking> tightening> astringent. The reliability of patients’ Deqi sensations ranks as sourness> numbness> distention> heaviness> pain. The reliability of influential factors ranks as manipulation> specificity of acupoint> TCM constitution> disease status> patient’s psychological condition> acupuncturists’ psychological guidance> clinical environment. This study is believed to provide additional evidence to the qualitative and quantitative research of Deqi in the future.


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## Body

## 1. Introduction

Acupuncture is one of the major treatment modalities in traditional Chinese medicine (TCM). For more than 2500 years of practice, it has been widely accepted by general population in China for its curative effect, wide range of indication, simplicity, and safety in practice. It has gradually become a global therapeutic method in recent decades. According to the theory of traditional acupuncture, the effect of acupuncture is achieved by regulating the channelQi. Therefore,Qiarrival (Deqi), also known as needling sensation, is considered to be closely related to the acupuncture efficacy [1]. In clinical practice,Deqiis measured by the sensation of acupuncturists’ finger and patient’s reaction. Generally speaking, whenDeqioccurs, an acupuncturist may feel sinking (Chen), astringent (Se), and tightness (Jin) around the needle by his/her fingers. Meanwhile, the patient may sense soreness (Suan), numbness (Ma), distention (Zhang), and heaviness (Zhong) around the acupoint; sometimes,Deqi sensation could be different like coldness, warmness, pain electric-shock feeling, and so forth. However, the intensity and property of acupunctureDeqi may differ as a result of the different physical and psychological conditions of individuals, which made it difficult to be comprehensively applied in clinics.Deqisensation scale, as an important qualitative and quantitative measuring tool forDeqi, was applied to acupuncture clinical trials and mechanism studies recently [2–5]. In 1989, the VincentDeqi scale was invented with 20 adjectives based on the McGill pain questionnaire. And then there were the ParkDeqiscale and the MacPhersonDeqiscale followed by [6, 7]. However, these scales had mainly focused on the patients’ sensations but no attention had been paid to theDeqi sensation of acupuncturist. Further, the SouthamptonDeqiscale was drafted based on the suggestions of both patients and acupuncturists but failed to discriminate the noxious pain sensation fromDeqi sensations according to a German trial [8, 9]. The Massachusetts general hospital acupuncture sensation scale (MASS), which was modified based on the subjective acupuncture sensation scale (SASS) [10], was composed of various needling sensations and had a measurement of the spreading ofDeqi and patient’s anxiety during needling. It has already been validated as a reliable and valid tool to measureDeqi in healthy young Chinese people [11]. However, till now no standardized, valid, and reliableDeqi scale has been formed due to the lack of sufficient evidence.In TCM classics, the process to achieveDeqi is also called “Qizhi,” which meansQi arrival orQi obtained through acupuncturist’s manipulations after needle insertion. One of the chief indicators of achievingDeqi is the sensation change felt by acupuncturist’s fingers. The activation, retention, and spreading ofDeqi are closely and directly related to acupuncture manipulation techniques, while recent literature indicates that research attention has been merely paid to the patients’ or healthy subjects’ needle sensations, with ignorance of theDeqi sensation felt by acupuncturists. Therefore, we conducted this survey by consulting acupuncturists, who are engaging in clinical practice in Chinese hospitals, to explore acupuncturist’s perspectives onDeqi and to further understand if there are different views among acupuncturists with different levels of experience.


## 2. Methods

The questionnaire for measuring acupunctureDeqi in acupuncturist was initially designed by 2 senior acupuncture experts, together with 2 clinical acupuncturists and 2 doctoral candidates. All participants of questionnaire design embrace rich experiences in acupuncture treatment with skillful acupuncture manipulation techniques. The current questionnaire we presented in this paper is an autonym questionnaire in Chinese that is finally completed after 5 times revisions according to acupuncture experts suggestions and comments. It contains three parts with 16 items relating to acupunctureDeqi. Part 1 includes 2 single choice questions and 1 open-ended question regarding the acupuncturist’s thoughts on the relationship betweenDeqi and acupuncture efficacy. The questions in part 2 include 2 single choice questions, 3 multiple choice questions, and 2 questions for multiple choices, aimed to identify the proper way to judgeDeqi in clinical practice. The questions in part 3 include 4 single choice questions, 2 multiple choice questions, and 1 question for multiple choices, aiming to find the proper manipulation for a better control and guidance ofDeqi in clinical practice.According to the latest literature [12], 90% acupuncturists thoughtDeqi was related to clinical efficacy. Based on assumption that it reached 96% in this study, a sample size of 200 at least is needed to achieve 90% power to detect a statistical significance by using a two-sided binomial test. The target significance level was 0.05. Thus, 250 acupuncturists were needed assuming a 25% dropout rate. A total of 250 questionnaires were sent out to 250 acupuncturists regardless of age or gender in 44 hospitals with express delivery. The included hospitals were geographically distributed inZhejiang, Jiangxi, Hunan, Shanxi, Qinghai, Sichuan, Yunnan, and Guizhou province andBeijing, Tianjin, and Chongqing municipal city. The rationale for choosing these hospitals in different areas of different directions of China is aiming to avoid deviations caused by the dominance of a specific acupuncture theory or schools in one region. Among them, there were 34 top grade hospitals (77.2%), and most of them are TCM hospitals, 7 second grade hospitals (16%), and 3 community hospitals (6.8%). All questionnaires were completed by included acupuncturists independently.The data of questionnaire was collected back-to-back by two researchers. Then, the data was completely and accurately transferred to computerized database for data processing including double data entry, edit checks, data cleaning, coding, and reconciliation. Continuous variables were summarized as means (SDs) and discrete data as frequency and percentage.


## 3. Results

### 3.1. Participants

250 questionnaires were sent out, and 202 (80.8%) were returned. 49.5% of the respondents were male. The participants were aged from 19 to 59 years (mean, 33.5), with working years ranging from 1 to 45 years (mean, 9.0 years) (1–5-year experience,N
=
96; 6–10-year experience, N
=
49; 10+ years of experience, N
=
57). Regarding the education level, there are 8 with associate degree, 93 participants with bachelor's degree, 73 with master degree, and 18 with Ph.D. degree. Regarding technical title, there were 7 physician assistants, 98 resident doctors, 43 attending physicians, 41 associate physicians, and 13 chief physicians.


### 3.2. Perspectives on the Relationship betweenDeqi and Acupuncture Efficacy

As shown in Table1, regarding the question “whether theDeqiwas crucial to clinical efficacy,” 194 acupuncturists responded, and 85.57% of them thought that in most casesDeqiwas crucial to clinical efficacy, and 8.76% thought it was absolutely crucial, while 2.06% of them stated that in most casesDeqiis not vital to therapy, and 3.61% of them were not sure. No one chose thatDeqiwas not related to treatment at all. Regarding the question “whether a higher intensity ofDeqiresulted in a more preferable efficacy,” most acupuncturists (65.80%) did not think so, while 34.20% of the participants agreed. For the reason why the higherDeqi intensity did not yield better efficacy, some acupuncturists (45.67%) thought it was related to patients’ acceptance and tolerability to acupuncture, because a higher intensity possibley resulted in harm of healthyqi or even noxious stimulation. 26.77% thought it was attributed to individual difference. 3.94% thought it was complicated. And 23.62% did not give any answers.Table 1
Perspectives on the relationship betweenDeqi and acupuncture efficacy.
Questions
Views
Respondents (n)/all respondents (n), %
(1) Do you thinkDeqi is crucial to acupuncture clinical efficacy?
① Yes, totally
17/194, 8.76%
② Yes, mostly
166/194, 85.57%
③ No, mostly not
4/194, 2.06%
④ No, totally not
0
⑤ Uncertainty
7/194, 3.61%
(2) Do you think a higher intensity ofDeqi results in a more preferable efficacy?
① Yes
66/193, 34.20%
② No
127/193, 65.80%


### 3.3. The Way to JudgeDeqi

As shown in Table2, Question (3) is a multiple choice question, and acupuncturist could make one or more choices. 87.56% of the acupuncturists said they jndged the occurrence ofDeqi according to patient’s sensation, 81.35% based on their personal sensation felt by fingers, and 36.27% according to the facial expression of patient. Question (4) demonstrated that there is only a small chance whenDeqi was felt by acupuncturist but not by patient. The results showed that 50.52% of acupuncturists thought the probability was 5%–10%, and 26.04% thought it is less than 5%. Regarding Question (5), 88.14% of the acupuncturists could tell whether theDeqi was achieved just by their manipulating fingers’ sensation regardless of patient’s sensation.Table 2
The way to judgeDeqi.
Questions
Views
Respondents (n)/all respondents (n), %
(3) Which way(s) do you prefer to judge the occurrence ofDeqi? (multiple choices)
① According to sensation of patient’s reaction.
169/193, 87.56%
② According to sensation of your fingers
157/193,81.35%
③ According to facial expression of patient
66/193, 36.27%
(4) What is the probability of the case thatDeqihas been felt by your fingers but the patient reported not?
① Less than 5%
50/192, 26.04%
② 5%–10%
97/192, 50.52%
③ 10%–15%
26/192, 13.54%
④ 15–20%
13/192, 6.77%
⑤ More than 20%
6/192, 3.13%
(5) Can you recognize whether theDeqi has appeared just by your fingers’ sensations during manipulations?
① Yes
171/194, 88.14%
② No
23/194, 11.86%
(6) What sensations have been felt by your fingers whenDeqi has emerged? (multiple choice)
① Sinking
176/185, 95.14%
② Astringent
141/185, 76.22%
③Tightening
180/185, 97.30%
④ Others
7/185, 3.78%
(7) Please rank the acupuncturists’Deqi sensations (those you chose in Question (6) in the order of their reliability for telling the arrival of Qi.
/
Shown in Figure1
(8) WhenDeqioccurred, what are the sensations reported by patients? (multiple choices)
① Sourness
182/196, 92.86%
② Numbness
170/196, 86.73%
③ Distention
189/196, 96.43%
④ Heaviness
139/196, 70.92%
⑤ Pain
104/196, 53.06%
⑥ Others
7/196, 3.57%
(9) Please rank the patients’Deqi sensations (those you chose in Question (8)) in the order of their reliability for telling the arrival of Qi.
/
Shown in Figure2Question (6) was also a multiple choice question. The highest frequency of any sensation felt by the acupuncturists duringDeqi was tightening (97.30%), followed by sinking (95.14%), astringent (76.22%), and others (3.78%). In Question (7), acupuncturists ranked the reliability of tellingDeqi according to their sensations shown in Question (6) in sequence. Figure 1 demonstrated that acupuncturist believed that sinking was ranked at the first place, while tightening the second, and astringent the third, in the reliability of tellingDeqi based on their personal sensations.Figure 1
The reliability order of acupuncturists’Deqi sensations in Question (6).Answers to Question (8) demonstrated that main sensations ofDeqi reported by patients were distention (96.43%), soreness (92.86%), numbness (86.73%), heaviness (70.92%), and pain (53.06%). In order to determine the reliability of tellingDeqi by patient’s subjective sensation, acupuncturists were required to answer Question (9). The result in Figure 2 showed that acupuncturist believed that soreness was ranked at the first place, while numbness the second, and distention the third, followed by heaviness and pain, in the reliability of tellingDeqi based on patients’ subjective sensations.Figure 2
The reliability order of patients’Deqisensations in Question (8).


### 3.4. The Way to ControlDeqi

As shown in Table3, Question (10), regarding the influential factors ofDeqi during clinical practices, was a multiple choice question. The main influential factors ofDeqiwere manipulation (98.43%), patient’s body constitution (95.29%), acupoint (87.43%), the state of illness (80.10%), and psychological condition of patient (68.06%). The importance and reliability ofDeqi’s influential factors toDeqi was ranked in the order as manipulation of acupuncturist> specificity of acupoints> constitution of patient> status of illness> pathogenetic condition of patient, as shown in Figure 3.Table 3
The way to controlDeqi.
Questions
Views
Respondents (n)/all respondents (n), %
(10) What is the influential factors ofDeqi during your clinical practices? (multiple choices)
① Manipulation of acupuncturist
188/191, 98.43%
② Specificity of acupoint
167/191, 87.43%
③ Constitution of patient
182/191, 95.29%
④ State of illnesses
153/191, 80.10%
⑤ Psychological factor of patient
130/191, 68.06%
⑥ Clinical environment
53/191, 27.75%
⑦ Psychological induction of acupuncturist
54/191, 28.27%
(11) Please rankDeqi’s influential factors (those you chose in Question (10)) in order according to their reliability and importance.
/
Showed in Figure3
(12) Which manipulation is the most commonly used to promote the arrival ofDeqi sensations?
① Lifting and thrusting
12/193, 6.22%
② Rotating
2/193, 1.04%
③ Combination of rotating, lifting, and thrusting
140/193, 72.54%
④ Supplementary manipulations like scrape, shake, and so forth.
4/193, 1.04%
⑤ Combination of ③ and ④
34/193, 17.62%
⑥ Others
1/193, 0.52%
(13) For deep or shallow insertion, which one more easily elicitsDeqi sensation according to your experiences?
① Deep
49/190, 25.79%
② Shallow
0/190, 0%
③ Depending on patients’ conditions
141/190, 74.21%
(14) For the strong sensations caused by rotating with one single direction, does this feeling belong toDeqi?
① Yes
90/192, 46.87%
② No
102/192, 53.13%
(15) HaveDeqi ever occurred as soon as the needle was inserted without any manipulations?
① Yes
190/193, 98.45%
② No
3/193, 1.55%
(16) If (15) has occurred, what is the approximate occurrence rate?
① Less than 20%
40/190, 21.05%
② 20%–40%
73/190, 38.42%
③ 40%–60%
55/190, 28.95%
④ 40–80%
19/190, 10%
⑤ More than 80%
3/190, 1.58%Figure 3
The order of influencing factors ofDeqi in Question (16).Regarding Question (12), the most frequently used manipulation to promoteDeqi sensations was the combination of rotating, lifting, and thrusting (72.54%), and supplementary manipulations such as scrape, shake, and press were also used by some acupuncturists (17.62%), while just one kind of manipulation was seldom applied. The questions (13) showed that most acupuncturists (74.21%) believed that the depth of insertion to elicitDeqi sensation should be based on the patient’s conditions, and 25.79% thought that deep insertion was easier, but few chose shallow insertion. In response to the question of whether the strong sensation produced by rotating the needle in single direction was trueDeqi or not, 46.87% acupuncturists agreed with this point. According to Question (15), the majorities of acupuncturists (98.45%) are able to induceDeqi right at the moment of needle insertion, even without needle manipulation. But the possibility was not high for 21.05% of acupuncturists thought it <20% and 38.42% of acupuncturists thought 20%–40%, indicated in Question (16).


## 3.1. Participants

250 questionnaires were sent out, and 202 (80.8%) were returned. 49.5% of the respondents were male. The participants were aged from 19 to 59 years (mean, 33.5), with working years ranging from 1 to 45 years (mean, 9.0 years) (1–5-year experience,N
=
96; 6–10-year experience, N
=
49; 10+ years of experience, N
=
57). Regarding the education level, there are 8 with associate degree, 93 participants with bachelor's degree, 73 with master degree, and 18 with Ph.D. degree. Regarding technical title, there were 7 physician assistants, 98 resident doctors, 43 attending physicians, 41 associate physicians, and 13 chief physicians.


## 3.2. Perspectives on the Relationship betweenDeqi and Acupuncture Efficacy

As shown in Table1, regarding the question “whether theDeqiwas crucial to clinical efficacy,” 194 acupuncturists responded, and 85.57% of them thought that in most casesDeqiwas crucial to clinical efficacy, and 8.76% thought it was absolutely crucial, while 2.06% of them stated that in most casesDeqiis not vital to therapy, and 3.61% of them were not sure. No one chose thatDeqiwas not related to treatment at all. Regarding the question “whether a higher intensity ofDeqiresulted in a more preferable efficacy,” most acupuncturists (65.80%) did not think so, while 34.20% of the participants agreed. For the reason why the higherDeqi intensity did not yield better efficacy, some acupuncturists (45.67%) thought it was related to patients’ acceptance and tolerability to acupuncture, because a higher intensity possibley resulted in harm of healthyqi or even noxious stimulation. 26.77% thought it was attributed to individual difference. 3.94% thought it was complicated. And 23.62% did not give any answers.Table 1
Perspectives on the relationship betweenDeqi and acupuncture efficacy.
Questions
Views
Respondents (n)/all respondents (n), %
(1) Do you thinkDeqi is crucial to acupuncture clinical efficacy?
① Yes, totally
17/194, 8.76%
② Yes, mostly
166/194, 85.57%
③ No, mostly not
4/194, 2.06%
④ No, totally not
0
⑤ Uncertainty
7/194, 3.61%
(2) Do you think a higher intensity ofDeqi results in a more preferable efficacy?
① Yes
66/193, 34.20%
② No
127/193, 65.80%


## 3.3. The Way to JudgeDeqi

As shown in Table2, Question (3) is a multiple choice question, and acupuncturist could make one or more choices. 87.56% of the acupuncturists said they jndged the occurrence ofDeqi according to patient’s sensation, 81.35% based on their personal sensation felt by fingers, and 36.27% according to the facial expression of patient. Question (4) demonstrated that there is only a small chance whenDeqi was felt by acupuncturist but not by patient. The results showed that 50.52% of acupuncturists thought the probability was 5%–10%, and 26.04% thought it is less than 5%. Regarding Question (5), 88.14% of the acupuncturists could tell whether theDeqi was achieved just by their manipulating fingers’ sensation regardless of patient’s sensation.Table 2
The way to judgeDeqi.
Questions
Views
Respondents (n)/all respondents (n), %
(3) Which way(s) do you prefer to judge the occurrence ofDeqi? (multiple choices)
① According to sensation of patient’s reaction.
169/193, 87.56%
② According to sensation of your fingers
157/193,81.35%
③ According to facial expression of patient
66/193, 36.27%
(4) What is the probability of the case thatDeqihas been felt by your fingers but the patient reported not?
① Less than 5%
50/192, 26.04%
② 5%–10%
97/192, 50.52%
③ 10%–15%
26/192, 13.54%
④ 15–20%
13/192, 6.77%
⑤ More than 20%
6/192, 3.13%
(5) Can you recognize whether theDeqi has appeared just by your fingers’ sensations during manipulations?
① Yes
171/194, 88.14%
② No
23/194, 11.86%
(6) What sensations have been felt by your fingers whenDeqi has emerged? (multiple choice)
① Sinking
176/185, 95.14%
② Astringent
141/185, 76.22%
③Tightening
180/185, 97.30%
④ Others
7/185, 3.78%
(7) Please rank the acupuncturists’Deqi sensations (those you chose in Question (6) in the order of their reliability for telling the arrival of Qi.
/
Shown in Figure1
(8) WhenDeqioccurred, what are the sensations reported by patients? (multiple choices)
① Sourness
182/196, 92.86%
② Numbness
170/196, 86.73%
③ Distention
189/196, 96.43%
④ Heaviness
139/196, 70.92%
⑤ Pain
104/196, 53.06%
⑥ Others
7/196, 3.57%
(9) Please rank the patients’Deqi sensations (those you chose in Question (8)) in the order of their reliability for telling the arrival of Qi.
/
Shown in Figure2Question (6) was also a multiple choice question. The highest frequency of any sensation felt by the acupuncturists duringDeqi was tightening (97.30%), followed by sinking (95.14%), astringent (76.22%), and others (3.78%). In Question (7), acupuncturists ranked the reliability of tellingDeqi according to their sensations shown in Question (6) in sequence. Figure 1 demonstrated that acupuncturist believed that sinking was ranked at the first place, while tightening the second, and astringent the third, in the reliability of tellingDeqi based on their personal sensations.Figure 1
The reliability order of acupuncturists’Deqi sensations in Question (6).Answers to Question (8) demonstrated that main sensations ofDeqi reported by patients were distention (96.43%), soreness (92.86%), numbness (86.73%), heaviness (70.92%), and pain (53.06%). In order to determine the reliability of tellingDeqi by patient’s subjective sensation, acupuncturists were required to answer Question (9). The result in Figure 2 showed that acupuncturist believed that soreness was ranked at the first place, while numbness the second, and distention the third, followed by heaviness and pain, in the reliability of tellingDeqi based on patients’ subjective sensations.Figure 2
The reliability order of patients’Deqisensations in Question (8).


## 3.4. The Way to ControlDeqi

As shown in Table3, Question (10), regarding the influential factors ofDeqi during clinical practices, was a multiple choice question. The main influential factors ofDeqiwere manipulation (98.43%), patient’s body constitution (95.29%), acupoint (87.43%), the state of illness (80.10%), and psychological condition of patient (68.06%). The importance and reliability ofDeqi’s influential factors toDeqi was ranked in the order as manipulation of acupuncturist> specificity of acupoints> constitution of patient> status of illness> pathogenetic condition of patient, as shown in Figure 3.Table 3
The way to controlDeqi.
Questions
Views
Respondents (n)/all respondents (n), %
(10) What is the influential factors ofDeqi during your clinical practices? (multiple choices)
① Manipulation of acupuncturist
188/191, 98.43%
② Specificity of acupoint
167/191, 87.43%
③ Constitution of patient
182/191, 95.29%
④ State of illnesses
153/191, 80.10%
⑤ Psychological factor of patient
130/191, 68.06%
⑥ Clinical environment
53/191, 27.75%
⑦ Psychological induction of acupuncturist
54/191, 28.27%
(11) Please rankDeqi’s influential factors (those you chose in Question (10)) in order according to their reliability and importance.
/
Showed in Figure3
(12) Which manipulation is the most commonly used to promote the arrival ofDeqi sensations?
① Lifting and thrusting
12/193, 6.22%
② Rotating
2/193, 1.04%
③ Combination of rotating, lifting, and thrusting
140/193, 72.54%
④ Supplementary manipulations like scrape, shake, and so forth.
4/193, 1.04%
⑤ Combination of ③ and ④
34/193, 17.62%
⑥ Others
1/193, 0.52%
(13) For deep or shallow insertion, which one more easily elicitsDeqi sensation according to your experiences?
① Deep
49/190, 25.79%
② Shallow
0/190, 0%
③ Depending on patients’ conditions
141/190, 74.21%
(14) For the strong sensations caused by rotating with one single direction, does this feeling belong toDeqi?
① Yes
90/192, 46.87%
② No
102/192, 53.13%
(15) HaveDeqi ever occurred as soon as the needle was inserted without any manipulations?
① Yes
190/193, 98.45%
② No
3/193, 1.55%
(16) If (15) has occurred, what is the approximate occurrence rate?
① Less than 20%
40/190, 21.05%
② 20%–40%
73/190, 38.42%
③ 40%–60%
55/190, 28.95%
④ 40–80%
19/190, 10%
⑤ More than 80%
3/190, 1.58%Figure 3
The order of influencing factors ofDeqi in Question (16).Regarding Question (12), the most frequently used manipulation to promoteDeqi sensations was the combination of rotating, lifting, and thrusting (72.54%), and supplementary manipulations such as scrape, shake, and press were also used by some acupuncturists (17.62%), while just one kind of manipulation was seldom applied. The questions (13) showed that most acupuncturists (74.21%) believed that the depth of insertion to elicitDeqi sensation should be based on the patient’s conditions, and 25.79% thought that deep insertion was easier, but few chose shallow insertion. In response to the question of whether the strong sensation produced by rotating the needle in single direction was trueDeqi or not, 46.87% acupuncturists agreed with this point. According to Question (15), the majorities of acupuncturists (98.45%) are able to induceDeqi right at the moment of needle insertion, even without needle manipulation. But the possibility was not high for 21.05% of acupuncturists thought it <20% and 38.42% of acupuncturists thought 20%–40%, indicated in Question (16).


## 4. Discussions

### 4.1.Deqi Is Crucial to Acupuncture Efficacy

In our study, 94.33% acupuncturists statedDeqiwas crucial to clinical efficacy. Of these, 85.57% thought it was crucial in most cases while 8.76% thought it was always crucial. No one denied its importance completely. A recently randomized controlled trial (RCT) of Bell’s palsy demonstrated that the strongDeqicould result in better outcomes [2], while another study stated no pain relief in osteoarthritis patients [13]. Regarding the intensity, the majority of acupuncturists did not believe that a stronger intensity would increase the benefits while 34.20% agreed. This result was similar to the results reported by Han [14], who showed that a low frequency (2 Hz) had better effects on easing pain than a high frequency (100 Hz). There is no doubt thatDeqiis crucial to clinical efficacy in our study. However, future clinical trials are required to confirm this.


### 4.2.Deqiand Acupuncture Manipulations

Our investigation showed that the most significant influencing factors ofDeqiwere the acupuncturist’s manipulation. Acupuncturists’ manipulation was also reported to be the most important influencing factor in clinical studies. It is accepted that manipulation could induce the release ofDeqiand promote the degree ofDeqior alleviate the strongDeqisensation. It is also known that different types of manipulation can result in differentDeqisensations. For promoting or controllingDeqi, acupuncturists preferred to use the combined manipulations of rotating, lifting, and thrusting and also used the supplemental manipulations such as scraping and shaking. As the issue of whether the strong feeling caused by rotating with one single direction was due toDeqi, acupuncturists themselves did not come to an agreement. Sometimes, nearly all acupuncturists have experienced thatDeqioccurred just as the needle was inserted without any other manipulations, but the probability was very low.Different depth of insertion has aroused considerable debate, and more researchers favor the idea that with deep insertion it is easier to produceDeqisensations. Functional magnetic resonance imaging (fMRI) has shown that deep electroacupuncture on GB34 and GB35 could generate strongerDeqisensations and more effectively modulate the pain-related neuromatrix than shallow electroacupuncture [15]. Other studies also proved that deep acupuncture could result in higherDeqisensations scores [16] and increase the skin and muscle blood flow [17] in healthy subjects. However, some studies report the opposite views. A fMRI research declared no significant differences in the blood oxygen level dependent (BOLD) responses by the deep and shallow stimulations [18]. RCT also showed that the same effects were achieved by both deep and superficial acupuncture in idiopathic anterior knee pain patients [19]. Our questionnaire results demonstrated that no one thought the shallow insertion made it easier to produceDeqisensations, and 25.79% of the acupuncturists stated that deep insertion made it easier, while the majority of the acupuncturists (74.21%) explained that it depended on the patients’ conditions and was not relevant to the depth of insertion. The shallow stimulation usually means that the needle tip reaches the subcutaneous tissue, while the deep stimulation may arrive at the muscular or nervous tissues.Deqisensation may not be completely relevant to the deep tissues. One study provided evidence thatDeqiwas not relevant to the deep median nerve contact nor median nerve penetration during needling in P6 point with ultrasound measurement [20]. Another study also explained that it depended on the patients’ conditions and no relevance was attributed to the depth of insertion because in healthy subjects the skin and muscle blood flow increased with no significance comparing deep and shallow stimulation, but in fibromyalgia patients there were significant differences [5].


### 4.3. TheDeqiSensation of Acupuncturists and Patients

It seems that the feelings of patient and acupuncturist are often used to judge whetherDeqi has been generated or not, but few researches have demonstrated the real details of judgment. The results of this study showed that the majority of acupuncturists recognized whether theDeqi had been achieved just by their fingers’ sensations during manipulations. These sensations were mostly tightening, sinking, and astringent, which were similar as those described in textbooks [1]. Interestingly, theDeqi sensations experienced by fingers were ranked as sinking, tightening, and astringent according to the reliability. In our survey, the patients’ sensations were mainly described as soreness (Suan), numbness (Ma), distention (Zhang), heaviness (Zhong), and pain (Tong). The results showed the order of frequency as distention, soreness, numbness, heaviness, and pain, and the orders of its reliability level scores ranked as soreness>numbness>distention>heaviness>pain. For the top three sensations, although there were different words and expressions to describe Zhang, Suan, and Ma, some previous researchers also demonstrated similar results [21–24]. So,Deqi sensation in both acupuncturist and patient, occurrence probability, and the order of reliability were revealed. These results may provide some advice for further quantification studies forDeqi.


### 4.4. Influencing Factors ofDeqi

Except for acupuncturist’s manipulation, the common influencing factors ofDeqiincluded the specificity of acupoint, the constitution of patient, and the patients’psychological factor as shown in our study. For the specificity of the acupoint, studies had shown that it existed and was related to clinical effects closely [25], but it needs further clinical study to determine its direct relationship withDeqi. Yet for all that, according to common sense, the feeling of pain is evident with needling the terminal points on the four limbs, while the soreness and distention are noted in thick muscle points. Meanwhile, the conditions of patient such as constitution, illness state, and psychology were considered as the important factors toDeqi in Chinese ancient and modern literatures [26–28]. As noted in “LingShuJing,” the speed ofDeqiemergence is faster in patient withyang excess constitution than the one withyin excess. Compared with healthy volunteers, patients suffering chronic pain tended to acquire a much strongerDeqisensation [29]. Some researchers believe thatDeqiis the brain awareness and consciousness because the sensations of the subjects were the same between sham laser acupuncture and true laser [30]. However, in the classical literature such as the “Huangdi Neijing” and the “Zhenjiu Dacheng,” psychological factors are important withDeqi, not only in the process of acupuncture but also in influencing the clinical outcomes. Clinical trials revealed that Bell's palsy patients with the personality factors of excitability, sociability, braveness, and intellectuality had an easier time to gainDeqi[31], and the anxiety and dominance were correlated with the treatment effects of primary dysmenorrhea [32]. In addition, the anxiety also affected the heart rate variability in healthy subjects [33].


### 4.5. Limitations

The main limitation of this survey is that the contents are designed according to Chinese acupuncturist’s customs, including manipulations, acupuncturist’s needling sensations, patient’s sensations, and the factors ofDeqi, and some items may be difficult to understand and do not conform with international conventions. Most of the acupuncturists came from the grade-three general province hospitals, and opinions from lower grade hospitals were insufficient. The results are from acupuncturists’ general perspectives; a supplementary survey of the patients’ views is necessary.


## 4.1.Deqi Is Crucial to Acupuncture Efficacy

In our study, 94.33% acupuncturists statedDeqiwas crucial to clinical efficacy. Of these, 85.57% thought it was crucial in most cases while 8.76% thought it was always crucial. No one denied its importance completely. A recently randomized controlled trial (RCT) of Bell’s palsy demonstrated that the strongDeqicould result in better outcomes [2], while another study stated no pain relief in osteoarthritis patients [13]. Regarding the intensity, the majority of acupuncturists did not believe that a stronger intensity would increase the benefits while 34.20% agreed. This result was similar to the results reported by Han [14], who showed that a low frequency (2 Hz) had better effects on easing pain than a high frequency (100 Hz). There is no doubt thatDeqiis crucial to clinical efficacy in our study. However, future clinical trials are required to confirm this.


## 4.2.Deqiand Acupuncture Manipulations

Our investigation showed that the most significant influencing factors ofDeqiwere the acupuncturist’s manipulation. Acupuncturists’ manipulation was also reported to be the most important influencing factor in clinical studies. It is accepted that manipulation could induce the release ofDeqiand promote the degree ofDeqior alleviate the strongDeqisensation. It is also known that different types of manipulation can result in differentDeqisensations. For promoting or controllingDeqi, acupuncturists preferred to use the combined manipulations of rotating, lifting, and thrusting and also used the supplemental manipulations such as scraping and shaking. As the issue of whether the strong feeling caused by rotating with one single direction was due toDeqi, acupuncturists themselves did not come to an agreement. Sometimes, nearly all acupuncturists have experienced thatDeqioccurred just as the needle was inserted without any other manipulations, but the probability was very low.Different depth of insertion has aroused considerable debate, and more researchers favor the idea that with deep insertion it is easier to produceDeqisensations. Functional magnetic resonance imaging (fMRI) has shown that deep electroacupuncture on GB34 and GB35 could generate strongerDeqisensations and more effectively modulate the pain-related neuromatrix than shallow electroacupuncture [15]. Other studies also proved that deep acupuncture could result in higherDeqisensations scores [16] and increase the skin and muscle blood flow [17] in healthy subjects. However, some studies report the opposite views. A fMRI research declared no significant differences in the blood oxygen level dependent (BOLD) responses by the deep and shallow stimulations [18]. RCT also showed that the same effects were achieved by both deep and superficial acupuncture in idiopathic anterior knee pain patients [19]. Our questionnaire results demonstrated that no one thought the shallow insertion made it easier to produceDeqisensations, and 25.79% of the acupuncturists stated that deep insertion made it easier, while the majority of the acupuncturists (74.21%) explained that it depended on the patients’ conditions and was not relevant to the depth of insertion. The shallow stimulation usually means that the needle tip reaches the subcutaneous tissue, while the deep stimulation may arrive at the muscular or nervous tissues.Deqisensation may not be completely relevant to the deep tissues. One study provided evidence thatDeqiwas not relevant to the deep median nerve contact nor median nerve penetration during needling in P6 point with ultrasound measurement [20]. Another study also explained that it depended on the patients’ conditions and no relevance was attributed to the depth of insertion because in healthy subjects the skin and muscle blood flow increased with no significance comparing deep and shallow stimulation, but in fibromyalgia patients there were significant differences [5].


## 4.3. TheDeqiSensation of Acupuncturists and Patients

It seems that the feelings of patient and acupuncturist are often used to judge whetherDeqi has been generated or not, but few researches have demonstrated the real details of judgment. The results of this study showed that the majority of acupuncturists recognized whether theDeqi had been achieved just by their fingers’ sensations during manipulations. These sensations were mostly tightening, sinking, and astringent, which were similar as those described in textbooks [1]. Interestingly, theDeqi sensations experienced by fingers were ranked as sinking, tightening, and astringent according to the reliability. In our survey, the patients’ sensations were mainly described as soreness (Suan), numbness (Ma), distention (Zhang), heaviness (Zhong), and pain (Tong). The results showed the order of frequency as distention, soreness, numbness, heaviness, and pain, and the orders of its reliability level scores ranked as soreness>numbness>distention>heaviness>pain. For the top three sensations, although there were different words and expressions to describe Zhang, Suan, and Ma, some previous researchers also demonstrated similar results [21–24]. So,Deqi sensation in both acupuncturist and patient, occurrence probability, and the order of reliability were revealed. These results may provide some advice for further quantification studies forDeqi.


## 4.4. Influencing Factors ofDeqi

Except for acupuncturist’s manipulation, the common influencing factors ofDeqiincluded the specificity of acupoint, the constitution of patient, and the patients’psychological factor as shown in our study. For the specificity of the acupoint, studies had shown that it existed and was related to clinical effects closely [25], but it needs further clinical study to determine its direct relationship withDeqi. Yet for all that, according to common sense, the feeling of pain is evident with needling the terminal points on the four limbs, while the soreness and distention are noted in thick muscle points. Meanwhile, the conditions of patient such as constitution, illness state, and psychology were considered as the important factors toDeqi in Chinese ancient and modern literatures [26–28]. As noted in “LingShuJing,” the speed ofDeqiemergence is faster in patient withyang excess constitution than the one withyin excess. Compared with healthy volunteers, patients suffering chronic pain tended to acquire a much strongerDeqisensation [29]. Some researchers believe thatDeqiis the brain awareness and consciousness because the sensations of the subjects were the same between sham laser acupuncture and true laser [30]. However, in the classical literature such as the “Huangdi Neijing” and the “Zhenjiu Dacheng,” psychological factors are important withDeqi, not only in the process of acupuncture but also in influencing the clinical outcomes. Clinical trials revealed that Bell's palsy patients with the personality factors of excitability, sociability, braveness, and intellectuality had an easier time to gainDeqi[31], and the anxiety and dominance were correlated with the treatment effects of primary dysmenorrhea [32]. In addition, the anxiety also affected the heart rate variability in healthy subjects [33].


## 4.5. Limitations

The main limitation of this survey is that the contents are designed according to Chinese acupuncturist’s customs, including manipulations, acupuncturist’s needling sensations, patient’s sensations, and the factors ofDeqi, and some items may be difficult to understand and do not conform with international conventions. Most of the acupuncturists came from the grade-three general province hospitals, and opinions from lower grade hospitals were insufficient. The results are from acupuncturists’ general perspectives; a supplementary survey of the patients’ views is necessary.


## 5. Conclusions

Our survey demonstrates thatDeqiis important to clinical effects according to the acupuncturist’s views. The integrated manipulations are the most common way to promoteDeqisensation. The reliability of primary acupuncturist fingers’Deqisensations ranks as sinking>
tightening
>astringent. The reliability of primary patients’Deqisensations ranks as sourness>numbness>distention>heaviness>pain as reported by patients. The reliability of primary patient’sDeqisensation factors ranks as manipulation>specificity of acupoint>TCM constitution>disease status>patient’s psychology>acupuncturist’s psychological hint>clinical environment.In short, this paper shows the perspectives of Chinese acupuncturists onDeqi. The results may provide some evidences to the qualitative and quantitative research ofDeqi. To formulate and evaluate aDeqi sensation scale, it may be better to include both of the sensations of acupuncturist and patient on the basis of the credible rank. In clinical research and practice, the influential factors ofDeqishould be considered.



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*Source: 684708-2015-04-15.xml*