Questions to Senior Acupuncturists:
When is it Too Much of a Good Thing?
by Tom Ingegno
After about six years of being licensed, my results have improved since first starting out and I am feeling comfortable with my treatment style. I feel that this is a critical stage, as I am starting to develop personal preferences, but at the same time I don’t wish to get caught up in my own ego or limited experience.
At this level, I have found that at the end of a treatment, many of my patients are reporting a good result, but their condition is not always completely alleviated. I do explain to them that acupuncture is a process and not a magic bullet, but I find it hard to fight the urge to end the treatment at this stage. In other words, even when I get a good result – say the patient reports 75-95-percent improvement – I am tempted to try to get a little more for the patient. Sometimes I do restrain myself, knowing that if I push it I run the risk of over treating and causing the patient to feel worse temporarily. In many American schools it is taught that this is a good thing: that the body is having a “healing crisis.” It is sometimes called the “law of cure,” and the adage, “it will get worse before it gets better” is often offered to patients.
While I have had the experience of patients calling me the day after a treatment in severe pain and the day after that calling to tell me they feel 100 percent better, it is a rough situation for both the patient and myself. I understand that each patient is an individual and must be considered on a case-by-case basis, but can anyone offer general guidelines for when to go for maximum relief and when to hold back?
Tom Ingegno M.S., L.Ac.
Baltimore, MD
This question was submitted to senior acupuncturists. The followings are three respondents in alphabetical order:
Respondent No. 1: Ikeda masakazu
Needle Stimulation
As practitioners, we are always concerned about how much needle stimulation to apply in our treatments. I will share my clinical experience on that subject here.
With Chinese needles, it is suitable to use about five needles to stimulate points mostly on the arms and legs. With Japanese needles, especially if you use the contact-needle technique as I do, four needles on each arm and leg and about 14 needles on the patient’s back and abdomen are adequate. It is important, however, to observe the flow of Qi and Blood in the meridians whenever you insert needles into the body. One method for checking changes in the flow of Qi and Blood in the meridians is pulse taking. Another method is inspection. You can ascertain the change in Qi flow by observing the patient’s facial complexion during the treatment. You can also palpate the surface of the skin to ascertain whether it is cold or feverish, moist or dry. You may detect a change in Qi flow simply by receiving Qi emanated by the patient or by observing improvements in the patient’s symptoms after an appropriate amount of stimulation.
1. Judging by the Pulse
If you have selected the correct acupuncture points on the arms and legs and your needle manipulation (reinforcing and reducing) is appropriate, the patient’s pulse will moderate (the so-called root treatment). This indicates the Stomach Qi is brimming over with vitality. When you see this change, you can conclude that an adequate moment of stimulation has been given and no further stimulation is required. If, after completing the whole treatment, the patient’s pulse has become tense or fast, this indicates that you may have over-stimulated your patient. In this case, you need to massage the Triple Warmer meridian to tonify Yang Qi and correct your mistake.
2. Local Stimulation
When the pulse moderates after the root treatment, but the patient still complains of a local pain, you should apply needles in the knotted region. The greater the patient’s pain, the weaker, softer and more superficial the stimulation should be. The contact needle technique is very suitable for this situation. In treating a knotted area, it is sufficient to insert the needle just to the point of touching the knot. If you pierce the knot, the symptom may worsen. When local stimulation is adequate, the symptom somehow resolves. However, if the patient experiences a recurrence of the symptom, your root treatment is incorrect. Because you did not know your root treatment (diagnosis) was incorrect, you applied too much local stimulation and ended up worsening the symptoms.
3. To Avoid Over Stimulation
In short, the practitioner should be deeply in tune with the patient. We should try to receive as much information as possible from the patient with our whole body, listening to his/her unconscious voice (as when we are in a meditative state) and applying needles to the area where the patient most wants it. This is what the ultimate acupuncture treatment is. When you have mastered this, you do not need to worry about over stimulating the patient. It is misguided to use acupuncture points like western drugs. If you would like see a true needle technique, please join my seminar [held annually in Sacramento or San Francisco.
Translated by Onishi Mayu
Respondent No. 2: Shudo Denmei
Thoughts on Amount of Stimulation in Acupuncture
Introduction
I am responding to a question posed by a NAJOM member, Tom Ingegno, “When does the amount of stimulation become excessive?” It is a very difficult question to answer. But the appropriate amount of stimulation in acupuncture is something I myself have always been concerned about. I decided to write about this because it might be a good opportunity to draw up some of my conclusion on this matter. The things written in the classics and the things taught by our predecessors don’t always work out in practice. I have tried out many things in my practice, and this article represents what I have learned and where I stand on the matter.
Conditions for mild and strong stimulation
These are general categories, and are not absolute. Please understand that these are general guidelines.
Gender: Women tend to tolerate stimulation, and men tend to be less tolerant.
Experience: Those who have experience with acupuncture are comparatively tolerant. When new to acupuncture, the initial anxiety and tension can cause fatigue.
Preference: Those who like acupuncture tend to be happy even if the treatment causes a little fatigue. Those who dislike acupuncture, no matter how many treatments they have, tend to tolerate stimulation less.
Season: People tend to tolerate stimulation less in the spring and summer, and better in the fall and winter.
Skin color: Those with darker skin tend to tolerate stimulation more, and those with lighter skin tend to tolerate it less.
Lips: Those with thick lips tend to tolerate stimulation more, and those with thin lips tend to tolerate it less.
Physique: When it comes to fat and thin, the fatter person tolerates stimulation more, and the thinner person less. In the case of fat patients, there are those that have a lot of muscle mass, those that have a lot of fat, and those with water retention. Those with muscle mass tolerate stimulation well. Those with lots of fat are not intolerant, but there is a tendency to over treat them because it’s so easy to insert needles. Even if thin, muscular people are tolerate stimulation well. Patients lacking muscle tone can’t take a lot of stimulation.
Work: Those who do mental workers tolerate stimulation less and those who do physical work can take stimulation. Athletes and those who exercise tolerate stimulation well.
Urban/Rural: There is a tendency for those in urban areas to tolerate stimulation less and those in rural areas to tolerate stimulation well. This is also related to their work.
Movements: Those who are quick in their movements tend tolerate stimulation less, and those with slower in movement tolerate stimulation well.
Alertness: Those whose eyes move rapidly and hear everything tend to tolerate stimulation less.
Pulse quality: Those with excess, wiry, tight, or sunken pulses tolerate stimulation more. Those with deficient, soft, faint, or floating pulses tolerate stimulation less.
Abdomen: Those with deficient, soft, mushy, and thin-skinned bellies tolerate stimulation less. Those with excess bellies that have a lot of resilience tolerate stimulation well.
Skin texture: Those with skin that is thin, soft, smooth, fine, damp, or without resilience can’t take much stimulation. Those who often feel pain when the needle is started, or sweat and get moist skin with needle sensation can’t take much stimulation. Those with “fair and delicate skin” are especially sensitive. They tend to have adverse reactions to acupuncture. Those with skin that is thick, rough, bumpy, or dry tolerate stimulation well. The skin is the most important factor for judging tolerance.
Pain threshold: Those who have low pain thresholds can’t tolerate much stimulation. This is a congenital tendency.
Reaction: Those who over-react to stimulation don’t tolerate it well, and those who are indifferent tolerate it well.
Depth: This is the depth of insertion. In general superficial insertion is mild stimulation and deep insertion is strong stimulation. The classics teach that needles should be inserted deeply and retained for fat people, manual laborers, chronic diseases, and in the winter. Likewise, needles should be inserted shallowly and removed right away for thin people, mental workers, acute diseases, royalty, and in the summer.
Size of Needle: This is about the thickness of the needle. Thin needles provide mild stimulation and thick needles give strong stimulation.
Technique: The needle technique can make the stimulation weak or strong. This factor, however, varies by the practitioner. It might depend on the degree of the finger manipulation of the practitioner.
In my case, even though I use very thin needles, I can give pretty strong stimulation. It is very important to always have a sense of how much stimulation your needling amounts to.
Response: This is about the body’s response after the treatment. How does the patient feel right after the treatment, or that evening, or the next day? The amount of stimulation is appropriate if they feel refreshed, their body feels lighter, or the pain has decreased. If there is fatigue or an increase in pain, the amount of stimulation has been excessive.
State of Mind: The amount of stimulation is appropriate if the patient becomes more light hearted after a treatment. It is inappropriate when the patient’s mood becomes worse.
Conclusion
The following can be said, putting all these conditions together:
Strong stimulation is indicated - The patient is fat, muscular, does physical work, or is athletic, and movements are rough. During the winter. Pulse qualities that are excess, wiry, tight, etc. Abdomens that are tight or have resilience. Skin that is thick, rough, or dry. Acute diseases.
Weak stimulation is indicated - The patient is thin, has swelling. Skin that is soft, damp, or lacking in resilience. Tendency to sweat easily. The patient does mental work and movements are quick. Pulse qualities that are deficient, soft, or faint. Abdomens that are soft and mushy with thin skin. The pulsation of the abdominal aorta is palpated readily.
People who over-react to slight pain.
There are exceptions
I have classified tolerance to stimulation above, but this doesn’t mean it applies in every case. These guidelines are decided by human beings, and sometimes they don’t work when faced with individual and unique patients.
For New Patients
When I see a patient for the first time I am compelled to make a judgment about how much stimulation is appropriate. The most important consideration is that the stimulation not be excessive. It is said that “too much of a good thing is good for nothing,” but in the case of acupuncture going overboard is a big mistake. We must avoid overdoing it. 80% of maximum is sufficient. The first thing is to discriminate patients who can’t tolerate much stimulation. Their movements are quick, they are not fat, their abdomen is soft, or at least not hard. Their pulse is not strong, it’s soft, and also floating, rootless, or hard to feel. Their skin is thin, soft, smooth, and becomes wet with a little stress. They sweat easily. Grasping their forearm, it feels soft. They might have a depressed expression. As a rule of thumb, I treat patients with these features using super-superficial insertion. Inserting needles can lead to problems. It is good to limit the number of points used as well. The number of points can be increased as they become used to acupuncture. Also some needles can be inserted.
The ones that fool you are the patients who have a good physique. We acupuncturists always want to insert the needle. We insert the needle believing that they can withstand stimulation because they are well built, but this can sometimes cause problems. Sometimes they have a solid body, but their pulse is weak. Or their pulse is strong but their abdomen is soft and weak. Or they may talk brave, but they begin to sweat as the acupuncture is started. In all cases like this, it is better to use mild stimulation. It is important not to be fooled and be careful even if there is only one red flag.
My Current Practice
Before I started using super-superficial insertion, I used superficial insertion and sometimes inserted needles deeply. I also often made mistakes about the amount of stimulation. In most of these cases, patients complained that they felt tired afterward. This sense of fatigue goes away in a day or two. But it is a mistake in treatment. I don’t make mistakes like this anymore after I started using super-superficial insertion, but recently I had two or three cases that reported feeling tired the next day, or having more pain. When I paid closer attention I found that I had inserted the needle a little bit without knowing it. After I paid more attention to my super-superficial insertion technique, these patients had no more complaints. It really takes a very small amount of stimulation in most cases. I am really concerned that the treatments of the average acupuncturist amounts to excessive stimulation. Unless we get it just right, patients don’t appreciate it, they don’t resonate. Acupuncture and moxibustion could be utilized by many more people. With the situation in Japan today, I believe at least half the population could benefit from acupuncture. This would increase the quality of life. If acupuncturists really understood this, there would be no more complaints about the reduction of patients.
When Needles are Inserted
There are many ways to do acupuncture, and it doesn’t make sense to use super-superficial insertion only. I myself routinely insert needles in several points, except in cases that require extremely mild stimulation. Most places that I insert have strong muscle tension. You can insert a needle to a certain depth and manipulate it if you feel that a certain point on a patient is a key point for local treatment. But you may want to reduce the amount of stimulation on other points accordingly.
Healing Crisis
Now, to conclude, let’s think about the question posed by Tom Ingegno. The first is about a healing crisis. “Many schools in America teach that it is desireable that symptoms get temporarily worse. This is called a “healing crisis,” or “healing principle,” and patients are told that “Things will get worse before they get better.”
In Japan also, the term “Menken,” or “Mengen phenomenon” is used to explain such aggravation of symptoms. The symptoms are supposed to improve after getting worse, but is this really a good thing? I wonder if such explanations are not being used as an excuse for symptoms that become worse. I believe that symptoms should gradually resolve. Even if there is a plateau in the improvement, it is the best both for the practitioner and patient when healing happens without aggravation.
Isn’t an aggravation of symptoms a mistake in treatment? It does the patient no good to be told as a cover-up for a mistake that it is a “principle.” It is best when there is no “Mengen phenomenon.” In order to avoid it, we must strive to make the minimum stimulation have a maximum effect. It is my belief that contact needling, super-superficial insertion, and superficial insertion are the best means to achieve this aim.
Let’s go back here and examine what the “Mengen phenomenon,” really is about. According to the Kampo Yogo Dai Jiten (Kampo Terminology Dictionary) Mengen is: “Various unexpected symptoms that appear temporarily after taking an herbal formula. These include nausea, dizziness, and restless in the chest.”
The text Nyumon Kampo Igaku (Beginners Herbal Medicine) published by the Japan Oriental Medicine Association gives the origin of the term Mengen. In the Shouming chapter of the Chinese classic Shang Shu, it says “Unless the medicine causes Mengen (Mingxuan), the disease will not heal.” Yoshimasu Todo (the leader of the Koho Kampo school) in his text drew from the above text in his Ancient Writings and Kosho Igen (Medical Sayings) stated “The (classic) text says unless the medicine causes Mengen, the disease will not heal,” and “When the medicine is effective, there is always Mengen and patients suffer and feels they are almost going to die.” So his commentary is that a disease cannot be cured if one fears the Mengen reaction of medicines.
Another Viewpoint
Otsuka Keisetsu (one of the founders of Japan Oriental Medicine Association) said, “Mengen is a reaction that occurs for the curing of a disease. But saying there is no reason to fear and taking medicine and becoming deathly ill is fearsome indeed…
We repudiate extreme views that diseases cannot be cured without the occurrence of Mengen.”
So the Japanese Oriental medical community is generally critical of the view of Yoshimasu Todo on this matter. What we know about this is that Todo drew the term Mengen from the Chinese classic Shang Shu, which is not a medical text and used it to justify his aggressive approach to therapy. Herbalists after him used this term to explain the strong reactions that occurred. I don’t know the actual details of their therapy because I have never prescribed herbs, but like the view of the Japan Oriental Medicine Association, it is generally not recommended. I wonder about those who take this idea and use it to explain reactions from acupuncture and moxibustion.
95% Treatment
The second issue in Mr. Ingegno’s question was, “Even when the patient is 75 or 95% better, I am tempted to do a little more treatment.” Ideally we would want to give treatment until we are sure the symptoms are all gone and they don’t return even without treatment. This is also the way I feel. But the circumstances of patients vary. When we consider their finances, time, and their effort involved in transportation, we have to think about what’s best for the patient. In cases where a back strain is 90% better and the rest will resolve naturally (as often happens with young people), we can explain this to them and discontinue treatment. What about cases of facial neuralgia where the symptoms are 90% better? The results of treatment are good for the first few months after the onset, but after that the outcome is extremely poor. I would explain this to the patient and have them continue treatments. In cases of chronic diseases, especially those of elderly patients, it is rare for there to get 100% back to the way they were. You can explain this to them and have them continue treatment with their consent. In my clinic, many patient like this come once a week. They keep coming for many years. Their symptoms improve gradually, if you view their condition over several years. In difficult cases, the symptoms don’t get any worse. This is also important. Many of those who no longer have any symptoms, or have 90% improvement, come for treatment once a month. This is a mutually satisfactory arrangement.
The main thing is to decide based on individual needs. But I also sense that Mr. Ingegno’s idea may be that, since there is 10% left that doesn’t resolve, he could use strong stimulation to bring about a 100% cure. Even if it becomes temporarily worse, it could change for the better. This is a “make it or break it” gamble. And if this is the case, I do not recommend it. You are likely to lose a patient who could have become a long-term patient. Also you could foster the idea in patients that acupuncture and moxibustion is effective medicine but it has a dangerous edge. There is no benefit to this idea no matter how we look at it. One of the saying in Japan is, “When you are in a hurry, take the long way around.” It is very aptly stated. Walking my path in life for 75 years, I am convinced that this is how life works. (Patience is virtue) in large things and small. It applies to all things in life. To treatments also.
Apology
I am sorry to have ignored the word limits set by the editor Mr. Takahashi, but giving the question serious consideration, these words poured out of me. Please accepr my sincere apologies. I pray that these words will be of some use.
Translated by Stephen Brown
Respondent No.3: Tanioka Masanori
How Much is Too Much?
How much acupuncture stimulation should I give to an adult patient? This is a difficult question to answer and one that both new and senior practitioners may have.
There are a few standard indicators for the proper dosage of stimulation.
1. Pulse Diagnosis
A good-quality pulse is neither floating nor deep, but rather neutral. It should be calm and steady. The condition of the pulse changes easily when one receives a treatment; therefore, it can also easily revert to its condition prior to treatment.
2. The Body Surface
The skin is the most important tissue to examine. It is only one-to-three millimeters thick. If you palpate it with too much force, you actually feel the muscles instead. You should examine the skin by stroking.
If the skin is tenser than normal after a treatment, this indicates the dosage was insufficient. If the skin becomes flabby, however, the dosage was excessive. When the skin becomes flabby, the patient tends to experience an abrupt cold sweat, and may feel sick or nauseous.
3.Abdominal Percussion
When percussion makes a uniform and comforting sound on any part of the abdomen after a treatment, it indicates that the treatment worked very well for the patient. If the sound becomes tympanic, however, the dosage was excessive.
One should not apply strong percussion to a patient with a gastric or duodenal ulcer, acute gastritis, or a patient experiencing a gallstone attack.
4.Other Indicators
Indications the patient has received sufficient treatment are when their breathing becomes deep and quiet and their expression is brighter.
With a young patient or one suffering an acute condition, you can aim to obtain maximum relief from his symptoms. However, if the patient’s bodily surface feels thin on palpation, you should apply a less stimulation, since his condition responds sensitively it. Otherwise, he will have a reaction.
With a senior patient or one suffering a chronic condition, it is best to go easy on the dose. Patients with a thick bodily surface, may respond more gradually to the treatment and it would be wise to exercise some caution.
When the patient has a cold sweat and his skin becomes flabby due to excessive stimulation, it is good to apply a small dose of a different type of stimulation. If you over stimulate the body with acupuncture, you can apply a little bit of moxibustion. If you give an overdose of moxibustion, apply acupuncture lightly. The skin will no longer be flabby and will gain normal elasticity.
I do not agree with the concept of having a “healing crisis.” This is obviously a reaction to over stimulation. With a smaller dose of stimulation, both the patient and practitioner can keep their smiles.
Translated by Takahashi Hideo
(NAJOM Volume 14 Number40 p5-p8)
When is it Too Much of a Good Thing?
by Tom Ingegno
After about six years of being licensed, my results have improved since first starting out and I am feeling comfortable with my treatment style. I feel that this is a critical stage, as I am starting to develop personal preferences, but at the same time I don’t wish to get caught up in my own ego or limited experience.
At this level, I have found that at the end of a treatment, many of my patients are reporting a good result, but their condition is not always completely alleviated. I do explain to them that acupuncture is a process and not a magic bullet, but I find it hard to fight the urge to end the treatment at this stage. In other words, even when I get a good result – say the patient reports 75-95-percent improvement – I am tempted to try to get a little more for the patient. Sometimes I do restrain myself, knowing that if I push it I run the risk of over treating and causing the patient to feel worse temporarily. In many American schools it is taught that this is a good thing: that the body is having a “healing crisis.” It is sometimes called the “law of cure,” and the adage, “it will get worse before it gets better” is often offered to patients.
While I have had the experience of patients calling me the day after a treatment in severe pain and the day after that calling to tell me they feel 100 percent better, it is a rough situation for both the patient and myself. I understand that each patient is an individual and must be considered on a case-by-case basis, but can anyone offer general guidelines for when to go for maximum relief and when to hold back?
Tom Ingegno M.S., L.Ac.
Baltimore, MD
This question was submitted to senior acupuncturists. The followings are three respondents in alphabetical order:
Respondent No. 1: Ikeda masakazu
Needle Stimulation
As practitioners, we are always concerned about how much needle stimulation to apply in our treatments. I will share my clinical experience on that subject here.
With Chinese needles, it is suitable to use about five needles to stimulate points mostly on the arms and legs. With Japanese needles, especially if you use the contact-needle technique as I do, four needles on each arm and leg and about 14 needles on the patient’s back and abdomen are adequate. It is important, however, to observe the flow of Qi and Blood in the meridians whenever you insert needles into the body. One method for checking changes in the flow of Qi and Blood in the meridians is pulse taking. Another method is inspection. You can ascertain the change in Qi flow by observing the patient’s facial complexion during the treatment. You can also palpate the surface of the skin to ascertain whether it is cold or feverish, moist or dry. You may detect a change in Qi flow simply by receiving Qi emanated by the patient or by observing improvements in the patient’s symptoms after an appropriate amount of stimulation.
1. Judging by the Pulse
If you have selected the correct acupuncture points on the arms and legs and your needle manipulation (reinforcing and reducing) is appropriate, the patient’s pulse will moderate (the so-called root treatment). This indicates the Stomach Qi is brimming over with vitality. When you see this change, you can conclude that an adequate moment of stimulation has been given and no further stimulation is required. If, after completing the whole treatment, the patient’s pulse has become tense or fast, this indicates that you may have over-stimulated your patient. In this case, you need to massage the Triple Warmer meridian to tonify Yang Qi and correct your mistake.
2. Local Stimulation
When the pulse moderates after the root treatment, but the patient still complains of a local pain, you should apply needles in the knotted region. The greater the patient’s pain, the weaker, softer and more superficial the stimulation should be. The contact needle technique is very suitable for this situation. In treating a knotted area, it is sufficient to insert the needle just to the point of touching the knot. If you pierce the knot, the symptom may worsen. When local stimulation is adequate, the symptom somehow resolves. However, if the patient experiences a recurrence of the symptom, your root treatment is incorrect. Because you did not know your root treatment (diagnosis) was incorrect, you applied too much local stimulation and ended up worsening the symptoms.
3. To Avoid Over Stimulation
In short, the practitioner should be deeply in tune with the patient. We should try to receive as much information as possible from the patient with our whole body, listening to his/her unconscious voice (as when we are in a meditative state) and applying needles to the area where the patient most wants it. This is what the ultimate acupuncture treatment is. When you have mastered this, you do not need to worry about over stimulating the patient. It is misguided to use acupuncture points like western drugs. If you would like see a true needle technique, please join my seminar [held annually in Sacramento or San Francisco.
Translated by Onishi Mayu
Respondent No. 2: Shudo Denmei
Thoughts on Amount of Stimulation in Acupuncture
Introduction
I am responding to a question posed by a NAJOM member, Tom Ingegno, “When does the amount of stimulation become excessive?” It is a very difficult question to answer. But the appropriate amount of stimulation in acupuncture is something I myself have always been concerned about. I decided to write about this because it might be a good opportunity to draw up some of my conclusion on this matter. The things written in the classics and the things taught by our predecessors don’t always work out in practice. I have tried out many things in my practice, and this article represents what I have learned and where I stand on the matter.
Conditions for mild and strong stimulation
These are general categories, and are not absolute. Please understand that these are general guidelines.
Gender: Women tend to tolerate stimulation, and men tend to be less tolerant.
Experience: Those who have experience with acupuncture are comparatively tolerant. When new to acupuncture, the initial anxiety and tension can cause fatigue.
Preference: Those who like acupuncture tend to be happy even if the treatment causes a little fatigue. Those who dislike acupuncture, no matter how many treatments they have, tend to tolerate stimulation less.
Season: People tend to tolerate stimulation less in the spring and summer, and better in the fall and winter.
Skin color: Those with darker skin tend to tolerate stimulation more, and those with lighter skin tend to tolerate it less.
Lips: Those with thick lips tend to tolerate stimulation more, and those with thin lips tend to tolerate it less.
Physique: When it comes to fat and thin, the fatter person tolerates stimulation more, and the thinner person less. In the case of fat patients, there are those that have a lot of muscle mass, those that have a lot of fat, and those with water retention. Those with muscle mass tolerate stimulation well. Those with lots of fat are not intolerant, but there is a tendency to over treat them because it’s so easy to insert needles. Even if thin, muscular people are tolerate stimulation well. Patients lacking muscle tone can’t take a lot of stimulation.
Work: Those who do mental workers tolerate stimulation less and those who do physical work can take stimulation. Athletes and those who exercise tolerate stimulation well.
Urban/Rural: There is a tendency for those in urban areas to tolerate stimulation less and those in rural areas to tolerate stimulation well. This is also related to their work.
Movements: Those who are quick in their movements tend tolerate stimulation less, and those with slower in movement tolerate stimulation well.
Alertness: Those whose eyes move rapidly and hear everything tend to tolerate stimulation less.
Pulse quality: Those with excess, wiry, tight, or sunken pulses tolerate stimulation more. Those with deficient, soft, faint, or floating pulses tolerate stimulation less.
Abdomen: Those with deficient, soft, mushy, and thin-skinned bellies tolerate stimulation less. Those with excess bellies that have a lot of resilience tolerate stimulation well.
Skin texture: Those with skin that is thin, soft, smooth, fine, damp, or without resilience can’t take much stimulation. Those who often feel pain when the needle is started, or sweat and get moist skin with needle sensation can’t take much stimulation. Those with “fair and delicate skin” are especially sensitive. They tend to have adverse reactions to acupuncture. Those with skin that is thick, rough, bumpy, or dry tolerate stimulation well. The skin is the most important factor for judging tolerance.
Pain threshold: Those who have low pain thresholds can’t tolerate much stimulation. This is a congenital tendency.
Reaction: Those who over-react to stimulation don’t tolerate it well, and those who are indifferent tolerate it well.
Depth: This is the depth of insertion. In general superficial insertion is mild stimulation and deep insertion is strong stimulation. The classics teach that needles should be inserted deeply and retained for fat people, manual laborers, chronic diseases, and in the winter. Likewise, needles should be inserted shallowly and removed right away for thin people, mental workers, acute diseases, royalty, and in the summer.
Size of Needle: This is about the thickness of the needle. Thin needles provide mild stimulation and thick needles give strong stimulation.
Technique: The needle technique can make the stimulation weak or strong. This factor, however, varies by the practitioner. It might depend on the degree of the finger manipulation of the practitioner.
In my case, even though I use very thin needles, I can give pretty strong stimulation. It is very important to always have a sense of how much stimulation your needling amounts to.
Response: This is about the body’s response after the treatment. How does the patient feel right after the treatment, or that evening, or the next day? The amount of stimulation is appropriate if they feel refreshed, their body feels lighter, or the pain has decreased. If there is fatigue or an increase in pain, the amount of stimulation has been excessive.
State of Mind: The amount of stimulation is appropriate if the patient becomes more light hearted after a treatment. It is inappropriate when the patient’s mood becomes worse.
Conclusion
The following can be said, putting all these conditions together:
Strong stimulation is indicated - The patient is fat, muscular, does physical work, or is athletic, and movements are rough. During the winter. Pulse qualities that are excess, wiry, tight, etc. Abdomens that are tight or have resilience. Skin that is thick, rough, or dry. Acute diseases.
Weak stimulation is indicated - The patient is thin, has swelling. Skin that is soft, damp, or lacking in resilience. Tendency to sweat easily. The patient does mental work and movements are quick. Pulse qualities that are deficient, soft, or faint. Abdomens that are soft and mushy with thin skin. The pulsation of the abdominal aorta is palpated readily.
People who over-react to slight pain.
There are exceptions
I have classified tolerance to stimulation above, but this doesn’t mean it applies in every case. These guidelines are decided by human beings, and sometimes they don’t work when faced with individual and unique patients.
For New Patients
When I see a patient for the first time I am compelled to make a judgment about how much stimulation is appropriate. The most important consideration is that the stimulation not be excessive. It is said that “too much of a good thing is good for nothing,” but in the case of acupuncture going overboard is a big mistake. We must avoid overdoing it. 80% of maximum is sufficient. The first thing is to discriminate patients who can’t tolerate much stimulation. Their movements are quick, they are not fat, their abdomen is soft, or at least not hard. Their pulse is not strong, it’s soft, and also floating, rootless, or hard to feel. Their skin is thin, soft, smooth, and becomes wet with a little stress. They sweat easily. Grasping their forearm, it feels soft. They might have a depressed expression. As a rule of thumb, I treat patients with these features using super-superficial insertion. Inserting needles can lead to problems. It is good to limit the number of points used as well. The number of points can be increased as they become used to acupuncture. Also some needles can be inserted.
The ones that fool you are the patients who have a good physique. We acupuncturists always want to insert the needle. We insert the needle believing that they can withstand stimulation because they are well built, but this can sometimes cause problems. Sometimes they have a solid body, but their pulse is weak. Or their pulse is strong but their abdomen is soft and weak. Or they may talk brave, but they begin to sweat as the acupuncture is started. In all cases like this, it is better to use mild stimulation. It is important not to be fooled and be careful even if there is only one red flag.
My Current Practice
Before I started using super-superficial insertion, I used superficial insertion and sometimes inserted needles deeply. I also often made mistakes about the amount of stimulation. In most of these cases, patients complained that they felt tired afterward. This sense of fatigue goes away in a day or two. But it is a mistake in treatment. I don’t make mistakes like this anymore after I started using super-superficial insertion, but recently I had two or three cases that reported feeling tired the next day, or having more pain. When I paid closer attention I found that I had inserted the needle a little bit without knowing it. After I paid more attention to my super-superficial insertion technique, these patients had no more complaints. It really takes a very small amount of stimulation in most cases. I am really concerned that the treatments of the average acupuncturist amounts to excessive stimulation. Unless we get it just right, patients don’t appreciate it, they don’t resonate. Acupuncture and moxibustion could be utilized by many more people. With the situation in Japan today, I believe at least half the population could benefit from acupuncture. This would increase the quality of life. If acupuncturists really understood this, there would be no more complaints about the reduction of patients.
When Needles are Inserted
There are many ways to do acupuncture, and it doesn’t make sense to use super-superficial insertion only. I myself routinely insert needles in several points, except in cases that require extremely mild stimulation. Most places that I insert have strong muscle tension. You can insert a needle to a certain depth and manipulate it if you feel that a certain point on a patient is a key point for local treatment. But you may want to reduce the amount of stimulation on other points accordingly.
Healing Crisis
Now, to conclude, let’s think about the question posed by Tom Ingegno. The first is about a healing crisis. “Many schools in America teach that it is desireable that symptoms get temporarily worse. This is called a “healing crisis,” or “healing principle,” and patients are told that “Things will get worse before they get better.”
In Japan also, the term “Menken,” or “Mengen phenomenon” is used to explain such aggravation of symptoms. The symptoms are supposed to improve after getting worse, but is this really a good thing? I wonder if such explanations are not being used as an excuse for symptoms that become worse. I believe that symptoms should gradually resolve. Even if there is a plateau in the improvement, it is the best both for the practitioner and patient when healing happens without aggravation.
Isn’t an aggravation of symptoms a mistake in treatment? It does the patient no good to be told as a cover-up for a mistake that it is a “principle.” It is best when there is no “Mengen phenomenon.” In order to avoid it, we must strive to make the minimum stimulation have a maximum effect. It is my belief that contact needling, super-superficial insertion, and superficial insertion are the best means to achieve this aim.
Let’s go back here and examine what the “Mengen phenomenon,” really is about. According to the Kampo Yogo Dai Jiten (Kampo Terminology Dictionary) Mengen is: “Various unexpected symptoms that appear temporarily after taking an herbal formula. These include nausea, dizziness, and restless in the chest.”
The text Nyumon Kampo Igaku (Beginners Herbal Medicine) published by the Japan Oriental Medicine Association gives the origin of the term Mengen. In the Shouming chapter of the Chinese classic Shang Shu, it says “Unless the medicine causes Mengen (Mingxuan), the disease will not heal.” Yoshimasu Todo (the leader of the Koho Kampo school) in his text drew from the above text in his Ancient Writings and Kosho Igen (Medical Sayings) stated “The (classic) text says unless the medicine causes Mengen, the disease will not heal,” and “When the medicine is effective, there is always Mengen and patients suffer and feels they are almost going to die.” So his commentary is that a disease cannot be cured if one fears the Mengen reaction of medicines.
Another Viewpoint
Otsuka Keisetsu (one of the founders of Japan Oriental Medicine Association) said, “Mengen is a reaction that occurs for the curing of a disease. But saying there is no reason to fear and taking medicine and becoming deathly ill is fearsome indeed…
We repudiate extreme views that diseases cannot be cured without the occurrence of Mengen.”
So the Japanese Oriental medical community is generally critical of the view of Yoshimasu Todo on this matter. What we know about this is that Todo drew the term Mengen from the Chinese classic Shang Shu, which is not a medical text and used it to justify his aggressive approach to therapy. Herbalists after him used this term to explain the strong reactions that occurred. I don’t know the actual details of their therapy because I have never prescribed herbs, but like the view of the Japan Oriental Medicine Association, it is generally not recommended. I wonder about those who take this idea and use it to explain reactions from acupuncture and moxibustion.
95% Treatment
The second issue in Mr. Ingegno’s question was, “Even when the patient is 75 or 95% better, I am tempted to do a little more treatment.” Ideally we would want to give treatment until we are sure the symptoms are all gone and they don’t return even without treatment. This is also the way I feel. But the circumstances of patients vary. When we consider their finances, time, and their effort involved in transportation, we have to think about what’s best for the patient. In cases where a back strain is 90% better and the rest will resolve naturally (as often happens with young people), we can explain this to them and discontinue treatment. What about cases of facial neuralgia where the symptoms are 90% better? The results of treatment are good for the first few months after the onset, but after that the outcome is extremely poor. I would explain this to the patient and have them continue treatments. In cases of chronic diseases, especially those of elderly patients, it is rare for there to get 100% back to the way they were. You can explain this to them and have them continue treatment with their consent. In my clinic, many patient like this come once a week. They keep coming for many years. Their symptoms improve gradually, if you view their condition over several years. In difficult cases, the symptoms don’t get any worse. This is also important. Many of those who no longer have any symptoms, or have 90% improvement, come for treatment once a month. This is a mutually satisfactory arrangement.
The main thing is to decide based on individual needs. But I also sense that Mr. Ingegno’s idea may be that, since there is 10% left that doesn’t resolve, he could use strong stimulation to bring about a 100% cure. Even if it becomes temporarily worse, it could change for the better. This is a “make it or break it” gamble. And if this is the case, I do not recommend it. You are likely to lose a patient who could have become a long-term patient. Also you could foster the idea in patients that acupuncture and moxibustion is effective medicine but it has a dangerous edge. There is no benefit to this idea no matter how we look at it. One of the saying in Japan is, “When you are in a hurry, take the long way around.” It is very aptly stated. Walking my path in life for 75 years, I am convinced that this is how life works. (Patience is virtue) in large things and small. It applies to all things in life. To treatments also.
Apology
I am sorry to have ignored the word limits set by the editor Mr. Takahashi, but giving the question serious consideration, these words poured out of me. Please accepr my sincere apologies. I pray that these words will be of some use.
Translated by Stephen Brown
Respondent No.3: Tanioka Masanori
How Much is Too Much?
How much acupuncture stimulation should I give to an adult patient? This is a difficult question to answer and one that both new and senior practitioners may have.
There are a few standard indicators for the proper dosage of stimulation.
1. Pulse Diagnosis
A good-quality pulse is neither floating nor deep, but rather neutral. It should be calm and steady. The condition of the pulse changes easily when one receives a treatment; therefore, it can also easily revert to its condition prior to treatment.
2. The Body Surface
The skin is the most important tissue to examine. It is only one-to-three millimeters thick. If you palpate it with too much force, you actually feel the muscles instead. You should examine the skin by stroking.
If the skin is tenser than normal after a treatment, this indicates the dosage was insufficient. If the skin becomes flabby, however, the dosage was excessive. When the skin becomes flabby, the patient tends to experience an abrupt cold sweat, and may feel sick or nauseous.
3.Abdominal Percussion
When percussion makes a uniform and comforting sound on any part of the abdomen after a treatment, it indicates that the treatment worked very well for the patient. If the sound becomes tympanic, however, the dosage was excessive.
One should not apply strong percussion to a patient with a gastric or duodenal ulcer, acute gastritis, or a patient experiencing a gallstone attack.
4.Other Indicators
Indications the patient has received sufficient treatment are when their breathing becomes deep and quiet and their expression is brighter.
With a young patient or one suffering an acute condition, you can aim to obtain maximum relief from his symptoms. However, if the patient’s bodily surface feels thin on palpation, you should apply a less stimulation, since his condition responds sensitively it. Otherwise, he will have a reaction.
With a senior patient or one suffering a chronic condition, it is best to go easy on the dose. Patients with a thick bodily surface, may respond more gradually to the treatment and it would be wise to exercise some caution.
When the patient has a cold sweat and his skin becomes flabby due to excessive stimulation, it is good to apply a small dose of a different type of stimulation. If you over stimulate the body with acupuncture, you can apply a little bit of moxibustion. If you give an overdose of moxibustion, apply acupuncture lightly. The skin will no longer be flabby and will gain normal elasticity.
I do not agree with the concept of having a “healing crisis.” This is obviously a reaction to over stimulation. With a smaller dose of stimulation, both the patient and practitioner can keep their smiles.
Translated by Takahashi Hideo
(NAJOM Volume 14 Number40 p5-p8)