Hindawi Publishing Corporation Evidence-Based Complementary and Alternative Medicine Volume 2014, Article ID 914878, 11 pages http://dx.doi.org/10.1155/2014/914878 Research Article De Qi , a Threshold of the Stimulus Intensity, Elicits the Specific Response of Acupoints and Intrinsic Change of Human Brain to Acupuncture Dai-ShiTian,1JinXiong,2QingPan,2FangLiu,2LuWang,2Sha-BeiXu,1 Guang-YingHuang,2andWeiWang1 1DepartmentofNeurology,TongjiHospital,TongjiMedicalCollege,HuazhongUniversityofScienceandTechnology, Wuhan430030,China 2InstituteofIntegratedTraditionalandWesternMedicine,TongjiHospital,TongjiMedicalCollege, HuazhongUniversityofScienceandTechnology,Wuhan430030,China CorrespondenceshouldbeaddressedtoGuang-YingHuang;[email protected];[email protected] Received12January2014;Revised23April2014;Accepted8May2014;Published6July2014 AcademicEditor:Cun-ZhiLiu Copyright©2014Dai-ShiTianetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense, whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited. Objectives.Deqiisthesubjectiveconstellationofsensationsperceivedbytheacupuncturistsandpatientsasdescribedinseveral literatures, but the absence of quantitative evaluation methods in de qi restricts the use of acupuncture treatment widely in the world. In the present study, we tried to investigate the intrinsic property of de qi is and how evaluate it quantitatively. Methods. 30 healthy adult volunteers were determined to investigate intrinsic changes in the human body after acupuncture with de qi. Results. Acupuncture treatment with de qi apparently increased acupoint blood flow, tissue displacement, and the amplitudeofmyoelectricityafterdeqionacupoints.Furthermore,acupuncturetreatmentinducedfMRIsignalincrease/decrease indifferentbrainregionsalthoughnosignificantchangeinelectroencephalography.Interpretation.Theintrinsicchangeofthe subjectsrepresentingthespecificresponseofacupointsandhumanbraintoacupunctureindicatedthatdeqimightbeevaluated quantitativelybythoseaboveaspects,whichfacilitatedtheconfirmationinvalidityandpropagationofthistreatmentmodality widelyintheworld. 1.Introduction flowof“vitalenergy,”istheresultanteffectofcharacteristic needle manipulation, sensations perceived by the patients, Now, acupuncture is becoming increasingly popular in the which manifests as numbness, heaviness, distention, and world and is routinely recommended for the treatment of soreness, with spreading sensation; and it is also perceived pain and for relief of many other symptoms such as nau- by the acupuncturists, which manifests as heavy and tight sea and vomiting associated with chemotherapy, substance sensation coming from beneath the needle [3]. Although dependency,andchronicdisordersdifficulttomanagewith the underlying therapeutic mechanism remains unclear, it conventionaltreatment[1].Inwomen’shealth,acupuncture is generally accepted that “de qi” is the sign of optimal has been found to be beneficial for patients with premen- effect of needle manipulation, and more importantly, de qi strual syndrome, dysmenorrhea, and several pregnancy- is considered as the sine qua non of acupuncture for the related conditions [2]. Whatever the exact pathway may achievement of a clinical therapeutic effect according to have been, by the time traditional Chinese medicine was traditionalChinesemedicine(TCM)[4–8].Thereisalong- codifiedatsometimeinthefirstcenturyBC(inacanonical held belief in the traditional theory and clinical practice of text known as the Inner Classic of the Yellow Emperor), acupuncturethat the intensityof thestimulusmust reach a acupuncture was already a signature therapy of Chinese thresholdtoelicitdeqi,whichplaysapivotalroleinachieving medicine. De qi, achieving qi, which is interpreted as the thebesttherapeuticeffects.Recently,ourstudywaspublished 2 Evidence-BasedComplementaryandAlternativeMedicine Zusanli (ST.36) Recording electrode Reference electrode Reference electrode Recording electrode Hegu (LI.4) Ground wire Ground wire Figure1:Acupointsschematicdiagram.Acupuncturewasperformedusingsteriledisposablestainlesssteelneedlesattwoacupuncture pointsontherightextremityinseparateruns:ST.36(traditionallyknownastheZusanliacupoint)onthelegandLI.4(traditionally,the Heguacupoint)onthehand.TheacupuncturepointST.36islocatedinthetibialisanteriormuscle,4fingerbreadthsbelowthekneecapand1 fingerbreadthlateralfromtheanteriorcrestofthetibia.TheacupointLI.4islocatedinthedorsalsurfaceofthewebbetweenthethumband theindexfinger.Recordingelectrodeandreferenceelectrodeareplacedonthedistalendofacupointsintherightlimbs.Groundwireswere placedonthedorsalsurfacetoavoidelectricaldisturbance. in CMAJ and found evidence that acupuncture with de acupuncture, healthy adult volunteers (not patients) were qi improved facial muscle recovery, disability, and quality recruited. The participants provide verbal but not written of life among patients with Bell palsy. Stronger intensity informed consent to participate in this study. The subjects of de qi was associated with better therapeutic effects [9]. were screened and those who had major medical illnesses, However,theabsenceofquantitativeevaluationmethodsin history of head trauma, neuropsychiatric disorders, use of deqirestrictstheuseofacupuncturetreatmentwidelyinthe medications within one week, and contraindications for world. And the fundamental aspects behind its therapeutic exposuretohighmagneticfieldswereexcluded. benefits are very poorly understood, and progress in this regardhasbeenfurtherhinderedbyaconsistentdiscrepancy 2.2.ProceduresofAcupuncture. Thesubjectswereinstructed betweentraditionaltheoryandscientificexplanations.There to lie still and keep their eyes closed during the procedure. is no an ideal evaluation criteria and standards for the Acupuncturewasperformedusingsteriledisposablestainless optimal effect and intensity of stimulation of acupuncture steel needles at different acupoints. The two acupuncture till now, thus many acupuncturists only settle for inserting points on the right extremity in separate runs: ST.36 (tra- the needle into the acupoints but ignore the essentiality ditionally known as the Zusanli acupoint) on the leg and of achieving a certain intensity of stimulation and optimal LI.4 (traditionally, the Hegu acupoint) on the hand (seen effect of needle manipulation in the course of acupuncture in Figure1). The acupoint ST.36 is located in the tibialis treatment,leadingtosuboptimalornotherapeuticeffectof anterior muscle, 4 fingerbreadths below the kneecap and acupuncture.Therefore,anunderstandingofthetherapeutic 1 fingerbreadth lateral from the anterior crest of the tibia. mechanism of acupuncture and establishing methods and The acupoint LI.4 is located in the dorsal surface of the criteriaforquantitativeevaluationofdeqiandtheintensity web between the thumb and the index finger. These two and threshold of acupuncture could play an important role acupointswerechosenbecauseoftheireasyaccessibilityofde in the demonstration of validity and the wider use of this qisensationandweremostfrequentlyusedinacupuncture. treatmentmodalityintheworld. Although several reports indicated that there was a differ- In the present study, 30 healthy adult volunteers were enceinacupointsandnonacupointswhenacupuncturewas recruited to investigate intrinsic change in the body after administrated, in the present study we only focus on the de qiduringacupuncture,suchaschangeinlocalregionof quantitativeevaluationofdeqiandtherelationshipbetween acupointsincludingacupointbloodflow,tissuedisplacement, deqidegreeandtheclinicaltherapeuticeffects. electromyography, electroencephalography, and brain func- Disposablesterilestainlesssteelneedles(KINGLIMedi- tionalmagneticresonanceimaging(fMRI). calApplianceCo.,Ltd.,Wuxi,China)of0.22mmindiameter and 40mm in length were used. The needle was inserted 2.MaterialsandMethods verticallytoadepthof2-3cm.Thesensitivityofthesubject toneedlemanipulationwastestedandadjustedtotolerance 2.1.SubjectsandProcedures. Thestudywasperformedon30 prior to procedure, aiming to elicit de qi sensation without right-handed,20–47yearsold(29.0±7.8),acupuncturenaive noxious pain. In the event of a sharp painful sensation, the healthy adult volunteers, 12 male and 18 female. The study needle position should be readjusted and the pain would was approved by the Ethics Committee of Tongji Medical disappear within a few seconds. During the acupuncture College,HUST.Forthequantitativeevaluationofdeqiduring procedure,thesubjectswerequestionedaboutthesensations Evidence-BasedComplementaryandAlternativeMedicine 3 thattheyhadfeltandwhetherthedeqisensations(aching, Needle in Needle out pressure, soreness, heaviness, fullness, warmth, cooling, numbness,tingling,anddullpain),sharppainoranyother R1 S1 R2 S2 R3 S3 R4 S4 R5 S5 sensations, occurred. The stimulation paradigm is depicted in Figure2. The needle was kept in place for 2min priorto 0 30s 60s 90s 120s 150s180s 210s240s 270s300s ∘ needlemanipulationandthenwasrotatedapproximately180 ineachdirectionwithevenmotionattherateofonecycleper Figure2:Acupuncturemanipulationparadigm.Manualacupunc- second,whichisatechniqueusedinclinicalpractice.Thetwo turewasadministeredtoLI4andST36ontheright.Thesubject’s sensitivitytoneedlingwaspretestedandadjustedtotoleranceprior stimulationblocks,forexample,S1andS2,wereseparatedby toscanning.Afterremaininginplacefor30s(R1),theneedlewas anintervalof30sasabreakperiodwithneedleremainingin rotatedforwardandbackwardwithstimulationfor30sattherateof place. ∘ 60timesperminutewithanamplitudeofapproximately180 ineach direction(S1).Afterarestperiodof30s(R2),needlemanipulation 2.3. Tissue Displacement. In vivo ultrasonic imaging using wasrepeatedinthesamemanner(S2).Theneedlewaswithdrawn aSystemFiVe(GE-Vingmed)at7.5MHzwasperformedon aftercompletionof5cyclesofR-Sacupuncture. thehealthysubjectsatdifferentstagesofacupunctureneedle stimulationincludingbeforedeqiandduringdeqi.Displace- ments were estimated using the ultrasonic radio-frequency for evaluating cerebral functions. In the present study, (RF) data, with a 2mm window and a window overlap of the EEG system, manufactured by Biopac Systems, Inc., 60%. Seventy RF scans were acquired continuously during was used on EEGs during acupuncture stimulation. EEGs eachexperimentattherateof13.2framespersecond.Cine´- were collected from 12 channels, and frequency bands with loopdisplacementimagesweregeneratedofflineduringand 𝛼-waves (8–13Hz), 𝛽-waves (13–30Hz), 𝜃-waves (4–8Hz), betweenthedifferentstagesofacupuncturestimulation. and 𝛿-waves (0.5–4Hz) as standards were used. EEGs consist mainly of 𝛼-waves and 𝛽-waves. It is abnormal if 2.4. Laser Doppler Perfusion Imaging (LDPI). A PeriScan EEG exhibits slow waves in the waking stage. The region PIMIILDPI(madebyPerimedCompany,Sweden)wasused of the brain per electrode was marked as frontal, parietal, in this study with a scanning laser wavelength of 670nm temporal, and occipital. The experimental subjects’ EEGs and a maximum output power of 1mW. An NR scanning weremeasuredthroughtheelectrodesviathe10–20electrode patternwasused,ofminimumscanningaccuracy,withusual placementmethod.Electrodeswereattachedtobothearsas samplingpointsat35(width)×40(height)andanimagewith referenceelectrodes. apixelsizeof0.5×0.5mm2 [2].LDPI2.5imagingsoftware was used for recording, storage, analysis, and processing of 2.7. Functional Magnetic Resonance Imaging (fMRI). Brain theacupointbloodperfusionimage. imaging was conducted on a 1.5-T Siemens Sonata MRI system equipped for echo planar imaging (EPI) with a 2.5.Electromyography(EMG). Theelectromyographysystem standard head coil. Functional scans were collected with (VikingQuest,NICOLET,USA)wasusedtoperformnerve sagittalsectionsparalleltotheAC-PCplane,slicethickness stimulation and reflex recording, before and after de qi 3.0mmwith20%gap.Imagingencompassedtheentirebrain, inducedbyacupuncturetreatmentatHeguandZusanliacu- includingthecerebellumandbrainstem.Thefunctionaldata ∗ points.Theskinresistanceoverlyingacupointswasmadeas wereacquiredbyaT2 -weightedgradientechosequence(TE minimalaspossiblebyshavingtheareaandbrushingitwith 30ms,TR4s,matrix64×64,FOV200mm,flipangle90∘, alcohol.Afterskinpreparationwith70%alcohol,disposable in-planeresolution3.125×3.125mm).Asetof3DMPRAGE silver-silver chloride pregelled snap on electrodes (9mm (magnetization-prepared rapid acquisition gradient echo) 3 diameterrecordingsurface)wereplaced15mmproximaland images,voxelsizeof1mm ,128imagesperset,andasetofT1- distaltoacupuncturepoint,inparallelwiththemusclefibers, weightedhigh-resolutionstructuralimages(TE3.39ms,TR formaximumselectivityandsensitivity.Thestimulatorwas 2.73s,matrix192×256,FOV256mm,flipangle7∘,in-plane placed over the distal to the peroneal nerve and median resolution1×1mm,slicethickness1.33mm)wereacquired nerve. A reference ground electrode was placed over the priortofunctionalscans. medial epicondyle or phalange of index finger, respectively, as recommended by EMG protocol. The EMG machine 2.8. Statistical Analysis. SPSS 13.0 software for Windows workedinconjunctionwithaPicoTechnologyLimitedADC- (SPSSInc.,USA)wasusedforstatisticalanalysis.Continuous 100 dual channel oscilloscope, which connected the EMG variableswereexpressedasmean±S.D.Thegroupcompar- machinetoalaptopcomputer.PicoLogdataloggingsoftware isonwasperformedwithtwo-tailedt-testandSNKmethod wasusedtocollectandanalyzetheEMGdata.Theprogram (ANOVA).The𝑃valuesoflessthan0.05wereconsideredto was set at a sampling rate of 1000Hz over the 10 seconds bestatisticallysignificant. testingtime.Thevolunteerswereinstructedtokeepthearm restingonthecouchthroughout. 3.Results 2.6. Electroencephalography (EEG). EEGs constitute an Acupuncture increased tissue displacement and skin blood objective, continuous, noninvasive, and simple method flowonacupointsafterdeqi. 4 Evidence-BasedComplementaryandAlternativeMedicine (a) (b) Figure3:Tissuedisplacementonacupointsfollowingneedlestimulationbeforeandafterdeqi.InvivoultrasonicimagingusingaSystem FiVe(Vingmed)at7.5MHzwasperformedonthehealthysubjectsatdifferentstagesofacupunctureneedlestimulationincludingbeforedeqi andduringdeqi.Displacementswereestimatedusingtheultrasonicradio-frequency(RF)data.SeventyRFscanswereacquiredcontinuously duringeachexperimentattherateof13.2framespersecond. It was found that soft-tissue displacement could be AcupuncturetreatmentinducedfMRIsignalincrease/de- estimatedusingonlythestimuluscausedbythemovementof creaseindifferentbrainregionsonZusanliacupointbefore theneedle.Inthepresentstudy,theamountoftissuedisplace- andafterdeqi. ments,inducedbyacupuncturetreatment,wasmeasuredby The results for fMRI (Figure7; Tables 1 and 2) dur- invivoultrasonicimagingbeforedeqiandduringdeqistage. ingacupunctureatST.36showedanactivation/deactivation AsshowninFigure3,thedistanceoftissuedisplacementsin pattern in the different brain regions. Representative color- Zusanliwasfoundtoincreaseinamplitudebyupto0.167± coded statistical maps derived from data obtained during 0.047mm during de qi stage (Figure3(b)), compared with the four stimulations paradigms (overlaid on morphologic 0.105±0.027mm,thedistancebeforedeqi(Figure3(a),𝑃< MRimages)showedthedistributionoffociwithsignificant 0.01). increases (shown in the spectrum from red to yellow) and In addition, change of blood flow in Hegu and Zusanli decreases (shown in the spectrum from blue to green) in acupointswasdeterminedbytheLDPItechnology.Wefound signalintensity,relativetothatoftherespectivestates. that blood flow increased transiently when the acupunc- Multiple regions of signal increase were observed dur- ture needle was inserted into the acupoint Hegu and then ingacupunctureneedlemanipulation.Acupuncture-induced revertedtobaselinebeforedeqi.Whenthevolunteersfeltthe activationovertheipsilateralinferiorparietallobule(Brod- sensationsofnumbness,heaviness,distention,andsoreness, mannareas40),ipsilateralsubcortexwhitematter,ipsilateral representingdeqi,theskinbloodflowincreasedsignificantly superior temporal gyrus (Brodmann areas 22), ipsilateral andwasmaintainedatarelativelyhighlevelforupto6min gyrus frontalis medius (Brodmann areas 47), ipsilateral (D1–D6, Figures 4(a1) and 4(a2)). Similar results were also prefrontal lobe (Brodmann areas 46), ipsilateral cuneate foundinZusanliacupoint(seeFigures4(b1)and4(b2)). lobe(Brodmannareas19),ipsilateralposteriorcentralgyrus Acupunctureincreasedamplitudeofmyoelectricityafter (Brodmannareas3),thecontralateralprecuneus(Brodmann deqi,althoughnoremarkablechangewasseeninEEG. areas7),thecontralateralinferiorparietallobule(Brodmann The Viking Quest portable EMG/evoked potential sys- areas40),thecontralateralcentraloccipitalgyrus(Brodmann temswereusedinthisstudyforanalysisofthemyoelectricity areas 19), the contralateral frontal lobe frame gyrus (Brod- anddeepresistance.ThedeepresistancebeforedeqiinHegu mann areas 10), and the contralateral supramarginal gyrus acupointofthehealthysubjectswas34.85±12.43uV,which (Brodmannareas40).Inaddition,therewasactivationinthe was increased to 51.98 ± 11.84uV after de qi (𝑃 < 0.01). ipsilateralventriculusdextercerebriandmesencephalon. ThesimilarresultswereseeninZusanliacupoint,whichwere Acupuncture needle manipulation related deactivation 39.38 ± 9.07uV before de qi and 55.18 ± 6.19uV after de (signal intensity decreased during de qi stage as compared qi (𝑃 < 0.01). Figures 5(a1), 5(a2), 5(b1), and 5(b2) are the withthatbeforedeqi)wasfoundbilaterallyinthemajorityof representativeimageofmyoelectricityinHeguacupointfol- structuresincludingposteriorcentralgyrus(Brodmannareas lowingacupuncturebeforeandafterdeqi.Theamplitudeof 2and3),putamen,inferiorparietallobule(Brodmannareas myoelectricityafterdeqiinHeguwassignificantlyincreased 40),culmencerebelli,intercerebralfissure,clivas,thalamus, thanthatmeasuredbeforedeqi. cingulate gyrus (Brodmann areas 24), and occipital lobe Inaddition,thechangeofelectroencephalograminHegu (Brodmann areas 18 and 19). In addition, deactivation also acupoint following acupuncture before and after de qi was occurred in the contralateral insular lobe, the contralateral determined.InFigure6,O-A,T-O,andC-Orepresentedthe mesencephalon, the contralateral subthalamic nucleus, the electrodesplacedinthedifferentbrainregions.Wefoundthat ipsilateralsuperiortemporalgyrus(Brodmannareas22and in different brain regions, the change of electroencephalo- 52), the ipsilateral gyrus frontalis medius (Brodmann areas grambeforeandafterdeqiwasnotevident. 6,9,and45),theipsilateraldentatebodyofcerebellum,the Evidence-BasedComplementaryandAlternativeMedicine 5 150 U)135 n (P112005 o erfusi 976050 p d 45 o 30 o Bl 15 0 −15 00:02:00 00:04:00 00:06:00 00:08:00 00:10:00 00:12:00 00:14:00 00:16:00 00:18:00 00:20:00 D1 D2 D3 D4 D5 D6 Base blood flow Pre-deqi Deqi Needle out (a1) 180 160 U) 140 P 120 n ( o 100 erfusi 80 d p 60 o o 40 Bl 20 0 Base Pre- D1 D2 D3 D4 D5 D6 Out Hegu (LI.4) acupoint (a2) U)150 P n (120 o usi 90 perf 60 d o 30 o Bl 0 00:02:00 00:04:00 00:06:00 00:08:00 00:10:00 00:12:00 00:14:00 00:16:00 00:18:00 00:20:00 D1 D2 D3 D4 D5 D6 Base blood flow Pre-deqi Deqi Needle out (b1) 160 140 PU) 120 n ( 100 o usi 80 erf 60 p d 40 o Blo 20 0 Base Pre- D1 D2 D3 D4 D5 D6 Out Zusanli (ST.36) acupoint (b2) Figure4:Bloodflowchangesatacupointsfollowingacupuncturebeforeandafterdeqi.APeriScanPIMIIlaserDopplerperfusionimaging (LDPI)wasusedinthisstudyforanalysisandprocessingoftheacupointbloodperfusionimage.Beforetheacupunctureneedlestimulation, thebasalbloodflowofthehealthysubjectswaslowandthensignificantlyincreasedwhendeep-puncturedbutwithoutDeqi(𝑃 < 0.05). Whenthehealthysubjectfeltdeqisensation,theskinbloodflowsattheacupointsweremoreevidentthanthosebeforedeqi(𝑃<0.01)and thesechangesweretime-dependent(Figures4(a1)and4(a2)forHeguandFigures4(b1)and4(b2)forZusanli). 6 Evidence-BasedComplementaryandAlternativeMedicine (a1) (a2) (b1) (b2) Figure 5: Myoelectricity and deep resistance at acupoints following acupuncture before and after de qi. The Viking Quest portable EMG/evokedpotentialsystemswereusedinthisstudyforanalysisofthemyoelectricityanddeepresistance.Thedeepresistancebefore deqiinHeguacupointofthehealthysubjectswas34.85±12.43,whichwasincreasedto51.98±11.84uVafterdeqi(𝑃<0.01).Thesimilar resultswereseenforZusanliacupointwhichwas39.38±9.07uVbeforedeqiand55.18±6.19uVafterdeqi(𝑃 < 0.01).Figure5isthe representativeimageofmyoelectricityatacupointsfollowingacupuncturebeforeandafterdeqi((a1)and(a2)forHegu;(b1)and(b2)for Zusanli).TheamplitudesofmyoelectricityafterdeqiinHeguandZusanliweresignificantlyincreasedthanthosebeforedeqi. O1A1 O2A2 T3O1 T4O2 C3O1 C4O2 (a) (b) (c) Figure6:ChangeofelectroencephalograminHeguacupointfollowingacupuncturebeforeandafterdeqi.O-A,T-O,andC-Orepresentthe electrodesplacedforthedifferentbrainregions.Wefoundthatindifferentbrainregions,thechangeofelectroencephalogrambeforeand afterdeqiwasnotevident. ipsilateralcorpuscallosum,andtheipsilateralmidtemporal no objective evaluation criteria for optimal effect of needle gyrus(Brodmannareas21). manipulation, the intensity of stimulation during acupunc- ture.Andevidencetosupporttheuseofacupunctureneeds 4.Discussion tobeestablished.Infact,ithasbeenacceptedthatinduction andoccurrenceofdeqiareaprerequisiteforacupunctureand Acupuncture has been widely used for a range of acute oftenanindicatorofaclinicalacupunctureeffect[4,6,7,9]. and chronic disorders in China, and during recent decades De qi, which manifests as numbness, heaviness, distention, acupuncture has been used in many countries around the and soreness, with spreading sensation and manifests as world. In spite of popular clinical applications, there are heavyandtightsensationcomingfrombeneaththeneedle, Evidence-BasedComplementaryandAlternativeMedicine 7 4 6 3 4 2 1 2 0 0 (a1) (b1) (a2) (b2) Figure 7: Change of functional magnetic resonance imaging (fMRI) in Zusanli acupoint following acupuncture before and after de qi. MeanresultsoffunctionalMRimagesofbrainactivation/deactivationofninesubjectsineachstimulationparadigm.Representativecolor- codedstatisticalmapsderivedfromdataobtainedduringthefourstimulationsparadigms(overlaidonmorphologicMRimages)showthe distributionoffociwithsignificantincreases(showninthespectrumfromredtoyellow)anddecreases(showninthespectrumfromblue togreen)insignalintensity,relativetothatoftherespectivestates. is the sine qua non of acupuncture for the achievement of tissue displacement, electromyography, electroencephalog- aclinicaltherapeuticeffectaccordingtotraditionalChinese raphy of local region at acupoints, and brain fMRI sig- medicine.Andmostoftheexpertsinacupunctureconsider nals. The results showed that needle stimulation after de that de qi is the intensity threshold of acupuncture treat- qi significantly increased blood perfusion, tissue displace- ment by means of needle rotation, upright and down, and ment,andtheamplitudeofmyoelectricityintheacupoints. acupunctureexertsitsclinicaltherapeuticeffectsonlyunder Furthermore, acupuncture treatment induced brain fMRI the certain condition of achieving qi (de qi). In spite of the signal increase/decrease in different brain regions although importanceandnecessityofdeqi,thereisalackofadequate nosignificantchangewasseeninelectroencephalogram.The experimental data to indicate what the intrinsic property intrinsicchangesindicatedthatdeqielicitedintenseresponse of de qi is and how to evaluate it quantitatively. Till now, ofhumanbodytoacupuncture,especiallyatthelocationof therearenoidealobjectiveevaluationmethodsandcriteria acupoints and even in the brain, and it could be evaluated for optimal effect of the needle manipulation and for the quantitatively, which might shed light on the therapeutic intensity of stimulation. Many acupuncturists only acquire mechanismofacupunctureandfacilitatethewideruseofthis acupuncture needle to stick into the acupoints but ignore treatmentmodalityintheworld. theessentialityofacupunctureintensityandthresholdinthe In our report, the amount of tissue displacements, courseofacupuncturetreatment,leadingtotheimpairment induced by acupuncture treatment, was measured by in ofthetherapeuticeffectofacupuncture. vivo ultrasonic imaging before de qi and during de qi. Inourstudy,itwasasurprisetofindthatdeqiinduced Tissuedisplacementswerefoundtosignificantlyincreasein intrinsic change in the human body during acupuncture amplitudeafterdeqicomparedtothosebeforedeqi.Tissue treatment, including changes in acupoint blood perfusion, displacement caused by acupuncture needle manipulation 8 Evidence-BasedComplementaryandAlternativeMedicine Table1:ActivatedregionsinfMRIafterdeqiinZusanliacupointfollowingacupuncture. Talairach Anatomy BA Side 𝑋(mm) 𝑌(mm) 𝑍(mm) 𝑍score Inferiorparietallobule 40 R 60 −38 42 3.93 Subcortexwhitematter R 22 −66 28 3.71 32 −52 38 3.02 Precuneus 7 L −24 −80 44 3.22 −12 −76 46 3.06 Superiortemporalgyrus 22 R 30 12 −22 2.91 Inferiorparietallobule 40 L −46 −58 52 2.86 −52 46 54 2.57 Gyrusfrontalismedius 47 R 36 22 −6 2.37 48 36 10 2.74 Centraloccipitalgyrus 19 L −30 −76 48 2.74 Prefrontallobe 46 R 44 38 18 2.68 Cuneatelobe 19 R 16 −80 20 2.62 Frontallobeframegyrus 10 L −40 40 24 2.59 Posteriorcentralgyrus 3 R 18 68 60 2.55 Ventriculusdextercerebri R 2 8 14 2.46 Mesencephalon R 4 −38 −20 2.44 Supramarginalgyrus 40 L −38 −52 34 2.42 Table1liststheTalairachcoordinates.NumbersincorticalareasoftheimagescorrespondtoBrodmannareas.Multipleregionsofsignalincreasewereobserved duringacupunctureneedlemanipulationoftherightlegatST.36.Acupunctureinducedactivationovertheipsilateralinferiorparietallobule(Brodmann areas40),ipsilateralsubcortexwhitematter,ipsilateralsuperiortemporalgyrus(Brodmannareas22),ipsilateralgyrusfrontalismedius(Brodmannareas 47),ipsilateralprefrontallobe(Brodmannareas46),ipsilateralcuneatelobe(Brodmannareas19),ipsilateralposteriorcentralgyrus(Brodmannareas3),the contralateralprecuneus(Brodmannareas7),thecontralateralinferiorparietallobule(Brodmannareas40),thecontralateralcentraloccipitalgyrus(Brodmann areas19),thecontralateralfrontallobeframegyrus(Brodmannareas10),andthecontralateralsupramarginalgyrus(Brodmannareas40).Inaddition,there wasactivationintheipsilateralventriculusdextercerebriandmesencephalon. following needle rotation may deliver a mechanical signal amplitude of myoelectricity, suggesting that the local tissue into the subcutaneous tissue and consequently generate ofacupointsrespondedtotheneedleacupuncture.However, important effects on cellular elements (fibroblasts, blood thechangeofelectroencephalogramindifferentbrainregions vessels, and sensory nerves) present within this tissue [1]. beforeandafterdeqiwasnotevident.TheEEGresultswere This may prove to be the key to acupuncture’s therapeutic consistent with those of Starr et al. [11] but appear to be mechanism and the proposed imaging technique, the key contradictory with other reports in the literature [12–15]. methodformonitoringthiseffect. Indeed,thisisnotentirelysurprisinginviewofthedifficulties Inaddition,changesofbloodflowatacupointsHeguand in the measurements being attempted and the techniques Zusanli were determined by the LDPI technology. In our adopted. During the recording of a normal EEG the signal study, the local response could be seen clearly around the mayvaryconsiderablyandtheeffectofacupuncturehastobe acupoint;theincrementofbloodperfusionwashigher(about foundwithinthesevariations[16].Inaddition,themagnitude 10%)aroundHeguandZusanliafterdeqithanthatmeasured ofthechangesbroughtaboutbyacupuncturemaybesmall beforedeqi,andtheincreaseofbloodperfusionwasmain- andconventionalpaperrecordingoftheEEGisunlikelyto tained at a relatively high level. The local increase of blood besufficientlysensitivetodemonstratechanges[16].Digital flow may be caused by axon reflection. An acupuncture- EEGrecordingsandbrainmappingtechniqueswhichallow induced neural signal can be reflected along the branch of morequantitativedataanalysisofferbetterprospectsinthis thesameaxontotheskinsurfaceandcancausetherelease regard. ofsubstance𝑃,whichfurtherevokesthereleaseofhistamine Finally,weinvestigatedthefMRIsignalchangeinduced fromnearbymastcellsandcausesvasodilatationandincrease bytheacupuncturetreatmentandfoundthatdifferentbrain ofbloodperfusion[10].Theincreaseofbloodperfusionand regions were activated or deactivated in response to the vasodilatationmightbeexplainedbythefindingthatseveral needlestimuli.Acupuncturewithdeqiresultedinamarked volunteersfeltthesensationofheatandperspirationduring predominance of signal attenuation or deactivation in the acupuncturemanipulation,whichindicateddeqi. posterior central gyrus, putamen, inferior parietal lobule, Furthermore,electrophysiologicalchangesinducedbyde thalamus, cingulate gyrus, occipital lobe, insular lobe, sub- qi of acupuncture were also determined in this study. We thalamic nucleus, superior temporal gyrus, gyrus frontalis foundthatacupunctureafterdeqisignificantlydecreasedthe medius, midtemporal gyrus, and cerebellum. On the other deepelectricalresistanceattheacupointsandincreasedthe hand, clusters of activated regions were seen in the inferior Evidence-BasedComplementaryandAlternativeMedicine 9 Table2:DeactivatedregionsinfMRIafterdeqiinZusanliacupointfollowingacupuncture. Anatomy BA Side Talairach 𝑍score 𝑋(mm) 𝑌(mm) 𝑍(mm) Posteriorcentralgyrus 2/3 L/R −16 −42 68 5.63 52 −24 18 5.33 Superiortemporalgyrus 22/52 R 58 2 0 5.29 58 10 −4 4.78 Putamen L/R −28 2 6 5.26 −26 −8 8 5.04 22 2 −2 3.99 Insularlobe L −45 22 18 4.55 −36 −18 12 4.06 Inferiorparietallobule 40 L/R −50 −34 22 5.14 58 −42 22 4.03 50 −44 24 4.00 Culmencerebelli L/R 8 −56 −8 4.72 −2 −46 −10 4.27 Intercerebralfissure L/R −2 −62 0 4.21 2 −34 22 3.36 Clivas L/R −2 −60 −18 3.51 36 −70 −28 4.51 26 −82 −28 4.06 16 −86 −28 3.85 Gyrusfrontalismedius 6 R −2 −24 64 4.57 9/45 R 48 6 30 3.99 56 18 26 3.56 Dentatebodyofcerebellum R 14 −58 −34 4.56 Mesencephalon L −10 −26 −8 4.45 Thalamus L/R −4 −12 2 3.63 14 −28 0 3.32 Cingulategyrus 24 L/R 4 0 28 4.08 −12 0 34 3.86 Corpuscallosum R 2 −4 20 4.27 Midtemporalgyrus 21 R 54 −60 6 4.10 Occipitallobe 18/19 L/R −52 −70 4 3.78 34 −82 12 3.50 Subthalamicnucleus L −8 −14 −8 3.44 Table2showstheTalairachcoordinates.NumbersincorticalareasoftheimagescorrespondtoBrodmannareas.Deactivationwasnotedbilaterallyinposterior centralgyrus(Brodmannareas2and3),putamen,inferiorparietallobule(Brodmannareas40),culmencerebelli,intercerebralfissure,clivas,thalamus, cingulategyrus(Brodmannareas24),andoccipitallobe(Brodmannareas18and19).Inaddition,deactivationalsooccurredinthecontralateralinsularlobe,the contralateralmesencephalon,thecontralateralsubthalamicnucleus,theipsilateralsuperiortemporalgyrus(Brodmannareas22and52),theipsilateralgyrus frontalismedius(Brodmannareas6,9,and45),theipsilateraldentatebodyofcerebellum,theipsilateralcorpuscallosum,andtheipsilateralmidtemporal gyrus(Brodmannareas21). parietal lobule, subcortex white matter, superior temporal validatedfindingsofthosepreviousstudies.Acupunctureat gyrus,ipsilateralgyrusfrontalismedius,prefrontallobe,ipsi- analgesicacupoints,suchasLI4(Hegu)andST36(Zusanli), lateralcuneatelobe,ipsilateralposteriorcentralgyrus,con- can modulate the hypothalamus and limbic system, which tralateralprecuneus,inferiorparietallobule,centraloccipital arepain-relatedneuromatrices[2,17,20,22–24].According gyrus, frontal lobe frame gyrus, and supramarginal gyrus. toTCM,allacupointsarelocatedalongthemeridians.ST36 Duringacupuncturemanipulation,severalcorticalandsub- is a commonly used acupoint on the stomach meridian of cortical areas of human brains responded, according to the foot-Yangming, which starts from the lateral side of the ala previousstudiesofacupunctureatST36,whichwerelocalized nasi,ascendstotheipsilateralforehead,anddescendstothe atthalamus,insula,cingulategyrus,temporalgyrus,andcere- dorsum of the foot, with a branch extending to the tip of bellum [17–21]. However, there are some different activated the great toe [25]. The activation of the ipsilateral middle areas, such as basal ganglia and PAVN. Our results further frontalgyrusisinaccordancewiththeTCMtheory.Thisarea 10 Evidence-BasedComplementaryandAlternativeMedicine of the brain includes the pathway of qi along the stomach pp.1209–1218,ChurchillLivingstone,London,UK,3rdedition, meridianoffoot-Yangming.Intheaspectofcurativeeffects, 1994. the stomach meridian of foot-Yangming has a therapeutic [6] B. Pomeranz, “Scientific basis of acupuncture,” in Basics of effect for mental problems, gastralgia, and intestinal pain Acupuncture,G.StuxandB.Pomeranz,Eds.,pp.4–60,Springer, [25].Ourpreliminarystudydemonstratedthatdeqielicited NewYork,NY,USA,3rdedition,1995. significant response to acupuncture in the specific brain [7] C.A.Vincent,P.H.Richardson,J.J.Black,andC.E.Pither,“The regions,butthemechanismswhetherdifferentacupointsare significanceofneedleplacementsiteinacupuncture,”Journalof coupled with specific brain regions are not clear, and the PsychosomaticResearch,vol.33,no.4,pp.489–496,1989. reasons that the specific brain regions responded to de qi [8] J. Filshie and A. White, Medical Acupuncture: A Western intensivelyalsoremaintobeelucidated. ScientificApproach,ChurchillLivingstone,London,UK,1998. [9] S.B.Xu,B.Huang,andC.Y.Zhang,“Effectivenessofstrength- ened stimulation during acupuncture for the treatment of 5.Interpretation Bell palsy: a randomized controlled trial,” Canadian Medical AssociationJournal,vol.185,no.6,pp.473–479,2013. In summary, we have shown that acupuncture with de qi [10] A. M. Seifalian, G. Stansby, A. Jackson, K. Howell, and G. elicitedtheintrinsicchangeofhumanbody.Theserecordings Hamilton, “Comparison of laser Doppler perfusion imaging, ofalltheaspectsabovemaybetakenasanindicatorofdeqi laser Doppler flowmetry, and thermographic imaging for sensation.Biochemicaleffectsshownbytissuedisplacement assessmentofbloodflowinhumanskin,”EuropeanJournalof andbloodflowchangeafteracupuncturemanipulationwere VascularSurgery,vol.8,no.1,pp.65–69,1994. derived from mechanical stimulation of connective tissue [11] A.Starr,G.Abraham,Y.Zhu,D.Y.Ding,andL.Ma,“Electro- and potential spreading of these effects along connective physiological measures during acupuncture-induced surgical tissue planes, which might deliver a mechanical signal into analgesia,”ArchivesofNeurology,vol.46,no.9,pp.1010–1012, the subcutaneous tissue, induce the release of several pain- 1989. relatedsubstances,andthenextendthecommunicatedsignal [12] T. J. Liao, H. Nakanishi, and H. Nishikawa, “The effect of spreading.Theseprocessesmightconsequentlyenhancethe acupuncturestimulationofthemiddlelatencyauditoryevoked response of specific brain regions and trigger the nerve- potential,” Tohoku Journal of Experimental Medicine, vol. 170, immune-secretionnetworktoalleviatepain.Ongoinginves- no.2,pp.103–112,1993. tigationsoveralargerpoolofhumansubjectscorrelatingwith [13] T. J. Liao, “Quantitative measurement of the acupuncture biochemicalandneurologicalaswellasmorphologicaleffects sensationcausedbytheacupuncturestimulation,”TheAnnals areexpectedtoshedimportantlightonthetherapeuticmech- ofAppliedInformationSciences,vol.17,pp.31–48,1992. anismofacupunctureandfacilitatetheintensivepropagation [14] M.Saito,M.K.Sim,andN.Suitzu,“Acupuncture-evokedEEG ofthistreatmentmodalityintheworld. ofnormalhumansubjects,”AmericanJournalofAcupuncture, vol.11,pp.225–229,1983. [15] R. S. Shapiro and H. E. Stockard, “Electroencephalographic ConflictofInterests evidencedemonstratesalteredbrainwavepatternsbyacupoint stimulation,”AmericanJournalofAcupuncture,vol.17,no.1,pp. The authors declare that there is no conflict of interests 25–29,1989. regardingthepublicationofthispaper. [16] P. Rosted, P. A. Griffiths, P. Bacon, and N. Gravill, “Is there aneffectofacupunctureontherestingEEG?”Complementary Acknowledgment TherapiesinMedicine,vol.9,no.2,pp.77–81,2001. [17] G.Biella,M.L.Sotgiu,G.Pellegata,E.Paulesu,I.Castiglioni, This work was supported by Grants of National Basic andF.Fazio,“Acupunctureproducescentralactivationsinpain Research Program of China (973 program, 2006CB504502) regions,”NeuroImage,vol.14,no.1,part1,pp.60–66,2001. toW.Wang. [18] X.L.Jin,L.Yi,andB.Yao,“Thecentrallyactingmechanisms ofacupuncturestimulationatST36,”ChineseJournalofReha- References bilitation TheoryandPractice,vol.9,no.2,pp.184–186,2003 (Chinese). [1] E. E. Konofagou and H. M. Langevin, “Using ultrasound to [19] J.P.Sun,L.Yi,andX.L.Jin,“AcupuncturestimulationatST36 understand acupuncture,” IEEE Engineering in Medicine and (ZUSANLI) brain functional MRI and animal study,” China BiologyMagazine,vol.24,no.2,pp.41–46,2005. BasicScience,vol.8,no.2,pp.39–41,2003(Chinese). [2] J.Park,K.Linde,E.Manheimeretal.,“Thestatusandfuture [20] M.T.Wu,J.C.Hsieh,J.Xiongetal.,“Centralnervouspathway of acupuncture clinical research,” Journal of Alternative and for acupuncture stimulation: localization of processing with ComplementaryMedicine,vol.14,no.7,pp.871–881,2008. functionalMRimagingofthebrain—preliminaryexperience,” [3] Y. Yuan, J. Ren, and L. Huang, Chinese English Dictionary Radiology,vol.212,no.1,pp.133–141,1999. of Traditional Chinese Medicine, People’s Medical Publishing [21] W.T.Zhang,Z.Jin,J.Huangetal.,“Modulationofcoldpain House,Beijing,China,1997. inhumanbrainbyelectricacupointstimulation:evidencefrom [4] J.S.HanandL.Terenius,“Neurochemicalbasisofacupuncture fMRI,”NeuroReport,vol.14,no.12,pp.1591–1596,2003. analgesia.,”AnnualReviewofPharmacologyandToxicology,vol. [22] K.K.Hui,J.Liu,N.Makrisetal.,“Acupuncturemodulatesthe 22,pp.193–220,1982. limbic system and subcortical gray structures of the human [5] R. Melzack, “Folk medicine and the sensory modulation of brain:evidencefromfMRIstudiesinnormalsubjects,”Human pain,”inTheTextbookofPain,P.D.WallandR.Melzack,Eds., BrainMapping,vol.9,no.1,pp.13–25,2000.