Filiform Needling Methods on Abdomen Points

1. Introduction

Abdomen points include the points located between the xiphisternal synchondrosis and the upper border of symphysis pubis. They belong to Conception, three foot yin, foot yangming, and foot shaoyang meridians respectively and mainly function to treat various ailments of liver, gallbladder, spleen, stomach, kidney, urinary bladder, intestines, and genital organs according to their local and adjacent therapeutic properties.

The appropriate posture for needling those points is supine posture in which patients feel comfortable and abdominal muscles are relaxed. Because of the loose skin at abdomen, the needle should be inserted coordinately with the help of both hands. Generally, stretch the skin where the point is situated with the thumb and index finger of the pressing hand, hold the needle with the puncturing hand and insert it into the point.

From of old, acupuncturists are very cautious when they are needling abdomen points because there are important internal organs at their deep levels. The suitable depth of insertion is no more than 35mm for most abdomen points according to acupuncture textbooks. However, in clinical practice the needling depth is quite different from person to person due to individual build. To achieve special curative effects, deep needling technique may be applied to some points. Sometimes the tip of the needle may even get into abdominal cavity safely depending on the mastery of local anatomy.

As for the manipulation on needles, rotating is much more frequently used than lifting and thrusting. Other auxiliary techniques such as vibrating, flying, twirling and so on are often applied to stimulate the circulation of Meridian Qi and strengthen the needling sensation.

This paper will focus on seven important abdomen points namely Jiuwei(CV15), Zhongwan(CV12), Tianshu(ST25), Guanyuan(CV4), Zhongji(CV3), Zhangmen(LR13), Riyue(GB24). The optional filiform needling techniques of each point will be discussed respectively. A case study of each one will be presented as well.

2. Needling methods on abdomen points

2.1 Jiuwei(CV15)

Jiuwei(CV15) is located on the anterior midline, 1 cun below the xiphisternal synchondrosis. Its indications include pain in the cardiac region and the chest, nausea, hiccup, mental disorders, epilepsy and so on.

This point need to be punctured obliquely upward 15-25 mm. The operator may feel the resistance under the needle when the tip of it touches the xiphoid process. Strong lifting and thrusting with large amplitude is not advisable at this point. Instead, manipulation of rotating the needle is frequently used to facilitate the arrival of Qi. Patients often describe the needling sensation as tingle.

To treat mental disorders, strong stimulation needs to be applied to this point. Hold the needle handle with the palmar surface of the thumb and radial surface of the index or middle finger. Twist the needle with the help of the bending and stretching movement of the metacarpophalangeal joint of the index or middle finger. Rotate the needle handle rapidly with the twisting speed reaching 200 times per minute or so. Twist the needle continuously for 2-3 minutes per time and repeat this manipulation 2-3 times during retaining period. Patients may feel strong aching and soreness around the point.

Case Study

Female 35 years

Depression for 4 weeks

The patient felt helpless and depressive since 3 months after delivery. She showed no interests to everything even to her baby and cried a lot everyday accompanied with palpitation, burning feeling in the chest, insomnia and poor appetite. The patient described that there was like a heavy stone oppressing on the chest.

Examination: Normal electrocardiogram. Red tongue little coating. Thin rapid pulse

Diagnosis: puerperal depressive state (Yu Syndorm)

Differentiation: Asthenia of heart Yin

Point: Jiuwei(CV15)

Method: Insert the needle obliquely upward with the tip of the needle reach the cartilage. Withdraw the needle a little bit. Rotate the needle forward and backward until the Qi sensation arrived. Then twist the needle rapidly with the speed of 200 times per minute for 2 minutes. The patient said the feeling of oppression on the chest disappeared suddenly. Retain the needle for half an hour. Repeat the manipulation of rapid rotation 2-3 times during that period. The patient accepted the treatment once a day. She felt the palpitation and burning sensation on the chest had been largely relieved and appetite improved after four sections. Her emotion got normal after ten sections.

2.2 Zhongwan(CV12)

Zhongwan is located on the anterior midline, 4 cun above the umbilicus or midpoint between the xiphisternal synchondrosis and the center of the umbilicus. It is one of the most important points at upper abdomen which can treat all symptoms caused by disharmony of spleen and stomach, such as stomachache, abdominal distention, borborygmus, nausea, vomiting, acid regurgitation, indigestion, diarrhea, insomnia, jaundice and so on.

Generally, this point may be punctured perpendicularly 20-40mm. Manipulation of rotating, or lifting and thrusting with small amplitude may be applied to the needle. Patients feel soreness, heaviness and distension around the point. This method has curative effects for most indications of this point. To strengthen the needling sensation, quick rotation may be applied to this point. Rotate the needle handle rapidly with the twisting speed reaching 200 times per minute or so. Twist the needle continuously for 2-3 minutes per time. Patients may feel warm in the stomach.

For patients of stomach convulsion whose acute pain can not be reduced by general acupuncture technique, deep puncturing method at this point possibly has amazing curative effect. Insert the needle vertically passing loose subcutaneous tissue and abdominal wall slowly. When the tip of the needle gets into the abdominal cavity, the operator will feel empty under the needle or the feeling of resistance disappearing suddenly. The tip of the needle will meet resistance again which is hard but elastic if it goes deeper. It means the needle touch the body of the stomach. Patients feel strong aching and distending. Stop thrusting the needle at once and withdraw it 3-5mm. Twist the needle about 1 min or lift and thrust the needle gently 2 or 3 times. In most cases, patients will feel the pain in stomach is largely alleviated. If no difference, withdraw the needle out of abdominal cavity where it retains for 10 minutes. Then thrust the needle again and repeat the above manipulation. The gauge of needles selected for this method should be 0.30 or 0.32 mm in diameter and 75-100 mm in length. For adults with middling build, the tip of the need will arrive at stomach after inserting it 65-75 mm.

Case study

Female, 21 years

Colicky pain at upper abdomen for 3 hours.

The patient drank a glass of very cold cola as breakfast in the morning. Half an hour later she felt strong colicky epigastric pain accompanied with nausea. The pain was getting worse and unbearable so she came to see a doctor. Examination: The muscles in the stomach area were in tension and refused pressure. Pale tongue, thin white coating. Tight pulse.

Diagnosis: Stomach pain

Differentiation: Stagnation of Qi due to invasion of cold

Point: Zhongwan(CV12)

Method:

Insert the needle vertically with the depth of 25mm. the operator felt heaviness and tenseness under the needle. The patient felt distension around the point. Apply reducing approach by twirling the needle rapidly with large amplitude 5 times. After retaining the needle for 20 minutes, the patient felt the pain was bearable but still strong. Withdraw the needle to the subcutaneous level, insert the needle vertically and slowly passing loose subcutaneous tissue and abdominal wall. When the tip of the needle touched the body of the stomach, lift it 5 mm and then twist it quickly with small amplitude for about 1 min. The patient felt relaxed in stomach immediately after manipulation. Lift the needle out of the abdomen cavity and retain the needle for 20 minutes. The pain disappeared after withdrawing the needle.

2.3Tianshu(ST25)

Tianshu(ST25) is 2 cun lateral to the centre of the umbilicus. It is one of the most commonly used points on abdomen. Its indications include abdominal pain and distension, borborygmus, pain around the umbilicus, constipation, diarrhea, irregular menstruation and so on. The suitable depth of this point is quite different from person to person according to the individual build. As for patients who are very thin or plump, the depth of insertion may be different from the following principles. The feeling of operators under the needle during manipulation is the most important point for the special cases.

The conventional needling method of Tianshu(ST25) is puncturing perpendicularly 20-35 mm. Manipulation of rotating, lifting and thrusting may be applied to the needle. Patients feel soreness, heaviness and distension around the point and their transmission upward and downward along the Stomach meridian of the same side. This method is effective for such ailments as abdominal pain and distension, constipation, chronic diarrhea, irregular menstruation and so on.

An important auxiliary manipulation on this point is circling. Insert the needle vertically to the acquired depth. After the Qi sensation is obtained, pull the needle to the superficial level. Hold the needle with the thumb and index finger. Lower the needle and move the handle of the needle in a circle clockwise or anticlockwise with uniform speed. Combined with lifting and thrusting technique, circling at Tianshu(ST25) has the function of reinforcing or reducing. Circling clockwise with thrusting the needle heavily functions to reinforce while circling counter clockwise with lifting the needle heavily serves for reducing. When repeated operation is conducted for several minutes, the patient may have a warm sensation at local area under reinforcing technique which is effective for asthenic cold of intestines or a cool sensation under reducing one for damp-heat of large intestine. This technique can regulate the qi of gastrointestinal tract and is special for the symptoms of digestive system.

To treat acute symptom of abdominal pain or diarrhea, deep puncture technique may be applied to Tianshu(ST25) which has good curative effect in relieving pain and stopping watery diarrhea. Insert the needle vertically, passing rectus abdominis and getting into abdominal cavity. Once the tip of the needle gets into abdominal cavity, the feeling of resistance under the operator’s hand disappears suddenly. The needle goes slowly until the depth of insertion up to 40-50mm. Rotate the needle about 1 minute, lift and thrust it lightly 2 or 3 times. Patients may feel strong aching and distension in the abdomen. If pain is not alleviated, lift the needle out of the abdominal cavity. After a few minutes, thrust the needle again and repeat the manipulation. In most cases, pain will be relieved after 2-3 times. Retain the needle outside the abdominal cavity for half an hour at last. The key of this technique is inserting the needle very slowly. Because the intestine can escape the tip of the needle spontaneously after stimulation, it is not easy for it to be stabbed if the speed of insertion is slow.

Stuck needling technique may be applied to Tianshu(ST25) for losing weight. Insert the needle horizontally downward with the tip of the needle toward Shuidao(ST28). The proper depth of insertion of this method is between 40-80mm. After the Qi sensation is obtained, rotate the needle backward from the tip of the index finger to the transverse creases of the distal interphalangeal joint with an angle of 360 degrees, causing muscle fibers to bind around the body of the needle tightly. The patient has strong needling sensation of heaviness and distension. The practitioner feels stuck sensation under the needle. Then, pull the needle outward three to five times. The muscle fibers are dragged outward as well. This technique, which is effective in eliminating adipose tissue may be repeated three to five times during retaining the needle.

Case Study

Male 14 months

Watery diarrhea for 2 days

The patient defecated 7-8 times per day without clear reason. Watery stool with small amount of undigested food. Borborygmus. Sudden onset. No vomiting. Low energy. Normal appetite.

Examination: Pale tongue with white coating. Deep pulse.

Diagnosis: Acute diarrhea

Differentiation: cold dampness disturbing the function of intestines

Point: Tianshu(ST25)

Use the needle of 0.30mm in diameter and 40 mm in length. Insert the needle vertically and slowly with the depth of 35mm, which is about 2.5-3 cun of finger measurement. Rotate the needle for half a minute and lift and thrust it gently 2 to 3 times and then withdraw the needle. The baby accepted treatment once a day. After one section, the times of defecation reduced to 4 times per day and got normal after 3 days.

2.4 Guanyuan（CV4）

Guanyuan（CV4）is on the anterior midline, 3 cun below the umbilicus. It functions to not only treat almost all the diseases of urogenital system, but also tonify the whole body. Its indications include enuresis, nocturnal emission, retention of urine, hernia, irregular menstruation, morbid leucorrhea, uterine bleeding, prolapse of the rectum, flaccid type of apoplexy and other syndromes with asthenia of primordial qi.

The conventional needling method of this point is puncturing perpendicularly 20-30mm or obliquely downward 25-50mm. Gentle manipulation of rotating, lifting and thrusting with small amplitude may be applied to the needle. Patients feel soreness and distension around the point. Or the feeling goes down to the external genital organs. Generally, reinforcing method is employed to Guanyuan（CV4） due to its characteristic of tonification. Be cautious to adopt this point if the patient is pregnant.

If Qi fails to arrive, vibrating technique is often selected to excite muscles and nerves. Hold the needle with the thumb and index finger. Rotate the needle forward and backward and at the same time move the needle up and down gently and rapidly. The operation of rotating, lifting and thrusting needs to be within very small amplitude while the frequency as high as possible like the hand trembling. Finger power should be chiefly used in this technique to make the needle quivering.

Flying technique is often used on this point to strengthen and spread the needling sensation. Hold the needle with the thumb and index finger. Twirl the handle of the needle gently 1 to 3 times and then release it quickly. Separate the fingers just like a bird spreading its wings. The needle might be left slightly quivering on the point. The needling sensation goes upward or downward along the Conception meridian.

To replenish the yang of kidney and the fire of vital gate, some special techniques may be employed to induce a warm feeling at this area. For example, Insert the needle vertically, after Qi arrived, twirl the needle forward with an angle of 360 degrees to cause muscle fibers binding around the body of the needle. Thrust the needle heavily while lifting the needle gently 5 to 7 times. Patients may have a warm feeling at the lower abdomen.

Case study

Female, 30 years

Sterility for 3 years

The lady had been planning on pregnancy for 3 years but did not succeed. Both of the couple accepted relevant examinations and have normal biochemical criterion. She got artificial abortion twice when she was 22 and 26. Scanty and light red menses in delayed cycle, Dull pain at lower abdomen which can be alleviated by warmth. Cold hands and feet all over the year. Watery leucorrhea which is whitish in color and profuse in amount.

Examination: soft abdomen. Pale tongue, thin white coating with excessive moisture. Deep pulse.

Diagnosis: Secondary infertility

Differentiation: kidney yang deficiency and cold in uterus

Points: Main point: Guanyuan(CV4) supplementary points: Zusanli(ST36), Sanyinjiao(SP6)

Method: Insert the needle to point Guanyuan(CV4) vertically with the depth of 35mm. twirl the needle backward and forward continuously until the arrival of Qi. Rotate the needle forward with an angle of 360 degrees. The practitioner felt stuck sensation under the needle, which indicated muscle fibers bound around the body of the needle tightly. Thrust the needle heavily while lifting the needle gently 5 times. In most cases, the patient felt warm at lower abdomen. Retain the needle for half an hour.

Apply reinforcing method by lifting and thrusting the needles to points zusanli(ST36) and sanyinjiao(SP6)

The patient accepted treatment twice a week. She got regular menstrual cycle and normal quality of flow firstly, and gestated after three months’ treatment.

2.5 Zhongji(CV3)

Zhongji(CV3) is on the anterior midline, 4 cun below the umbilicus. It serves to treat such disorders of urogenital system as enuresis, nocturnal emission, impotence, hernia, uterine bleeding, irregular menstruation, dysmenorrheal, morbid leucorrhea, frequency of urination, retention of urine, vaginitis and so on.

Patients need to be asked to micturate before puncturing this point to avoid hurting urinary bladder. This point may be punctured perpendicularly 15-25mm or obliquely downward 40-50mm with the tip of the needle toward pubic symphysis. Rotating and lifting-thrusting manipulation with small amplitude may be applied to the needle. Auxiliary manipulation of vibrating is frequently employed to facilitate the arrival of meridian Qi. Hold the needle with the thumb and index finger. Rotate the needle with small amplitude or apply lift-thrust and rotating movement quickly and lightly in a trembling way. Patients may feel soreness, heaviness and distension at the local area. They may also feel electric numbness spread around the point.

To elevate the curative effectiveness, some manipulation techniques need to be adopted to push the needling sensation downward to the diseased part of the body. For example, arching technique functions to promote the circulation of Qi. After the qi sensation is obtained, hold the handle of the needle with the thumb and index finger forcefully to keep the Qi around the tip of the needle. Both the patient and the practitioner focus all their attention on the needling sensation under the tip of the needle. Press the needle body lightly upward with the help of the middle and ring finger. Bend it in the shape of a bow. The needling sensation may be pushed downward to the urinary bladder, vagina or penis to treat retention of urine, vaginitis, impotence, and so on.

Another technique is swinging the needle left and right like a green dragon swaying tail. After the Qi sensation is obtained, withdraw the needle a little. Press the meridian at upside of the point with the thumb of assistant hand to stop the Qi going upward. The needling hand sways the needle slowly from one side to the other within the amplitude of 45 degrees. The needling sensation may go downward to the external genital organs.

Case study

Female, 27 years

Postpartum retention of urine for 16 hours.

No urination after spontaneous delivery. Have urgency of urination but no urine discharge. Distension in the lower abdomen. Restlessness and anxiety. Examination: muscles at lower abdomen were in tension. The Margo superior of filling bladder is between Qugu(CV2) and Zhongji(CV3) by percussion. Dark purplish tongue with little coating. Weak rapid pulse.

Diagnosis: Retention of urine

Differentiation: Damage of Qi in urinary bladder

Point: Zhongji(CV3)

Method: Insert the needle perpendicularly with the depth of 30mm. Hold the needle with the thumb and index finger. Rotate and move the needle up and down gently and rapidly within very small amplitude like the hand trembling. Hold the needle forcefully against the strong Qi sensation under the tip of the needle. Arch the body of the needle slowly with the tip of it downward. Patients felt strong distension and numbness going down to the perineum. Retain the needle for 20 minutes and then withdraw it. Half an hour later, the patient urinated.

2.6 Zhangmen(LR13)

Zhangmen(LR13) is on the lateral side of the abdomen, below the free end of the eleventh rib. Its indications include distending pain in the hypochondrium and in the lower abdomen, borborygmus, diarrhea, and so on, which are due to stagnated liver Qi invading spleen.

Generally, this point may be punctured perpendicularly 15-20mm. The deep level of Zhangmen(LR13) at right side is Lobus hepatis dexter. It is the inferior part of the spleen at left side. To avoid hurting the important internal organs, too much depth is not allowed in this direction, especially for the patients of hepatomegaly or splenomegaly. Manipulation of rotating the needle is much safer and more frequently used than lifting and thrusting. Patients may feel strong distension at local area. Sometimes, its transmission spread over the hypochondrium.

To strengthen and spread the needling sensation, auxiliary manipulation of flying is commonly applied to this point. Hold the needle with the thumb and index finger. Twirl the handle of the needle gently for 1 to 3 times and then release it quickly. Separate the fingers just like a bird spreading its wings. Patients may feel distention at lateral abdomen and its transmission to the posterior abdominal wall.

The insertion could be deeper if it is punctured obliquely forward or backward. Passing the skin and loose subcutaneous tissue, the tip of the needle reaches the comparatively harder layer of muscles, including obliquus externus abdominis, obliquus internus abdominis and transverses abdominis. Stop thrusting the needle at this depth. Some patients may feel electric numbness along the rib because the tip of the needle touches the intercostal nerve. If the patients can not get the required sensation, the needle should be withdrawn to the subcutaneous level and changed to other direction rather than kept going deeper.

Case study

Male 45 years

Distending pain in the hypochondrium for 3 days

The patient suffered from distending pain in the hypochondrium after arguing with one of the colleagues. The symptom got worse in the following two days accompanied with poor appetite, preference for sighing, diarrhea and distention in upper abdomen. It is usual for him to be impatient and easy to get angry.

Examination: Pale red tongue with thick white coating. Wiry pulse

Diagnosis: distending pain in the hypochondrium

Differentiation: Stagnation of liver Qi and invasion of spleen

Points: Main point: Zhangmen(LR13) supplementary points: Yinlingquan(SP9), Taichong(LR3)

Method: Insert the needle to Zhangmen(LR13) perpendicularly with the depth of 20mm. Rotate the needle forward and backward continuously with small amplitude until the patient felt distention around the point. Twirl the handle of the needle 3 times with the thumb and index finger and then separate them quickly to strengthen the needling sensation. Lift the needle to the subcutaneously level and then thrust it obliquely backward along the 11th rib with the depth of 40mm. The tip of the needle got into the layer of muscle. There was a sensation of electric numbness spreading over the rib. Withdraw the needle without retaining. The patient felt relaxed at hypochondrium and upper abdomen at once.

To elevate the curative effect, apply reinforcing manipulation to Yinlingquan(SP9) and reducing one to Taichong(LR3) by lifting and thrusting method.

The patient accepted treatment once a day. All symptoms disappeared after three sections.

2.7Riyue(GB24)

Riyue(GB24) is directly below the nipple, in the seventh intercostals space, 4cun lateral to the anterior midline. Main indications of this point include pain in the hypochondriac region, vomiting, acid regurgitation, hiccup, jaundice, mastitis, and so on.

This point may be punctured obliquely 15mm to treat disorders of liver and gallbladder. Regarding to intercostal neuralgia, the needle may be inserted subcutaneously along costal margin with the depth of 20-25 mm. Deep insertion is not allowed to avoid hurting important internal organs in the deep level. Rotating needle with small amplitude may be applied to this point gently. Flying technique is often employed to strengthen the needling sensation. Patients often feel aching and tingling as needling sensation.

Case Study

Male 31 years

Intercostals neuralgia for 2 months

Sharp burning pain moving along the 7th intercostal space of left side after getting common cold. Pain intensified at night, by pressure, and on moving arm.

Examination: purple tongue with white coating, deep pulse

Diagnosis: intercostals neuralgia

Differentiation: hypochondrium pain due to blood stasis

Point: Riyue(GB24) of left side

Method: Insert the needle subcutaneously along costal margin with the depth of 25 mm. Hold the needle handle with the palmar surface of the thumb and radial surface of the middle finger. Twist the needle with the help of the bending and stretching movement of the metacarpophalangeal joint of the middle finger slowly but continuously for 2 minutes per time and repeat this manipulation 2-3 times during retaining period. Retain the needle as long as 45 minutes. Patients may feel strong aching and soreness spreading at the intercostal space.

3. Conclusion

As for the abdomen points, depth of insertion is the difficulty of acupuncture. Too deep insertion may increase the risk of hurting important internal organs. On the other hand, it can not achieve the required curative effects provided the insertion is too shallow. Because the suitable depth is different from person to person, operators need to pay more attention to the feeling under the needle instead of figurers stated in the books. Mastery of local anatomy and recognition of needling different kinds of tissues are the preconditions of operators’ successful treatment.

Another tip of needling points on abdomen is thrusting the needle slowly, which allows operators to taste the feeling under the needle carefully. More importantly, it gives time to some internal organs especially the stomach and intestines to escape the tip of the needle spontaneously by peristalsis after stimulation. Therefore to avoid stabbing internal organs, insertion on abdomen points need to be very slow and careful.

The inquiring of anamnesis and percussion by doctors are necessary as well before selecting abdomen points for avoidance of injury and accident. For example, points on lower abdomen are not suitable for women who have been pregnant for more than three months. Doctors need to be very cautious to use upper abdomen points for patients of hepatomegaly or splenomegaly. Percussion of urinary bladder is required for patients of retention of urine before needling lower abdomen points.

At last, not all abdomen points can be discussed here, but adjacent points have the similar needling methods according to their similar regional anatomy and therapeutic functions. Therefore, the methods and ideas mentioned above for each point may be applied to neighboring points by analogy.