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Title: Deqi and associated physiological changes
Authors: Yu, Tai Wai David
Degree: Ph.D.
Issue Date: 2014
Abstract: Acupuncture has been widely used in China for thousands of years. One of the fundamental characteristics of acupuncture is "obtaining qi" during acupuncture, known as deqi. Based on Traditional Chinese Medicine (TCM) concepts, qi must flow in appropriate strength and quality along body meridians so that health can be maintained. It is believed that the flow of qi can successfully be altered by the acupuncture technique only if deqi is elicited during the technique. There are a number of studies in Western medicine that have attempted to quantify deqi sensations. The Massachusetts General Hospital Acupuncture Sensation Scale (MASS) appears to be the most comprehensive assessment tool in measuring/reporting needle sensations. However, the validity and reliability of MASS have not been properly established. Furthermore, MASS is an English instrument and the precise Chinese terms that best describe the deqi sensation in the Chinese population have not been determined. Therefore, the first aim of this doctoral thesis is to establish and validate a Chinese version of the MASS and to test its psychometric properties. The first study was a methodological and exploratory study. The English version of MASS was first translated into Chinese using standardized forward-backward translation procedures. Content validity was conducted by 9 experts in acupuncture. The "pre-final" Chinese version of MASS (C-MASS) was then administered to 30 acupuncture-naive healthy subjects. Electroacupuncture was then performed on the right Hegu (LI4) and Quichi (LI11) for 30 min. Test-retest reliability measurement was administered again 1-2 weeks later. Construct validity was examined by comparing the C-MASS and the Short-form McGill Pain Questionnaire (SF-MPQ). The construct validity was further assessed by the principle component analysis. Results of this study showed that the C-MASS demonstrated a content validity ratio on relevance and importance which ranged from -0.04 to 1.00. Convergent validity was demonstrated by its significant association with the sensory dimension of the SF-MPQ (γ=0.63, p<0.05). Discriminant validity was demonstrated by its low association with the affective dimension of the SF-MPQ (γ=-0.3, p=0.111). A five-factor structure for the C-MASS was established by factor analysis. The C-MASS had good internal consistency (Cronbach's α = 0.71) and test-retest reliability (ICC= 0.92). Further analysis of the structure suggested that the descriptor "sharp pain" was not related to deqi sensations and was therefore deleted from the inventory. A new instrument, namely, the Modified Massachusetts General Hospital Acupuncture Sensation Scale Chinese version (C-MMASS), was compiled. Reports on the relationship between deqi intensity and changes in autonomic nervous system (ANS) activity are scanty. The second study in this doctoral thesis therefore aims to investigate modulation in the ANS (as reflected by changes in heart rate variability) and cardiovascular changes associated with deqi and to determine any relationship that might exist between deqi intensity and such changes. This second study was a single blinded, randomized, placebo, controlled trial. Thirty-six subjects (19 males), aged 34.5±4.6 years, were randomly assigned to Group 1 - electro-acupuncture at 2 Hz, 0.4 ms to right LI4 and LI11 for 30 min.; Group 2 - electro-acupuncture stimulation to bilateral knee caps; or Group 3 - sham electro-acupuncture to right LI4 and LI11 but over Duoderm® pads. Heart rate (HR), mean arterial blood pressure (MAP) and heart rate variability by low/high frequency spectral analysis (LF/H/F) were recorded 5 min before, during and 5 min after the intervention. Needle sensations were quantified by C-MMASS, and the C-MMASS index was computed. Results of this second study showed that there was a significant increase in LF/HF, MAP and HR in Group I. A small and significant increase in LF/HF was observed in Group 2 but the changes in MAP and HR in Group 2 and 3 were not significant. The C-MMASS index was highest in Group 1 (5.3± 1.3), moderate in Group 2 (3.5±0.7) and lowest in Group 3 (0.77±0.2). A positive correlation between the deqi intensity and changes in LF/HF, MAP and HR was observed. This study suggests that during the electroacupuncture procedure, deqi is associated with changes in cardiovascular parameters and the deqi intensity increases with an increase in sympathetic discharge of the ANS. While positive effects of acupuncture have been acknowledged by many studies, adverse effects associated with the application of acupuncture have also been reported. These include transmission of infectious disease, organ puncture such as pneumothorax, cardiac tamponade, and broken needles with remnants migrating to other locations. Therefore, non-invasive techniques including acupressure and laser acupuncture, have become "safer" alternatives. Recently the application of Transcutaneous Electrical Nerve Stimulation over Acupoints (Acu-TENS) was reported in association with improved clinical outcomes. Whether Acu-TENS is associated with acupoint sensations similar to deqi experienced during acupuncture, has not been investigated. The third study therefore investigates whether acupoint sensations were experienced during Acu-TENS and whether such sensations were associated with any concomitant changes in ANS activity. The third study was a single blinded, randomized, controlled trial. Thirty-six healthy subjects were randomly assigned to either Experimental Group (Acu-TENS on LI4 and LI 11); Control Group (Acu-TENS to bilateral knee caps); or Placebo Group (Sham Acu-TENS on right LI4 and LI11). Results of this study demonstrated that subjects in the Experimental Group showed significant increase in HR (73.5±6.3 to 75.9±6.7 bpm, p=0.027), MAP (88.5±4.5 to 91.0±4.1 mmHg, p=0.004), SDNN (l43.36± 8.58 to 153.69± 7.64 ms, p=0.002) and LF/HF (1.26±0.19 to 1.31±0.21, p=0.037) during the intervention. The Control Group showed significant increase in SDNN (140.21±8.72 to 143.39±9.47ms, p=0.009) and LF/HF (1.21± 0.09 to 1.23±0.12, p=0.033). There were no significant physiological changes in Placebo Group. Overall C-MMASS index for Experimental, Control and Placebo groups were 3.23±0.3, 2.14±0.6 and 0.29±0.32 respectively. Between-group difference was statistically significant (F=139.24, df=2, p<0.05). However, correlation analysis did not support any association between sensation intensity and cardiovascular response in any groups (γ ranged from -0.36 to 0.25). This study therefore confirmed that "acupoint sensations" were experienced when Acu-TENS was applied to LI4 and LI 11 but such sensations were not associated with cardiovascular changes in response to the stimulation.
Acu-TENS applied to the acupoint Dingchuan has been reported to be effective in reducing dyspnoea sensation and improving forced expiratory flow in 1 second (FEV1) in patients with COPD and asthma. The relationship between Acu-TENS, deqi, and induced autonomic responses has not been reported. It was unclear whether the reported effects of Acu-TENS over Dingchuan in patients with COPD or asthma were associated with deqi or sympathetic modulation. The last project in this thesis therefore presents a case study on the application of Acu-TENS over LI4 and LI11 (acupoints that influence autonomic activity), in two patients with COPD; one emphysema predominant and the other asthma. The specific aim of the case study is to see whether Acu-TENS over LI4 and LI11 has any effect on FEVI, deqi (acupoint sensation) and autonomic nervous system activity modulation. The last project involved application of TENS to LI4 and LI11 for 45 minutes in two patients. One diagnosed with COPD but predominant with emphysema (Patient A) (male, 67 years old) and the other with predominant asthma characteristics (Patient B) (male, 65 years old). Both patients attended the laboratory three times, two weeks apart. At each visit, spirometry lung function assessment, 6 minute walk test (6MWT), resting heart rate, blood pressure, respiratory rate and Sp02 were recorded, and BODE index was computed. At the second visit, Acu-TENS was applied over LI4 and LI11 for 45 minutes. During the intervention, heart rate (HR) was monitored continuously. At 5 minute intervals, mean arterial blood pressure (MAP) and heart rate variability [low/high frequency (LF/H/F) and standard deviation of the NN interval (SDNN)] were computed. Immediately after Acu-TENS, patients were asked to complete C-MMASS for quantification of the acupoint sensations during the electrical stimulation and the C-MMASS index was computed. Results of this observational study showed that Patient A demonstrated an increase in 6-minute walk distance (6MWD) by 10.3% and an increase in FEV1 by 5.3%. MAP was elevated throughout the intervention period but heart rate and the SGRQ-HK score and remained unchanged. Analysis of heart rate variability showed that LF/HF ratio increased by 10.5% and maintained an increase of 3.9%, at 5 minutes after stimulation. SDNN increased by 11.6% and remained raised by 6.1 % until the end of the intervention. The overall C-MMASS score was 3.34. For Patient B, the increase in 6MWD was by 14.1% and increase in FEV1 was nearly 9.3%. Effects on SGRQ-HK score, HR and MAP were similar to Patient A. LF/HF ratio increased by 8.2% and remained elevated by 3.5% after stimulation, and SDNN increased by 8.8% and remained 1.9% above baseline after Acu-TENS. The overall C-MMASS was 3.59. There were no overall changes in BODE Index and SGRQ-HK scores. While data were only from 2 patients, therefore, the results are far from conclusive. Further studies with larger sample size and inclusion of control groups are necessary for meaningful investigation of the role of Acu-TENS and its associated mechanisms in the management of patients with COPD. In summary, the work involved in this thesis included development of a valid and reliable Chinese version of an international tool to quantify deqi sensations; further work then showed that acupuncture to LI4 and LI11 increased sympathetic ANS activity and deqi was positively correlated with such physiological changes. Furthermore, application of a non-invasive modality Acu-TENS to LI4 and LI11 suggested that Acu-TENS is associated with increase in autonomic activity, but the acupoint sensations experienced are not associated with such responses. Lastly, clinical application of Acu-TENS to patients with COPD showed improved FEV1 and 6MWD after 45 minutes of Acu-TENS, associated with increase in ANS activity. The work on this thesis suggests that the role of Acu-TENS in patients with COPD warrants further investigation.
Subjects: Acupuncture.
Acupuncture -- Evaluation.
Hong Kong Polytechnic University -- Dissertations
Pages: xxviii, 169 leaves, 73 variously numbered leaves : color illustrations ; 30 cm
Appears in Collections:Thesis

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