•Infection prevention and control is an essential consideration for TCM practitioners when providing patients with safe health care services.

Pathogens Relevant  to Acupuncture Practice

•Hepatitis A – contact Food or drink

•Hepatitis B -- blood and other body fluids  

•Hepatitis C -- contaminated blood

•Tuberculosis-- breathing in droplets

•AIDS-- blood and other body fluids

•Influenza-- breathing in droplets

•Skin Infections-- broken skin

Hand Hygiene

•Hand washing should be done:

· before and after patient contact or acupuncture treatment;

· when hands are contaminated during the treatment;

· immediately after inadvertent exposure to blood or body fluids;

· after contact with environmental surfaces or equipment;

· after removing gloves;

Hand Washing Procedure

•Remove any hand or wrist jewelers and avoid use of artificial nails. Follow these 6 steps when hand washing.

•1. Wet your hands in warm running water.

•2. Apply sufficient liquid soap to achieve lather.

•3. Wash all surfaces of your hands including backs of hands, fingertips, between fingers, wrists, base of thumbs, and around and under fingernails. Scrubbing should last approximately 15 seconds.

•4. Rinse well and leave water running.

•5. Dry thoroughly with a disposable paper towel or electric hand dryer.

•6. Turn off the water with the towel, and not with your bare hands.

Establish a Clean Field

•Use a metal tray or clean paper towel:

• Ensure area for supplies is clean, lay out the clean field without contaminating it.

• Place only clean supplies in field, set out needles, cotton balls. lay out an appropriate number of needles for the procedure without contaminating the site or the needles. Sterile needles must not be placed on a non-sterile environment (e.g., tray, cotton).

• Touch clean supplies only with clean hands

• The waste bag and sharps container must be established in an area away from the clean field.

Safe Handling and Disposal of Sharps

•Use only sterile disposable needles

•Sharp Container must be:

• Puncture resistant

• Leak proof

• Designed to allow sharps to be easily deposited, but difficult to remove

• Designed with a secure lid and handle for carrying

• Clearly marked “Biohazard” with easily identifiable symbol

• Large enough to hold all sizes of sharps

Size

Width

Length

■Width x length (in mm)

■ EXAPLE: 0.20X30, 0.25X30, 0.25X40

Management of Possible Accidents

Fainting:

Cause:

This is often due to nervous tension, delicate constitution, hunger, fatigue, improper position or to the too forceful manipulation.

Manifestations:

During acupuncture treatment. there may appear dizziness, vertigo, palpitation, short breath, nausea, pallor, cold sweating, weak pulse. In severe cases, there may be cold extremities, drop of blood pressure, and loss of consciousness.

Management:

When fainting aurae such as dizziness, vertigo and nausea appear, stop needling immediately and withdraw all the needles. Then help the patient to lie down and offer him some warm or sweet water. The symptoms will disappear after a short rest. In severe cases, press hard with the fingernail GV 26, PC 9, PC 6 and ST 36, or apply moxibustion to DU 20, Ren 6 and Ren4.

Generally, the patient will respond, but if not, other emergency measures should be taken.

Prevention: 

Avoid needling patient when their hunger or fatigue, not to forceful manipulation the needles.

Stuck needle

Cause:

This may arise from nervousness, strong spasm of the local muscle after the insertion of the needle, twirling the needle with too large amplitude or in one direction only, causing muscle fibers to bind, or from a change of the position of the patient after the insertion of the needles.

Manifestations:

After the needle is inserted, it is found at times difficult or impossible to rotate, lift and thrust the needles.

This situation is known as stuck needle.

Management:

Ask the patient to relax.

If the needle is stuck due to excessive rotation in one direction, the condition will release when the needle is twirled in the opposite direction.

If the stuck needle is caused by the tension of the muscle temporarily, leave the needle in place for a while, and then withdraw it by rotating, or by massaging the skin near the point or by inserting another needle nearby to transfer the patient's attention.

If the stuck needle is caused by the changing of the position of the patient, the original posture should be resumed and then withdraw the needle.

Prevention:

Sensitive patients should be encouraged to release their tensions.

Avoid the muscle tendons during insertion.

Twirling with too large amplitude or in one direction only shall in no case be allowed.

In the process of manipulation, the posture of the patient should remain original.

Bent needle

Manifestations:

It is difficult to lift, thrust, rotate and withdraw the needle. At the same time, the patient feels pain.

Cause:

This may result from unskillful manipulation or too forceful manipulation, or the needle striking the hard tissue, or a sudden change of the patient's posture for different reasons, or from an improper management of the stuck needle.

Management:

When the needle is bent, lifting, thrusting, and rotating shall in no case be applied. The needle may be removed slowly and withdrawn by following the course of bend. In case the bent needle is caused by the change of the patient's posture, move him to his original position, relax the local muscle and then remove the needle. Never try to withdraw the needle with force.

Prevention:

Perfect insertion and gentle manipulation are required. The patient should have a proper and comfortable position. During the retaining period, change of the position is not allowed.

Broken needle

Cause:

This may arise from the poor quality of the needle or from too strong manipulation of the needle, from strong muscle spasm, or a sudden movement of the patient when the needle is in place, or from withdrawing a stuck needle.

Manifestations:

The needle body is broken during manipulation and the broken part is below the skin surface.

Management:

When it happens, the patient should be asked to keep calm to prevent the broken needle from going deeper into the body.

If the broken part protrudes from the skin, remove it with forceps or fingers.

If the broken part is at the same level of the skin, press the tissue around the site until the broken end is exposed, then remove it with forceps.

If it is completely under the skin, surgery should be resorted to.

Prevention:

To prevent accidents, careful inspection of the quality of the needle should be made prior to the treatment.

The needle body should not be inserted into the body completely, and a little part should be exposed outside the skin.

On needle insertion, if it is bent, the needle should be withdrawn immediately. Never try to insert a needle with too much force.

Hematoma

Cause:

This may result from injury of the blood vessels during insertion, or from absent pressing of the point after withdrawing the needle.

Manifestations:

Local swelling, distension and pain after withdrawal of the needle.

Management:

If the local swelling and pain are serious, apply local pressing, or light massage, or warming moxibustion to help disperse the hematoma.

De Qi (Qi sensation) AND MANIPULATIONS 

Normal reaction of needles/ De Qi

De-Qi, also known as arrival of qi (acupuncture sensation)

a commonly experienced sensation of warmth, tingling or tightness, numbness, mild electrical shooting sensation that last for seconds, distension, soreness. These are all good sensations of de Qi.

It should be noted that all needles, can cause pain when a nerve ending, or blood vessel is contacted during insertion. If the patient complains of sharp pain, remove the needle slightly and or change the angle of the needle.

Manipulation to help get Qi

After the insertion of the needles, in order to promote Qi Sensation, certain manipulating techniques are used.

The basic manipulating techniques include lifting-thrusting techniques and rotating techniques.

Manipulation of the needle refers to use of various needling techniques to promote De-Qi, regulate De-Qi and perform reinforcing/tonify and reducing manipulations.

1 . Lifting and thrusting techniques

Method

The needle pushed from the shallow region to the deep region is called thrusting and from the deep region to the shallow region is called lifting.

Such a repeated manipulation of the needle is known as lifting-thrusting techniques.

2. Rotating techniques

Method

When inserted into acupoint, the needle is rotation repeatedly forward and backward in the acupoint; This technique is called rotation.

•Skin scraping therapy

•Gua – (to scrape or rub) 

•Sha – (the reddish raised petechiae -subcutaneous hemorrhage- that appear under the skin after application).

Clinical Applications

• Strongly Moves Qi and Reduce Blood stasis -- Musculoskeletal pain

• Alleviates fever due to external pathogenic factors -- Acute respiratory illness (common cold, flu, bronchitis, asthma)

Contraindications

•Avoid local treatment to acute inflammatory injuries.

•Do not scrape over sun burn, rash, lesions, or previous sha that has yet to heal.

•Avoid the sacrum and abdomen of pregnant patients.

Precautions and Contraindications in Acupuncture Treatment 

1) It is advisable to apply few needles or to delay giving acupuncture treatment to the patients who are hungry, over fatigued or very weak.

2) It is contraindicated to puncture points on the lower abdomen and lumbosacral region for women pregnant less than three months. After three months pregnancy it is contraindicated to needle the points on the upper abdomen and lumbosacral region. 

Points causing strong sensation such as Hegu (LI4), Quepen(ST12), Sanyinjiao (SP6), Kunlun (BL60), Jianjing (GB21), Contraindication for women pregnant.

3) Points on the vertax of infants should not be needled when the fontanel is not closed. In addition, retaining of needles is forbidden since the infants are unable to cooperate with the practitioner.

4) Needling should avoid the blood vessels to prevent bleeding. 

5) Dangerous Points:

Points are located close to the eyeball. Points are located close to Vital organs. Points are deeper are close to spinal canal.

see Appendix 1-safety_program_handbook) On CTCMA website

6) No needle on ST17 and Ren8

Needles:

The three-edged needle is developed from the lance needle of the Nine Needles created in the ancient times.

The needle is shaped in a round handle, a triangular head and a sharp tip.

Blood Lancets more used now.

Indications:

promote the smooth flow of qi and blood in meridians, dispel blood stasis and eliminate the heat.

It is advisable to treat blockage of the meridians, blood stasis, excess syndrome and heat syndrome, such as high fever, loss of consciousness, sore throat.

Precautions:

I) Sterilize the needles and the local area to be treated is applied to prevent infection.

2) Avoid injuring the deep large arteries.

3) Caution with hemorrhagic patients or people taking blood thinner medications.

Tonification (Bu) and Reduction (Xie) Techniques

Tonification (Reinforcing):

To strengthen immunity and invigorate weakened physiological function.

Reduction (Sedation):

To eliminate pathogenic factors and harmonize hyperactive physiological functions.

1. by lifting and thrusting

When Qi is obtained after insertion, the needle is manipulated from the shallow region to the deep region with more thrusting and less lifting as well as repeatedly heavy thrusting and gentle lifting. This is the strengthening technique, thrusting as the main technique.

2. by rotation

•Method

•Clockwise (Left rotation) of the needle, with the thumb pushing forward and the index finger backward, means strengthening

 Contraclockwise (Right rotation) of the needle, with the thumb pushing backward and the index finger forward, means reducing

3. by speed

•Method

•Slow insertion and quick withdrawal means strengthening.

• While quick insertion and slow withdrawal means reducing

4. by confrontation and following

•Method

the tip of needle following the meridian route to nourish qi means strengthening.

The tip confronting the meridian route to reduce means reducing

5. according to respiration

•Method

•To insert or rotate the needle in the exhalation of the patient and to withdraw the needle in the inhalation means strengthening.

The opposite practice means. reducing

6. Nine-Six strengthening and reducing techniques

•Method

•Six means reducing

•Nine strengthening.

• Less number of needles for tonify, more number of needles for  reducing.

9. Needles retention time

Even techniques

•Method

Cups:

• In ancient times, animal horns were used.

•Bamboo, glass, ceramic, iron and brass 'cups' were developed today, cups made of glass or bamboo are by far the most common.

•They are available in many sizes and selected according to the skin surface and method of treatment.

Indications:

• Expels Wind-Cold invasion

• To move Qi and Blood

Methods of Cupping:

•Fire Fixed cups: Light an alcohol (90-99%) -soaked cotton ball and wave it inside a tempered glass cup 1-3 times with forceps. Quickly place the cup on the skin.

•Moving cups: Apply oil or lubricant, then place cups on the skin. Moving the cups along a channel strongly moves Qi and Blood.

Precautions:

• Avoid skin lesions, severe edema, and painful inflammation

• Avoid the sacrum and abdomen of pregnant patients

• Cupping should not be administered to patients experiencing high fever, convulsions.

Attention:

•Cupping may cause mild bruising, redness and some local tenderness for several days. Patients must agree, prior to cupping, to the likelihood of skin marks.

•Blisters may appear if the suction was too strong or left on too long. Normally cup keep 10 to 20 minutes in same location. While not dangerous, they may be uncomfortable or itchy.

•Cups should be washed in warm soapy water after treatment. If the cups come in contact with blood or body fluids, be sure to soak the cups in bleach over night, and then bake in a hot oven for an hour before using on another patient.

The dermal needle is also known as the plum-blossom needle and seven-star needle, which is made of five to seven stainless steel needles inlaid onto the end of a handle.

It is used to prick the skin superficially by tapping to promote the smooth flow of qi in the meridians and regulate the functions of the zang-fu organs.

Indications: 

This superficial tapping is particularly suitable to treat disorders of the nervous system and skin disease.

It is used for headache, dizziness and vertigo, insomnia, gastrointestinal disease, skin disease, painful joints and paralysis.

Precautions:

1) The tips of the needles should be even and free from any hooks. On tapping, the tips of the needles should strike the skin at a right angle to the surface to reduce pain.

2) Sterilize the needles and the local area to be treated. After heavy tapping, the local skin surface should be cleaned and sterilized to prevent infection.

3) Tapping is not allowed to apply to the local trauma and ulcers.

• As far back as many thousands of years ago, there is mention of auricular acupuncture points  Huang Di Nei Jing.

•Historically, only a few points were recorded in the Chinese classical text, whereas today almost any condition can be treated solely using auricular techniques.

• Sympathetic:

It is located on the inner part of the helix, meet with inferior crus. 

•Function:

•This point balances sympathetic nervous system.

It improves blood circulation by corrects irregular or rapid heartbeats, reduces angina pain, reduces visceral pain from internal organs, and calms smooth muscle spasms.

•It is also used for the treatment of kidney stones, gall stones, gastric ulcers, asthma and dysfunctions of the autonomic nervous system.

Kidney point: on the lower border of the inferior antihelix crus, in the ear’s center. 

Liver Point: Found along the inside ridge of antihelix, near the ending part of crus helix.

Heart Point: on the center of Cavum Concha.

Lung Point: Tow points Located on Cavum Concha, one above and one below the heart points. 

NADA Protocol

•Reduced cravings for alcohol and drugs, including nicotine

•Minimized withdrawal symptoms

•Increased calmness, better sleep, and less agitation

•Relief from stress and emotional trauma

Moxibustion (“Moxa”) has been an integral part of Traditional Chinese Medicine. The Chinese word for acupuncture (“zhen jiu”) contains both the word for needle (zhen) and moxibustion (jiu).

Characteristics of the Plant

Mugwort (Ai Ye) is pure yang in nature. It is bitter and acrid, with a spicy fragrance, Primarily burned over the skin and acupuncture points to expel cold and restore yang, encourage the flow of Qi in the meridians, and relax the sinews.

Indication:

Disperses Cold, tonifies Yang Qi, and alleviates pain

Stimulates blood circulation (especially stubborn stasis that acupuncture alone cannot resolve)

Direct Methods

Cone or rice grain-size moxa is placed over the area, and then lit with incense. The loose moxa cone is taken off before the embers touch the skin (non-scarring) or left to burn to the skin (scarring moxa), which is thought to stimulate the release of immunological mediators resulting in a prolonged healing reaction.

Direct methods strongly penetrate the skin, used for deeper pathologies, such as abdominal, visceral, or joint problems.

Indirect Methods

Moxibustion is commonly applied indirectly, without contacting the skin.

Stick moxa supplies infrared heat to the skin around acupuncture points.

Moxa Box, Raised over the skin, and with a built-in heat filter, the Moxa Box provides prolonged gentle heat to a broad area.

Barriers of salt, garlic, ginger, or other herb that absorbs some of the heat and transports some healing substances from the herbs.

Needle Moxa (Warming Needles) is put moxa bar on the tail of the needles, the moxa is then ignited from the side closest to the skin.

Guidelines for Treatment

Moxa is best used for treating chronic or cold conditions and is preferred over acupuncture for severely deficient patients.

In general, stick moxa is performed for 10-15 minutes (though hour-long treatments are possible), or 3-7 cones of direct moxa is applied at each point during an acupuncture treatment.

Frequently Used Channels & Points:

• The Ren, Du, and UB channels are most frequently used.

• Other common points used with moxibustion include: St 36, and Sp 6

 The scalp acupuncture have been in use for the last 30 years.

 Using modern brain mapping, reflex zones on the scalp influence motor, sensory, and functional regions of the brain.

 In this way, specific areas of the body can be targeted, and CNS pathologies can be treated (occasionally with mild electrical currents)

Indications:

 Disorders of the central nervous system

 Stroke or brain damage

 Acute and chronic pain

 Motor and/or sensory nerve deficiency (paralysis, numbness)

 Psychosomatic disorders (dementia, developmental disorders)

 Vestibular disorders (poor balance, vertigo)

Cautions:

 Use gentle stimulus with e-stim

 Do not use on patients with very high blood-pressure (220/120),

 local infection,

 on infants whose fontanels have not yet closed.

 May induce miscarriage

Standard Scalp Lines:

The Scientific Group considered the scalp acupuncture lines as well as the underlying functional zones of the brain.

It proposed the following nomenclature, using the alphabetic code MS (derived from “micro-system” and “scalp point”).

 MS1 to MS14

Electrical Stimulation

Developed as a way to provide continuous stimulation to acupuncture points without the use of manual manipulation.

Electrical acupuncture, or “e-stim”, is beneficial for chronic pain, muscle spasm, and paralysis.

Indications:

• Chronic pain

• Muscle spasms

• Paralysis