A New Explanation of Needle Sickness: A Special Reaction

to Obtaining Qi

Shuang Liu Jiangxue Zhou Jilin Wang Yingxia Sun

Abstract: In this paper, we analyze the implications and extensions of the concept of needle sickness ［i.e., fainting during acupuncture treatment］ by combing through ancient and modern literature on needle sickness and combining it with clinical practice. 〖JP2〗We propose that needle sickness is a common reaction to acupuncture stimulation when the body is in a state of “spirit-qi vacuity” (subpar physical and mental states such as hunger, fatigue, and mental tension). It should be regarded as a special reaction to gaining qi. This change in understanding will certainly have a significant impact on clinical practice.

Keywords: Needle sickness; concept of needle sickness; obtaining qi; conceptual research

Needle sickness ［i.e., fainting during acupuncture treatment］ is a commonly observed response to needling in the clinical practice of acupuncture. Various editions of textbooks and research studies on this subject classify needle sickness as an abnormal response to acupuncture needling^{［1-2］ ［3］}. Needle sickness is considered to fall within the scope of acupuncture needling safety issues and is defined as an adverse event, adverse reaction^［4］, acupuncture incident, or acupuncture accident. Most sources take a negative stance and state that this reaction should be avoided if possible. Modern research tends to focus on describing the causes and manifestations of needle sickness, as well as how to handle it, with very little exploration of the link between needle sickness and treatment effects. A literature search revealed that as early as the Qing dynasty, Li Shouxian’s text Zhenjiu Yixue ［Easy-to-Learn Acupuncture and Moxibustion］ explicitly stated that “［a patient who experiences］ needle sickness will definitely have a great ［treatment］ effect”, but this did not attract enough attention. In recent years, there have been numerous reports of enhanced treatment effects after needle sickness and the viewpoint that needle sickness has synergistic effects has been discussed multiple times by different scholars. In 2004, Professor Greenwood proposed that the synergistic effects of needle sickness would trigger a major revolution in empirical knowledge.^［5］

Implications of the concept of needle sickness

Ancient and modern understandings of the concept of needle sickness

Needle sickness is defined as the phenomenon of fainting during the process of acupuncture needling, and its clinical manifestations may be either mild or severe. Mild needle sickness manifests with lassitude of essence-spirit, dizziness, and nausea with a desire to vomit. Severe needle sickness manifests with flusteredness, shortness of breath, a somber white facial complexion, cold sweat, and a fine and weak pulse; there may even be symptoms like coma, green-blue or purple lips and nails, a drop in blood pressure, fecal and urinary incontinence, and a faint pulse verging on expiry^［1］. Early literature describes the manifestation of needle sickness as “collapse”; for instance, chapter 10 of Lingshu ［The Magic Pivot］, entitled “Channel Vessels”, states: “［when］ draining … then ［there is］ collapse”. The text Jin Zhen Fu ［Ode to the Golden Needle］was the first to use the term “needle sickness”, saying that “one who ［experiences］ needle sickness ［has］ spirit-qi vacuity”. This text considers the root cause of needle sickness to be a state of “spirit-qi vacuity”. Scholars outside of China have referred to needle sickness using terminology such as needle shock, acupuncture syncope, reflex syncope, vasovagal syncope, vasovagal shock, or vasomotor reflex［7］. It is clear that many scholars outside of China endorse the idea that needle sickness is a vasovagal response, but there is some disagreement regarding the specific clinical manifestations, as they use terms like “syncope”, “shock”, and “reflex” to define needle sickness. Ancient and modern understandings of the causes of needle sickness are essentially the same; it is mainly associated with the state of the patient’s body (subpar physical and mental states such as hunger, fatigue, and mental tension) and excessively vigorous manipulation by the practitioner.

Elaborating upon the concept of needle sickness

Most editions of textbooks and authoritative dictionaries define needle sickness as the phenomenon of syncope during the course of acupuncture needling (see Table 1); only Zhonghua Yixue Baike Quanshu ［The Chinese Medical Encyclopedia］defines it as a series of symptoms. While the objectives of the former differ from those of the latter, the former texts also provide descriptions of other clinical manifestations of the needle sickness reaction in later passages, so they actually confirm that the needle sickness reaction is a series of symptoms. In addition, mild needle sickness reactions are more commonly seen in clinical practice, while those that manifest with “syncope” are relatively rare; a literature search only found a handful of reports on the latter reaction^［12］and there were no reports of severe adverse consequences caused by needle sickness^［13］. The 2017 edition of Yixue Baike Quanshu ［The Chinese Medical Encyclopedia］^［11］defines needle sickness as a series of symptoms that include dizziness, nausea, sweating, and even fainting, thereby emphasizing the variable and concurrent nature of needle sickness symptoms while also clarifying that there are mild and severe cases. In the same year, Christensen et al.^［7］ proposed that the use of terminology such as “syncope” and “shock” to describe needle sickness is not sufficiently accurate and may even be an overexaggeration, as these terms can cause patients to feel anxious and fearful. Therefore, the authors of the present work believe that definitions of needle sickness should include the clinical manifestations of at least 2 different levels of severity, namely the dizziness and nausea of mild needle sickness reactions and the flusteredness, cold sweat, and fainting of severe needle sickness reactions. Moreover, the objective should be to convey that there is a series of symptoms or reactions. Modern research has proven that there is a strong correlation between the causes of needle sickness and the state of the patient’s body. Scholars have used methods from evidence-based medicine to summarize 348 cases of needle sickness; in 347 of these cases, the needle sickness was caused by subpar mental or physical conditions, and only 1 was caused by excessively vigorous manipulation^［14］. The authors believe that the strength of needle manipulation is a relative concept with a certain degree of individual variation, so there is no way to correctly define gentle or vigorous manipulation; thus, there is a certain degree of relativity regarding excessively vigorous manipulation as a cause. In light of this, the present paper proposes that internal causes due to the state of the patient’s body at the time play the leading role.

Surveying ancient and modern literature, there is significant disagreement on whether or not to remove the needles when responding to needle sickness. Ancient literature, represented by Zhenjiu Dacheng［The Great Compendium of Acupuncture and Moxibustion］, emphasizes that one must not remove the needles after needle sickness occurs; the chapter entitled “Draining and Supplementing ［Techniques］ of Li from Nanfeng”^［15］states: “for all ［cases of］ needle sickness ［…］ ［one］ must not remove the needles ［…］ removing the needles will harm the patient”. This text claims that removing the needles after needle sickness will further exhaust the qi and cause severe adverse consequences that will “harm the patient”. In contrast, modern literature such as Zhenjiuxue ［The Study of Acupuncture and Moxibustion］and authoritative dictionaries claim that one must immediately remove the needles after needle sickness occurs. The reason for this disagreement may be due to a difference in focus; the ancients paid more attention to the effects of needling in cases of needle sickness and believed that removing the needles would affect the treatment results, so they adopted practices such as not removing the needles and “needling the frog flesh ［i.e., the prominence of the bicep muscle］”. Meanwhile, in modern times people are more concerned about the patient’s physical state of discomfort, so they remove the needles to eliminate this state; this serves to stop the needle stimulation and enables the patient to rest in an appropriate position.

Another noteworthy issue is the fact that none of the aforementioned dictionaries and textbooks mentioned the link between needle sickness and treatment effects, ignoring the potential harm or benefit that needle sickness may contribute to the clinical efficacy of the treatment. Their stance on needle sickness is restricted to the attitude of patients towards needle sickness, so they take a negative view of the phenomenon (see Table 1).

Table 1. Concepts of needle sickness

Extensions of the concept of needle sickness

Comparison of needle sickness and abnormal responses to acupuncture needling

Various editions of Zhenjiuxue［The Study of Acupuncture and Moxibustion］and Cifa Jiufa Xue ［The Study of Needling and Moxibustion Methods］classify the phenomenon of needle sickness as an abnormal response to acupuncture needling. An abnormal response, as opposed to a normal one, implies that this type of situation happens relatively rarely in acupuncture treatments. Aside from needle sickness, this type of situation includes stuck needles, bent needles, broken needles, hematoma, puncturing internal organs, puncturing the cerebrospinal tract, and peripheral nerve injuries. Among these, needle sickness, stuck needles, bent needles, and hematoma are relatively common; if treated in time, patients can typically recover from these conditions on their own, so they present less of a hazard to patients. A stuck needle can also be used as part of a special technique to treat soft tissue disorders. Puncturing internal organs, puncturing the cerebrospinal tract, and peripheral nerve injuries tend to cause adverse effects and present a more serious hazard to patients, and the majority of these situations are caused by inappropriate needling practices. While both types of situation are classified as abnormal responses to acupuncture needling, they differ greatly in terms of the level of harm and causes. The latter type of situation unquestionably falls within the scope of needling safety issues.

Comparison of needle sickness and needling safety issues

Acupuncture needling safety issues can be classified as adverse needling events, adverse reactions to needling, needling incidents, needling accidents, and needling complications^［16］. Most modern literature categorizes needle sickness among the aforementioned incidents in order to evaluate the safety of acupuncture needling. Should needle sickness be included under the concept of acupuncture needling safety? Taking into account the previous discussion of the implications and causes of needle sickness, this question may be analyzed as follows: (1) The occurrence of needle sickness is related to the state of the patient’s body and the amount of needle stimulation, but there is some degree of individual variation, so it is not necessarily caused by the treatment; therefore, it is not caused by needling alone. In addition, there is a chance that it may happen even when following standard practices, so it is not due to external factors or accidental causes. (2) Regarding the causes of needle sickness, it is possible to foresee and avoid them to some degree. (3) Patients can recover from needle sickness reactions if the practitioner responds promptly and the final outcome will not impact treatment effects, or may even enhance them. Through a comparison with concepts of acupuncture needling safety (see Table 2), it is clear that needle sickness does not conform to these concepts.

Table 2. Acupuncture needling safety concepts

From a comprehensive comparison between the features of the concepts of needling safety and needle sickness, it would be too simple to relegate needle sickness to the scope of needling safety issues, as it is not completely aligned with the concept of needling safety. As needling is an invasive therapy, it can cause some discomfort in the body; whether or not this discomfort is considered “adverse” must be judged based on whether the end result of the treatment aligns with the goals of acupuncture needling^［17］. Therefore, the key to determining the nature of needle sickness is whether or not the end result after needle sickness occurs aligns with the treatment goals.

Real cases of synergistic effects from needle sickness

The text Jin Zhen Fu, published in 1439, was the first to use the term “needle sickness”, but there was no mention of the relationship between needle sickness and treatment effects until 1798, when the text Zhenjiu Yixue clearly stated that “［a patient who experiences］ needle sickness will definitely have a great ［treatment］ effect”. From this point, later generations of practitioners discovered numerous cases in which needle sickness had synergistic effects. In her text Xin Zhenjiu ［New Acupuncture and Moxibustion］, published in 1954, modern acupuncture scholar Zhu Lian recorded a case of intractable enuresis that resolved completely after needle sickness. In 1981, a practitioner in Fujian province with the surname Zheng^［18］was treating a patient with “facial muscle spasm” who had not eaten anything prior to treatment and a needle sickness reaction occurred. After the needle sickness symptoms subsided, no spasms or jerking movements were observed in the facial muscles, which was a clear improvement compared to the previous 3 treatments, and a follow-up 3 months later found that the issue had not reoccurred. In 2011, a practitioner in Henan province with the surname Feng^［19］reported 4 cases of needle sickness; in each of these 4 cases, all of the patient’s symptoms disappeared after the needle sickness subsided. Among them, there was 1 case of a patient with “diaphragm muscle spasms”; after Zhongwan ［CV-12］ was needled, the needle sensation surged upward to the throat and a needle sickness reaction occurred. After the needle was removed and the patient lay flat in the supine position, the hiccups, gastric distention, and other symptoms all vanished, and the patient was cured in 1 treatment. In 2015, a practitioner in Beijing with the surname Jiang^［20］reported 4 cases of improved treatment effects after needle sickness; the results of 1 treatment were equivalent to those of 3-5 typical sessions, which significantly shortened the course of treatment. In one case, a patient who had headaches for 5 years was cured in 1 treatment after experiencing needle sickness and a follow-up 1 year later found no recurrence. In recent years, there have been repeated reports of cases with synergistic effects from needle sickness both in China and abroad. In 2017, Christensen et al.^［7］reported 3 cases of synergistic effects following needle sickness; for all 3 patients, it was their first experience with acupuncture and they all had various levels of mental stress. After recovering from needle sickness, the pain in the 3 patients’ head, neck, shoulders, and back decreased and their range of motion returned to normal. Cases with synergistic effects from needle sickness further demonstrate that needle sickness cannot simply be classified within the scope of abnormal situations or acupuncture needling safety issues.

Needle sickness is a special type of reaction to obtaining qi

Manifestations of needle sickness conform to the diversity of reactions to obtaining qi

Reactions to obtaining qi may vary and needle sickness conforms to the manifestations of these reactions. Obtaining qi refers to the physical state of qi arriving under the needle after the needle has been inserted, which plays a critical role in the treatment that follows^［21］. Obtaining qi is also referred to as “needle sensation”, and was called the “arrival of qi” in ancient times. From the practitioner’s perspective, there are many types of needle sensation, such as sinking, tightness, roughness, and stagnation. From the patient’s perspective, these sensations are even more complex and varied. The only needle sensations recorded in Su Wen ［Elementary Questions］are related to heat and cold; by the Qing dynasty, sensations such as soreness, numbness, and pain were added. At present, recognized needle sensations include several singular or more complex compound sensations such as aching, distending pain, heaviness, numbness, coolness, heat, itchiness, convulsions, or a feeling of insects crawling on the skin^［22］. Professor Wang Xinming claimed that needle sickness reactions with brief periods of dizziness, nausea, and sweating are also reactions to obtaining qi. Wang proposed that the phenomenon of obtaining qi is the process of mobilizing the functions of the whole body, which is also a process that consumes qi; if the patient uses up too much qi, this manifests as needle sickness^［25］.

Chapter 1 of Ling Shu, entitled “The 9 Needles and 12 Sources”, states: “The key to needling ［is］ that the arrival of qi ［makes the treatment］ effective”. This emphasizes that the arrival of qi is the key reason for the effectiveness of acupuncture needling. Viewing needle sickness as a special type of reaction to obtaining qi allows for a better understanding of Li Shouxian’s statement in the chapter “On Needle Sickness” in Zhenjiu Yixue^［26］: “［a patient who experiences］ needle sickness will definitely have a great ［treatment］ effect; this is because of the peaceful interaction of blood and qi”. Needle sickness accelerates the process of the“peaceful interaction of blood and qi”, and this interaction also serves as the “arrival of qi”. This is what is meant by the saying that “if qi arrives quickly, results will occur quickly; if the qi arrives slowly, results will occur slowly”. Thus, patients who experience needle sickness get results quickly after recovering from needle sickness. The discussion on “recovering from needle sickness” in Huang Zhuzhai’s modern text Zhenjiu Jingxue Tukao ［An Illustrated Book of Acupuncture Channels and Points］^［27］agrees with Li Shouxian’s viewpoint. The large number of cases in which needle sickness caused synergistic effects reported in modern research also corroborate this viewpoint from a therapeutic perspective.

Sakai et al.^［28］discovered that obtaining qi increased the power of all bands of brain waves except for the gamma band; there was a strong correlation between the sensation of obtaining qi and changes in the patient’s brain waves. Yin et al.^［29］claimed that there are synchronous correlations between changes in brain waves and the sensation of obtaining qi. Kwon et al.^［30］found that there were 2 explosive increases in the absolute power of the brain wave signals of a patient experiencing needle sickness: the first was after qi was obtained following needling, and the second was after the needle sickness occurred. This showed that the patient’s brain wave signals when needle sickness occurred were similar to those at the time of obtaining qi.

Most current perspectives consider needle sickness to be a type of vasovagal response (VVR), which is caused by the vagus nerve and changes in vascular tone. For example, Christensen et al. and other scholars outside of China refer to needle sickness as an acupuncture-associated vasovagal response. VVR is a common clinical manifestation of an autonomic nervous reflex that occurs under conditions of psychological or physiological stress. Mild cases manifest with the warning signs of needle sickness, while moderate and severe cases manifest with loss of consciousness. Fainting due to causes such as blood phobia, needle phobia, long periods of standing, and emotional agitation is classified in this category^［31］. Some of the effects of the channels and network vessels are closely related to the vagus nerve; a large body of research has proven that acupuncture needling can achieve treatment results through regulation of the vagus nerve^［32］. Research has shown that electroacupuncture on points on the heart channel can regulate the vagus nerve and the sympathetic nervous system to effectively decrease myocardial oxygen consumption and improve myocardial ischemia^［33］. Chen et al.^［34］claimed that stimulation from needling tones the vagus nerve, enhances the balance of sympathetic/vagus nerve activity, lowers serum myocardial enzyme levels, and reduces myocardial damage. The needle sickness reaction can also excite the vagus nerve; the manifestations of bradycardia and hypotension are consistent with a vagus nerve effect caused by acupuncture needling.

In summary, the authors believe that needle sickness is a special type of reaction to obtaining qi. It has the characteristics of a reaction to obtaining qi, but it differs from common reactions to obtaining qi; most subjects who experience a needle sickness reaction to obtaining qi are in a special state of “essence-spirit vacuity”.

Clinical significance and looking to the future

With modern technological advances and improvements in the quality of research, the depth of research on acupuncture has gradually increased, and the understanding of the needle sickness reaction has changed accordingly. A growing number of scholars have recognized that needle sickness can have unexpected synergistic effects that align with initial impressions of needle sickness, i.e. “［a patient who experiences］ needle sickness will definitely have a great ［treatment］ effect”. Scholars have also 〖JP2〗attempted to explore its mechanism, though there are different viewpoints on this topic^［35-36］. This paper considers the needle sickness reaction to conform to the diverse manifestations of obtaining qi and the synergistic effects of needle sickness are also consistent with the effects of obtaining qi, so needle sickness can be viewed as a special type of reaction to obtaining qi, namely one that occurs in response to needling stimulation when the body is in a special state of “essence-spirit vacuity”. Based on a comprehensive analysis of the characteristics of needle sickness, it should not be categorized within the scope of acupuncture safety. In terms of how to respond to needle sickness, one can choose not to remove the needles in mild or moderate cases as long as they do not affect the patient’s ability to lie flat in the supine position. In addition, after Ni Chunhui and other scholars^［37］recognized the impact of the “synergistic effects of needle sickness”, they actively explored “needle sickness therapy” in clinical practice. Using methods such as psychological suggestion and passive motion acupuncture techniques, they induced “critical needle sickness”, i.e. mild needle sickness, with the aim of improving clinical efficacy. Unfortunately, no follow-up reports on this research have been found, but this attempt is still noteworthy. It is possible that the patients’ experience in this process was negative and may even have caused fear, which limited research on needle sickness. At present, we are still in the initial phase of understanding the mechanisms of needle sickness; the vast majority of research results consist mainly of inferential hypotheses. In order to gain a more objective understanding of the mechanisms of needle sickness and its synergistic effects, more empirical research is needed.

Author information:

Dr, Zhao Zhongzhen， Former deputy dean and professor of the School of Chinese Medicine of Hong Kong Baptist University, distinguished professor of Beijing University of Chinese Medicine, and founding director of the Compendium of Materia Medica Research Institute.

Dr. Li Liang Hong Kong Baptist University, 7 Baptist University Road, Kowloon Tong, Hong Kong.

Dr. Eric Brand Hong Kong Baptist University, 7 Baptist University Road, Kowloon Tong, Hong Kong.

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暈針新解——一種特殊的得氣反應

劉爽 周江雪 王吉林 孫英霞

摘要：本文通過梳理暈針古今文獻，分析暈針概念的內涵與外延，並結合臨床實踐，分析後提出暈針是機體處於“神氣虛”（飢餓、疲憊、精神緊張等不佳的身心狀態）的狀態時接受針刺刺激產生一種常見反應，暈針後可見臨床療效的提高，因此應視為特殊得氣反應。這種認識的改變必然會對臨床產生較大影響。

關鍵詞: 暈針；暈針概念；得氣；概念研究

暈針是針灸臨床常見的一種針後反應。曆版教材及相關研究中都將暈針歸於針刺異常情況^{［1-2］ ［3］}認為暈針屬於針刺安全性的範疇，將暈針定性為不良事件、不良反應^［4］、針刺意外或針刺事故，多持否定態度，應當盡量避免。

現代臨床研究多着眼於暈針的原因、表現及處理進行闡述，鮮少探究暈針與療效的聯繫。檢索文獻發現早在清代李守先的《針灸易學》已明確提出“暈針者，必獲大效”，但並未引起足夠重視；近年來暈針後療效提高的案例屢有報道，暈針增效的觀點也多次被不同學者論及，2004年Greenwood教授提出暈針增效將會引起一場對經驗性認識的大變革^［5］。

暈針概念的內涵

暈針概念內涵的古今認識

暈針定義為針刺過程中出現的暈厥現象，臨床表現上分為輕、重兩種程度。

輕度暈針表現為：精神疲倦,頭暈目眩,噁心欲吐。

重度暈針表現為：心慌氣短,面色蒼白,出冷汗,脈象細弱,甚則神志昏迷,唇甲青紫,血壓下降,二便失禁,脈微欲絕等症狀^［1］。

早期文獻將暈針表現描述為“仆”，如《靈樞經·經脈》^［6］云“瀉之……則仆”，直到《金針賦》首次提出“暈針”一詞，言：“暈針者，神氣虛也。”認為“神氣虛”的狀態是患者暈針的根本原因。

國外學者將暈針稱為針刺休克、針刺暈厥、反射性暈厥、血管迷走神經性暈厥、血管迷走神經性休克或血管激動反射等術語^［7］，可以見得，國外學者多認可暈針是血管迷走神經反應，但對其具體臨床表現略有分歧，採用“暈厥”、“休克”、“反射”等詞定義暈針。對暈針的原因古今認識基本一致，主要與患者機體狀態（飢餓、疲憊、精神緊張等不佳的身心狀態）與醫者手法過重有關。

暈針概念發微

曆版教材及權威辭典多將暈針定義為針刺過程中的暈厥現象（詳見表1），僅有《中華醫學百科全書》將其定義為一系列症狀，前者雖與後者落腳點不同，但在其後文中補充描述了暈針反應的其他臨床表現，實則肯定了暈針反應是一系列症狀，且在臨床中輕度暈針反應更多見，表現為“暈厥”者較少見，查閱文獻也僅有寥寥幾篇報道^［12］，未見有暈針引發嚴重不良後果的報道^［13］。

2017年《醫學百科全書》^［11］暈針定義為針刺過程中患者出現頭暈、噁心、汗出甚至暈厥等一系列症狀，既強調了暈針症狀的多樣性及相兼性又明確了輕、重兩種程度。

同年，Christensen K A等^［7］認為“暈厥”、“休克”等術語描述暈針不夠準確甚至存在夸大的嫌疑，會造成患者的焦慮恐慌。

因此，本文認為暈針定義應包涵至少兩種程度的臨床表現，即頭暈、目眩、噁心等輕度暈針反應和心慌、出冷汗、暈厥等重度暈針反應，而且其落腳點應為一系列症狀或反應。

現代研究證實暈針原因與患者機體狀態有強相關性，有學者採用循證醫學的方法總結報告了348例暈針事件，其中有347例因身心狀態不佳而暈針，只有1例因手法過重而暈針^［14］。筆者認為針刺手法輕重是一個相對概念，存在一定個體差異性，無法準確界定手法的輕與重，因此對於手法過重這一原因存在一定的相對性。

鑒於此，本文認為對於暈針而言，機體當前狀態的內因佔住導地位。

縱觀古今文獻，在暈針處理上對於是否起針有重大分歧。以《針灸大成》為代表的古代文獻強調暈針後不可起針，《南豐李氏補瀉》^［15］言“凡針暈者……不可起針……若起針，壞人。”認為暈針後起針會加重耗氣而導致嚴重不良後果“壞人”。而以《針灸學》及權威辭典為代表的現代文獻則認為暈針後需立即起針。

兩者分歧的原因可能在於兩者的側重點不同，古人對針刺暈針事件中重點關注的是針刺效應，認為起針會影響針刺療效，故而採用不起針、“加刺蛤蟆肉”等方法。

今人多關注患者不適的機體狀態，為了解除此狀態而起針，一方面可以停止針刺刺激，另一方面方便患者以適當體位休息。

另一個需要注意的問題是上述辭典及教材均未提及暈針與療效的聯繫，忽略了暈針對臨床療效可能產生的損益，對於暈針的態度也僅根據患者對暈針的態度制定，因而對其持否定態度（詳見表1）。

表1暈針概念

暈針概念的外延

暈針與針刺異常情況的比較

曆版《針灸學》、《刺法灸法學》均將暈針現象歸為針刺的異常情況，異常與正常相對而言，意為此類事件在針刺治療中較少發生。除暈針外這類異常情況還包括滯針、彎針、斷針、血腫、刺傷內臟、刺傷腦脊髓及外週神經損傷。其中暈針、滯針、彎針及血腫相對常見，而且通過及時處理一般可自行恢復，對患者危害較小，滯針也可作為一種特殊手法治療軟組織疾病；刺傷內臟、刺傷腦脊髓及外週神經損傷易引發不良後果，對患者危害較大，多因針刺操作不當引發。二者同屬針刺異常情況，卻在危害程度及產生原因有較大區別，後者歸屬於針刺安全性範疇是無爭議的。

暈針與針刺安全性的比較

針刺安全性可分為針刺不良事件、針刺不良反應、針刺意外、針刺事故、針刺併發症^［16］。現行文獻多以將暈針歸於上述事件，以評價針刺療法的安全性。暈針是否屬於針刺安全性範疇的概念？結合上文對暈針內涵及原因的探討，現分析如下：

1.暈針的發生與機體狀態和針刺刺激量有關且存在一定的個體差異性，不一定是由療法引起，不屬於針刺自身原因，此外即使操作規範也有概率發生，不屬於外界因素和意外原因；

2.針對暈針的原因，可以一定程度預見及避免；

3.暈針反應一般可通過及時處理而恢復，最終產生的結果不影響療效，甚至有可能提高療效。與針刺安全性的概念比較可得（詳見表2），暈針不符合針刺安全性概念。

表2針刺安全性概念^［16］

綜合對照針刺安全性的概念及暈針的特點比較，將暈針划分至針刺安全性的範疇略嫌簡單，它與針刺安全性的概念不完全統一。針刺作為一種侵入性療法，機體可能會有一些不適感，這種不適是否屬於“不良”的針刺事件須根據治療最終結局是否符合針刺治療目的來判斷^［17］。因此，決定暈針的定性的關鍵是暈針後的最終結局是否符合治療目的。

暈針增效實例

1439年《金針賦》首次提出“暈針”一詞，關於暈針與療效的關係直到1798年《針灸易學》明確提出“暈針，必獲大效”，由此後世醫家在臨床實踐中也發現了大量暈針增效的案例。

1954年現代針灸學家朱璉在其著作《新針灸》中記載了遺尿痼疾患者暈針後痊愈的案例。

1981年福建省鄭氏^［18］在治療1例空腹狀態下的“面肌痙攣”患者時，出現了暈針反應，暈針症狀消失後，面肌未見痙攣抽動，較前3次治療療效明顯提高，後隨訪3個月未見復發。

2011年河南馮氏^［19］報道了4例暈針案例，這4例患者在暈針緩解後全部症狀均消失：其中1例“膈肌痙攣”患者，在針刺中脘時，針感上沖咽部，出現暈針反應，起針平臥後，打嗝、胃脹等症狀消失，1次而愈。

2015年北京姜氏^［20］報道了４例暈針後療效提高的案例，一次治療就收到了相當於3-5次的療效，大大縮短了療程，其中1例患者頭痛5年，在針刺暈針後，一次痊愈，隨訪一年未再復發。

近年來，暈針增效案例在國內外屢有報道，2017年Christensen K A等^［7］報道了3例針刺暈針後增效的案例：3名患者系首次接觸針刺且均有不同程度的精神壓力。在針刺暈針恢復後，3人頭、頸、肩、背部疼痛均減輕，且活動度恢復正常。

暈針增效的案例進一步說明了不能簡單的將暈針歸為異常情況和針刺安全性的範疇。

暈針是一種特殊的得氣反應

暈針表現符合得氣反應多樣性

得氣反應的表現有多樣性，暈針符合得氣反應的表現。得氣是指針入後氣至針下的機體狀態，對後續療效起關鍵作用^［21］。

得氣又稱“針感”古稱氣至，針感於醫者而言包括多種，如沉、緊、澀、滯等；於患者而言，這種感覺更加複雜多樣，《素問》記載的針感只涉及寒、熱，至清代補充了酸、麻、痛，發展至今認識到針感包括酸痛感、脹痛感、沉重感、麻木感、涼感、熱感、癢感、抽搐或蟻行等多種單一感覺或更加複雜的復合感覺^［22-24］。

王新明教授認為短暫的眩暈、噁心及出汗等暈針反應也是得氣現象，並提出得氣現象是調動全身機能的過程同時也是耗氣的過程，病人耗氣過多則會表現為暈針^［25］。

《靈樞·九針十二原》中有言：“刺之要，氣至而有效。”強調氣至是針刺取效的關鍵原因，將暈針視為一種特殊的得氣反應也能更好的理解清代李守先先生在《針灸易學·論暈針》^［26］提出的“暈針者，必獲大效，以血氣交泰之故”的觀點。

暈針加速了“氣血交泰”的過程，而“氣血交泰”則為“氣至”，所謂“氣速至而速效，氣遲至而效遲”，因此暈針者在暈針恢復後可達到速效。

近代黃竹齋先生的《針灸經穴圖考》^［27］ “救暈針法”中也認同李守先先生的這一觀點。

現代研究報道了大量的暈針增效案例，也從療效方面印證了以上觀點。

Sakai S等^［28］發現，得氣可以升高除γ波以外的所有腦電波波幅，得氣感與患者的腦電波變化有很強的相關性。Yin C S等^［29］認為，腦電波的變化與得氣感具有同步的相關性。Kwon OS等^［30］發現暈針的患者腦電波信號的絕對功率有兩次爆發，第一次是在針刺得氣後，第二次是在暈針發生後，證實暈針發生時的腦電波信號與針刺得氣時患者腦電波信號相似。

現行觀點多認為暈針是一種血管迷走神經反應（VVR），是由迷走神經和血管張力變化引起的，如Christensen K A等國外學者將暈針反應稱為針灸相關的血管迷走神經反應。VVR是心理或生理應激條件下一種常見的自主神經反射的臨床表現，輕度表現為暈厥先兆症狀，中、重度表現為意識喪失，暈血、暈針、長時間站立、情緒激動等的暈厥均屬此類^［31］。部分經絡效應的發揮與迷走神經密切相關，大量研究證實針刺可以通過調節迷走神經達到治療目的^［32］。

研究證實電針心經穴能夠調節迷走神經和交感神經，有效降低心肌耗氧量，改善心肌缺血^［33］。陳偉等^［34］認為針刺刺激使迷走神經緊張，改善交感/迷走活動平衡，降低了血清心肌酶，減輕心肌損傷。暈針反應也可以興奮迷走神經，表現為心動過緩和血壓降低與針刺刺激迷走神經效應有一致性。

綜合上文，筆者認為暈針是一種特殊的得氣反應，它具有得氣反應的特點，但與普通得氣反應不同，暈針得氣的受試者多處於“神氣虛”的特殊狀態。

臨床意義與展望

隨着現代技術的進步及科研水平的提高，對針灸的研究逐漸深入，關於暈針反應的認識也在隨之變化。越來越多的學者認識到暈針會有意料之外的增效作用與暈針的初印象相合即“暈針者，必獲大效”，學者們也嘗試對其機制進行探索，各家觀點不一^［35-36］ 。本文認為暈針反應符合得氣多樣性的表現，暈針增效也與得氣的效應一致，可以將暈針視為一種特殊的得氣反應，當機體處於“神氣虛”的特殊狀態下，對針刺刺激的產生的得氣反應。根據暈針的特點綜合辨析暈針不應屬於針刺安全性的範疇。在處理上，對於輕、中度暈針在不影響平臥位的前提下也可不起針。

此外，倪春暉等學者^［37］在認識到“暈針增效”的效應後，在臨床實踐中積極探索“暈針療法”，通過心理暗示、被動運動針法等方法，誘導患者出現“暈針臨界化”即輕度暈針反應，以期提高臨床療效，可惜的是未見有後續報道，但這次嘗試卻是值得關注的。可能在此過程中患者的體驗感差，甚至會造成恐懼，限制了暈針的相關研究。

目前對於暈針機制的認識尚處於初級階段，大多數研究結果以推論假說為主，想要更加客觀的認識暈針、暈針增效的機制還需要更多的實證性研究。

作者簡介：

劉爽，女，針灸推拿學碩士，住院醫師，中國中醫科學院西苑醫院濟寧醫院，郵箱：[email protected]

通讯作者：

孫英霞，女，副教授，副主任醫師，醫學博士，碩士生導師，山東中醫藥大學針推學院，郵箱：[email protected]

其他作者：王吉林，住院醫師，海軍青島特勤療養中心，郵箱： [email protected]

周江雪，住院醫師，泰安市中醫醫院，郵箱：[email protected]

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