Fu’s Subcutaneous Needling

Chapter 16

Fu’s Subcutaneous Needling

Zhonghua Fu; Li-Wei Chou


The authors thank Professor Chang-Zern Hong for his critical review of the manuscript.

Concept and Terminology

Myofascial trigger points (TrPs) are discrete, focal, hyperirritable spots located in skeletal muscles. They produce pain and often accompany chronic musculoskeletal disorders. A TrP is a key concept for musculoskeletal pain problems. We have used the theory of TrPs for several years in our clinical practice; however, we have found that the concept of TrPs is not always suitable to our practice, which is why in 2014 we developed a new concept, referred to as ‘tightened muscle (TM)’.

TM (in Chinese: 患肌) refers to the condition in which a normal muscle remains semicontracted for a prolonged period of time. This condition results in a tight, hard band felt in a part of the muscle or throughout the entire muscle, but most commonly in the area of the muscle belly. TrPs are in embedded in TM. Fu developed the term ‘TM’ in 2014 with collaboration by other practitioners of Fu’s subcutaneous needling (FSN) in China. In one of his Chinese FSN books, he translated ‘患肌’ into ‘pathological tight muscle’, but after the recommendation by Dr. Jidong Wu in Cambridge, UK, Dr. Fu agreed to the term ‘tightened muscle’ instead (Fu, 2016).

Before answering the question why the term TM is preferred over TrP, an introduction to the FSN technique is indicated. FSN is a therapeutic approach for musculoskeletal painful disorders and some chronic benign visceral disorders, which originated from traditional acupuncture. This procedure is performed by inserting a solid needle, usually a special trocar needle, into the subcutaneous layer around a TM to achieve a desired effect (Fig. 16.1). Different from traditional acupuncture, FSN has no special insertion point. The FSN needle is inserted anywhere in the vicinity of a TM with the needle tip pointing towards the TM. Apart from not having fixed insertion points, other aspects of FSN also contributed to the need to replace the more traditional TrP construct and terminology.

  1. 1. The term ‘myofascial’ is an adjective referring to skeletal muscle and its fascia. Fascia has been described in detail in Chapter 3. Myofascial refers not only to muscle tissue. The perception with palpation is that TM is mostly muscle tissue, especially in the muscle belly. Fascia does not have the same TM quality with palpation.
  2. 2. The word ‘trigger’, as used in TrP, is more or less meaningless in the practice of FSN. The trigger reaction is felt when a needle touches muscle fibres. In FSN, needles do not touch the muscles as the technique is strictly used subdermally.
  3. 3. The word ‘point’, as used in TrP, is also not suitable in the practice of FSN because FSN targets what is perceived as a slice or band.

Fig. 16.1
Fig. 16.1 A graphical map of Fu’s subcutaneous needling.

The name FSN, or Fu Zhen (浮针, in simplified Chinese; 浮針, in Traditional Chinese), has some profound implications. ‘Fu Zhen‘ is the Chinese pronunciation for FSN. Fu is the surname of the inventor, who is also the first author of this chapter. In Chinese, ‘Fu, 浮’ means floating, and it could also mean superficial. ‘Zhen’ means acupuncture or needling. Therefore in some English-language papers, FSN is also called ‘floating acupuncture‘ (Huang et al., 1998), Fu’s acupuncture (Zhang, 2004), Fu needling (Xia & Huang, 2004), and floating needling (Fu & Huang, 1999). However, neither floating nor superficial are precise translations; the word ‘subcutaneous’ is a better substitute in terms of demonstrating the manipulation features of FSN.

Although FSN originated from classic acupuncture, FSN’s manipulation and theory have nothing to do with the concepts of traditional acupuncture such as meridians, acupoints, Yin-Yang, and Qi. Therefore FSN is not some variety of acupuncture and should not be referred to as acupuncture. Fig. 16.2 shows the FSN needle in a subcutaneous layer of a human cadaver. Another approach, called intradermal needle therapy, is easily confused with FSN. The intradermal needle (Fig. 16.3) is a type of short needle made of stainless steel wire, especially used for embedding in the skin rather than in the subcutaneous layer (Cheng, 1987).

Fig. 16.2
Fig. 16.2 Fu’s subcutaneous needling needle located in the subcutaneous layer of a human cadaver.

Fig. 16.3
Fig. 16.3 The intradermal needle.

The term ‘Fu’s subcutaneous needling’ was first mentioned in a 2005 article by Fu and Xu, in which they described the treatment method (Fu & Xu, 2005), followed by several other research papers (Fu et al., 2006, 2007). FSN should be clearly distinguished from dry needling (DN), which involves the insertion of a fine single-use sterile needle into a TrP for the treatment of myofascial pain. DN has been in use since the 1970s and differs from the use of needling from an Oriental paradigm (Baldry, 1995, 2000, 2002; Hsieh et al., 2007; Hong, 2000, 2002, 2004, 2006; Simons, 2004, 2008). TrP DN is based on a Western anatomical and neurophysiological paradigm and has been increasingly utilised in the Western world, especially in the US, UK, The Netherlands, Canada, Belgium, Norway, Australia, Switzerland, Ireland, Brazil, South Africa, and Spain, among others (Dommerholt et al., 2006). Unlike traditional acupuncture, DN does not consider ancient Chinese philosophy and traditional ideas. Traditional acupuncture is based on prescientific ideas such as meridians, Qi (a kind of invisible energy), and Yin–Yang (Ellis & Wiseman, 1991; White & Ernst, 2001; Kim, 2004), whereas DN is entirely based on the recent understanding of scientific neurophysiology, anatomy, and pain sciences (Ghia et al., 1976; Melzack et al., 1977; Melzack, 1981). The manipulation method used in acupuncture differs from that used in DN and is based on different theoretical foundations and principles.

Contemporary research and the emergence of DN have reduced the sense of mystique surrounding noninjection therapies for pain (Amaro, 2008). Although acupuncture and DN have different theoretical bases, they are similar in some aspects.

  1. 1. Nothing is injected into the body.
  2. 2. Needles may target the same points known as either a trigger point in DN or an Ah-shi point in Chinese medicine.
  3. 3. Many of the pain indications overlap.

Further, in TrP DN the importance of the local twitch response is emphasised, which is a reaction during needling with some resemblance to the ‘De-Qi’ effect in acupuncture (Hong, 1994). Chou and associates (2008, 2009, 2011, 2014) have modified the technique used in acupuncture into a procedure similar to Hong’s DN technique. Therefore in a ‘broad sense’ acupuncture can be considered as one type of DN.

FSN borrowed some ideas from traditional acupuncture, but the essential features are different from those of traditional acupuncture. Acupuncture and FSN are based on different theories and techniques and manipulations are employed with entirely different kinds of needles. Traditional acupuncture theory is mystical, even to Chinese doctors. FSN is a much easier approach, which does not consider the traditional theories. Compared with the current practice of DN, FSN has several unique features. There are at least two differences between FSN and DN. FSN needles are inserted into nondiseased areas and FSN is confined to subcutaneous layers, whereas DN inserts the needles into TrPs and often deep into the muscles. FSN is considered a particular type of DN. FSN shares the same scientific neurophysiological and anatomical foundation as TrP DN.

Origin of fu’s subcutaneous needling

The following three sources led to FSN’s evolution from traditional acupuncture.

Contemplation of De-Qi

De-Qi or Qi is an acupuncture phenomenon that occurs during needle manipulation, experienced by the patient as a particular sensation (e.g., soreness, aching, numbness, or ‘needle grasp’) or by the acupuncturist as a pulling sensation (Cheng, 1987; Lin, 1997; Langevin et al., 2006; White et al., 2008). Traditionally, De-Qi must be achieved in the process of acupuncture regardless of the manipulation used; otherwise, the therapeutic results are poor (Cheng, 1987). In every textbook on acupuncture in Chinese, the importance of De-Qi is always emphasised and reiterated and acupuncturists repeatedly highlight De-Qi. As a result, most Chinese patients believe in the adage, ‘no De-Qi, no effect.’ Sometimes patients will be disappointed in the acupuncturist if they fail to acquire De-Qi, even though it may cause discomfort to the patient.

Acupuncturists and patients are not the only ones who consider De-Qi to be pivotal. Some scientists also believe that De-Qi plays an important role in acupuncture analgesia (Cao, 2002; Park et al., 2005). Acupuncture needling may activate afferent fibres of peripheral nerves to elicit De-Qi, the signal that ascends to the brain, activates the antinociceptive system, including certain brain nuclei, modulators (opioid peptides) and neurotransmitters, and through the descending inhibitory pathway, which results in analgesia (Cao, 2002).

However, occasionally acupuncture does work without De-Qi and could fail even when the patients achieve strong De-Qi. Furthermore, many acupuncture substitutes, such as cupping, moxibustion, transcutaneous electrical nerve stimulation (TENS), and so on, do not elicit De-Qi, but they appear to be effective nevertheless (Chen & Yu, 2003).

Therefore De-Qi may be not as relevant as traditionally is often suggested. To prove the insignificance of De-Qi, the best method is to stimulate the tissue without obvious direction and then observe what will happen. The elicitation of De-Qi is related to the needling depth (Lin, 1997). There are few free nerve endings and proprioceptive receptors in the subcutaneous layer, whereas free nerve endings are abundant in the epidermis and dermis. Proprioceptive receptors do exist in the muscular layer (Tortora, 1989). Therefore there should be no occurrence of De-Qi even if the subcutaneous layer is stimulated. Under such a condition, does the needling effect still exist? For an acupuncturist, it is easy to verify the existence of the needling effect, and this simple trial was one of several factors resulting in the discovery and development of FSN. One example of a form of acupuncture where achieving De-Qi has been shown to not be critical is wrist–ankle acupuncture.

Clinical Application of Wrist–Ankle Acupuncture

Wrist–ankle acupuncture (WAA) (Jiang et al., 2006) is also called wrist–ankle needling (Song & Wang, 1985). Dr Xinshu Zhang, a neurologist who has worked at the Second Military Medical University in Shanghai, developed WAA in 1972. WAA divides the whole body into 12 longitudinal regions, six for each half of the body (Fig. 16.4). There are six points 2 cun (about 50 mm) above the wrist joint corresponding to the six regions above the diaphragm, and there are six points 3 cun (about 75 mm) above the ankle joint corresponding to the other six regions (Fig. 16.5). A cun is a measure of distance relative to a person’s body dimensions that is commonly used in traditional Chinese medicine. If a disorder occurs in one of the regions, the corresponding point should be chosen. Unlike conventional acupuncture, WAA inserts an acupuncture needle only superficially in the subcutaneous layer; some authors claim that WAA is effective in the treatment of pain with various origins (Zhu & Wang, 1998). Needling superficially in WAA wrist or ankle points to treat distant disorders often has a good effect (Song & Wang, 1985; Chu & Bai, 1997), leading to the idea that needling close to the afflicted area could be at least as effective as needling in an area remote from that which is afflicted, and that needling closer may be preferable. These thoughts motivated the principle author to seek answers through clinical trials.

Fig. 16.4
Fig. 16.4 Twelve longitudinal regions according to wrist–ankle acupuncture.

Fig. 16.5
Fig. 16.5
Fig. 16.5 The insertion style of wrist–ankle acupuncture.

Ancient Techniques

The Medical Classic of the Yellow Emperor (also known as The Yellow Emperor’s Canon on Internal Medicine or The Yellow Emperor’s Inner Classic), written thousands of years ago, is a fundamental book of traditional Chinese medicine. The book states that needling superficially and needling nearby are two characteristics of the ancient techniques for the treatment of painful problems. The principle author of this chapter learned from and was inspired by these techniques in the process of developing FSN. In The Medical Classic of the Yellow Emperor, there is a chapter entitled ‘Guanzhen,’ which records 26 special techniques. The 26 techniques are classified into three groups: a 9-technique group, a 12-technique group, and a 5-technique group.

The characteristic of superficial needling refers to quite a few techniques such as MAO Ci in the 9-technique group, Zhizhen Ci and FU Ci in the 12-technique group, and Ban Ci in the 5-technique group. Among them, especially Zhizhen Ci resembles FSN: hold up the skin with the thumb and index fingers of the left hand; insert the filiform needle into the skin; and then go forward toward the painful spot obliquely. Zhizhen Ci can be said to be a precursor to FSN without FSN needling and its swaying movement.

Needling nearby is often seen in the 26 techniques such as Fen Ci in the 9-technique group; Hui Ci, Qi Ci, Yang Ci, Duan Ci, and Pangzhen Ci in the 12-technique group; and Baowen Ci, Guan Ci, and Hegu Ci in the 5-technique group.

Aside from the practicable techniques mentioned previously, The Medical Classic of the Yellow Emperor also describes many systemic theories such as meridians, acupoints, and Yin–Yang. Nevertheless, from then on, most ancient acupuncture texts adopted meridians, acupoints and other theories instead of practicable techniques as their main interests. The long-term neglect of more practicable techniques resulted in today’s acupuncturists having little knowledge about this valuable ancient technique, which really is a precursor to FSN.

Based on these ideas and thoughts, Fu devoted himself to seeking a new and effective treatment strategy and finally developed FSN in 1996, when he worked at the First Military Medical University in Guangzhou, China. The university ran a TCM Clinic in Zengcheng, a city near Guangzhou. In the clinic, patients who were in significant pain were more numerous than the author could deal with, which encouraged him to find ways to relieve the painful problems much more efficiently and quicker.

Fu attempted to treat a patient with tennis elbow, or lateral epicondylitis, by needling the patient near the painful spot, which caused a positive response, and as such became the first successful case of FSN. From then on, a series of clinical trials were completed, and positive results were commonly achieved. In the same year, Fu wrote a brief introduction to FSN, which was published in a Chinese health newspaper (Fu, 1996). The next year Fu published his first research paper in Chinese in the Journal of Clinical Acupuncture and Moxibustion (Fu, 1997).

Development of fu’s subcutaneous needling

Fu continued using FSN in his clinics and accumulated more and more evidence, which improved the technique and clinical efficacy of FSN. The initial focus was on developing the FSN needle and on increasing the indications of FSN.

Innovation of the Fu’s Subcutaneous Needling Needle

In physics, scientific theories usually precede technologies. However, in traditional medicine, technologies or therapies often precede theories. Without any past experience to draw from or previous theories to follow, Fu had to develop FSN by trial and error. During FSN’s early months, he used a filiform acupuncture needle, but over time several factors changed his thinking:

  •  When the range of the lesion was large or deep, FSN did not work well with filiform needles even when using many needles simultaneously.
  •  FSN needs a period of retention, and the patients could not stay in any settled position for extended periods of time. The patients should be able to move their bodies and limbs during needle retention. With a stainless-steel filiform needle patients easily can get hurt.
  •  In spite of the absence of discomfort or pain, patients often worried about the steel needle.
  •  FSN requires the needle to sway from side to side. The filiform needle is too elastic to allow for the swaying movement.

Fu realised that certain changes had to be made to the FSN needle; however, the challenge he faced was how to determine what kind of needle would go through the skin quickly and stay beneath the skin safely.

Initially, a physical method was developed: a needle was invented using a new material. The material was solid at low temperatures and became soft at high temperature. When not in use, the needle was stored in a refrigerator to keep it solid. When FSN was used, the needle would become soft after insertion due to the patient’s body temperature. The concept was acceptable, but the material used for the needle and the refrigerators were too expensive for most acupuncturists.

Next, a chemical method was considered. Fu tried to produce a biological hard needle made of a high-polymer material such as absorbable catgut, which would dissolve subsequently by tissue fluids. A large amount of time and energy was devoted to finding such a material, but none was found. Finally, Fu invented a trocar needle, which is still used at this time. The FSN needle consists of two parts: a solid stainless steel needle and its soft casing tube. The former is hard enough to break through the skin quickly and to ensure that the FSN needle can be easily controlled; the latter is soft enough to remain beneath the skin without continuously sticking the patient. A patent application for the FSN needle was filed in December 1997. A Chinese invention patent was granted in August 2002.

Increase of Fu’s Subcutaneous Needling Indications

To determine whether a particular disorder would be a suitable indication for FSN, an immediate effect would need to occur with FSN, which was later referred to as ‘the golden criterion’. Disorders or symptoms for which FSN did not get immediate results were not included in the indications for FSN. After the first successful case, Fu continued searching for other FSN indications, a process which occurred in roughly four stages.

Stage 1: Fu’s subcutaneous needling was mainly used to treat patients with soft tissue injuries of the extremities

In the early months, FSN was used mainly for the treatment of patients with painful problems in the extremities, such as epicondylitis, stenosing tenosynovitis of the styloid process of the radius, snapping finger, osteoarthritis of the knee, sprain and strain of ankle, among others. Due to limited experience with FSN in those early days, the success rate of the treatment of painful problems of the extremities was only about 40%. Therefore FSN was not considered for the treatment of complex diseases or diagnoses of the trunk.

Stage 2: Fu’s subcutaneous needling was used to treat patients with nonvisceral diseases in the trunk

In the autumn of 1998, the primary author saw a patient who was suffering from severe neck pain and who had been treated unsuccessfully in the university hospital for nearly 1 month. A friend of the author requested his assistance and pleaded whether something could be done for the patient, who happened to be her father-in-law, before leaving in a couple of days. The author had no better option for treatment than FSN. Surprisingly, the neck pain was immediately relieved, after which the author started using FSN to treat patients with nonvisceral painful diseases in the trunk such as low back pain with or without sciatica, cervical syndrome, and mild ankylosing spondylitis.

Stage 3: Fu’s subcutaneous needling was used to treat patients with benign painful visceral problems

FSN is performed superficially; hence superficial illnesses such as soft tissue injuries were regarded as primary FSN indications. FSN was never expected to be used for the treatment of persons with visceral diseases, until an 80-year-old Chinese acupuncturist wrote the author that he had treated a patient with appendicitis using FSN. Although FSN may not always be suitable for the treatment of appendicitis for a variety of reasons, the letter implied that FSN may in fact be used in the treatment of persons with visceral diseases. From then on, FSN was used to treat individual with acute and chronic gastritis, cholecystitis, pain due to urinary calculus and painful menstruation, among others.

Stage 4: Fu’s subcutaneous needling was used to handle painful problems in the head and face and nonpainful diseases

After the successful treatments of patients with visceral diseases, more confidence in FSN was gained. The primary author moved on to treat patients with painful head and face problems. The experiences convincingly showed that FSN is effective for the treatment of localised headaches and for painful problems of the face caused by temporomandibular pain and dysfunction and accessory sinusitis. FSN was mainly used to deal with painful problems for which an immediate response could always be achieved. The question was raised whether FSN could effectively manage nonpainful diseases. After many years of practice, it was found that FSN can also deal with nonpainful problems. At present, several nonpainful indications have been treated successfully, including chronic cough without sputum, onset of chronic asthma, and localised numbness.

Fu’s subcutaneous needling manipulations

Although FSN originated from traditional acupuncture, the technique of FSN is quite different, especially in the way the needle is manipulated.

Structure of the Fu’s Subcutaneous Needling Needle

FSN needles, individually packaged and presterilised with ethylene oxide gas, are designed for single use. The FSN needle is made up of three parts (Fig. 16.6): a solid steel needle core (bottom), a soft casing tube (middle), and a protecting sheath (top).

Fig. 16.6
Fig. 16.6 Three parts of a Fu’s subcutaneous needling needle.

The needle core consists of a needle and the needle core handle. The needle is made of stainless steel with a beveled tip. When the needle enters the skin, the bevel of the tip should face upward. The handle is made of plastic and square-shaped, and one of the four sides has 10 protuberances. The protuberances are on the same side as the bevel of the tip. If the protuberances face upward, the bevel will also face upward. The needle core allows the FSN needle to have sufficient rigidity to quickly go through the skin, go forward along the superficial layer, and smoothly sway from side to side. A soft casing tube encases the FSN needle.

The soft casing tube consists of two parts, namely a fluoroplastic body and the tube’s hub, which is made of regular plastic. The two parts are connected to each other by a metal wedge. The tip of the casing tube is about 3 mm beyond the tip of the needle core when the needle core is embedded inside the casing tube. The casing tube has two functions. It covers the tip of the needle until the needle is pulled back by 3 mm; thus the tip of needle stick will not damage surrounding organs or tissues during the swaying movement. The casing tube can substitute for the steel needle core beneath the skin and reduce the patient’s pain during retention.

The protective sheath covers the needle core and the casing tube and keeps the FSN needle sterile.

Preparation Before Treatment

Select a treatment posture

The FSN needle is thicker than an acupuncture needle, and the FSN manipulation lasts longer than an acupuncture or DN treatment. Therefore selecting a suitable treatment posture is crucial for FSN manipulation. The following postures are commonly used with FSN:

  •  Sitting position: Appropriate for manipulating locations in the head, face, neck, shoulder, upper back, and upper extremities.
  •  Supine position: Appropriate for manipulating in the abdomen.
  •  Prone or sidelying: An appropriate posture when treating diseases of the back and the posterior side of the lower extremities.

The treatment postures may need to be modified dependent on the patient’s condition. More accurately, we should change the patient’s postures, especially when there is no immediate effect after several minutes of the FSN swaying movement. For example, although the sitting posture is the first choice for the treatment of neck and upper back pain, if there is no relief of symptoms, changing to the prone position may be a better option. When a particular posture causes too much pain, a different treatment posture would be indicated. For example, if back pain is felt only during standing, the FSN needle could be inserted while the patient is in the prone position (Fig. 16.7). Before performing the swaying movement, the patient would be asked to stand up (Fig. 16.8).

Fig. 16.7
Fig. 16.7
Fig. 16.7 Prone or sidelying position.

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Oct 7, 2019 | Posted by in RHEUMATOLOGY | Comments Off on Fu’s Subcutaneous Needling

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